Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
COP.1: Uniform care of patients is provided in all settings of the organization and
is guided by the applicable laws, regulations and guidelines.
Purpose: To provide guideline instruction for ensuring uniform care of the patient.
Scope: Hospital Wide
Policy:
All patients approaching the hospital for medical treatment will receive care appropriate to their
healthcare need and scope of services provided by the hospital.
Quality of medical care will be same in all care settings of the hospital and no discrepancy of any
sort will be followed in the provision of medical care.
All treatment orders would be signed, dated and timed by the concerned clinician.(Refer to
Medical Record Policy).
Any treatment order initiated by a hospital’s clinician different from the primary treating
consultant of the patient will be countersigned by the primary treating consultant within 24
hours.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 1 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Incase required the primary treating consultant of the patient may consult other care providers
available within the hospital for patients care related issues.
Patients response to treatment, his /her health status , further treatment plan etc will be
discussed among the clinical and nursing staff involved in provision of care to the patient
The primary treating consultant can refer the patient to other clinical specialty either within the
hospital or to the identified external healthcare institutions if the patient’s medical need
demand the same (Refer Policy Referral of Patients).
The clinicians may resort to evidence based medicine which is the conscientious, explicit and
judicious use of current best evidence in making clinical decisions about the care of individual
patients.
Clinicians are encouraged to consider the following points in using evidence based medicine
for the provision of optimum care to the patients which are:
Convert information need into answerable questions.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 2 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Track down the best evidence to answer the question (with maximum efficiency).
Critically appraise the evidence for its validity and usefulness.
Integrate appraisal results with clinical expertise and patient values.
Evaluate outcomes.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 3 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
COP.2: Emergency services are guided by policies, procedures and applicable
laws and regulations.
Purpose: To provide guideline instructions for the provision of immediate relief to and
management of the patients arriving at the hospital with acute medical and
surgical
emergencies with any injuries by accidents, sudden attacks of illness, head trauma, Physical
abuse, poisoning, burns and rape cases etc without any discrimination
Scope: Scope of services of the ED range from providing episodic, primary, acute
(comprehensive) care to referrals.
Responsibility: Emergency Medical Officer, Emergency staff Nurse and Emergency Pharmacist
Departmental Hierarchy:
Emergency Medical Officer
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 4 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
ED Nursing Staff
ED Attendants
Housekeeping Staff.
Objectives:

To triage all incoming patients.

To have patients assessed by qualified individuals.

To diagnose, treat, admit and provide appropriate referral and follow up.

To ensure critically ill patients receive the top priority care as determined by triage
guidelines.

To initiate lifesaving treatment.

To provide end of life care.
Emergency Department (ED) Classification of Capability & Staffing
1. The Emergency Department of Marudhar Hospital offers comprehensive emergency
care 24 hrs a day.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 5 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
2. One Emergency Medical Officer is on duty in the ED during the morning and two
emergency medical officers are available in the evening and night shift respectively.
3. During peak hours, the consultants of all medical services are available in the hospital
and can be reached immediately incase of any need.
4. During non peak hours the consultants from each clinical department are available on
call basis.
5. In case of Accidents involving numerous individuals at a time all consultants and staff
members responsible to provide critical can be called as per the requirement.
Emergency Care Services
The ED service covers evaluation, resuscitation and treatment of all the emergency conditions; it
involves both pre-hospital and in-hospital emergency services of the following types:
1. Cardio-pulmonary emergencies.
2. Surgical Emergencies
3. Trauma Related Emergencies
4. Medico Legal Emergencies
5. Endocrinal Emergencies
6. Obstetrics & Gynecological Emergencies
7. Infectious Emergencies
8. Ambulance Services
Emergency Preparedness Plan (Disaster preparedness plan)
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 6 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
1. Response Time
All patients will come to the ED for emergency medical evaluation or treatment will receive care
by qualified personnel in a timely manner consistent with the acuity of their illness. Marudhar
Hospital has a policy to attend to the patients arriving in the ED immediately. The Nurse
assessment at the triage is done immediately. All patients arriving in the ED are examined and
attended by doctors without delay. The Consultants of respective specialty are called & they
attend to the patient immediately during the regular hours of operations of the OPD. During
after hours, Consultants on call are contacted immediately upon need. Treatment to patients
who are critical is initiated immediately without any delay for the purpose of documentation
and consent.
2. Triage
Emergency Department patients will receive prompt initial assessment by a registered nurse and
will have emergency care initiated according to their level of acuity.
The desired out come of the triage process is that all Emergency Department patients will
receive expedient treatment according to established priorities.
Emergent patients requiring immediate intervention are transferred to the appropriate bed
station in the ED to initiate the patient assessment & care process.
The registration process of the patient is also initiated in the ED if the patient condition permits.
In case of limb and life threatening situations the registration and consent process are
postponed so as to facilitate the initiation of appropriate emergency care.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 7 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
TRIAGE
1. The most severe patients are treated and transported first, while those with lesser injuries
are transported later.
2. Decision is made about who will be managed first.
In a choice between a patient with a catastrophic injury, such as severe open head trauma, a
patient with an acute intra abdominal hemorrhage the proper course of action in an
Multiple Emergency Incidents (MEI) is to manage first the salvageable patient : - The one
with the abdominal hemorrhage. Treating severe head injury patients first probably will
cause loss of both the patients. As it is not salvageable the abdominal hemorrhage patient
because of time, equipment and personnel spent managing the unsalvageable patient. Keep
the salvageable patient from getting simple care that are almost certainly keep her alive
long enough to reach definite surgical cost.
3. The following “TRIAGE” is used in the ED for prioritizing the emergency patient care
according to the acuity of the patient’s condition:
1. Immediate: Those patients whose injuries are critical but who will require minimal time or
equipment to manage and who have a good progress for survival. E.g.:- patient with a
compromised airway or massive external hemorrhage.
2. Delayed: Those patients whose injuries are debilitating but who do not need immediate
management to salvage life or limb. E.g.:- Long Bone fracture
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 8 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
3. Expectant: Whose injuries are so severe that they have only a minimal chance of survival.
E.g.:- Patient with 90% full thickness, burns are thermal pulmonary injuries.
4. Minimal: Who have minor injuries that can wait for treatment are who may even assist in
the intern by comforting other patients.
5. Dead: Who is unresponsive, pulse less, Breathless, in a disaster, resources rarely allow for
attempted resuscitation.
Triage Decisions
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 9 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Patient brought to the ER
Initial assessment done by EMO& nurse. Initial assessment
to be done by 10mins
Initial assessment includes Level of consciousness, temp, BP,
PR, RR, Spo2 to be checked
Stable
Unstable
Treated
and sent
home
Brought in dead
Patient is made fit for
transfer. ABC secured
Consultant
reference
Admit under
Consultant if
facilities to treat
the patient are
available
MLC initiated
Body handed over to
police
Refer to
higher/other
center if facilities
are not available
Consent for Treatment
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 10 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
1. The Hospital requires consent for all invasive or therapeutic procedures. The general
consent form is filled and signed either by the patient if possible or the patient
representative if the patient is not is a state to give his consent. In case of a patient
incapable of giving consent, it is taken from the patient representative or guardian.
2. Life-sustaining measures are not withheld for lack of formal consent if there is no time
to obtain the consent for urgent procedures. The consent process is postponed and
treatment is started immediately in such cases.
3. Consent is required for elective blood transfusions that are not life threatening.
Patient Initial Screening Exam
1. The initial assessment will be done by the ED EMO/ nurse for emergency patients.
2. The time frame for the initial assessment will be 10 minutes.
3. The Initial assessment will include ascertaining the level of consciousness, checking the
blood pressure, Pulse, temperature, Spo2, GRBS in case of diabetics.
4. The initial assessment will ascertain the condition of the patient whether stable or
unstable and appropriate measures will be taken.
5. Initial Assessment will include nutritional assessment of patient
6. initial assessment by the medical officer will include the following criteria:
a. Assessment criteria for non Road Traffic Accident patients include:
i.
Presenting History:
ii.
Past Medical History:
iii.
Allergies:
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 11 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
O/E:
iv.
 Temp. ,BP , PR, Spo2-, GRBS(optional),
v.
CVS/RS/ABD/CNS:
vi.
Investigations done:
vii.
Provisional diagnosis:
viii.
Treatment given:
ix.
Course of action: outpatient/admission/transfer
out/references
b. Assessment criteria for Road Traffic Accident patients include:
i.
Presenting history:
ii.
Past medical history:
iii.
Allergies:
iv.
Last meal:
v.
O/E:
 Level of consciousness- , GCS, Pupils, Temp-, BP- ,PR
vi CVS/RS/ABD/CNS:
vii.L/E:
viii.Investigations done:
ix.Provisional diagnosis:
x.Treatment given:
xi.Course of action: outpatient/admission/transfer out/references
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 12 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
xii.MLC initiated
7. The initial assessment will result in documented plan of care.
Ambulance Services
Please refer to the Ambulance Services Document
Maintenance of Medical Records (Registers and Documents maintained)
The following records are maintained in the ED:
1. List of Consultants on Duty (During Peak Hours) and on call (during non peak hours)
2. Case files of patients attended in the ED
3. MLC register for medico legal cases
4. Drug Inventory Register
5. Controlled Drugs and Psychotropic Drugs Inventory
6. Brought Dead Certificate
7. Death Certificate
Radiology Services & Laboratory Services
The ER of Marudhar Hospital is equipped for undertaking all essential lab investigations and
radiological work up for the patient , it collaborates with the laboratory and imaging department
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 13 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
to provide such services on an emergency basis. After the necessary investigations are ordered,
results are obtained from the laboratory by phone in cases urgency.
Admitting Patients from the Emergency Department
1. In case admission of the patient is necessary, the EMO / Consultant on duty make the
decision for admission and authorize it. The EMO admits the patient under the specialty
Consultant on duty (during peak hours) and on call basis (during non peak hours).
2. The ED nurse is informed if the patient is to be admitted.
3. Admission to the ICU is approved by the attending Consultant.
4. After the patient representative makes the necessary admission procedure & admission
is confirmed, necessary arrangements are made to transfer the patient to the floor by
the ED nurse staff on duty in collaboration with the housekeeping staff.
5. The ED nurse communicates with the nurse in charge of the floor and confirms the
availability of the bed and initiates the transfer of the patient to the floor admitted.
6. Patient is transferred to the floor by transport by the housekeeping staff as per patient's
acuity. Monitored patients are transferred with a Nurse. All documents and reports of
the patient are transferred to the floor along with the patient.
7. Exceptions occur in cases of life and death emergencies. The patient will be transferred
to the ICU directly from the ED and registration & documentation may be postponed.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 14 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Transfer of patient:
Transfer out of stable patients from ED/Ward (at request /non availability of facilities)
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 15 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Transfer from ER
Transfer from ward
Decision to shift out the
patient by the consultant /
EMO
Decision to shift out the
patient by the consultant
Transfer out process initiated by the MO
(ward / ED)






Ensure availability of bed / other required facilities with the ED – EMO of
the transferring hospital. Details of the patient should be communicated
over bally
Ambulance requisition form filled up, Ambulance driver informed
Ambulance equipment to be checked, drugs to be checked. Ambulance
check list signed by the nurse
Nurse to be arranged by the nursing in charge for patient care during the
transfer.
To check all the required documents- Transfer out form, investigation
reports to be handed over to the patient/patient attendant.
Details of the transferring hospital (if available) to be filled in the ED book /
patient medical record.
Shift out the patient
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 16 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Transfer of unstable patient from ED/ward (on request /non availability of services)
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 17 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Transfer from ER
Transfer from ward
Decision to shift out the
patient by the consultant /
EMO
Decision to shift out the
patient by the consultant
Transfer out process initiated by the EMO
(ward / ED)






Ensure availability of bed / other required facilities with the ED – EMO of
the transferring hospital. Details of the patient should be communicated
verbally
Ambulance requisition form filled up, Ambulance driver informed
Ambulance equipment to be checked, drugs to be checked. Ambulance
check list signed by the nurse
Nurse to be arranged by the nursing in charge for patient care during the
transfer.
To check all the required documents- Transfer out form, investigation
reports to be handed over to the patient/patient attendant.
Details of the transferring hospital (if available) to be filled in the ED book /
patient medical record.
Shift out the patient
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 18 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Transfer out incase of discharge against medical advice – ED/Ward.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 19 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Stable patient
Unstable patient
Decision to shift patient by patient attender against medical advice.
Consequence of shifting patient is explained to patient/patient attender
DAMA form filled and signed by the attendant
Patient made fit to
transfer
Treatment details duly
entered investigation
reports to be handed over
to the patient/patient
attendant by the EMO.
Treatment details duly
entered investigation
reports to be handed over
to the patient/patient
attendant by the EMO.
Repeat vitals of the patient
to be checked before the
transfer.
Repeat vitals of the patient
to be checked before the
transfer.

Prepared and Issued By:QM-Dr Pratima
Shift out the patient
Singh
Ambulance to be arranged
by the patient party.
Reviewed and Approved By:Director Dr
Shivraj
Page 20 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Shifting out of patients for diagnostic test not available in the hospital
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 21 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Investigation ordered by consultant and
Requisition form given
Radiology department fixes the appointment time and date with
the diagnostics
ED EMO is informed to ensure the availability of ambulance
Stable patient






Unstable patient

Requisition letter with patient
details collected from the radiology
department by the nurse
accompanying the patient
Copy of the letter to be filed in
radiology
Unit nurse to shift the patient in a
wheelchair to the ED
Unit nurse accompanies the patient
during transfer
Ambulance equipments to be
checked, drugs to be checked.
Ambulance check list signed by the
nurse





Requisition letter with patient
details collected from the radiology
department by the nurse
accompanying the patient
Copy of the letter to be filed in
radiology
Ambulance driver to shift the patient from
the unit to ambulance in the ambulance
trolley.
Unit nurse to accompany the stable
patient
Unstable patient will be accompanied by
the nurse & ward EMO
Ambulance equipments to be checked,
drugs to be checked. Ambulance check list
signed by the nurse
Shift the patient
Prepared and Issued By:QM-Dr Pratima
Reviewed and Approved By:Director Dr
Singh
Shivraj
Page 22 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
MLC (Medico Legal cases)
Brought Dead
Take past history – HTN / DM / IHD etc.,
Look for / Ask about any suspicious signs:

Poisoning – Smell

Strangulation – Ligature mark around neck / abnormal sings

Any external injuries

Expose the body completely and look for any sings

Palpate the head and look for any hematoma, etc which may be missed.
If a female, ask history of married life and if it is less than 7 years register it as MLC, - it is
mandatory.
Register all brought dead cases as medico-legal case if death has occurred unexpectedly or from
an unexplained cause.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 23 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
On arrival, the Emergency Medical officer should examine the patient thoroughly. He / She
should go into the history in detail and look for signs of homicide, suicide, violence, external
injuries to rule out any suspicious cause for the death. In case of female patient, marital history
should be elicited and if EMO feels suspicious cause for the death, Medico Legal Case has to be
registered.
After complete examination and confirmation by clinical evaluation death & is confirmed, the
individual should be declared as Brought in Dead (BID) and the accompanying relatives/friends
must be explained and informed about the probable cause of death and they are given only a
Brought Dead Certificate until the cause of death is confirmed. The local police should be
informed immediately in case suspicion or foul play. The police will do the further disposal of
the dead body after inquest. The Emergency Medical Officer will render necessary assistance.
Death on Arrival:
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 24 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
If a patient has sudden Cardio-Respiratory Arrest
on arrival at the Emergency Room, the
patient has to be resuscitated as per ACLS protocols (Ref. Document). Once death is confirmed
the case should be treated as death on arrival, and necessary documentation should be done.
EMO should go into the detailed history of the patient and arrive at the probable cause of death.
On the basis of this, death certificate should be issued and arrangements for release of the body
are taken after settlement of hospital dues.
Handling of Death & Release of Dead Body
Death of a patient is handled carefully with concern without complacency. Counseling of next of
kin with sympathy is given at most importance. All help in shifting the body from the hospital is
extended to the next of kin. The dead body is released as soon as possible after completion of all
formalities.
Acknowledgement for receipt of the body and the Death Certificate is obtained from Next of
Kin/Legal representative. Handing-over of the body is a Solomon occasion and it is ensured that
hospital staff takes due care and concern in this respect. Due arrangements are made if
preserving the body in the mortuary is found necessary.
A security staff of the hospital is present till the departure of the deceased and ensure
orderliness in handing over the body to the next of kin.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 25 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Death Certificate:
EMO should certify the cause of death in the Death Certificate after careful and thorough
examinations of the patient after discussing with the concerned consultant. Death certificate is
initiated if the death occurs within the hospital, unless there are grounds and evidence to the
contrary. The cause of death should be well documented and a copy of the Death certificate
should be filed along with the medical documents of the deceased patient.
Storage of Medicines in Emergency Department
1. All Emergency medications will be available 24 hrs in the ER ( refer list of emergency
medication)
2. All Emergency medications will be replenished by the nurse/pharmacist on duty with each
case and on daily basis.
3. Medication inventory / Crash cart will be checked by the nurse on duty with each shift
change, to detect loss or theft.
4. Narcotics drugs will be kept in the narcotics box and will be under the supervision of the
nurse in Charge.
5. Narcotic drugs will be released only on the signed requisition of the consultant/MO.
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6. Working condition of the ER equipments will be checked by the nurse on duty with each
change in shift.
7. Any Malfunction /nonfunctioning of the equipment will be brought to the notice of the
nurse in charge and the Chief medical officer and work order is raised.
Infection Control in ED
1. All Emergency Medical officers will undergo training on infection control
2. All Emergency Medical officers will follow the infection control procedures as laid down
by the infection control Committee.
3. All Needle prick injuries will be reported through incident report to the chief medical
officer
4. Since ED is one of the high risk areas standard precautions will be taken by the staff at
all times.
5. Equipment cleaning and sterilization will be supervised by the nurse in charge
6. Swabs will be taken from the different areas and will be screened for nosocomial
pathogens.
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7. Swabs will be taken once in 30 days and follow up of the report will be done by the
nurse in charge
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COP.3: The ambulance services are commensurate with the scope of the services
provided by the organization.
Purpose:
To ensure proper and timely transportation of patient to the hospital for appropriate
medical attention.
To ensure proper transfer of patient from the hospital.
Scope: Hospital wide
Responsibility: Emergency Medical Officer
Policy:
The ambulance service provides the first point of access to health care for a wide variety
of patient conditions, ranging from life-threatening emergencies to chronic illness and
social care.
Abbreviation:
EMO – Emergency Medical Officer.
ED
- Emergency Department.
Key standards for ambulance services include:
1. Responding to life-threatening calls.
2. Responding to non-life threatening calls.
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3. Getting Emergency drugs and blood for hospital emergency
4. To provide any such service that the hospital may find deem.
5. Ambulance will not be used for carrying dead bodies except incase where the patient
expires during transportation.
6. Ambulance services will be available within city limits and will be restricted to
carrying
patients to the hospital or transferring patient to the referred medical center.
Protocol
1. All Ambulance drivers will be BLS trained.
2. Drivers must be in uniform and ID tag when driving the ambulance.
3. All ambulance drivers must have the CUG phone in possession while on duty.
Responsibility for Maintenance of the ambulances:
The ambulance driver shall maintain the ambulance in clean and good condition.
The ambulance driver is responsible to maintain 90% of the medical gas (oxygen) to the
total storage capacity of Oxygen. If the level of the Oxygen storage goes less than 50%
the ambulance driver requests the ED staff to replace a 100% full refilled Oxygen
cylinder.
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The ambulance driver has to ensure the pneumatic pressures of the wheels are within
stipulated pressure. If found less it is to be notified and refilled with informing the EMO
and a movement entry has to be made in the designated register.
The ambulance driver has to upkeep all the non clinical equipments inside the ambulance
if in case of any malfunction it is to be reported to the ED which has to be entered in the
designated register.
The ambulance driver shall check the brake-oil level, Engine oil level, Wheel pneumatic
pressure. Engine coolant, oxygen level, fuel level, siren, lights ups charge and the
equipments in the ambulance twice every day .
The ED Pharmacist will be responsible to maintain the required medicines in the
Ambulance. The availability of medicines in the ambulance will be checked by the ED
pharmacist at 8:00 am in the morning, the entry of the same would be made in the
designated register. Prior to the dispatch of the Ambulance the ED rechecks the
medicines
in the Ambulance to ensure the availability of all the essential drugs.
Once the Ambulance returns, the on duty ED Pharmacist checks the medicines to
replenish any medicine which has been used.
The ambulance Driver shall upkeep and maintains all the documentation relating to the
ambulance
The ambulance driver shall always maintain the adequate fuel in ambulance and procures
diesel as and when it reaches the safe minimum level of stock.
The ambulance driver requests for the diesel indents from the designate clerk in the
administrative office as and when ambulance diesel stock level goes below the safe stock
level. The diesel is got filled from the authorized vendor decided by the administration.
The movement of ambulance for the refill of the fuel is to be notified to the EMO and an
entry of the same is made in the designated register.
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Emergency calls:
The Emergency ambulance call is received in the ED, then the time and Number of the
caller is noted down by the ED staff responding to the call and transfer the call
immediately to the EMO.
The EMO collects the exact address location and landmark etc, from the caller and
advices for the precautions to be taken to patient. .
The Ambulance driver reports to the Emergency Medical Officer.
All the movements of the Ambulance are controlled only by the emergency medical
officer. Apart from the Emergency room medical officer the Director, Chief Medical
Superintendent and Medical Superintendents can control the movement in conjunction
with the Emergency Medical Officer.
All the patient calls that are entertained by the hospital are considered load and go
situation so the patient is picked up and moved to the hospital as soon as possible.
The ambulance driver may assist on all the load-and –go situation in scene of emergency.
The ambulance will not move out of the hospital without the EMO concern when patients
are being transferred.
The EMO summons the Ambulance driver and briefs the Ambulance driver of the
location and landmarks etc. On being briefed by the EMO the ambulance driver does all
the pre-departure check and brings the ambulance to the front patio of the emergency
department.
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Picks up the Waiting nurse (Refer Transfer of patient policy) in patio and drives to the
destination to pick up the patient safely and as fast as possible.
The Emergency drugs and the Clinical therapeutic, diagnostic equipment will be kept in
the Emergency Department and will be moved into the ambulance only during calls as
per the advice of the EMO.
The ED staff pharmacist will be responsible for the same.
The ambulance driver will have to assist in-shifting of the patient as directed by the
EMO.
All communications are done from the ambulance to the ground station through the CUG
phone in possession with the Ambulance driver.
The patient when being brought is wheeled in and loaded in the ED trolley and the
Ambulance driver sets back all the system in the ambulance and cleans the ambulance
with the assistance of the house keeping personnel inside the hospital. This cleaning
operation shall not exceed 20 min.
In case of any planned shifting and transfer of the patient all the modalities are worked
out by the emergency medical officer in conjunction with the respective departments.
The ambulance driver will be informed by the Emergency medical officer and an entry is
made in outgoing ambulance register the ambulance driver brings the ambulance to the
patio and takes the trolley to the pickup point of the patient inside the hospital and moves
the patient accompanied by the nurse/doctor to the ambulance and proceeds.
In this operation the Ambulance driver will not be liable to satisfy any clinical documents
or requirements.
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In case of any purchase of pharmacy drugs and Blood done by the ambulance team, the
medical officer shall handover the requisite prescription and cash and briefs the
ambulance drive as to where and when and how to get it.
In case of non emergency planned pick up of the patient the Ambulance driver may be
informed in prior and handed over the trip sheet by the medical officer not exceeding 48
hours in advance.
In the Transfer and shifting of the patients, depending upon the condition of the patient a
nurse/doctor may accompany the patient.
For referral –the referral hospital must be informed before sending the patient. Staff
accompanying the patient must be seated at the back with patient .Only one person will
be allowed to accompany the patient in the ambulance. Relatives \ accompanying the
patients to do so at their own risk.
Sirens – Silent –if the road is empty .Only lights on-cold case will be used. Siren only onif carrying ill case and/or to clear traffic.
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COP.4: Policies and procedures guide the care of patients requiring cardiopulmonary resuscitation.
Purpose: To provide guideline for uniform resuscitation of patient throughout the
organization.
Scope: Hospital wide.
Policy Guideline:

Assess the condition of the patient to ascertain the need of CPR.

Assess the responsiveness by shaking and calling the patient.

Assess the cardiac and respiratory status of the patient (Presence of respiration
and pulse) and previous history of cardiac arrest.

Check that CPR kit is complete.

Follow the steps of ABC of basic life support.

Ensures the safety of self and the victim.
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
Place the patient on hard surface in supine position and rescuer also in correct
position.

Make sure that airway is cleared by proper position (Hyperextension of head &
neck) and artificial dentures are removed.

Initiate mouth-to-mouth breathing if breathing not restored

Ensure the closing of nostrils of victim with thumb and index finger and enclosing
his mouth with rescuers mouth to maintain the airtight seal for effective
ventilation of lungs.

Repeat the procedure 12-20 times at the rate of one inflation every 3-5 secs.

Ensure the inflation of lungs corresponds to the respiration of the victim.

If victim is pulse less, give cardiac compression following initial four rapid
breaths to maintain circulation.

Correct location of lower half of the sternum when cardiac compression is used.

Artificial breathing cardiac massage corresponds to normal respiration and pulse
rate 5:1 with two rescuers and 15:2 with one rescuer.(cardiac massage: breathing)

Ensure the establishment of respiration and circulation: constriction of pupils,
regular pulse, normal B.P, normal skin colour & rhythmic respiration.

Observe for any complications: Sternal and rib fracture pneumothorax.

Document the procedure, date, time, method and response of patient.
After care of patient
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
Make the patient comfortable.

Observe for any complication again and take appropriate action.
COP.5: Policies and procedures define rational use of blood and blood products.
Purpose: To provide guideline instruction for rational use of blood.
Scope: Hospital wide
Policy:
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Request
To ensure patients safety, blood / blood components should not be prescribed unless there is a
real indication.
Request should be made by a consultant/doctor working in the hospital.
Blood transfusion request form should be filled completely by a doctor
Consent for transfusion should be taken from patient / guardian after explaining the transfusion
requirement or doctor can give consent in case of unaccompanied patients
who are incapable
of giving consent.
Blood sample should be taken for ABO & Rh grouping and cross matching and labeled at
bedside.
The entire request for blood should be sent to the Blood Storage Center.
Grouping
All patients should be grouped in case:
Any intermediate or major surgery is planned
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Any invasive procedures are planned where a risk exists such that blood transfusion is a
possibility.
Transfusion of blood is planned
The patient is diagnosed with a medical disease with likelihood of blood transfusion
requirement.
Blood Reservation
Blood should be reserved before all elective surgeries. The procedure will be as under:
The requisition for blood along with the consent form duly signed by the recipient and the blood
sample will be sent to the blood storage center immediately on admission / when the need for
transfusion is established.
The blood storage center will ascertain availability of stocks and inform the same to the
consultant / ward nurse.
Cross matching and issue of blood will be done on receiving firm demand from the ward /
OR
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In case of rare blood groups (‘AB’ Rh positive and all Rh negative blood groups), the treating
consultant will discuss with the In Charge of blood storage center before the patients admission
in order that suitable arrangements can be made in advance.
Issuing Blood
Blood will be issued from the department only after compatibility testing which for red cells
normally would minimally take 60 minutes. However for all planned surgeries and requirements
the requests for compatibility should be sent well in advance.
Blood compatibility slip will be issued by the Blood storage Center along with all blood products.
This has to be kept in patients file and responsibility of the document will be that of the in
charge nurse of the floor / ward / OT.
After completion of the transfusion, duly filled transfusion feed back has to be dispatched to the
Blood Storage Center within 24hrs of transfusion.
The date of collection and expiring of all unit of blood / FFP / Cryo etc. will be mentioned on all
units & these will be issued as per inventory maintenance, normally ‘first in-first out’ basis in
order to optimize blood usage.
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Procedure before Transfusion:
Blood should be checked by the doctor and the following details should be verified: blood bag
with patients blood group, Name, Patient’s hospital registration number for correct
identification of recipient.
Check BP / Pulse / Temperature and record in the case file before transfusion.
PROCEDURE DURING TRANSFUSION
Monitoring of vitals can be done by nurses
Visual observation is often the best way of accessing the patient during transfusion.
Record base line observations at the start of each unit and of each transfusion.
Temperature/ Pulse should be measured 15 minutes after the start of each unit and hourly
thereafter.
Monitor rate of flow to ensure transfusion progress, under no circumstances should any drug be
administered through the same IV line.
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Management of:
Blood transfusion reactions
i. Step 1 - Stop transfusion
ii. Step 2 - Keep IV line open with 0.9 % NaCl
iii. Step 3 - Notify attending physician and blood bank
iv. If transfusion is terminated
Send freshly collected post – transfusion sample of blood (preferably from opposite arm) and
sample of urine to blood bank.
Send the residual blood component unit along with administration set to blood bank.
Fill in the adverse blood transfusion form and forward the same to the Head of clinical audit
committee. The committee evaluates the same to determine the cause of reaction, recommend
appropriate actions for prevention of the same in future.
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Reaction
Signs and symptoms
Aetiology
Allergic
Pruritus Urticara (Hives)
Antibodies to
platelets ,plasma
, protein.
Clinical action




Allergic or
Febrile
Antibodies to
platelets , plasma
, protiens usually
IgA


anaphylaxis ,anxiety, chestpain, headache,
dyspnoea, chills,fever,red
urine,agitation,hypotension
Gram negetive
sepsis,hemolytic


unexplained bleeding , hemoglobinaemia
transfusion

Anxiety,pruritus,fever,chills,agitations,
flusing,hives,tachycardia,milddyspnoea,
hypotension,anaphylaxis.
Acute
Hemolytic
Prepared and Issued By:QM-Dr Pratima
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Follow step 1-3
Administer
antihistamines.(ora
l IM or IV)
Resume
transfusion if
improved
If no improvement
after 30 mins treat
as under
Follow step 1-5
Administer
antihistamine,antip
yrectics ,
vasopressors and
corticosteroids as
needed.
Follow step 1-5
Treat shock with
vasopressors,IV
fluids and
corticosteroids as
needed.
Maintain adequate
airway
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reaction



Increase renal
blood flow with IV
fluid ,furosemide ,
mannitol,maintain
brisk diuresis.
If DIC is present
consider
heparinisation.
Administer Blood
components
(FFP,Platelets etc)
as needed.
If no reactions complete transfusion, fill the feedback form and send it to the blood storage
center.
Whole blood / packed cells can be transfused over 3 – 4 hours.
FFP / Cryo: Can be issued within 30 minutes, Should be transfused immediately, If not used can’t
store again, will not be accepted by the blood storage center.
Blood should only be warmed using a specifically designed commercial device with a visible
thermometer and audible warning. Blood must not be warmed by insertion in hot water,
microwave or on a radiator.
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Blood giving set must be changed every 2 units or at least every 12 hours.
COP.6: Policies and procedures guide the care of patients in the intensive Care and
High Dependency Units.
Responsibilities:
Consultant (Medical staff. M.D)
Job Summary
Responsible for the diagnosis and treatment of medical diseases and conditions, as well
as the provision of medical care in the field of surgical Critical Care, in accordance with
current medical staff bylaws, rules and regulations and the department’s policies and
procedures.
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Duties and Responsibility:

Provide the highest attainable standard of medical care for the patients for whom
he / she is responsible.

Conducts ward rounds as per policy and reassesses inpatients under care.

Implements Clinical Pathways/ Guidelines for the department.

Directs and advices junior staff on patient management, especially in the field of
surgical Critical Care.

Guides and actively participates in the training and teaching of Residents, and
junior staff.

Actively participates in the educational activities and training programs of the
department.

Ensuring research is carried out in the unit by participating in and/or supporting
research.
Assistant lecturer:
Job Summary:
Provide departmental supervision of training of residents in the department.
Provide active support for consultants in patient management and acting up if required.
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Duties and Responsibility Anesthesia department Policy Deliver day to day clinical
management of all patients in the Intensive Care Unit, providing 24 hour cover. Assistant
lecturer is accountable to the consultant on duty of Intensive Care for all matters
concerning the Unit
Manage the more junior staff in the department in the performance of their clinical duties
and specific vocational training programs.
Initiate evaluation and treatment of patients; modify evaluation and treatment of patients
begun by resident in furtherance of the highest quality of patient care.
Be involved in teaching sessions, both as an attendee and as a presenter. This includes the
Journal Club and Tutorials.
Participate in research.
Resident
Job Summary
To assist in the day-to-day clinical management of patients in Intensive Care, to
participate in clinical research, and quality assurance activities of the Unit.
Duties and Responsibility


Residents are primarily responsible for the day to day care of patients in the
Intensive Care Unit.
Residents should document in the patient notes all relevant facts surrounding new
admissions to the Unit and major changes to the patients’ therapies. Residents are
expected to make a legible, written medical note for all of their patients, during
their shift.
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
Document all recognized incidents that actually or potentially lead to patient
morbidity.

Ensure adequate documentation of all deaths, including date, time and criteria
used.

Ensure nursing staff are aware of patient management plans and that the plans are
carried out. Notify nursing staff of any changes as soon as they are written. Verbal
orders alone are neither sufficient nor legal.

Residents will be required to perform invasive procedures when he or she has
been shown to be capable of performing these procedures under supervision.

Notify appropriate staff of the results of investigations and consultations, and help
formulate management plans consequent on these results.

Be familiar with entry criteria for research projects and inform senior staff when
potential candidates are identified.

Assist with aspects of research where necessary (e.g. Aid in collection and
collation of data as required).
ADMISSION AND DISCHARGE POLICY
ADMISSION CRITERIA
Diagnosis Model
This model uses specific conditions or diseases to determine appropriateness of ICU
admission.
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Cardiac System
 Acute myocardial infarction with complications.
 Cardiogenic shock.
 Complex arrhythmias requiring close monitoring and intervention.
 Acute congestive heart failure with respiratory failure and/or requiring
hemodynamic support.
 Hypertensive emergencies.
 Unstable angina, particularly with dysrhythmias, hemodynamic instability, or
persistent chest pain
 S/P cardiac arrest
 Cardiac tamponade or constriction with hemodynamic instability
 Dissecting aortic aneurysms
 Complete heart block
Pulmonary System
 Acute respiratory failure requiring ventilatory support
 Pulmonary emboli with hemodynamic instability
 Patients in an intermediate care unit who are demonstrating respiratory
deterioration
 Need for nursing/respiratory care not available in lesser care areas such as floor or
intermediate care unit
 Massive hemoptysis
 Respiratory failure with imminent intubation
Neurologic Disorders
 Acute stroke with altered mental status
 Coma: metabolic, toxic, or anoxic
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







Intracranial hemorrhage with potential for herniation
Acute subarachnoid hemorrhage
Meningitis with altered mental status or respiratory compromise
Central nervous system or neuromuscular disorders with deteriorating neurologic
or pulmonary function
Status epilepticus
Brain dead or potentially brain dead patients who are being aggressively managed
while determining organ donation status
Vasospasm
Severe head injured patients
Drug Ingestion and Drug Overdose
 Hemodynamically unstable drug ingestion
 Drug ingestion with significantly altered mental status with inadequate airway
protection
 Seizures following drug ingestion
Gastrointestinal Disorders
 Life threatening gastrointestinal bleeding including hypotension, angina,
continued bleeding, or with comorbid conditions
 Fulminant hepatic failure
 Severe pancreatitis
 Esophageal perforation with or without mediastinitis
Endocrine

Diabetic ketoacidosis complicated by hemodynamic instability, altered mental
status, respiratory insufficiency, or severe acidosis.
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







Thyroid storm or myxedema coma with hemodynamic instability
Hyperosmolar state with coma and/or hemodynamic instability
Other endocrine problems such as adrenal crises with hemodynamic instability
Severe hypercalcemia with altered mental status, requiring hemodynamic
monitoring
Hypo or hypernatremia with seizures, altered mental status
Hypo or hypermagnesemia with hemodynamic compromise or dysrhythmias
Hypo or hyperkalemia with dysrhythmias or muscular weakness
Hypophosphatemia with muscular weakness
Surgical
 Post-operative patients requiring hemodynamic monitoring/ventilatory support or
extensive nursing care.
Miscellaneous
 Septic shock with hemodynamic instability
 Hemodynamic monitoring
 Clinical conditions requiring ICU level nursing care
 Environmental injuries (lightning, near drowning, hypo/hyperthermia)
 New/experimental therapies with potential for complications
Objective Parameters Model
Objective criteria have been requested, expected and reviewed from individual hospitals
as part of the Joint Commission on Accreditation of Healthcare Organizations' review
process of special care units in the past. While the review process has recently been
changed (13), it is understandable that hospitals would continue to incorporate objective
parameters as part of the admitting criteria. The criteria listed, while arrived at by
consensus, are by necessity arbitrary. They may be modified based on local
circumstances. Data demonstrating improved outcome using specific criteria levels are
not available.
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Vital Signs
 Pulse < 40 or > 150 beats/minute
 Systolic arterial pressure < 80 mm Hg or 20 mm Hg below the patient's usual
pressure
 Mean arterial pressure < 60 mm Hg
 Diastolic arterial pressure > 120 mm Hg
 Respiratory rate > 35 breaths/minute
Laboratory Values (newly discovered)
 Serum sodium < 110 mEq/L or > 170 mEq/L
 Serum potassium < 2.0 mEq/L or > 7.0 mEq/L
 PaO2 < 50 mm Hg
 pH < 7.1 or > 7.7
 Serum glucose > 800 mg/dl
 Serum calcium > 15 mg/dl
 Toxic level of drug or other chemical substance in a hemodynamically or
neurologically compromised patient Radiography/Ultrasonography/Tomography
(newly discovered)
 Cerebral vascular hemorrhage, contusion or subarachnoid hemorrhage with
altered mental status or focal neurological signs.
 Ruptured viscera, bladder, liver, esophageal varices or uterus with hemodynamic
instability.
 Dissecting aortic aneurysm.
 Electrocardiogram.
 Myocardial infarction with complex arrhythmias, hemodynamic instability or
congestive heart failure.
 Sustained ventricular tachycardia or ventricular fibrillation.
 Complete heart block with hemodynamic instability.
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Physical Findings (acute onset)
 Unequal pupils in an unconscious patient
 Burns covering > 10% BSA
 Anuria
 Airway obstruction
 Coma
 Continuous seizures
 Cyanosis
 Cardiac tamponade
Admission Policy

The patient is managed by the ICU staff during their stay in ICU

The management plan is the responsibility of the ICU medical staff.

All admissions to ICU must be approved by the ICU staff.

Resuscitation or admission must not be delayed where the presenting condition is
imminently life threatening, (e.g. profound shock or hypoxia), unless specific
advanced directives exist and are clearly documented.

Such admissions should be discussed with the Consultant As Soon As Possible.

All patients admitted to the ICU must have an admission summary
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
The admitting consultant must be notified and invited to record an admission
summary for patients admitted directly to ICU. This is to ensure that admitting
consultant is aware that a patient has been admitted in the ICU.

The admission note should incorporate all relevant aspects of the patient’s
medical history, clinical examination and results of appropriate investigations.

Admission is reserved for patients with actual or potential vital organ system
failures, which appear reversible with the provision of ICU support.

Department requesting elective postoperative surgical beds must confirm bed
availability on the day of surgery, prior to the operation commencing.
Guidelines for admission of a new patient to ICU:

Handover from the referring doctor. Obtain as much information as possible.

Primary survey:

Ensure adequate airway, breathing and place patient on highest FiO2 until a blood
gas is done.

Check circulation and venous access.

Secondary survey: fully examine patient.

Document essential orders:

Ventilation

Sedation / analgesia

Drugs, infusions
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
Fluids
Outline plan to nursing staff.
Secure basic monitoring/procedures as appropriate:

SpO2

ECG

Arterial line

Nasogastric tube
Central venous catheter for the majority








Basic investigations:
Routine biochemistry, blood picture and coagulation studies.
Septic screen/microbiology as indicated.
Arterial blood gas
CXR (after placement of appropriate lines)
ECG
Notify the ICU staff on duty.
Document in case notes.
Discharge Criteria
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
Patient not on any support or intervention (or unlikely to need them in the next 24
hours) that cannot be provided in the ward. This includes equipment and nurse
staffing issues.

Low likelihood of deterioration in the next 24 hours. For long-stay patients and
those with low systemic reserve, the duration should be extended to 48 hours or
more.

Supplemental inspired oxygen concentration <50%

Hemodynamically stable; any fluid losses should be at a rate manageable in the
ward environment

The admission etiological factor is under control or not significant any more

Patients in whom treatment has been withdrawn and only need basic nursing care
and drugs for comfort
Discharge Policy:
All discharges must be:

Approved by the ICU medical staff.

Discussed with the referring department prior to patient transfer, including any
potential or continuing problems.

A discharge summary must be completed and a copy included with the patient
case notes.
Deaths Policy:


The ICU medical director, or his representative must be informed of all deaths.
The ICU resident must ensure:
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

A death certificate is completed
Referring doctors are notified.
INFECTION CONTROL PRACTICES
Purpose:

Prevention and containment of nosocomial infection is a fundamental principle of
effective medical practice.

The critically ill patient is highly vulnerable to nosocomial infection, which
results in significant morbidity, prolonged length of hospital stay, increased cost
and attributable mortality.
Policy:












It is the responsibility of every member of the health care team to ensure
compliance with Hospital and Unit infection control policies. This may include
reminding senior colleagues or visiting teams to conform to basic issues such as
hand-washing or additional precautions.
Hand-hygiene remains the only established method of effective infection control
and must be strictly performed by all members of the health care team.
Strelium or Alcohol must be used by all staff:
Before wearing gloves
Before and after patient contact
Before and after contact with a patient’s environment
Hand wash with soap where
Contact with blood or bloody fluid.
Hands are visibly soiled
After removing gloves.
Hand wash with Alkanol (Chlorhexidine in Alcohol)
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



Gloves
Disposable gloves must be worn for all contact with patient’s bodily fluids,
dressings and wounds.
Gloves must be disposed of within the patient cubicle on leaving
Plastic aprons are to be worn with gross physical contact with the patient (e.g.
patient turns).
Contact precautions should be taken for all patients infected with:

Methicillin Resistant Staph. Aureus

Vancomycin Resistant Enterococcus

Multiresistant gram negatives

Clostridium difficile
Aseptic technique:
Aseptic technique is to be used for all patients undergoing major invasive procedures
(refer to procedures section).
This includes:

Hand disinfection: surgical scrub with chlorhexidine for >1 minute

Sterile barrier: full gown, mask, hat, gloves and sterile drapes.

Skin prep with chlorhexidine 2% in 70% alcohol (Alkanol): let the skin dry.

Once the patient has been transferred or discharged, the area should remain vacant
until “terminally cleaned” in accordance with HOSP policy.
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
Environmental swabbing in Intensive Care is conducted as required by Infection
Control staff.
TRANSPORT OF CRITICAL PATIENTS
Purpose:
Because the transport of critically ill patients to procedures or tests outside the intensive
care unit is potentially hazardous the transport process must be organized and efficient.
Policy:
 The resident shall be in attendance during transport at all times.

Mechanically ventilated patients shall not be transported intra-hospital on a
ventilator without the authorization of the attending MD.

In mechanically ventilated patients, bag valve ventilation, or portable ventilator
could be used during patient transportation.

The Patient shall be connected to the portable ventilator in the manner of transport
for at least 2 minutes prior to leaving the unit to ensure tolerance. If any instability
from baseline is noted within this time period, the MD shall be notified for reevaluation.
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
The complete process as well as any issues experienced during transport shall be
documented on the ICU flow sheet. The MD shall be notified of these issues and
his/her notification and any actions taken shall also be documented on the ICU
flow sheet.
Procedures:
a) Personnel:

Two people should accompany critically ill patients.

A physician with training in airway management and ACLS, and critical care
training or equivalent should accompany unstable patient.

When the procedure is anticipated to be lengthy (e.g. dialysis) and the receiving
location is staffed by appropriately trained personnel, patient care may be
transferred to those individuals if acceptable to both parties. If care is not
transferred, the transport personnel will remain with the patient until returned to
ICU.
b) Equipment:
 ECG monitor, pulse oximeter, BP monitor should accompany every patient
without exception.

Full cylinder with no leak.

Ambu bag with mask.

Laryngoscopes and endotracheal tubes sized appropriately for each patient.

Basic resuscitation drugs, including atropine, epinephrine, and anti-arrhythmic
drugs.

Sedative and narcotic drugs as appropriate.
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c) Appendix:
Patient transportation checklist:

Preparation and equipment adapted to the procedure (MRI)

Sufficient medication, O2 and electrical reserves
Breathing:

Intubation secured

Mechanical ventilation adapted to the patient (alarm and monitoring of tidal
volume and insufflation pressure, trigger)

Intubation equipment, bag + valve + mask, portable aspirator + suction catheters,
SpO2,
Circulation:

Route for venous access isolated and secured (quick injection, administration of
vasopressors).

Medication (emergency, sedation, analgesia, paralysing agents), fluid loading
solutions

Alarms adjusted and activated (ECG, IAP)

Lines, cables and drainage tubes (Heimlich chest tube valve, abdomen, bladder)
unclamped functional, secure, untangled (i.e. no crossovers) and transportable
TRANSPORT TEAM:
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
A minimum of three escorts available (including one experienced doctor who is
familiar with the patient’s medical history)
TRANSPORT ORGANISATION:

.

Transport route clear, lifts and emergency room available.

Operational equipment (O2 and electrical supplies, ventilator, aspirator) for
continuous treatment at sites of procedure.
CLINICAL STABILITY OF PATIENT:

Preparation adapted to the clinical status of each patient:

Breathing (orotracheal intubation, chest drain, synchronisation with MV etc)

Circulation: optimised hemodynamics (blood volume, vasopressor), hemostasis

Neurological status: pupils, GCS.

Sedation – analgesia – muscle relaxant - hypothermia: prevention and anticipation

Breaks stabilised, burns and wounds protected

Head raised if possible (to prevent ICHT and VAP)
INTUBATION OF PATIENTS
Purpose:
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
To provide guidelines for the ICU staff’s role in the intubation of ICU patients.
Policy:

The physician shall be responsible for the determination of need for intubation.

All routine intubations will be done orally unless contraindicated.

The patient will have if needed sedatives and paralytics prior to intubation as
ordered by the physician.

The type and size of endotracheal tube is at the discretion of the intubating
physician.

The patient will be bagged with 100% FIO2 throughout the procedure then placed
on appropriate ventilator settings.

A Chest X-ray will be preformed post intubation.
Procedures:
a) Personnel:

Intubation is a 3-4 person procedure - skilled assistance is mandatory

The “top end” intubator coordinates the procedure

One person to administer drugs
One person to apply cricoid pressure (CP) post-induction:
 This is routine for all emergency intubations
 CP is considered safe in the presence of suspected spinal injury.
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
CP must be correctly applied - distortion of the larynx and difficulty in intubation
may occur if poorly applied.

One person to provide in-line cervical spine immobilisation (trauma and spinal
patients only).
b) Equipment/Supplies:













Laryngeascope Handle and blade
Bag/Mask
100% FIO2
Tape
Endotracheal tubes
Stethoscope
Gloves
Suction device with different size catheters
Induction drugs as ordered by attending staff
Ventilator
Emergency supplies
Laryngeal Mask Airway (LMA)
Oral airways
c) Drugs


Induction agent- propofol, fentanyl, ketamine, midazolam
Succinyl choline- 1-2mg/kg is the muscle relaxant of choice.
Contraindicated in:
a. Burns > 3 days
b. Chronic spinal injuries (i.e. spastic plegia)
c. Chronic neuromuscular disease (e.g. GBS, motor neurone disease)
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

Atropine 0.5-1 mg available
Adrenaline 10 mL 1:10000 solution
EXTUBATION OF PATIENTS
Purpose:
 To standardize the procedure for extubating patients with endotracheal tubes.
Policy:


The decision to extubate is made when an artificial airway is no longer needed
because the indications for its original placement no longer exist, i.e.:
Obstruction

Protection of airway

Suctioning

Ventilatory failure

Hypoxemia

Extubation should take place during a period of the day when adequate physician,
nursing and therapist staffs are readily available.

Monitoring and continuous evaluation of the patient are necessary as well as the
presence of skilled personnel who can reintubate the patient is necessary.

Prior to extubation, all of the equipment necessary for reintubation should be
available at the bedside in case of acute decompensation.
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Procedures:
a) Equipment



Intubation equipment
Laryngeascope Handle and blade
Bag/Mask







100% FIO2
Tape
Endotracheal tubes
Stethoscope
Gloves
Suction device with different size catheters
Induction drugs as ordered by attending staff
b) Technique:

Explain the procedure to the patient.

Place the patient in intermediate or high Fowler’s position.

Wash hands thoroughly and wear gloves and mask.

Select the appropriate suction catheter size for the patient’s airway.

Hyperoxygenate the patient with 100% O2 prior to extubation.

Remove tape or Tube Fixation System which secures the endotracheal tube.

Suction the endotracheal tube adequately with pre and post hyperoxygenation and
then suction the pharynx above the endotracheal tube cuff.
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
Insert a new catheter into the trachea via the endotracheal tube and instruct the
patient to breathe slowly and deeply.

Deflate the cuff or cut the pilot balloon.

Ask the patient to take a deep breath and to cough, apply vacuum, and at the peak
of inspiratory effort, rapidly remove the tube.

Administer humidified oxygen therapy.

Continue to evaluate the patient post extubation for signs of respiratory
compromise.
CENTRAL LINE INSERTION POLICY
Purpose:

To provide evidenced based guidance to staff in Intensive Care Units;

To reduce mechanical complications associated with the insertion and usage of
central venous catheters eg, bleeding, pneumothorax, hemopneumothorax, air
embolus, thrombus, vascular foreign body, and vascular damage;

To provide a central venous catheter (CVC) for the safe administration of fluids,
nutrition and drugs; and

Reduce the risk of local or systemic infection related to CVC use.
Policy:

Only competent staff (or training staff supervised by competent staff) are to insert
a percutaneous CVC

Assistance should be provided by a nurse or other appropriate assistant when
inserting a CVC to ensure asepsis and appropriate technique is used
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
If possible, explain to the patient or parent/guardian the procedure and need for a
CVC.

The sterile set up should be prepared immediately prior to the procedure.

Accurate documentation and record keeping must be maintained on the Central
Line Insertion
Procedures:
a) Insertion site




Subclavian is the preferred site for routine stable patients, followed by internal
jugular.
Femoral access is preferable where:
Limited IV access (burns, multiple previous CVC’s),
Inexperienced staff requiring urgent access, where supervision is not immediately
available.
b) Equipment











Sterile gown, sterile gloves, theatre hat and mask.
Basic dressing tray.
Gauze squares.
Large sterile drape.
Local anesthetic + needle/syringes.
Suture material + suture handle + scissors + forceps.
0.9% sodium chloride solution + syringe.
Three-way tap for each lumen.
0.5%chlorhexidine in 70%alcohol (Alkanol).
500ml sodium chloride solution, transducer set if required.
CVC.
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
Dressing + adhesive label.
c) CVC Care
Bag Change
 All IV bags must be labeled with date and time when hung. If the bag contains no
medications: label “No additives”or “No cMedications” with date and time.

All IV bags must be changed every 24 hours.
Tube Change

IV tubing should be changed and dated every 96 hours.

TPN / Lipid IV tubing should be changed every day with new TPN / lipid bag

Hub care

Must be wiped well with alcohol swab every time accessed.

Cap change: every 7 days with dressing changes.

HUBS SHOULD NEVER BE LEFT OPEN WITHOUT A CAP
Dressings

Sterile, transparent, semi-permeable, self-adhesive, (standard or hyperpermeable),
polyurethane dressings are recommended to protect the site from extrinsic
contamination, allow continuous observation of the insertion site.

Replace semi-permeable dressings on insertion site according to manufacturer’s
recommendations OR every 7 days.
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
If gauze is used, it must be changed at least every 48 hours.

When a patient has multiple catheters, each catheter must be dressed as a separate
procedure.
d) Catheter duration and replacement

Replace CVCs only on clinical indications i.e. clinical infection +/- purulence at
the insertion site.

Change ALL CVCs as soon as possible and no longer than 48 hours after
insertion (when it is considered safe for the patient), if inserted with potentially
compromised aseptic technique or under an emergency situation (eg. During
resuscitation in Emergency Department)

Continually review the need for central venous access in all individual patients.

Do not use guide-wire CVC exchanges routinely (over a guide-wire inserted into
the in-situ catheter) for percutaneous catheters, to prevent infection.

For guide-wire CVC exchanges, the same meticulous aseptic technique and use of
full sterile barriers as described for insertion of a new CVC are mandatory.

After vigorously cleansing the site with the antiseptic solution, inserting the
guidewire, removing the old catheter, and cleaning the site once more with the
antiseptic solution, the operator must re-glove and re-drape the site, as the original
gloves and drapes are likely to have become contaminated from manipulation of
the old catheter.
ARTERIAL LINE INSERTION
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Purpose:

To provide an arterial line for continuous monitoring of patient’s arterial blood
pressure as well as to frequently sample blood for arterial blood gases and other
laboratory investigation.
Policy:

Only competent staff (or training staff supervised by competent staff) are to insert
an arterial line catheter.

Assistance should be provided by a nurse or other appropriate assistant when
inserting an arterial line catheter to ensure asepsis and appropriate technique is
used.

Hypotensive patient may require fluid resuscitation or inotropic support before the
artery can be accurately palpated.
Procedures:
Insertion Site:

In order of preference: radial > dorsalis pedis > femoral > brachial.

The femoral artery may be the sole option in the acutely shocked patient.
Equipment:

Radial line: 20G (pink) cannula – longer is better

Femoral line: Single lumen or femoral arterial line kit
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
Guidewire – open and ready for use if required

Alkanol to sterilize insertion site OR alcohol swabs

Local anaesthetic – 1% lidocaine (without epinephrine)

500 mL bag of saline to hyperextend patient wrist – for radial lines

Arterial line transducer (set-up pre-procedure)
CHEST TUBE INSERTION
Purpose:

The purpose of this policy is to provide instruction to the physicians in
performing the surgical placement of chest tube.
Policy:
Chest Drains rarely need to be inserted as an emergency and should be inserted within
hour except for:
 Tension pneumothorax

Pneumothorax in ventilated patients

Traumatic hemothorax.

Only a trained physician with chest tube insertion shall insert or remove a chest
tube.

The physician’s order for chest tube placement shall include the drainage system
to be employed, suction requirements, and chest x-rays.
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
Any coagulaopathy or platelet defect should be corrected prior to chest drain
insertion.

A Chest Xray must be available and be reviewed at the time of the drain insertion
except in the case of a tension pneumothorax

A rapid IV access shall be established prior to insertion if none present.

Base line vital signs shall be recorded prior to insertion and monitored frequently
during post-insertion care.
Procedures:
a) Equipment














Sterile gloves
Sterile gown
Skin antiseptic solution – i.e. 2% chlorhexidine, 70% isopropol alcohol (Alkanol)
Sterile drapes
Sterile Gauze swabs
A selection of syringes and needles (2125G)
Lignocaine 1%.
Scalpel and blade.
Sutures.
Chest drain pack – containing an instrument for blunt dissection.
Chest drain.
Connecting tubing.
Closed drainage system and sterile water.
Sterile Dressing.
b) Technique
Premedication: Midazolam 1-2 mg and or Fentanyl 50-100 mcg or morphine 2-5 mg
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Aseptic technique:
 Gloves and a gown must be worn
 The patient should be covered by a sterile drape.

The skin should be sterilised with two applications of an alcohol based skin
preparation (2% chlorhexidine, 70% isopropol alcohol).
Anesthesia:
 Local anaesthetic (lignocaine 10mls with 10mls of normal saline in a 20 ml
syringe), should be infiltrated into the skin and more deeply to anesthetise the
intercostal muscles and the pleural surface.

The chest wall hole must be 2-3 cm wide in order that a finger can be inserted into
the pleural space

Blunt dissection is used to enter the pleural cavity.

The chest tube should be attached to an underwater seal and secured to the skin
using a 0 or 1/0 silk suture.
Maintenance:

Surgically placed drains are the responsibility of the surgeon and should only be
removed in consultation.

If a pneumothorax fails to resolve following chest drain insertion, the drain can be
placed on suction (1020cm H2O).

Chest tubes are never to be clamped except when ordered by a physician.
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
If chest tube comes apart at the distal end, quickly reconnect tubes rather than
clamping. X-ray should be obtained immediately.

The drainage system should be kept lower than the level of the bed and tubing
shall be free from loops. This prevents clots from occurring, obstructing the
drainage system and causing increased pressure in the lungs.


Chest tubes are clamped only when:
Patient is receiving chemotherapy or a sclerosant such as talc, atabrine or
tetracycline via the chest tube;

Changing a full chest drainage unit; or

Chest tube is being removed.
Removal:

Remove or replace drains inserted in unsterile conditions as soon as possible.

Leave the drain in situ until:
Radiological resolution of pleural collection (air/fluid)
No ongoing air-leak (no drain bubbling)
Minimal drainage (< 150 ml/24 hrs).

Additionally, in ventilated patients, consider clamping drain for ≥ 4 hours and
removing if the patient remains stable and/or post CXR.
URINARY CATHETER INSERTION
Purpose:
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
The urinary tract is the most common site of nosocomial infection, accounting for
approximately 40% of nosocomial infections in most hospitals. The
recommendations included in this policy will assist in the prevention and control
of nosocomial urinary tract infections.
Policy:

Urinary catheters will be inserted only when clinically indicated and removed
immediately when they are not longer required.

Indwelling urethral catheters will be used for a limited duration as much as
possible and only after careful consideration of the alternative methods of
management.

All health care workers providing urinary catheter care will be educated in the
epidemiology of and infection prevention and control procedures for preventing
urinary tract infections.
Procedures:
a) Personnel

Only healthcare workers who are competent in the correct technique of aseptic
insertion and maintenance of urinary catheters should handle catheters.
b) Catheter Insertion

Insert catheters using aseptic technique and sterile equipment.

Use gloves, drape, sponges, an appropriate antiseptic solution for periurethral
cleaning, and a single-use packet of lubricant jelly for insertion.
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
Use as small a catheter consistent with good drainage, to minimize urethral
trauma.

After insertion, secure indwelling catheters properly to prevent movement and
urethral traction.
c) Closed Sterile Drainage

Use a sterile, closed continuous drainage system.

Do not disconnect the catheter from the drainage tube unless irrigation is
necessary for diagnostic or therapeutic reasons or the catheter cannot be irrigated
through the sampling port.

If the system becomes overtly contaminated (via disconnection, leakage, or other
mechanism), replace the catheter, tubing, and collection bag.

If the catheter, tubing, or collection bag is disconnected or leakage occurs but are
not overtly contaminated, reconnect the collection bag and tubing after wiping the
ends with an alcohol pleglet. Use aseptic technique to disinfect the end of the
catheter, which connects to the new tubing.
d) Irrigation:

Avoid irrigating the catheter unless necessary for diagnostic or therapeutic
reasons. If frequent irrigation is required and replacement is not contraindicated,
the catheter should be replaced .

When indicated, closed, continuous irrigation with a 3-way indwelling catheter
may be used to prevent obstruction (e.g., with bleeding after prostate or bladder
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surgery). Continuous irrigation of the bladder with antimicrobials is not useful
and is not recommended as a routine infection prevention measure.


To relieve an obstructed catheter, the sampling port may be used. Disinfect the
port with an alcohol swab, and then using a large-volume sterile syringe and
sterile irrigant enter the sampling port. Discard any remaining solution and the
syringe. Use aseptic technique to perform irrigation.
Only disconnect the catheter and drainage tube if the sampling port cannot be
used.
e) Catheter Change Interval

Change indwelling catheters when medically indicated rather than at arbitrarily
fixed interval.
TRACHEOSTOMY MANAGEMENT
Purpose:

To safely change a tracheostomy tube and provide patency of care while insitu.

Outlines the process for the safe and effective weaning of a patient from a
tracheostomy tube in order to facilitate decannulation.
Policy:

Tracheostomy is usually considered if artificial airway is required longer than 1014 days.


Early tracheostomy within the first 5-7 days is usually indicated in
Upper airway obstruction

Neurological disease
1. Glasgow coma score ≤ 6 on day 4.
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2. Spinal cord injury at or above C4
3. Acute neuromuscular disease with autonomic dysfunction or
underlying lung disease.

ARDS score ≥ 2.5 on day 7

A tracheostomy may be performed as a surgical procedure under general
anesthesia in the operating theatre or as a percutaneous procedure within the
intensive care setting.

Strict aseptic technique shall be maintained with a new stoma and a clean
technique once it is completely healed.
Procedures
a) Post-procedural care

Xray to confirm placement.

ABG approximately 30 minutes.

Position patient to semi-fowlers

Ensure tracheostomy of the same size and one smaller with tracheal dilators are at
the bedside in the event of an emergency
Observe for early sign of:
 Hemorrhage

Wound infection

Pneumothorax
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
Pneumomediastinum

If a surgical tracheostomy is performed leave the dressing intact for 24hrs to
prevent potential bleeding and displacement.
b) First change of tracheostomy
Equipment
 Ensure all emergency equipment is working and ready

Dressing pack/trolley

Suitable size tracheostomy.

Sterile water.

20ml syringe.

Sterile gloves

Keyhole dressing

Suction catheter.

KY jelly
A skilled practitioner should perform the first change on day 7. This is because the stoma
and track to the skin form the patient’s trachea may not be well formed. Assistant lecturer
being within close proximity for prompt airway intervention if required

Ensure enteral feeds are ceased 6hrs prior to procedure and aspirate NG tube
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
Position patient approximately 30 degree, head moderately extended.

Suction lower airway once

Perform cuff release on second suction. Briefly deflate and then reinflate cuff as
requested.

Remove old tracheostomy dressing

Pre-oxygenate with 100% for 3-5 minutes

Deflate old tracheostomy and remove the tube

Rapidly insert new tube angled at 90 degrees to the trachea, rotate to a downward
position
c) Tracheostomy care procedure
It should be done every 48 hours
Technique
 Wash hands.

Explain procedure.

Place patient in high fowlers position.

Open sterile pack.

Remove & discard neck dressing with clean gloves.
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
Open/don sterile gloves.

Set up sterile field & separate sterile basins
Place sterile drape over patient

Using non-dominant hand (now the “clean” hand), pour solutions into basins (1
NACL & 1 H2O2/NACL mix)

Remove the inner cannula using “clean” hand & drop into the NaCl/peroxide mix)

Dip sterile applicators & gauze in NaCl/peroxide mix, & clean around trach site

Next, rinse trach site using sterile applicators & gauze

Pick up inner cannula with “clean” hand on “clean” end & scrub interior &
exterior with brush

Rinse inner cannula in NaCl

Reinsert cannula with “clean” hand/lock into place

Apply a sterile drain sponge to trach site with forceps or sterile hand

Thread clean ties through flange holes & tie securely/carefully cut & remove
soiled ties

To prevent undue weight and movement of the ventilator tubing, support as
necessary.
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d) Decannulation protocol of tracheostomy tube:
To implement this protocol, the patient must be medically stable and meet the
minimum criteria.

Five to seven days postoperative, to ensure a mature stoma, following a temporary
tracheostomy.

No acute respiratory problems (such as pneumonia, shortness of breath,
respiratory insufficiency)

Minimal secretions (suctioning less than every 4-6 hours) with a strong cough
reflex sufficient to clear secretions

Oxygen saturation in an acceptable range.

Not on mechanical ventilation.

No anatomical upper airway obstruction or limitation.
Postoperative temporary tracheostomy patients may be candidates for this protocol.
Permanent tracheostomy (e.g. total laryngectomy) patients, or those managed by the ENT
service, are not probable candidates for this protocol.
Protocol initiation:
 A trial of breathing with the trach cuff deflated will be undertaken.

If this is tolerated, the current trach tube may remain in place with the cuff
deflated, or a qualified practitioner will change the trach to a cuffless tube.

If this is tolerated the trach tube may then be plugged with the plug.
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
Observe and monitor the patient for 5-10 minutes. If plugging in successful
observe and monitor the patients every 2 hours for 24-48 hours.

If this is tolerated tube could be removed.
ABDOMINAL PARACENTESIS
Purpose:
Abdominal paracentesis is an invasive procedure performed

To withdraw fluid for diagnostic examination.

To remove ascitic fluid when large accumulation of fluid causes severe symptoms
and is resistant to other therapy.

To prepare for other procedure (peritoneal dialysis, ascitic fluid reinfusion,
surgery, etc.)

To identify presence of blood in the abdomen following trauma.
Policy:

Abdominal paracentesis is performed by medical staff trained in this procedure.

The procedure is considered relatively contraindicated in the presence of
thrombocytopenia (platelets < 20.000) or coagulopathy (INR>2.0)

The sterile set up should be prepared immediately prior to the procedure.

Document date, time, location of puncture site, presence of any sutures.
Procedures:
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• Equipment

Sterile paracentesis tray and gloves

Drape or cotton blankets

The skin should be sterilised with application of an alcohol based skin preparation
Alkanol (2% chlorhexidine, 70% isopropol alcohol).

Lidocaine hydrochloride 1%

Syringe, 10 mL

Injection needles, 22 gauge

Cannula 16 guage

Collection bottle (vacuum bottle)

Specimen bottles and laboratory forms

Adhesive dressing
PREVENTION OF VENTILATOR ASSOCIATED PNEUMONIA
Purpose:

To provide evidence-based recommendations for prevention of ventilatorassociated pneumonia
Policy:

Intubation and Mechanical ventilation
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
Intubation and reintubation should be avoided if possible as it increases the risk of
VAP

Noninvasive ventilation should be used whenever possible in selected patients
with respiratory failure

Orotracheal intubation over nasotracheal intubation to prevent nosocomial
sinusitis and to reduce the risk of VAP



Removing potentially contaminated secretions from above the tracheal cuff may
reduce VAP
Deep orophyayngeal (subglottic ) suctioning will be completed
Every (Q6) hours and as need

Prior to manipulation of the tracheal cuff air volume

Prior to retaping/repositioning of the endotracheal tube

Prior to extubation.

Contaminated condensate should be carefully emptied from ventilator circuits and
condensate should be prevented from entering either the endotracheal tube or
inline medication nebulizers

Daily interruption of continuous sedation shortens the duration of mechanical
ventilation.

Body position and enteral feedings

Patients should be kept in the semirecumbent position (30 to 45 degrees) rather
than supine to prevent aspiration especially when receiving enteral feeding
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
Enteral nutrition is preferred over parenteral nutrition to reduce the risk of
complications related to central intravenous catheters and to prevent reflux villous
atrophy of the intestinal mucosa that may increase the risk of bacterial
translocation

Modulation of Colonization: Oral Antiseptics and Antibiotics

Colonization of oral mucosa and dental plaques with pathogenic bacteria places
patients at risk for microaspiration. Regular oral care may decontaminate the oral
cavity and reduce VAP
Oral care procedure:
 Administer chlorhexidine gluconate (0.12%) by irrigation/suction to oral cavity
every 8 hours

-4 hours
using 0.9% NaCl

Stress Bleeding Prophylaxis and Transfusion

All mechanically ventilated patients require stress bleeding prophylaxis as
outlined in the Stress Bleeding Prophylaxis clinical practice guideline.

Red blood cell transfusion has been independently associated with the
development of VAP. Follow transfusion restricted protocol.
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COP.7: Policies and procedures guide the care of vulnerable patients
(elderly, physically and/ or mentally challenged and children).
Purpose:

To provide guideline instructions in order to ensure a safe environment for
vulnerable patients (children, disabled and elderly patients).
Scope: Hospital wide.
Policy:

Wheelchair accessibility is possible within the hospital.

Handrails are provided for the senior citizens to move around the hospital.

For children, disabled and elderly patients where ever possible arrangement is
made for bed side accommodation of bystanders.

Signage boards with contrasting colors; large fonts in English as well as the
regional language are placed to help senior citizens and disabled people.

Parking spaces are reserved for the disabled near to the entrance of the hospital.

Clear pathways are provided for the disabled and senior citizens to move around
at their own pace.

Washrooms with grab bars are designed mainly for the disabled and aged people.
Prepared and Issued By:QM-Dr Pratima
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Reviewed and Approved By:Director Dr
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COP.8: Policies and procedures guide the care of high-risk obstetrical patients.
Purpose:

To provide comprehensive care in the specialty of Gynecology and Obstetrics including
management care of high risk pregnancy.
Scope:

Extends to all staff and patients under the purview of department of Obstetrics and
Gynecology.
Responsibility:

Consultant doctor, Medical Officers, Nurses of the department of Obstetrics and
Gynecology.
Departmental Hierarchy:
Head – Department of Obstetrics and Gynaecology
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Senior Consultant – Obstetrics and Gynaecology
Consultant – Obstetrics and Gynaecology
Nursing Staff – Obstetrics and Gynaecology
Ward Boys/Ayas
Policy:
Consultants: full time consultants of varied experience are available in the hospital between
8.00 a.m. and 2.00 p.m. Between 2.00 p.m. and 8.00 a.m. consultants are available on call and
will be able to reach the hospital within 20 min.
Medical Officers trained in Obstetrics and Gynaecology are available twenty hours in the
hospital
Nurses: suitably qualified nurses, experienced in midwifery provide care in the delivery suite and
women wing .
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Pediatric consultants are available between 8.00 am to 2.00pm.Between 8.00 am to 8.00 pm
Consultants are available on call after 8 pm and they would be able to reach the hospital within
20 mins.
OPD Services:

The OB&G outpatient clinics functions six days a week from 8:00 am in the morning to
2:00 pm in the afternoon. The services aim at providing diagnostic, curative, preventive,
and rehabilitative services on an ambulatory basis.
Emergency Services:

The Emergency department of the hospital functions round the clock with qualified
gynecologist available 12 hrs + On call. Senior consultants are available round the clock
on call.
Inpatient Services:

The inpatient services are meant for patients requiring regular monitoring in the
inpatient care facility of the hospital.

Patients in labor are admitted for the delivery in the obstetric ward.
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Diagnostic services:



24 hr on call laboratory services for routine and urgent tests like clotting profile.
Radiologists to perform USG on a 24 hr basis. (On call & 10am to 02pm & 06 pm to 08
pm)
Blood and blood component storage facility and facility for cross matching.
Support services:






Surgical/ Anesthetic services
Infection control
Pharmacy
Physiotherapy
Dietetic services
Technical equipment support services
Provision of care
a. Antenatal
i. 24 hrs emergency
ii. Antenatal well being programme to prepare patients for delivery.
iii. Consultation with dietician for diet modifications if required.
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b. Intranatal
i.
Well Equipped Labour Room Facility
ii.
Trained nursing support for high risk cases
iii. 24 hr OT availability
iv.
Facility for instrument vaginal delivery
Inpatient Admission:
The patient requiring in-patient care would be suggested so in writing by the treating
consultant. No patient admitted in IPD facilities without written request of treating
consultant, on duty the staff nurse receives the patient.
a. Normal Working Hours
During normal working hours of the hospital, the patient is seen in the OPD clinic of the
consultant doctor who after assessing the patient determines the need for inpatient
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admission. Incase the patient is to be admitted, the same is indicated in writing in the
patient’s case sheet (Refer to admission policy ).
If the patient is directly taken to the emergency department of the Female Wing, the
Obs and Gynae Consultant on duty will undertake the initial treatment and the available
senior consultant (on call) is immediately informed if required. The patient is seen by
the senior consultant immediately (if required) and treatment initiated by the senior
consultant. Incase the patient need inpatient admission the same is indicated in the
patients case sheet and the admission procedure is initiated as per the admission policy
of the hospital.
b.Non peak hours
Patient is directly taken to the emergency department of the female wing , the on duty
OBS and Gynae consultant will undertake the initial treatment and the senior consultant
on call is immediately informed (if required). The senior consultant on call will reach the
hospital within a maximum time gap of 20 minutes.
On arrival the senior consultant examines the patient and initiates the treatment. Incase
the patient is to be admitted , the treating doctor on call indicates the same in writing.
The patient is admitted as per the hospital policy and treatment is initiated.
Referral of patient to other specialty:
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If the primary treating consultant of the patient feels the need to refer the patient to
consultants of some other specialty, a referral slip is filled by the primary treating
consultant of the patient with details relating to the patients complain, diagnosis and
treatment initiated.
The referral slip is attaché with the patient case record for the perusal of the referred
consultant.
Management of High Risk Pregnancy
A high risk pregnancy is one in which some condition puts the mother, the developing
fetus , or both at higher than normal risk for complications during or after the pregnancy
and birth.
1.Diagnosis:
A woman with a high-risk pregnancy will need closer monitoring than the average
pregnant woman. Such monitoring may include more frequent visits with the
primary caregiver, tests to monitor the medical problem, blood tests to check the
levels of medication, amniocentesis, serial ultrasound examination, and fetal
monitoring. These tests are designed to track the original condition, survey for
complications, verify that the fetus is growing adequately, and make decisions
regarding whether labor may need to be induced to allow for early delivery of the
fetus.
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Nutritional Assessment of the patient forms an integral part of the diagnosis
process. This is done to ensure the nutritional status of the mother and fetus .The
findings of the patient’s nutritional and the clinicians recommendations on the
same are documented in the patient care record.
2.Treatment
Treatment varies widely with the type of disease, the effect that pregnancy has on
the disease, and the effect that the disease has on pregnancy. Additional tests may
help determine the need for changes in medication or additional treatment.
The Obstetric department of Marudhar Hospital is competent to handle high risk
pregnancies. For this there are trained are qualified and trained Consultants & well
trained nursing staff. Facilities for undertaking such pregnancies are available in the
hospital. Incase of associated complication, hospital has fully equipped Intensive Care
Units functional on an 24hrs basis. The High Risk pregnancies include the following but
are not exhaustive:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
Pre Eclampsia & Eclampsia
Intra Uterine Growth retardation
Post Partum haemorrhage
Non-reassuring Fetal heart Tracing
Premature rupture of membrane
Post Dated Pregnancy
Prolonged Labour
Cord Prolapse
Placenta Previa
Diabetes Completing Pregnancy
Obstructed Labour
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COP.9: Policies and procedures guide the care of pediatric patients.
Purpose: To provide guideline instruction for efficacy in the operational aspect of the
department.
Scope: Pediatrics department.
Responsibility Person: Head Department of Pediatrics.
Departmental Hierarchy:
Head – Department of Paediatrics
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Senior Consultant - Paediatrics
Consultant – Paediatrics
Staff Nurse
Housekeeping Staff.
Policy:
Outdoor Clinics:
The paediatric outpatient clinic runs for six days in the week from 8.00 am in the morning to
8.00 pm in the evening.
Emergency Services:
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The Emergency Department of the hospital functions round the clock where qualified paediatric
consultants are available on call.
Inpatient Services:
The inpatient services are meant for patients who require regular monitoring in the inpatient
care facilities of the hospital.
Care Person: Clinical care is provided by post graduate qualified and experienced pediatricians.
Nursing care is provided by qualified, trained and registered nursing staffs.
The department provides specialized care in the following areas:
Childbirth and New Born:
All newborn babies are attended by the paediatrician of the hospital. All caesarian deliveries are
attended by the paediatrician .Normal deliveries are attended by a pediatrician on request by
the concerned gynaecologist.
The paediatrician examine the child everyday during their stay in the inpatient care facilities of
the hospital .The babies are given regular vaccination during their stay in the hospital.
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After discharge the paediatrician follows the child regularly in the outpatient clinic to ensure
their proper growth and development along with their vaccination requirements.
Sick Babies:
The hospital has a Neonatal Intensive Care Unit hence sick babies requiring such care are
transferred to “NICU” where facility for Neonatal Intensive Care Unit is available.
For other children:
i .Emergency care :
a. Bronchial asthama
b. Diarrohea and vomiting with dehydration
c. Allergic reactions
d. Fits
ii Other problems like :
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a. Growth and Development Abnormalities
b. Endocrine problems like hypothyroidism
c. Heamatological problems like anaemia
d. Renal problems like nephritic syndrom and urinary infections
e. Neurological problems like epilepsy
f. Respiratory problems like asthama and pneumonia
g. Infective problems like typhoid ,dengue and malaria etc.
Clinical Care:
i. Outpatient Clinic
4.i.i Initial Assessment :
a. As soon as a patient enters the OPD we observe the following :-
A) Look of the child - a) Normal or b) sick looking in appearance
B) General appearance / Behavior :-
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i. Consciousness
i.a. Dull & lethargic
i.b Normal
i.c Overactive or Imitable
C) Is there any puffiness or pallor over the face
D) Gait
a) Walking normally
b) Alaxia etc
E) Nutritional status of the child
F) Immunization History , etc
The following information are also taken into account as a part of the initial assessment of the
child :
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


H/O Present illness
H/O past illness
Family history.
General examination of the patient includes:-













Consciousness of the child
Anemia
Cyanosis
Jaundice
Edema
clubbing
nutritional status
temperature
P/R
R/R
BP – as & when needed
Lymphadenopathy
Petechic
With the help of the patient’s history & general examination followed by systemic examination,
a provisional diagnosis of the patient’s conditions is made. In light of the above information the
relevant investigations are suggested incase needed, so as to ascertain the provisional diagnosis.
However immediate treatment of the patient is initiated on the basis of the provisional
diagnosis as their is a time gap in reporting of investigation. Once investigation reports are
received the paediatric consultant starts the definitive treatment of the patient. Patient’s
relatives are explained about the complication and the treatment
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Inpatient Services:
If the general condition of the patient is poor or critical and requires regular monitoring, the
treating consultant immediately admits the patient in the paediatric ward and treat accordingly.
Patients are admitted in the inpatient care facility of the hospital only if the treating paediatric
consultant prescribes the same in writing. However incase of emergency the EMO on duty or
any other doctor of the hospital may admit the patient in the inpatient care facilities but the
final decision regarding continuation of the patient is taken by the paediatric consultant strictly
on the basis of the condition of the patient.
Basic guidelines for admitting the patients
When home care is not adequate for the treatment of the patient.
If the patient’s condition is poor or critical.
When the vitals such as pulse, respirations, B.P etc, are not satisfactory
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For any other reason as deemed necessary by the treating doctor in accordance with the
condition of the patient.
Prior to the admission of the patient, the condition of the child along with the reasons for his
admission is explained clearly to the parents by the treating doctor. Once the decision for
admitting the patient is made and consent taken from the relative, the indoor admission file
prepared .The treating doctor immediately records the details about the patient and his
condition in the indoor files, fills up the investigations form and prescribe the treatment.
The patient is shifted to the paediatric ward along with the ward boy. The sister in-charge of the
paediatric ward receives the patient ,allots a bed and makes the patient comfortable, the
samples are taken for investigation as prescribed in the indoor file of the patient and treatment
is started within 5 to 10 minutes.
However if the patient is in critical state, all the formalities are left behind and treatment is
started immediately.
The pediatric consultants takes regular visit of the paediatric, emergency, private and obstetric
ward (for new born babies) thrice a day.
Apart from the regular rounds, whenever needed the ward sister sends the call through cell
phone of the treating doctor who attends the patients within 5 - 10 minutes prior to 2.00 pm.
After 8.00 pm, the patient is attended by the Emergency Medical Officer on indoor duty who if
needed consults or calls the pediatricians depending upon the condition of the patient.
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Incase needed, the treating paediatric consultant discuss the patient’s condition with the other
paediatric consultants of the department or with consultants from other specialties like surgery,
gynaecology etc as deemed necessary by the treating consultant.
All the details regarding the treatment of the patients, investigations suggested and their findings ,
medicines and diet prescribed , patients vitals at periodic intervals ,progress made etc are
recorded in the inpatient file of the patient by the treating doctor and the same is signed, dated
and timed.
7. Emergency Services:
If the patient arrives in the emergency department of the hospital during normal working hour
of the hospital, the Emergency Medical Officer on duty attends the patients and the paediatric
consultant is informed who immediately attends the patient and initiates further treatment.
If the patient arrives in the hospital after 8.00pm , the emergency medical officer on duty
attends the patients and provides the initial treatment .The pediatrician on call is informed over
phone who incase needed ( depending upon the condition of the patient) attends the patient
within 20 minutes.
All cesarian operation is attended by a pediatrician on call duty and all newborns delivered by
normal delivery are attended in morning and early rounds.
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COP.10: Policies and procedures guide the care of patients undergoing moderate
sedation.
Purpose: To provides guidelines for monitoring oral or intravenous sedation administered to
patients undergoing invasive, manipulative, or diagnostic procedures or patients admitted with
mechanical ventilations in ICU etc.
Scope: Hospital wide
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DEFINITIONS OF SEDATION
1. Minimal sedation (anxiolysis)
A drug-induced state during which patients respond normally to verbal commands. Although
cognitive function and coordination may be impaired, ventilator and cardiovascular functions
are unaffected.
2. Moderate sedation/analgesia (“conscious sedation”)
A drug-induced depression of consciousness during which patients respond purposefully to
verbal commands, either alone or accompanied by tactile stimulation. No interventions are
required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular
function is usually maintained.
3. Deep sedation/analgesia
A drug-induced depression of consciousness during which patients cannot be easily aroused, but
respond purposefully following repeated or painful stimulation. The ability to independently
maintain ventilator function may be impaired. Patients may require assistance in maintaining a
patent airway and spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained.
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GOALS
1. to guard the patient’s safety and welfare
2. to minimize physical discomfort, pain, or anxiety
3. to minimize negative psychological responses to treatment by providing sedation and
analgesia, and to maximize the potential for amnesia
4. to control behavior
5. in some children and uncooperative adults, to expedite the conduct of procedures
which are not particularly uncomfortable but which require that the patient not move.
6. to return the patient to a state in which safe discharge, as determined by recognized
criteria, is possible for outpatients or to return inpatients to pre-sedation status
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PROTOCOL:
i. LOCATION
Moderate or deep sedation is practiced in various departments and locations within the
organization.
ii. PROCEDURE

All moderate or deep sedation will be ordered and supervised by a qualified
physician/dentist. He/she will assume the responsibility of the patient until patient
meets discharge criteria and/or returns to pre-sedation status.

The licensed professional nurse (RN) responsible for managing the care of patients
receiving moderate or deep sedation will complete and maintain competency in the
skill.

The chairman or medical director of each department administering moderate or deep
sedation will be responsible for ensuring that departmental policies and procedures are
applicable and consistent with this hospital policy.
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
Emergency equipment must be immediately available to every location where moderate
or deep sedation is administered or recovery occurs, and includes at least the following:
defibrillator, suction device, oxygen, airway management tools, emergency drugs,
intubation equipment, and EKG monitor.

All patients must have an intravenous access secured prior to administration of
moderate or deep sedation. Children under age 8 may receive only chloral hydrate up to
a dose of 100 mg/kg or only oral midazolam up to a dose of 0.5 mg/kg without an
intravenous access.
iii. Qualification of staff administering sedation in the hospital:

Sedation of patient will be done only by qualified and trained medical and nursing staff.

Doctors and nurses supervising, administering, and monitoring moderate or deep
sedation are required to have proficiency in the delivery of sedation. These individuals
are required to:
1. be familiar with proper dosages, administration, adverse reactions, and
interventions for adverse reactions and overdoses
2. know how to recognize an airway obstruction and possess knowledge of basic
life support.
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3. assess total patient care requirements or parameters, including but not limited to
respiratory rate, oxygen saturation, blood pressure, cardiac rate, and level of
consciousness
PREPROCEDURE ASSESSMENT :
All patients requiring sedation will have a preprocedure evaluation and assessment including,
but not limited to:
1. history and physical performed by a physician/dentist
2. current medications, including any allergies
3. prior history of adverse reaction to sedation or anesthesia
4. NPO status
5. proper consent forms signed
6. vital signs: heart rate, blood pressure, respiratory rate, oxygen saturation, pain score,
level of consciousness, temperature when applicable
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The physician will decide that the patient is a suitable candidate for planned sedation based on
assessment.
MONITORING DURING PROCEDURE
Monitoring of the patient is to be performed throughout the procedure and will include
documentation of vital signs: heart rate
blood pressure
respiratory rate
oxygen saturation
level of consciousness
end-tidal CO2
1. prior to initiation of sedation.
2. reviewed every 5 minutes (minimum).
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3. recorded every 5 minutes (minimum) for deep sedation and every 10 minutes (minimum) for
moderate sedation.
4. after completion of procedure.


For deep sedation, except pediatric patients < 30 kg. It is recognized that ETCO2
measurement may not be indicated during bronchoscopy.
If maximum drug dosage is exceeded, the reason should be documented by the
physician.
POSTPROCEDURE ASSESSMENT
Postprocedure documentation must include: heart rate
blood pressure
respiratory rate
oxygen saturation
pain score
level of consciousness
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Postprocedure observation must occur in a suitable location. Monitoring and documentation
will continue every 10 minutes for 1 hour after the last dose of sedation or
until patient meets discharge criteria and/or returns to pre-sedation status. Patients receiving
reversal agents will be monitored for a minimum of 2 hours. If discharged, the patient or
responsible person must be provided verbal and written instructions regarding diet,
medications, activities, and signs or symptoms of complications with course of action to take if
any complication develops.
i. Post procedure / Post sedation Recovery Guidelines- Adult
Patient Sign
Criterion
Consciousness
Awake, responds easily,
Responds readily, but easily falls asleep
Respiratory
Breathes easily with adequate volume.
Slightly decreased rate and/or volume.
Circulatory
BP and pulses within baseline limits.
BP and pulses approaching baseline limits
Activity
Able to move extremities voluntarily or on
command ( or returned to baseline)
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ii. Post procedure / Post sedation Recovery Guidelines- Pediatric
Patient Sign
Criteria
Consciousness
Awake or returned to baseline
Responding to stimuli
Respiratory
Breathes easily with adequate volume
Circulatory
BP pulses within baseline limit or approaching
baseline limit.
Activity
Moving limbs purposefully ( or returned to
baseline)
Sedation of Patients in ICCU:
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i.
All patients admitted in ICCU will be sedated in such a manner that will
a. enable tolerance of endotracheal Intubation.
b. enable tolerance of mechanical ventilation.
c. enable pain relief in such a way that they are calm and yet arousable.
d. ensure that the patient is not aware of any procedures done.
ii.
All patient on endotracheal intubation and mechanical ventilation will be managed as
follows :
a) Inj. Midazolam 2mg slow IV as initial bolus followed by 1mg IV every hour.
The dosage will be reduced over a period of time. During procedures a bolus
of 2 mg will be administered.
b) Inj. Diazepam 4mg slow IV followed by continuous infusion @ 1.2 mg/hr will
be done if the patient is restless, struggling with the ventilator or markedly
hyperventilating.
c) If the patient continues to resist the ventilator then Inj Thiopentone 0.5 gm IV
infusion will be given.
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d) Muscle Relaxant- Inj. Vecuronium 6mg slow IV bolus (0.1 mg/kg), followed
by 1mg every hr will be the last resort.
Rescue of patient from deeper level of sedation :
iii.
Rescue of a patient from a deeper level of sedation than intended is an intervention by
a practitioner proficient in airway management and advanced life support.
iv.
The qualified practitioner corrects adverse physiologic consequences of the deeperthan-intended level of sedation (such as hypoventilation, hypoxia and hypotension) and
returns the patient to the originally intended level of sedation
COP.11: Policies and procedures guide the administration of anesthesia.
Purpose: To provide guideline instruction for administration of Anaesthesia so that


Need and Expectation of the customers are established
Customer satisfaction is enhanced on a continuous basis
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MH/CoP/01-18
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Jaipur Ph.: 2356944, 2357570
Scope: All patients who have undergone any form of Anaesthesia / Sedation in the Hospital.
Responsibility Persons: Anesthetists
Departmental Hierarchy:
Head – Department of Anesthesiology
Senior Consultant - Anesthesiology
Consultant- Anesthesiology.
Operation Theatre Nurse.
Operation Theatre Attendants.
Housekeeping Staff.
Policy :
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i. Pre-Anaesthesia Assessment:
All patients undergo preaneasthesia assessment by the anaesthetists a day before their
scheduled day of operation in the PAC clinic/Bedside (if needed) and all the findings are
recorded in the specific form (Refer Preoperative Anesthetist Checkup format). Anaesthesia plan
for the patient is prepared on the basis of the Preaneasthesia assessment findings and the same
is documented. Anaesthesia plan depicts the type of Anaesthesia (local, general, epidural etc),
monitoring, plan for post operative analgesia etc.
ii. Consent:
Prior to the administration of anaesthesia, the patient / relatives is informed about the planned
anaesthetic procedure, risk and benefits involved etc. An informed consent (Consent format No
: ) is obtained from the patient by the concerned anesthetist. Incase the patient is incapable,
minor etc consent is obtained from the patients relatives as specified by the hospital (Refer to
Policy No : ).
iii. Pre-operative Re-evaluation:
An immediate pre - evaluation of the patient is done by the anesthetist to assess their status
prior to the surgery. The pre-evaluation includes recording of patient’s vitals, amount of drugs
and agent (Ref: Format).
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iv. Administration of Anaesthesia
 Anaesthesia will be administered in OT complex only.
 It will be administered by Anaesthesiologist only.
Procedure
1. Anaesthesia will be general, spinal, epidural, regional, dissociate or sedation.
2. During any anaesthesia procedure BP, Pulse, SPO2 will be monitored.
3. Emergency crash cart with defibrillator will be available in the OT complex.
4. Patients will be premedicated in preoperative ward as per Anaesthesiologists
instructions.
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5. The procedure for general Anaesthesia administration will be




Preoxygenation will be done for three minutes.
Induction: Thiopentone / Propofol + Medazolam + Analgesics.
Intubation: Where required- Scolene / Atracurium / Vecuronium
Maintenance: O2 + N2O, Inhalational Anaesthetic agents, Analgesics and
muscle relaxants.
 Neuromuscular block will be reversed with the Neostigmine and Glycopyrollate,
where non depolarizing relaxants are used.
 Recovery from Anaesthesia and neuro muscular blockade will be assessed
clinically and patient shifted to the recovery room.
7. Following steps will be followed during Regional, Spinal, Epidural Anaesthesia:
 Strict aseptic precautions will be followed.
 Patient will be properly positioned for the procedure.
 The administration of Regional and central neuronal blockade will be in
accordance with the documented practice.
 Level and adequacy of the blockade will be reviewed and done before the
operating procedure.
 Inadequate blockade will be supplemented with General Anaesthesia or
Sedation.
 All monitoring as for general Anaesthesia will be followed.
 Resuscitative equipment, ETT, Laryngoscope will be readily available.
8. For patients undergoing local anaesthesia with sedation the following method will be
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adhered to:
 All monitoring and resuscitative equipment must be available in OT.
 Endotracheal tube, laryngoscope, oxygen and means for ventilation (Anaesthesia
machine) must be available.
 Patients will be induced to sedation using Inj Propofol , Inj Ketamine , Inj Mezolam , Inj
diazepam, Inj Promethazine, Inj Fortwin etc (may vary from between patients) after the
operating area has been cleaned and draped.
 Local infiltration will be done only after sedation.
 All monitoring intra op and post op as done for GA will be followed.
Monitoring of patient during Anaesthesia:
An Qualified anaesthesia personnel shall be present in the room throughout the conduct of
surgery to monitor the patient and provide anaesthetist care. Monitoring of patient is done
since there are rapid changes in the patient status during anaesthesia. Monitoring includes
recording the following:
1. Patients Heart rate
2. Cardiac Rhythm
3. Respiratory rate
4. Arterial Blood Pressure
5. Oxygen Saturation
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6. Airway Security
7. Patency
8. Level of Anaesthesia
9. Evaluation of the circulatory function
10. Temperature (incase clinically significant changes in body temperature are intended,
anticipated or suspected).
The time based record of the events is documented. Any unusual events during the
administration of Anaesthesia is recorded .The status of the patient at the conclusion of
anaesthesia is recorded.(Format No : )
Transfer of Patient from the OT to the Post Operative Recovery Area:
Post surgery , patient are transferred to the post operative recovery area where they are kept
for a minimum of 30 minute after recovery from anaesthesia , exception being patient who
require ICU management for poor cardiac and respiratory status .Such patient will be directly
shifted ICU.
Post Anaesthesia Care :
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All patients who have received either general, spinal, epidural and dissociate regional or
sedation shall receive post anaesthesia care in the Post Operative Recovery Area of the hospital.
The medical aspect of the care in the Post Operative recovery Area shall be under the
supervision of the OT staff. The patient shall be observed and monitored. During the stay in
Recovery room the patients will be monitored with multifunction monitor showing
· ECG (if needed)
· SpO2
· Pulse
· Blood Pressure
Patients will also be monitored for pain relief, restlessness respiratory, and distress / depression
sedation. In the event of alteration of any of the parameters such as Abnormal rhythm in ECG,
Fall in SpO2 to less than 95%, Pulse rate less than 60 or more than110, Blood pressure less than
100mm Hg systolic or more than 150 mm Hg systolic, In adequate pain relief, Restless ,
Respiratory rate less than 12 or more than 30 , when patient cannot be aroused etc the
anaesthesiologist will be informed.
General Medication and Supervision of the patient while in the post operative recovery area will
be under the care of the Anesthesiologist in consultation with the consultant surgeon.
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Guidelines for Discharge from the Post Operative Recovery Area:
Anaesthesiologist takes the decision for discharge of the patient based on the following signs:
1.
2.
3.
4.
5.
Respiratory Rate
Cardiac Rhythm
Blood Pressure
Oxygen Saturation
Pulse Rate
Discharge decision from the Post Operative Recovery Area is taken by the anesthesiologist and
the consultant surgeon of the patient.
COP.12: Policies and procedures guide the care of patients undergoing surgical
procedures.
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MH/CoP/01-18
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Jaipur Ph.: 2356944, 2357570
Purpose: To provide guideline instruction for surgical care services with the aim that
a. Need and expectations of the patients are established.
b. Patient satisfaction is enhanced on a continuous basis.
Scope: It covers all patients undergoing any form of surgical treatment in the hospital.
Responsibility Person: Head-Department of Surgery
Departmental Hierarchy:
Consultant - Surgery
Resident
Staff Nurse
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Housekeeping Staff.
Policy:
1. Qualification of staff:
a. Surgical care is provided by post graduate qualified and experienced surgeons.
b. Anaesthesia is provided by post graduate qualified and experienced anaesthesia.
c. Nursing care in the OT is provided by qualified and registered nursing staff.
2. Patient Assessment:
a. Surgical OPD
1. Patient visit the surgical OPD either by themselves anticipating their problem or are
guided by the registration counter clerk.
2. Patients are also referred by other clinicians as per the care needed by the patient.
3. Initial Assessment includes patient’s past medical history, general examination and
routine investigations to confirm patient’s need for surgical intervention.
4. Incase the patient need cardiac assessment prior to surgery, the patient is referred to
the cardiologist for evaluation.
5. After confirming the patient’s need for surgical intervention the plan of care is drawn by
the surgeon of the patient.
6. Patients and their relatives are informed about the need for surgery, expected outcome,
risk involved, prognosis of the patient etc by the concerned surgeon.
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7. The date and time of surgery is scheduled and the patient is informed to get admitted a
day before the scheduled date of surgery for undergoing all needed preparation
including the required investigations.
b. Emergency Department:
1. Patients directly visit the emergency department of the hospital.
2. The emergency medical officer on duty immediately attends the patients and undertakes
the initial assessment to determine the care needed by the patient.
3. Incase the patient need surgical intervention, the surgeon on call is immediately
informed by the on duty EMO.
4. The patient is attended by the surgeon who evaluates the patient’s condition and the
need for surgical intervention.
5. If the patient’s need for surgical intervention is not immediate in nature the patient is
admitted for further evaluation prior to the surgery.
6. Incase the patients condition is severe and requires immediate surgical intervention ,the
surgeon informs the patient relatives about the need for immediate surgical intervention
for saving the life of the patient , outcome expected ,risk involved etc.
3. Preoperative Assessment:
Once the patients need for surgical intervention is established the patients has to undergo a
preoperative checkup by the concerned surgeon which include the following:
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a.
b.
c.
d.
Patients Vitals
Blood Pressure ,Cardiac Rhythm etc
Examination of the chest.
Investigation such as X-Ray chest , ECG etc
The patient’s preoperative check up findings is documented in the specified format in the
patients case sheet.
The preoperative check up for patients requiring immediate surgical intervention is done
immediately after the surgeon’s decision for emergency surgical intervention.
After the preoperative check up by the surgeon, the patient is referred to the anesthetist for
preanaesthesia checkup.
4. Pre anesthesia Check up:
The consultant anaesthetist undertake the preanaesthesia check up (ref PA Checkup format) of
the patient which include the following :
a.
b.
c.
d.
Medical History such as HT/Dm/ Chest Pain etc
Surgical and Anesthetics history if any
General Examination such as Pulse ,BP,RR etc
Systemic Examinations etc
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All preanaesthesia check up findings are documented in the specified format attached with the
patients bed head ticket (BHT).
The pre aneasthesia check up for patients requiring immediate surgical intervention ,is done
immediately after the surgeon’s decision for emergency surgical intervention.
5. Preoperative order to the nursing staff:
A. Ward Nursing Staff:The preoperative order to the nursing staff of the concerned ward where the patient is admitted
includes the following:
1.
2.
3.
4.
Drug orders for example morbidity medications like antihypertensive drugs etc.
Patient preparation instructions including marking of the surgical site.etc
Time and date of surgery.
Specific documents such as X-Ray plates etc, if any to be forwarded along with the
patient to the OT.
B. OT Nursing Staff:-
1. List of patient to be operated should be prepared a day prior to the scheduled day of
surgery.
2. List should include a patient wise distribution of scheduled surgeries, type of anesthesia
to be administered .The information thus prepared is to be informed to the consultant
surgeons and anaesthetist.
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6. Informed Consent for Surgery:
Consent for the patients and or relatives for the surgery is obtained by the operating surgeon in
the specified format after explaining the following details :
1.
2.
3.
4.
5.
Nature of Surgery.
Reason for the procedure.
Expected Outcome.
Risk Involved.
Expected duration of recovery etc.
The consent is obtained from the patient and or the surrogate (Refer # Informed consent Policy)
as per the hospital’s policy a day prior to the scheduled date for the surgery.
7. Prevention of Wrong Procedure/Side/Site and Wrong Patient:
The prevention of wrong site/side/procedure and patient begins with the preoperative
evaluation of the patient.
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This involves the following activities such as marking of the surgical side, verification of patient
prior to the shifting of the patient from the ward to the OT, at the time of patient’s entrance to
the OT suite and prior to the initiation of the procedure inside the theatres ,etc
The policy for prevention of wrong procedure/side/site and patient could be referred for the
hospital’s detailed policy.
8. Transfer of Patient to Operation Theatre:
a. Prior to the transfer of the patient the ward nurse informs the OT nurse about the
patient details and confirms the scheduled time for surgery forty five minutes prior to
the scheduled time of surgery.
b. The ward nurse prior to the transfer of the patient ensures that the nurse’s preoperative
checklist is dully filled and all the patient details as required by the surgeons are
arranged in the proper order.
c. The patient is transferred to the OT as per the hospital’s intramural transfer policy.
9. Receiving of patient and immediate preoperative assessment:
a. The patient is received in the preoperative pateint holding area of the theatre.
b. The OT nurse evaluates the patient’s details and checks the preoperative nursing
checklist filled by the ward nurse to ensure the patients preparedness and confirms the
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patient’s identity as per the bed head ticket.
c. The patient is transferred to the operating rooms where the concerned surgeon and
anesthetist undertakes immediate preoperative evaluation.
10. Post Surgery process :
a. Post Operation the patient is shifted to the post operative recovery area of the OT suite.
b. In the recovery area patient is kept under the supervision of the specialist anesthetist,
consultant surgeon
nursing care in the post operative area is provided by Operation Theatre nurses.
c. Prior to discharge from the post operative recovery area a brief operative note is
documented by the concerned surgeon in the patient’s bed head ticket.
d. The consultant surgeon documents the post operative condition of the patient, post
operative treatment plan etc. The surgeon concerned will not leave the hospital until and
unless he/she is assured about the stable condition of the patient
e. Post operative treatment plan includes informs regarding the need for keeping the
patient under intensive care, post operative medications , examinations required if any
etc
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Jaipur Ph.: 2356944, 2357570
11. Quality Assurance Programme for Surgical Services:
Surgical service is a very specialized specialty of medicine and there is a need of quality in
everything. Quality in surgical services is achieved through:











Surgery of any type is done only by appropriately qualified (as per MCI guidelines) and
experienced surgeons.
Any form of Anesthesia is administered by Qualified Anesthetist (MCI guidelines).
Nursing care is provided by qualified, trained and experienced nursing staff
Documentation of patient’s surgical plan ( Ref Patients Case File)
Documentation of patient’s preoperative condition
A. Preoperative Surgeons Assessment ( Ref Format No # )
B. Preoperative Anesthetist Assessment (Ref Format No # )
C. Preoperative Nursing Checklist. (Ref Format No # )
D. Immediate pre operative assessment of the patient by the consultant surgeon and
the anesthetist.
( Ref Format No # )
Transfer of patient to the OT is done by designated staff ( Ref Hospital Policy #)
Time based intra operative monitoring of the patient by the anesthetist ( Ref format # )
Post surgery monitoring of the patient in the post operative recovery area
Documentation of the surgical procedures performed, outcome, post operative
condition of the patient and post operative treatment plan etc by the consultant
surgeon.
Appropriate zoning of the operating theatre suite and strict adherence to infection
control activities (Ref hospital policy # ) in the operating theatre complex.
Well established method for reporting any surgical site infection , its analysis by a
multidisciplinary committee for formulation of adequate control and prevention plan.
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Jaipur Ph.: 2356944, 2357570
COP.13: Policies and procedures guide the care of patients under restraints
(physical and/ or chemical).
Purpose: To provide written guidelines for managing patients under restraints
Scope : Covers patients declared to be cared under restraint by the treating
Consultant /Medical Officer.
Definition:
Restraint: Restraint may be defined as a method which restricts the movement of the whole or a
portion of patient’s body for the purpose of preventing intentional harm to self or others.
Policy:
i.
It is the policy of Marudhar Hospital that patient may be secluded in accordance and
compliance with NABH standards and applicable law.
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Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
ii.
Restraint shall not be used for staff convenience or as a form of punishment. All
restraints will be conducted in humane, safe and effective manner without intent to
harm or create undue discomfort to the patient.
iii.
Restraint are to be used only in an emergency , when there is imminent risk of an
individual physically harming himself or herself or others ,including staff.
iv.
When the patient is violent and is likely to injure him or others in the vicinity physical
restraints needs to be applied with proper precautions.
v.
Similarly when found necessary chemical restraints measures may also be used. Such a
patients needs to be monitored more frequently by the nurse-in-charge and periodically
by the Doctor on duty
vi.
Physical Restraints should be soft and not injuring the parts of the patients
vii.
For those patient who have a history of physical abuse and/or sexual abuse ,special
attention is paid to psychological risk during restraint.
viii.
Any patient who needs to be observed and cared under restraints is to be so declared by
the treating Consultant/Medical Officer with the reasons for such restraints.
ix.
Any complications / problems arising out of such restraints should be communicated
with the Consultant in-charge and his / her further advice sort.
x.
Patients family members has to be kept informed about the need for putting the patient
under restraint ,patients condition etc.
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Care of Patients
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MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Procedure:
1. Restraint shall be limited to :
1. Preventing and reducing serious, destructive /damaging actions by the patients
such as :
a. Threatening to self
b. Threatening to others
c. Threatening to staff
d. Assaultive to self
e. Assaultive to other patients
f. Assaultive to staff , etc
2. Patients rights regarding restraints – The patient has a right to expect that, prior to the
use of restraint , the staff will assist him/her in regaining control by :
i.
ii.
iii.
iv.
Less rectrictive interventions including :
a.Verbal conversation to descalate the patient.
b.Mediating in disputes
c.Offering PRN medications
v.
vi.
PRN medication to be offered PO initially
IM PRN medication will be used if patient refuses PO medication
and poses a threat to self or others.
It is expected that all restrictive non-physical interventions will
have been tried prior to utilizing restraints, when possible.
vii.
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Jaipur Ph.: 2356944, 2357570
3. Physicians responsibility :
a. The physician must see and evaluate the need for restraint within one hour
after the initiation of restraint.
b. A nurse , when physician is not immediately available ,may asess the situation
and initiate the ‘emergency’ use of restraint.
c. The physician will write a written order on the doctor’s order sheet designating
the application of restraint and the device for the same.
d. The order for use of restraint may not exceed four hours per order.
e. When a written order cannot be obtained immediately, verbal order for
restraint is to be entered doctors order sheet by the nursing staff.
f. All verbal orders for restraint must be counter signed by a physician within one
hour.
g. Within one hour the physician shall evaluate the patient to determine
i. whether continued restraint is appropriate and document this
evaluation in
ii. the patients progress note.
h. If restraint is continued beyond four hour a physicians personal reevaluation is
necessary .
Nurse’s Responsibility:
1.In an emergency situation when a physician is not readily available , the nurse
may assess the situation for appropriateness, and if it is deemed appropriate,
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authorize an ‘emergency use of restraints” for upto one hour.
2.Make a clinical determination as to whether additional staff are necessary to
place the patient in restraints to ensure the safety of the patient and staff.
3.Explain to the patient the reason for restraint and the explicit behavioral
criteria for termination.
4.Contact a physician and obtain an order (written/verbal) for use of restraints
within the first one hour of the patient being restrained.
5.Assess the patient to assure that all medical needs are addressed during
restraints.
Procedure to be observed pre and post application of restraint :
1. Inspect the bed, chair , restraints and any other equipment which will be used
in the restraint process for safety prior to use.
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2. Explain to the patient , the staff’s role in assisting him/her to regain control
by utilization restraints. Attempt to persuade the patient to be cooperative
with the process.
3. At no time will the patient be assisted into or out of restraints by less than two
nursing staff.
4. All harm full objects ,i.e. shoes, jewelry ,scarves, belts, shoelaces and
matches etc must be removed before the restraints are applied.
5.After administration of restraint patient will be kept under observation .
6. Attention will be paid during these observation to the patient’s need for
regular meals, bathing , toileting and fluids.
7. Once every 30 minutes the on duty nurse will assess the patient to determine
that :
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a.Circulation is adequate
b.Restraints are secure
c.Body alignment is correct
d.If clinically indicated, restraints are adjusted ,body realigned assuring the
above conditions are met.
8.Not less than every two hours , the physician and/or the assigned nurse must
assess the patient for the purpose of determining whether continued restraints
are necessary.
9. Vital Signs:
a. Patient receiving intramuscular medication while being restarined will have
their blood pressure (BP) and pulse assessed and documented half an hour
after the administration of the IM psychotropic medication ,unless it s
contraindicated by the patient’s behavior.
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b. If the blood pressure and pulse cannot be assessed within that time frame
due to patient’s behavior, this fact must be documented in the record and an
effort to obtain this data must be made at least by end of shift.
c. If a patent is restrained for four hours or more,BP and P are to be taken
every shft i.e every six hours for the duration of restraints.
d.A physician must be notified of any significant change in the patients’s BP
or Pulse.
10.At the change of shift the incoming /outgoing nursing staff will assess and
document the continuing need for restraint.
11.In the event of bruising or any other form of injury during the process of
applying restraints, the same will be treated immediately accordingly and a
record must be documented in the patients bed side ticket (BST).
Documentation:
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MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
The order for restraint shall :
1.
2.
3.
4.
5.
6.
Be written with date and time
Specify the type of restraint to be used
Be limited to four hours.
State the specific behaviors requiring restraints
Specify any special instructions or conditions of restraints
Be signed by the physician – incase of an emergency , the order must include
the name of the doctor authorizing the restraint ,the name of the nurse
obtaining the order.
Documentation during restraint shall include :
1.Patients behavior every 30 mins
2.Any medication ,treatment given to the patient during the time the patient was
restrained ,include effectiveness .
3.Nurse to assess and document adequacy of circulation ,security of restraints
and body alignment not less than every thirty minutes.
4.Offering of fluid to patient every two hours.
5.Oral hygiene/bath given .
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Jaipur Ph.: 2356944, 2357570
If the patient has to be released from restraint , the condition of the patient
justifying the reason to withdraw the patient from restraint has to be clearly
documented by the physician and a summary/termination note must be
documented.
Training of staff:
The administrative department of the hospital headed by the Chief Medical
Superintendent shall provide education and training inclusive of an assessment
of skills,to ensure clinical competency ,minimization of the use of restraint and
the safety of the process
Education and training shall be provided:
a. During the orientation for all new nursing staff (fresh recruit/transferred)
b. On going via scheduled training sessions.
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COP.14: Policies and procedures guide appropriate pain management.
Purpose: To provide guideline instruction for management of pain.
Scope: Hospital wide
Policy:
The hospital and its staff members:
• Recognizes the right of individuals to appropriate assessment and management of pain.
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• Plans, supports, and coordinates activities and resources to ensure that the pain of all
individuals is recognized and addressed appropriately.
• Provides individualized care in settings responsive to specific needs.
• Provides education on pain management as part of the patient’s treatment considering
the patient’s personal, cultural, spiritual, and/or ethnic beliefs.
• Develops plan in conjunction with the patient, if on discharge the patient has pain, to
address management at home.
• Monitors the performance of the pain management program.
Patient Rights
1.Patients rights include :
a. Information about pain and pain relief measures,
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b. A concerned staff committed to pain prevention and management,
c. Health professionals who respond quickly to reports of pain,
d. That reports of pain will be believed,
e. State-of-the-art pain management.
2.Patients responsibilities which include :
a. Ask the doctor or nurse what to expect regarding pain and pain management,
b. Discuss pain relief options with the doctors and nurses,
c. Work with the doctor and nurse to develop a pain management plan,
d. Ask for pain relief when pain first begins,
e. Help the doctor and nurse assess the pain,
f. Tell the doctor or nurse if the pain is not relieved, and
g. Tell the doctor or nurse about any worries regarding taking pain medication.
Assessment:
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1. A patient’s report of pain will be accepted and respected as the key indicator of the
amount of pain he/she is experiencing. Medical/nursing staff will assign the rating only if
the patient is unable to report their pain.
2. The presence of pain is assessed on admission to the hospital, at the initial clinic
visit, post invasive procedure and when the patient complains of pain. The
assessment is performed by: a physician,anaesthetist, nurse and documented in
the medical record.
3. The frequency of pain reassessment shall be dictated by the intensity of the patient’s
pain and the effectiveness of pain relief strategies. However, when pain is present, a
pain reassessment is generally performed at least every 4 hours and more often as
needed by a licensed healthcare provider. The physician is notified of the patient’s pain
when treatment fails to reduce the pain to a level acceptable to the patient, as ordered
by the physician, or pain score > 5 using the approved Pain Scales. If no pain is present,
the healthcare provider will reassess for pain as warranted by patient condition, when
the patient complains of pain and post invasive procedure.
4. Pain Scales :
The Numeric Pain Intensity Scale (NPIS) will be used universally to assess pain
for patients 13 years or older. Patients will be asked to rate their pain a scale of
0-10. Zero represents no pain; a rating of 5 would indicate that the patient is
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Jaipur Ph.: 2356944, 2357570
experiencing moderate pain, and a rating of 10 would indicate the worst
imaginable pain.
5. If pain is present, a more comprehensive assessment is performed, which may include:
a. Intensity (Numerical 0 -10, Wong-Baker Face Scale)
b. Quality
c. Location(s) (All pain locations are assessed)
d. Onset
e. Duration
f. Variation
g. Alleviating and aggravating factors
h. Present pain management regimen and effectiveness
i. Medication history
j. Presence of common barriers to reporting pain and using analgesics
k. Past interventions and response
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l. Manner of expressing pain
m. Effect of pain on activities of daily living, sleep, appetite, relationships, emotions and
concentration.
n. Pain goal, expressed as measures of intensity and function.
o. Physical examination:
1) Mental status examination
2) Motor and sensory examination
3) Reflexes
4) Gait
5) Maneuvers targeted to pain diagnoses
6. Documentation of pain, for all patients, should include the following:
a. Type of pain and/or location
b. Intensity scale
c. Level of consciousness
d. Respiratory rate
e. Activity
f. Side effects
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g. Medication
h. Patient and family education
i. Treatment goal.
7. Staff shall be educated about pain assessment, including the availability of
nonpharmacological interventions.
Treatment
1. Pain is managed by pharmacological treatment, nonpharmacological treatment, and
interventional procedures.
a. Pharmacological treatment may include non-opioids, opioids, and adjuvants.
b. Nonpharmacological treatment may include physical interventions and cognitive
behavioral strategies.
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1) Physical interventions may include:
a). Heat
b). Cold
c). Electrical stimulation (e.g TENS)
d). Exercise
e). Physical/Occupational therapy
f). Immobilization
g). Manipulation
h). Massage
i). Acupuncture
2) Cognitive behavioral strategies may include:
a). Distraction
b). Relaxation
c). Hypnosis
d). Other coping strategies
2. The hospital provides safe medication prescription or ordering.
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a. Pain medication shall be ordered to be given as a specific dose with a regular schedule.
b. PRN orders shall include specific indications for specific dosing. Example: Time ranges such as
“every 2-3 hours prn ” are not acceptable. A specified interval such as “every 3 hours prn pain”
is acceptable.
c. Range orders shall be avoided unless accompanied by a sliding scale. Example: Dose ranges
such as 4-10 mg. Morphine IV every 3 hours are not acceptable unless it is tied to a measurable
pain severity measure (i.e. For pain rating 5-7 administer morphine 5 mg. IVP every 2 hours prn
pain; For pain rating 8-10 administer morphine 10 mg IVP every 2 hours prn pain).
d. Specific protocols shall be used for PCA and epiduralanalgesia.
e. Only one long-acting agent shall be prescribed at any time.
Pain Reassessment:
A. Pain will be reassessed:
1. Every eight hours for all hospitalized patients.
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2. For patients will high potential for pain ( i.e. post surgical patients, patients with
chronic pain ).
a. at least every 2 hours for the first 24 hours, then every 4 hours.
b. prior to pan relieving intervention.
c. within 30 – 60 minutes after pain relief intervention.
Patient Education
1. Patient education may focus on fears commonly held by patients in pain, including:
a. Fear of drug addiction,
b. Fear of drug dependence,
c. Fear of drug tolerance,
d. Fear of appearing uninformed or unable to understand, and
e. Fear of inability to function normally.
Patient teaching will include the following :
1. Patient and family education about physiological causes of pain that might be specific
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to patient (e.g., mass pressing on nerve, tumor obstructing bowel, etc.).
2. Patient and family education about some non-invasive methods, which might help
prevent or alleviate pain (e.g., distraction, music, reading, prayer, meditation, guided
imagery, massage therapy, etc.).
Pain Scale:
1) Numerical pain scale (0-10)
2) Wong-Baker Faces pain scale (0-10)
c. Explanation of treatments:
1) Pharmacological
2) Procedural
3) Non-pharmacological
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Discharge:
Discharge notes shall include reference to physical needs, emotional needs, and symptom
management.
Documentation:
1. Inpatient: The following information will be documented
a .initial pain screening.
b. initial pan assessment
c. pain score .
c. pain management procedure used.
d. discharge instructions
2. Outpatient: The following information will be documented
a. initial pain assessment.
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b. initial pain screening
c. pain score.
d. pain management procedure
e. instructions for the patients.
COP.15: Policies and procedures guide appropriate rehabilitative services.
Purpose: The purpose of the Physiotherapy Department is to provide an expert
physiotherapy service, with systematic methods of assessing musculo-skeletal, cardioPrepared and Issued By:QM-Dr Pratima
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vascular, etc disorders of function including pain and those of a psychosomatic origin and
dealing with or preventing these problems by natural methods based essentially on
movement, manual therapy and physical agencies.
Scope: Include staff and patients involved in the process.
Definitions and Abbreviations:
1.Postural Drainage
Positioning the patient according to the anatomy of the bronchial tree in order to use
gravity to assist drainage of secretions.
2.Gait Training
Gait training begins by teaching transfers to the bed, mat and wheel chair, then improving
standing balance on the affected limb. The patient is taught the most optimal gait pattern
in and out of the parallel bars, and on stairs, ramps, and curbs. Orthosis (braces) and other
assistive devices are used to correct gait deviations, and may decrease energy expenditure
during gait. Harnesses to provide partial body weight support may accelerate early
ambulation.
3.Vertigo
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Vertigo, or dizziness, is a symptom, not a disease. The term vertigo refers to the sensation
of spinning or whirling that occurs as a result of a disturbance in balance (equilibrium). It
also may be used to describe feelings of dizziness, faintness, and unsteadiness vertigo
usually occurs as a result of a disorder in the vestibular system (i.e., structures of the
inner ear, the vestibular nerve, brainstem, and cerebellum). The vestibular system is
responsible for integrating sensory stimuli and movement and for objects in visual focus
as the body moves.
4.Abbreviations
ABBREVIATIONS
FULL FORM
IFT
Interferential therapy
UST
Ultrasound therapy
SWD
Shortwave diathermy
CVT
Cervical traction
LBT
Lumbar traction
WXT
Wax therapy
MOT
Moist therapy
LAS
Laser therapy
CPM
Continuous passive movement
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PD
Postural drainage
GAT
Gait training
PSN
Post natal exercise
MBZ
Mobilization exercise
CPT
Chest physiotherapy
SPN
Spinal exercise
PVF
Pelvic floor exercise
PFT
Pulmonary function test
ROM
Range of motion
Mm
Muscle power
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Inpatient Work Process:
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Patient in ward
Doctor refers patient for
physiotherapy
treatment
Nurse informs physiotherapist
& send request form to physio dept
Assessment and
evaluation of the patient
Physio treatment starts
Entry Made in Patients’
BST
Order entry
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Out patient work process :
Consultant refers to
Physiotherapy department
Patient with reference enters
the physiotherapy
department
Patient assessment and
evaluation done
Plan of treatment and
treatment starts
Appointment given
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Entry made in
Patient’s case sheet
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Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Treatment modalities
1.
Interferential Therapy :
Procedure:
It is a method of producing Low frequency current selectively at any tissue depth
without the
problem of skin resistance
a. Preparation of patients:
i. Position the patient comfortably with the area to be treated
adequately supported, exposed and relaxed.
ii. Inspect the part of any cuts, abrasions, excessive swelling,
warmth or any skin condition.
iii. Inform the patient about the treatment and sensation to be
experienced – a mild pricking sensation but pleasant.
b. Treatment:
i. Explain the procedure to the patient
ii. Apply the electrodes firmly on the patient’s complaint area
iii. Make sure sponges are adequately damped
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iv. Position the electrodes so that the red and black leads are
diagonally across
v. Turn on the equipment, select the programme, frequency, and
increase the intensity up to the patient tolerance
vi. Duration of the Treatment – between 10 – 15 minutes, based on
level

Acute

Sub acute

Chronic
c. Precautions:
i. Patient should not feel the heat, burning sensation, discomfort, or
pinching sensation beneath the electrode
ii. Do not apply electrodes over mucous membranes
iii. Patient should remove all kind of jewels before treatment.
d. Infection control:
i. Cleaning the electrode pads with water before and after the
treatment.
ii. Electrode pads must be cleaned with alcohol swabs in infectious
patients
2.Ultrasound Therapy:
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Procedure:
Ultrasound is high frequency sound waves that produce temperature elevation to the
deeper structures with out causing excessive heating of the superficial layers through the
use of coupling agents
a. Preparation of the Patient:
i. Position the patient comfortably with the area to be treated adequately
supported, exposed and relaxed.
ii. Inspect the part for any cuts, abrasions, excessive swelling, warmth or
any skin condition
iii. Inform the patient about the treatment and sensation to be experienced
– a mild heat
b. Treatment:
i. Explain the procedure
ii. Apply generous amount of coupling agent. Spread the gel evenly over
the transducer
iii. Slowly increase the intensity apply the transducer to the skin and move
continuously in small circular motions
iv. Duration of the Treatment is between 10 – 15 minutes, based on levels

Acute

Sub acute
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Jaipur Ph.: 2356944, 2357570

Chronic
c. Precautions:
i. Keep the transducer head moving continuously on the skin or burning
may occur through over heating of tissues
ii. Do not hold the transducer head in the air or break treatment contact,
this could damage the transducer head crystals
iii. Do not treat near the heart
iv. Not to be used during pregnancy
v. Patients with the Pace maker should not be in the treatment area/
undergo treatment.
d. Infection control:
i. Clean the transducer head with tissue paper after every use
ii. Transducer head must be cleaned with the alcohol swabs in infectious
patients
3. Paraffin Wax Bath :
Procedure:
Paraffin wax bath is utilization of paraffin wax at a temperature 40- 44 degree Celsius.
The application of hot wax through dipping with the lint cloth and apply to patient’s
extremities .This wax has low thermal conductivity, so that the heat will stay in the
tissues for a longer period.
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MH/CoP/01-18
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Jaipur Ph.: 2356944, 2357570
a. Preparation of the patient:
i. Position the patient comfortably with the area to be treated
adequately supported, exposed and relaxed.
ii. The part to be treated must be cleaned and free form cuts, rashes or
infections
iii. Inform the patient about the treatment and sensation to be
experienced – a mild heat
b. Treatment:
i. Explain the procedure
ii. Therapist should wear gloves
iii. Dip the lint clothe in the wax bath, clear the excess wax on the cloth
and wrap it around the area to be treated
iv. Duration of the treatment 20 – 30minutes
c. Precautions:
i. Patient should be cautioned not to change position during treatment
ii. Paraffin can easily fall to the floor during treatment making the floor
slippery
iii. Paraffin wax is flammable.
d. Infection control:
i. Change the lint cloth once a week
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Jaipur Ph.: 2356944, 2357570
ii. Wax bath to be cleaned with the spirit when the wax is replaced with
new (once in four months)
iii. Lint cloth has to be discarded if used in infectious patient
4.Moist Heat Therapy:
Procedure:
Silicon hot packs are conductive type of superficial moist heat. The temperature has to be
maintained between 70 – 100 degrees Celsius
a. Preparation of the patient:
i. Drape the patient, expose the area to be treated, place the patient in
comfortable position
ii. The part to be treated must be cleaned and free form cuts, rashes or
infections
iii. Inform the patient about the treatment and sensation to be
experienced – a mild heat
b. Treatment:
i. Explain the procedure to the patient
ii. Place the towel between the patient’s skin or treatment area and the
hot packs
iii. Wrap additional towels depending on patient’s tolerance to heat
iv. Duration of the treatment is 20 – 30 minutes
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Jaipur Ph.: 2356944, 2357570
c. Precautions:
i. Extra towel must be utilized, so heat is not transferred too quickly
and results in burn.
5. Short Wave Diathermy:
Procedure:
1. High frequency current produced deep heat with in body tissues for therapeutic
purposes. Produces heat below the skin surfaces through conversion heat
transmission.
a. Preparation of the patient:
i. Drape the patient, expose the area to be treated, place the patient in
comfortable position.
ii. The part to be treated must be cleaned and free form cuts, rashes or
infections
iii. Inform the patient about the treatment and sensation to be experienced
– a Deep heat
b. Treatment:
i. Explain the procedure to the patient
ii. Place one layer of the towel over the treatment area.
iii. Position the treatment area midway between two electrodes
iv. Allow the machine to warm up first two minutes
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Jaipur Ph.: 2356944, 2357570
v. Increase the intensity until the patient feels a soothing sensation
vi. Give the patient the call bell in case the heat is more.
vii. Duration of the treatment 15 – 30 minutes
c. Precautions:
i. Patients with the Pace maker should not be in the treatment area
ii. Patient should not move during treatment or touch cable or the
machine
iii. Due to electromagnetic radiation all watch, jewellery and hearing aids
should be removed
d. Infection control:
i. Change the towel used for disc and pads everyday
6. Traction:
Procedure:
1. Mechanical traction applies a distraction force to the spine to attempt to separate
vertebral bodies and elongate spinal structures.
a. Preparation of the patient:
i. Check the weight of the patient
ii. Patient is positioned supine on the table with belt underneath
iii. Inform the patient about the treatment and pull to be experienced
b. Treatment:
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Jaipur Ph.: 2356944, 2357570
i. Explain the procedure to the patient
ii. Set the tension according to the patient’s body weight
iii. See that the belt around the patient is secured
iv. Adjust the traction machine height for correct pull alignment
v. Have an emergency shut off device available to the patient
vi. Duration of the treatment is 15 – 20 minutes
c. Precautions:
i. Do not move during the treatment
ii. Use the emergency shut off device if needed
iii. Traction not advised during osteoporosis, pregnancy, bone tumors,
spinal infection and fractures
d. Infection control
i. Wrap a tissue paper on the cervical head halter for every treatment.
7. Electric Stimulation:
Procedure:
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Electrical stimulation is the use of electricity to stimulate nerves and muscles. It is used to
accomplished a variety of therapeutic purposes, such as effect on de innervated muscles,
innervated muscle and decreased spasm
a. Preparation of the patient:
i. The part to be treated must be cleaned and free form cuts, rashes or
infections
ii. Inform the patient about the treatment and sensation to be experienced
– mild pricking sensation
b. Treatment:
i. Explain the procedure to the patient
ii. Place the dispersive electrode on an antagonistic muscle surface and
active electrode over area being treated
iii. Set the intensity based on the muscle contraction
iv. Duration of the treatment 10 – 20 minutes
c. Precautions:
i. Use correct type of current for de innervated and innervated muscles
ii. Equipment should be over mackintosh sheet
iii. Make sure the intensity knob to be turned to zero prior to turning on
the machine
d. Infection control:
i.
Use a new cotton padding for every treatment.
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8. Continuous Passive motion :
Procedure:
The passive movement of lower extremities through a predetermined range of motion by
the use of a mechanical device.
a. Preparation of the patient:
i. The part to be treated must be covered with a dressing to maintain sterile
conditions
ii. Inform the patient about the treatment and movement in the knee
within pain free
range.
b. Treatment:
i. Explain the procedure to the patient
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ii. Adjust the unit under the patient with the anatomical joint aligning
with the mechanical hinge joint on the machine.
iii. Place joint in the machine and secure safety straps
iv. Set the beginning and end range of motion degrees on the machine.
v. Turn the unit on and monitor for security of treatment area, joint
placement, and patient complaints
vi. Provide the patient with an emergency shut off switch in case of any
discomfort
c. Precautions:
i. For safety of the patient, be sure to remove all linen and clothing away
from roller tracks
ii. Make sure the setting knob to be turned to zero prior to turning on the
machine
d. Infection control:
i. Clean the equipment with spirit once a week
9. Exercise Therapy :
Procedure:
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Exercise is physical activity in order to improve one’s health. Physicians, and physical
therapist, have found that exercise plays an important role in the maintenance of brain,
nerve and muscle function in the human body. Therapeutic exercises have been designed
to enhance a variety of aspects of physical fitness in patients suffering from diseases and
dysfunctions. New research suggests that exercise may delay mental deterioration with
age and disease.
a. Goals of Exercise therapy
i. To improve blood circulation
ii. To improve co-ordination
iii. Maintain balance
iv. To increase muscle power
v. Joint mobility
vi. To improve flexibility
vii. To strengthen the muscles
viii.
To increase respiratory capacity
b. Preparation of the patient:
i. Positioning the patient
ii. Explanation and demonstration of the exercise
c. Various types of exercise are
i. Active exercise
ii. Active Assistive exercise
iii. Resistive exercise
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iv. Passive exercise
v. Mobilization
vi. Independence in mobility
vii. Spinal exercise
viii.
Respiratory exercise
ix. Strengthening exercise
x. Co-ordination exercise
xi. Vertigo exercise
xii. Mat exercise
xiii.
Postural drainage
xiv.
Massage
xv.
Chest manipulation
xvi. Diabetic exercise
xvii. Antenatal exercise
xviii. Post natal exercise
xix. Pre operative exercise
xx.
Post operative exercise
xxi. Pelvic floor exercise
xxii. Ambulation exercise
10.Pulmonary Function Test:
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Pulmonary function test is performed to assess the functional states of the lungs. It
measures how well the lungs take in and exhale air and how efficiently they transfer
oxygen into the blood.
a. Procedure:
In a pulmonary function test or spirometry test, a person breathes into
mouthpiece that is connected to an instrument called a spiro meter. The
spiro meter records the amount and the rate of air that is breathed in and
out over a specified time. Some of the test measurements are obtained by
normal, quiet breathing and other tests require forced inhalation or
exhalation after a deep breath.It is designed to measure changes in volume
and can only measure lung volume compartments that exchange gas with
the atmosphere. Spiro meters with electronic signal outputs also measure
flow (volume per unit of time). A device is usually always attached to the
spiro meter which measures the movement of gas in and out of the chest and
is referred to as a spiro graph. Sometimes the spiro graph is replaced by a
printer. The resulting tracing is called a spiro gram. Many computerized
systems have complex Spiro graphs or printouts that show the predicted
values next to the observed values (the values actually measured). The unit
will have in memory all of the prediction tables for males and females
across all age groups.
b. Precautions:
i.
Do not eat a heavy meal before the test
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ii.
Do not smoke for 4 – 6 hours prior to the test
iii.
Do not exercise strenuously prior to the test
iv.
If you have dentures, wear them during the test to help you to form a
tight seal around a mouth piece of the spiro meter.
c. Infection control:
i.
Turbine pneumotach as to be cleaned once a week with cidex
solution
ii.
Mouth piece has to be discarded after each use
G. Departmental Policy :
1.Qualifications of physiotherapists:
All Physiotherapists should have completed bachelors Degree/Diploma in physiotherapy.
2. Initial Assessment of patient:
An initial assessment of every patient will be entered by a physiotherapist in the patients
case sheet, for inpatient initial assessment must be recorded in the patients bed side ticket.
a. Initial assessment will include information gathered by the
physiotherapist as follows:
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Jaipur Ph.: 2356944, 2357570
i. Past medical, surgical history, present history and forms of
treatment
ii. Doctor provided primary and secondary diagnosis, with onset
iii. Patient’s current clinical condition
iv. Pain assessment
v. Muscle power
vi. Range of motion
vii. Functional limitations
viii.
Problems of dysfunction
ix. Activities of daily living (ADL)
x. Splints used or anticipated
xi. Treatment plan
b. All assessment and evaluation must be performed by the
physiotherapist. Patient’s progress is entered in patients case sheet/Bed
side Ticket as applicable and will exhibit overall response to the initial
treatment plan.
3. Discharge Plan :
Patient will be discharged from the department according to the assessment of the
patient’s level of functioning and treatment goal. Through assessments and evaluations
of patient progress, discharge plans will be formulated. An assessment of the patient’s
home programme will be made upon initial assessment to allow for formulation of early
plans for discharge.
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a. The Discharge plan includes:
i. Total length of time in active physiotherapy care.
ii. Comparison of all objective data (range of motion, strength,
special testing) to initial findings
iii. Comparison of patient complaints.
iv. Treatment provided to the patient during the course of treatment.
v. Physiotherapy care.
vi. Patient’s current clinical condition and status as discharged from
active physiotherapy care
vii. Plans for discharge will be formulated in a collaborative manner
with the patient.
viii.
Communication with the consultant about the patient’s
condition
ix. Arrangement of all necessary medical aids for the patient prior to
discharge
x. The patient will be discharged when the above mentioned criteria
have been met.
xi. If the inpatient have to continue physiotherapy after discharge will
be mentioned in the discharge summary by the consultant.
4. Safety Measures :
Department Precautions :
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1.
The physiotherapist is responsible for maintaining safety standards,
developing safety rules, supervising and training staff in departmental
standards.
2.
The physiotherapist is responsible for informing facility in case of any
safety hazard.
3.
All physiotherapy employees shall report defective equipment, unsafe
conditions and acts, or safety hazards to the head of the department.
4.
Safety measures include:
a. Keeping electrical cords clear of passageways. Avoid using electrical
extension cords.
b. Proper storage of all equipment and supplies. Do not store heavy items on
top shelves. Scissors, knives, pins, razor blades and other sharp
instruments must be safely stored and used.
c. Turning off all electric machines with heat producing elements when not
in use.
d. Notification to facilities department immediately of improper illumination
and ventilation.
e. Arrangement of furniture and equipment must be arranged to allow
passage and access to exits at all times.
f. Giving information regarding minor spills, such as water to cleaning team
by the employee who discovers the spill immediately.
g. Reporting faulty equipment to the clerk incharge for equipment
maintenance or vendor as per policy.
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h. Obey warning signs.
i. Usage of appropriate personal protective equipment.
j. Safety precautions such as closing file drawers and cabinet doors when not
in use. Open only one drawer at a time. Even distribution of material to
prevent the file cabinet from being unbalanced and tipping over
k. Frequently inspect cords, plugs, switches, sockets and outlets for damage.
Report any defects such as frayed cords, broken plugs, etc. immediately.
5.
Not leaving equipment standing in traffic lanes. Return equipment to its
proper location when not in use.
6.
Do not obstruct fire equipment. Know location of fire fighting equipment
and how to use it. Know evacuation routes and what to do in case of fire.
H.
Patient Safety:
1. Patient’s safety is at all times given highest priority. No action should be
undertaken which would knowingly be harmful or potentially harmful to
patient
2. All patients shall receive the utmost care and attention from the
physiotherapy staffs. All patients shall be assured of their privacy and
dignity while on their treatment.
3. Explanation of the procedure and hand out is to be given before the
treatment
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4. No In patients will be shifted to the physiotherapy department for
treatment with out an accompanying hospital staff.
5. Patients will be lifted correctly. Get help when needed. Use mechanical
aids when necessary.
6. Be sure that disc and pads are wrapped with towels to prevent accidental
burns to the patient.
7. Obtain the necessary assistance to safely aid the patient in ambulating and
exercise therapy.
8. Do not leave elderly, pediatric or confused patients unattended on therapy
tables or in therapeutic wax bath.
9. When transporting a patient to the treatment area by wheelchair, take the
following safety precautions.
a. Lock the wheel brakes or otherwise secure the vehicle in place
before moving patient to/from transport.
b. Prevent the patient from falling by using safety belts or side rails.
c. Position yourself at the patient’s head, push slowly, steadily.
I.
Maintenance of patient’s confidentiality:
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1. In the course of performing work responsibilities all information with regard
to patient, their family, their physician and / or the hospital will be kept
confidential.
2. Physiotherapist are cautioned by the administration of the hospital not to
discuss any such information with others,
3. Causal comment with fellow co-workers in the hallways, lobby or other place
may be overheard and violate the trust others have placed in physiotherapist.
J.
Maintenance of Equipment:
The following aspects of equipment maintenance are to be ensured :
a. Periodic servicing: Service to be conducted by Qualified company
Service personals
b. Proper technical care to be taken during the maintenance.
Periodic Servicing:
a. Periodic servicing must be done as instructed by the respective
instrument’s manual or by the company person. Mention in the
equipment history card the date of equipment commissioned and break
down during warranty period.
b. Equipment not working must be tagged “OUT OF ORDER”
c. Any work carried out by the instrument / equipment’s technician or
engineer should be recorded in Instrument History card as follows:
i. Time spent for servicing.
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ii. Description of service being carried out
iii. Status of equipment after servicing
iv. Name of the technician / engineer attended
Logging complaint during Breakdown
a. First switch off the equipment.
b. Inform the clerk incharge of equipment maintenance and higher
authorities.
c. Raise the work order.
d. The company person is called .
e. Log complaint to company service department.
f. Display out of order board near the machine.
g. Log the incident in the History card with time.
h.Once the engineer has diagnosed the problem inform authorities.
Reporting Format (Monthly ) to be forwarded to the Chief Medical
Superintendent :
Enter daily statistics
DATE
1
2
3
4
5
6 7
8
9
-
-------------------
3
1
to
tal
OP pts
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IFT
0
ULTRASOUN
D
0
WAX
0
TRACTION
0
MOIST
THERAPY
0
COLD
THERAPY
0
CPM
0
SHORT
WAVE
0
ELECTRICA
L
STIMULATI
ON
0
EXERCISES
0
sub total
0
0
0
0
0
0 0
0
0
0
0
0
0
0
IP pts
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 188 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
CHEST
PHYSIO
0
ORTHO
EXERCISES
0
NEURO
EXERCISES
0
US
0
SWD
0
TRACTION
0
IFT
0
CPM
0
COLD
THERAPY
0
EXERCISES
0
sub total
0
0
0
0
0
0 0
Prepared and Issued By:QM-Dr Pratima
Singh
0
0
0
0
0
0
0
Reviewed and Approved By:Director Dr
Shivraj
Page 189 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
COP.17: Policies and procedures guide nutritional therapy.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 190 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Purpose: To provide & document the method of providing Dietetic /Nutrition & Food Services
System with the aim to :



Establish the effective, efficient and safe practices,
Patient requirements are being satisfied,
Continually improve the Quality Management System.
Scope of services: It covers all patients who are admitted in Hospital.
Responsibility Persons: Dietician, Kitchen In charge and Medical Superintendent
Procedure:
The competence of all persons working is regularly assessed and the practical skills are
monitored.
Daily general hygiene of all staff is checked for cleanliness. Uniforms are issued and cleaned
uniforms are used in regular hours. Health check up of all staff working is checked at least once
a year.
Daily duty roaster is prepared for Cooks and put on notice board and every person. Adequate
leave / compensation are given for extra duty performed.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 191 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
A Diet Sheet is prepared by duty nursing staff as per the treating consultant instruction on the
patient’s case sheet, which contain the:



Name of patient
Room number / Ward
Diet recommended by Doctor.
The Dietician collects these in morning from respective wards.
In case patient is directed to have special food which is not available in the hospital or the
patients insist upon having home made food, the dietician/ward nurse shall educate the patient
relative about the specific requirement of the patient and the precautions to be taken while
preparing the diet.
Hot tea is served in morning as per diet sheet.
Hot milk and Bread is served in evening.
Dietician checks all:
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 192 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570



Diet sheets
Necessary changes in the diet to be provided (based on information received).
Checks the issue quantity and quality of food materials for lunch
Each patient’s medical records are checked by doctor and changes made in their diet depending
on
their
condition,
tastes
and
medical
requirement.
Changes made are recorded on the diet sheet. Each and every patient is met daily.
Cleaning Activities:
Utensils are cleaned with help of servant after every meal.
All equipment cleaned after every meal.
Floor is washed after every meal.
Windows & tiles are cleaned as need based.
Garbage and kitchen waste segregated in dry and wet and disposed in separate plastic bags and
are removed from food service area
Purchasing:
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 193 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Sources identified & rate fixed through purchase committee. Purchase order made for all
suppliers used in kitchen.
Purchases are ordered to suppliers in written, on the approved rate as per requirements and
patients strengths.
Weekly requirements as per need are put up on requisition for approval for ordering.
In case of emergencies cash purchases are made on petty cash system.
All materials purchased are entered at main gate and checked by Non-Medical store In charge.

Quantity ordered placed& quantity received Qty

Quality-brand

Date of expiry

Vegetables checked
Food storage area exists to ensure food preservation.
COP.18: Policies and procedures guide the end of life care.
Care Activity:

CPR to be given by Medical Officer on Duty and the attending nurse

Information to the treating Consultant to be given by Medical Officer on duty,
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 194 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570

Medical Superintendent) of the hospital to be informed about the death.

The necessary details regarding condition of the patient and details of CPR is to be
written in patient’s file to ensure proper medical record for MRD.

In case of the event of impending death of a patient, the medical team regularly updates
the
patient’s
representatives
about
the
patient’s
condition.
The
patient’s
representatives are allowed to interact with the patient. At most sensitivity is
maintained by the medical team in educating and counseling the patient
representatives.

Death of a patient is handled carefully with concern without complacency. Counseling of
next of kin with sympathy is given at most importance. All help in shifting the body from
the hospital is extended to the next of kin. The dead body is released as soon as possible
after completion of all formalities.

Acknowledgement for receipt of the body and the Death Certificate is obtained from
Next of Kin/Legal representative. Handing-over of the body is a Solomon occasion and it
is ensured that hospital staff takes due care and concern in this respect. Due
arrangements are made if preserving the body in the mortuary is found necessary.

A representative of the hospital is present till the departure of the deceased. Security
personnel on duty ensure orderliness in handing over the body to the next of kin.

Incase of MLC case, the local police station informed. The body is handed over to the
police and entry made in the MLC register.

Religious sentiments are given due consideration. Patients relatives are allowed time
with the body. Incase of impending death of a patient, relatives are allowed to perform
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 195 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
the religious beliefs without disturbing other patient. The hospital management along
with its staff extends all possible help.
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 196 of 197
Marudhar Hospital
Quality Operating
Process
Document No :
Manual of Operations
Care of Patients
Date of Issue :
01/01/2013
MH/CoP/01-18
A-93-99, Singh Bhoomi, Khatipura,
Jaipur Ph.: 2356944, 2357570
Prepared and Issued By:QM-Dr Pratima
Singh
Reviewed and Approved By:Director Dr
Shivraj
Page 197 of 197