KHYBER MEDICAL INSTITUTE PESHAWAR PAKISTAN
Standard Operating Procedures
2010
By: P&D-M&E
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
TABLE OF CONTENTS
DEPARTMENT OF MEDICINE ......................................................................................................................................... 6
SOPS FOR EMERGENCY TRAY .............................................................................................................................................. 6
Emergency Tray Equipment............................................................................................................................................ 6
Emergency Medicines ..................................................................................................................................................... 7
SOPS FOR PRESCRIPTION OF DRUGS .................................................................................................................................... 8
General Principles for Prescribing of Drugs ................................................................................................................. 8
Administering intravenous drugs .................................................................................................................................... 8
Administering Oral Drugs .............................................................................................................................................. 8
SOPS FOR ADMISSION TO IN PATIENT CARE ON THE WARD ................................................................................................. 9
Who Can Admit ............................................................................................................................................................... 9
SOPS FOR DISCHARGING THE PATIENTS ............................................................................................................................ 10
In patient Consultation Between Different Units of the Hospital ................................................................................. 10
SOP FOR PRIVATE ROOMS ................................................................................................................................................. 11
Admission Criteria ........................................................................................................................................................ 11
Admission Process ........................................................................................................................................................ 11
Private Rooms Services ................................................................................................................................................ 11
SOPS FOR CONSULTANT OPD ............................................................................................................................................ 11
SOPS FOR WARD ROUND ................................................................................................................................................... 12
SOPS FOR G.I. ENDOSCOPIES ............................................................................................................................................. 12
DEPARTMENT OF SURGERY......................................................................................................................................... 12
INTRODUCTION ......................................................................................................................................................... 13
ATTENDANCE, PUNCTUALITY AND LEAVE: .......................................................................................................... 13
Admission to Surgical units: ......................................................................................................................................... 13
Admission to Private Rooms ......................................................................................................................................... 14
History Sheets ............................................................................................................................................................... 14
Duty Rotas .................................................................................................................................................................... 14
Academic Activities: ..................................................................................................................................................... 14
Emergency Patients ...................................................................................................................................................... 14
Patient Preparation for Surgeries; ............................................................................................................................... 15
OPD .............................................................................................................................................................................. 15
OPERATION THEATRE: ............................................................................................................................................. 17
MINOR OT: .................................................................................................................................................................. 17
WARD ROUNDS: ......................................................................................................................................................... 17
DURG ADMINISTRATION: ......................................................................................................................................... 18
INDENT BOOK: ........................................................................................................................................................... 18
SAFETY MEASURES: .................................................................................................................................................. 18
WARD CLEANLINESS AND MAINTAINANCE:.......................................................................................................... 18
DEPARTMENT OF GYNAE &OBSTETRIC .................................................................................................................. 19
INTRODUCTION ......................................................................................................................................................... 19
ATTENDANCE, PUNCTUALITY AND LEAVE: .......................................................................................................... 19
Admission to Gynae Units & Labour Room: ................................................................................................................ 19
Admission to Private Rooms ......................................................................................................................................... 20
History Sheets ............................................................................................................................................................... 20
Duty Rotas .................................................................................................................................................................... 20
Academic Activities: ..................................................................................................................................................... 20
Emergency Patients ...................................................................................................................................................... 21
Patient Preparation for Surgeries; ............................................................................................................................... 21
Postoperative Care: ...................................................................................................................................................... 22
OPD & ANC: ................................................................................................................................................................ 22
OPERATION THEATRE: ............................................................................................................................................. 22
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
WARD ROUNDS: ......................................................................................................................................................... 22
DURG ADMINISTRATION: ......................................................................................................................................... 24
DISCHARGE: ............................................................................................................................................................... 24
Labour Room ................................................................................................................................................................ 24
CLINICAL AUDIT: ....................................................................................................................................................... 25
DOCUMENTATION:.................................................................................................................................................... 25
INDENT BOOK: ........................................................................................................................................................... 25
SAFETY MEASURES: .................................................................................................................................................. 25
WARD CLEANLINESS AND MAINTAINANCE:.......................................................................................................... 25
RESEARCH AND CLINICAL TRIALS: ........................................................................................................................ 26
DEPARTMENT OF OTO-RHINO-LARYNGOLOGY (ENT) ....................................................................................... 27
ATTENDANCE, PUNCTUALITY AND LEAVE: .......................................................................................................... 27
Admission to ENT units: ............................................................................................................................................... 27
Admission to Private Rooms ......................................................................................................................................... 28
History Sheets ............................................................................................................................................................... 28
Duty Rotas .................................................................................................................................................................... 28
Academic Activities: ..................................................................................................................................................... 28
Emergency Patients ...................................................................................................................................................... 28
Patient Preparation for Surgeries ................................................................................................................................ 29
OPD .............................................................................................................................................................................. 29
OPERATION THEATRE: ............................................................................................................................................. 29
WARD ROUNDS: ......................................................................................................................................................... 30
DURG ADMINISTRATION: ......................................................................................................................................... 31
INDENT BOOK: ........................................................................................................................................................... 31
SAFETY MEASURES: .................................................................................................................................................. 31
WARD CLEANLINESS AND MAINTAINANCE:.......................................................................................................... 31
DEPARTMENT OF OPHTHALMOLOGY ...................................................................................................................... 32
INTRODUCTION ......................................................................................................................................................... 32
ATTENDANCE, PUNCTUALITY AND LEAVE: .......................................................................................................... 32
Admission to units ......................................................................................................................................................... 33
Admission to Private Rooms ......................................................................................................................................... 33
History Sheets ............................................................................................................................................................... 33
Duty Rotas .................................................................................................................................................................... 33
Academic Activities ....................................................................................................................................................... 33
Emergency Patients ...................................................................................................................................................... 34
Patient Preparation for Surgeries ................................................................................................................................ 34
OPD .............................................................................................................................................................................. 35
OPERATION THEATRE ............................................................................................................................................... 35
WARD ROUNDS .......................................................................................................................................................... 35
DURG ADMINISTRATION .......................................................................................................................................... 36
INDENT BOOK: ........................................................................................................................................................... 36
SAFETY MEASURES: .................................................................................................................................................. 36
WARD CLEANLINESS AND MAINTAINANCE:.......................................................................................................... 36
DEPARTMENT OF PEDIATRICS & CHILD HEALTH ............................................................................................... 37
Admission Policy .......................................................................................................................................................... 37
Ward Discharge Policy ................................................................................................................................................. 37
Ward Round Policy ....................................................................................................................................................... 38
Patients Investigations & Procedures Policy ............................................................................................................... 38
Inject able Drug Policy ................................................................................................................................................. 38
Ward Referral Policy .................................................................................................................................................... 38
Ward Emergency Policy ............................................................................................................................................... 38
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
ACCIDENT & EMERGENCY SERVICES DEPARTMENT ......................................................................................... 40
Standard Operative Procedures ................................................................................................................................... 40
Dog Bite ........................................................................................................................................................................ 40
STANDARD OPERATIVE PROCEDURES ................................................................................................................................ 41
General Instructions: .................................................................................................................................................... 41
Medicines in casualty: .................................................................................................................................................. 41
STANDARD OPERATIVE PROCEDURES ................................................................................................................................ 42
Trauma/Fire arm injury/Road traffic accident ............................................................................................................. 42
Airway ........................................................................................................................................................................... 42
Breathing: ..................................................................................................................................................................... 42
Circulation:................................................................................................................................................................... 42
Disability and deformity: .............................................................................................................................................. 43
AVPU System ................................................................................................................................................................ 43
Glasgow Coma Scale ...................................................................................................................................................................43
Exposure and Environment ........................................................................................................................................... 44
Adjuncts ........................................................................................................................................................................ 44
Vital signs ..................................................................................................................................................................... 44
MASS EMERGENCIES/BOMB BLAST INJURY/TERRORIST ACTIVITIES .................................................................................. 45
CCU CARDIOENT OF ACUTE MYOSPITAL - SOPS .................................................................................................. 46
GATE PASS SOPS ............................................................................................................................................................ 46
I/V LINE ........................................................................................................................................................................ 46
Management of Acute Myocardial Infarction Admitted to CCU .................................................................................. 47
SOPS FOR SURGICAL ICU .............................................................................................................................................. 49
ADMISSION CRITERIA ......................................................................................................................................................... 49
ON ARRIVAL IN SICU ........................................................................................................................................................ 49
MORNING ROUNDS ............................................................................................................................................................. 49
EVENING ROUNDS .............................................................................................................................................................. 50
INFECTION CONTROL .......................................................................................................................................................... 50
I/V LINE ........................................................................................................................................................................ 50
GATE PASS SOPS ............................................................................................................................................................ 50
SOPS FOR MEDICAL ICU ................................................................................................................................................ 51
Hierarchy ...................................................................................................................................................................... 51
Criteria for admission in MICU ................................................................................................................................... 51
Documentation .............................................................................................................................................................. 51
GATE PASS SOPS ............................................................................................................................................................... 52
Infection Control ........................................................................................................................................................... 52
IV line ........................................................................................................................................................................... 52
PULMONOLOGY UNIT .................................................................................................................................................... 53
STANDING OPERATING PROCEDURE FOR BRONCHOSCOPY ................................................................................................. 53
Duties of Bronchoscopy Technician/Reg/TMO ............................................................................................................. 53
STANDING OPERATING PROCEDURE FORASPIRATION & BIOPSY ........................................................................................ 54
Duties of Technician, Reg/TMO/MO ............................................................................................................................ 54
STANDARD OPERATING PROCEDURE FOR CHEST INTUBATION .................................................................... 54
Duties of Technician, Reg TMO/MO ............................................................................................................................ 54
STANDARD OPERATING PROCEDURES .................................................................................................................... 56
PATIENT’S HISTORY, MANAGEMENT AND TRAINING OF JUNIOR DOCTORS. ............................................ 56
SOPS FOR ANESTHESIA DOCTORS ............................................................................................................................. 57
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
Checking Anesthesia Equipments ................................................................................................................................. 58
Anesthetizing a Patient ................................................................................................................................................. 58
Documentation / Record Keeping ................................................................................................................................. 58
SOP’S FOR UTILIZATION OF ZAKAT FUND.............................................................................................................. 59
Investigations:............................................................................................................................................................... 59
DECISIONS ...................................................................................................................................................................... 62
DISASTER …………………BE PREPARED -A GENERAL REVIEW ...................................................................................................63
Steps to be taken ........................................................................................................................................................... 64
1.
2.
3.
4.
5.
6.
7.
Nomination of a focal person .............................................................................................................................................64
Formation of Disaster Management Groups (DMGs) ........................................................................................................64
Medicines...........................................................................................................................................................................64
Equipments ........................................................................................................................................................................64
Blood .................................................................................................................................................................................65
Instruments ........................................................................................................................................................................65
Ambulances .......................................................................................................................................................................65
Crisis Management Team (CMT) ................................................................................................................................. 66
Objective ....................................................................................................................................................................... 66
Group of Surgeons / Anesthetist ................................................................................................................................... 67
Doctors to be present at site of Mass Emergency ......................................................................................................... 69
Diagnostic Services Management Group ..................................................................................................................... 70
Medicine and Surgical Disposable Management Group .............................................................................................. 70
DMG-6
Information and Registration Group ......................................................................................................... 70
MASS EMERGENCY AREAS (RED ZONES) ......................................................................................................................................71
Logistics ........................................................................................................................................................................ 71
TELEPHONE NUMBERS OF PROFESSORS ............................................................................................................. 72
Introduction .................................................................................................................................................................. 74
Guidelines for the patients ............................................................................................................................................ 74
Ultrasound .................................................................................................................................................................... 74
X-ray ............................................................................................................................................................................. 74
CT Scan......................................................................................................................................................................... 74
MRI ............................................................................................................................................................................... 74
Staff ............................................................................................................................................................................... 74
Revenue ......................................................................................................................................................................... 75
Duty Rota ...................................................................................................................................................................... 75
Cleanliness .................................................................................................................................................................... 75
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DEPARTMENT OF MEDICINE
SOPS FOR EMERGENCY TRAY



Every unit should have an emergency medical tray with purpose built portable trolley.
Medical emergency tray be kept in an accessible & should be routinely monitored by staff
nurse to ensure that all supplies are replaced & weekly checked by registrar & monthly by
hospital inspection team
All the equipment should be in working condition & emergency life saving drugs should be up
to date.
EMERGENCY TRAY EQUIPMENT























Following equipment should be present in working condition all the time.
Ambu bag at least two checked for physical integrity once a week.
Masks of different types & sizes
Flash light with extra batteries
Portable small size oxygen cylinders with proper gauge & masks
BD syringes of various sizes
Swabs, sponges, cotton & adhesive taps
Gloves
Stethoscope, blood pressure set of good quality
Laryngoscope
Disposable oral airways of various sizes
Scissors
IV canulas of different sizes
Catheters & naso gastric tubes of various sizes
CVP lines
Lumber puncture needles of different sizes
Cat gut, silk & artery forceps
Small portable sucker machine
Defibrillator(01)
ECG machine (01)
Nebulizers(02)
Chest tube with under water seal(03)
Glucometer with strips
Ophthalmoscope
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
EMERGENCY MEDICINES
S.NO
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
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Medicine
Adrenaline of different strength
Antihistamine like Avil injection
Atropine Sulphate
Hypertonic
Soda bicarbonate & Calcium gluconate vial
Injection Dobutrex & Dopamine
Inj. Solucortef of different strength
Inj. Decadron
Inj.Lignocaine
Inj. Diazepam
Tab. Inderal, thyroxine & lanoxin
Tab. Asprin
Angesid ( Sublingual nitrate tab.)
Inj. Lasix
Inj. Nalaxone
Inj. Flumazanil
Activated Charcoal
Drips
Potassium Chloride
Isoket Inj.
Inj. Vitamin K
Inj. Zantac
Inj. Transamine
Ventoline Solution
Atem nebulas
Inj. Aminophyline 250 mg
Humalin Regular. 70/30
Anti snake venoms
Inj. Sandostatin
Kleen enema
Inf. Hemacell
Quantity
5
10
5
10
5 each
5 each
10 each
10
5
5
10
10
03
10
05
05
05
10
05
05
05
05
05
03
20
10
05
10
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
SOPS FOR PRESCRIPTION OF DRUGS
GENERAL PRINCIPLES FOR PRESCRIBING OF DRUGS
 To prescribe a drug is to take responsibility to relive ( or otherwise) the suffering of a patient
by a doctor
 Prescription should be written in clear hand writing & capital letters preferably ( write for
others than your own self). Poor hand writing can result in lethal mistakes. The doctor should
sign each prescription with his/ her name written beneath his/her signature.
 The drug advised should be easily available, economical & effective. The word effective means
that the drug is considered effective by the institution or the Deptt. or the unit
 The doctor should be well versed with the use, interactions & side effects of the drug
prescribed
 The strength of drug , dosage, mode of administration & duration of use should be clearly
mentioned in English/ universal technical language on in patient treatment sheet. For out
patient prescription, preferably, local language/ urdu should be used.
 A leading zero may be used( eg. 0.5 mg as 5mg may be read as 5 mg). Avoid using trailing zero
which may be misread ( eg. 5.0mg may be read as 50 mg)
 The doctor should know the cost of medicine prescribed & tailor it according to the socioeconomic status of the patient as it may be the only cause of non-compliance.
 Drugs available in hospital pharmacy should be given priority.
 If a drug is not available in the hospital pharmacy then drugs available at endowment fund
pharmacy should be prescribed
 Drugs from outside the hospital should only be prescribed when utterly necessary after
discussion with the team
ADMINISTERING INTRAVENOUS DRUGS
First dose of IV drug should be given by the doctor on duty with attention of the following
 Identify the patient
 Ask the patient about history of adverse reaction to the drug being given
 Check the name , strength & expiry date of the vial with a team member( Doctor Or Nurse)
 Intradermal test dose
 Make sure adrenaline, hydrocortisone & antihistamine injections are at hand
 Document that 1st. dose was given (time, date, doctor name with designation & signature)
with no adverse reaction. In case of adverse reaction, a detail account must be documented.
 If a drug needs to be given frequently after the 1st. dose( on the same admission) it should be
given by a nurse who should follow step 1.4 & document in the nursing note/ treatment sheet
 If an IV line is blocked, the nurse on duty should inform SHO/TMO to replace it so that the
patient can be given prescribed drug.
ADMINISTERING ORAL DRUGS
Nurse should administer oral drugs with attention to the following points
 Identify the patient
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR


Ask the patient about history of adverse reaction to the drug being given
Check the name, strength & expiry date of the drug with a team member (nurse)
SOPS FOR ADMISSION TO IN PATIENT CARE ON THE WARD
WHO CAN ADMIT
o Admission from OPD should be done by the registrar & above
o Admission through casualty should be done by on call member of the team( SHO/ TMO) after
proper referral from CMO ( Pt should receive emergency treatment in the casualty, stabilized &
only then referred to ward on call
1. If SHO/ TMO believe there is sufficient reason. he can admit the patient
2. If SHO/ TMO can not make a decision he can put the patient under observation & call
the registrar & seniors while starting requisite treatment of the patient
o Casualty can not be used as OPD. Non- emergency patients using casualty as portal of
admission to ward on call should pay executive admission fee
o Admission after 2 Pm from consultants private clinic should be direct to ward on call with out
going through ( executive admission fee may be levieved)
o Referral from other hospitals should be admitted via casualty
o On admission , detail history should be taken by the house officer on arrival, followed by a
summary of the patient by the TMO on duty
o For medico-legal cases proper official referral & presence of police is mandatory
o Proof of identity should be must for every patient
o Afghans with out registration cards should be separately marked
o RMO must accompany un accompanied & with out identity patients ( Lawaris patient) to the
ward for admission & should arrange all the necessary arrangements for management.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
SOPS FOR DISCHARGING THE PATIENTS
o Patient should be discharged by senior registrar or above
o The decision of discharging the patient should be taken a day earlier with intimation to patient
& his/ her relatives
o Discharge summary should be prepared by the SHO & checked by TMOO/ Junior registrar/ SR
with particular attention to the following details
1. Patient name
2. Admission number
3. Date of admission
4. Date of discharge
5. Diagnosis
6. Details of investigations & treatment given
7. Details of intra or interdepartmental consultation
8. Details of treatment to be taken at home
9. Details of follow up
IN PATIENT CONSULTATION BETWEEN DIFFERENT UNITS OF THE HOSPITAL
o Call for consultation to other units be sent before 11 AM
o Call in emergency or off hours should be directed to JR/SR
o Each call should be properly written with clearly identified purpose of consultation along with
all investigations
o During working hours, SR/ Asstt. Prof. should write call to VS, VP Or VG and then follow it up to
ensure that calls are appropriately written & attended to with desired help to the patient
o After working hours, the concerned 3rd. year post graduate trainee, JR/SR will write the call &
follow it up
o The consultant/SR of the call receiving unit shall attend the call. In case of their non
availability the JR/ MO/TMO shall attend the call with information to the consultant/SR later
o Once a unit has taken over a patient through a call then they should follow that patient
through out his stay in the hospital & later on through OPD when necessary
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
SOP FOR PRIVATE ROOMS
ADMISSION CRITERIA
o Patient should be hemodynamicaly stable
o Patient does not require frequent monitoring( monitory devices)
o Patient does not have violence issues/ suicidal thoughts)
ADMISSION PROCESS
o Private Room admission should be done on single occupancy basis
o Consultant/ SR, can admit patients in private room directly via CMO
o Consultant/ SR, JR can admit in patients from the ward to private room
o After admission , MO of private room should take history, send investigations & start
treatment as directed by the admitting doctor
PRIVATE ROOMS SERVICES
o There should be one registrar for each side of private rooms
o One MO should be present in each duty shift in each side of private rooms
o One staff nurse should be present in each duty shift on each side of private room
o Registrar of respective side of private rooms should conduct the morning & evening rounds
o 24 hours laboratory & radiological services should be available
o Each room should be connected to nursing station via telecom services
o Each section should have emergency trolleys fully equipped with emergency medicines &
instruments & placed at an accessible area of the nursing station.
o The consultant/ SRs are authorized to shift the patient from private room to respective ward if
needed.
o The consultant /SRs of the respective medical unit will conduct the morning round of the
respective patients in private room & the JR of the respective medical unit will conduct the
evening round.
SOPS FOR CONSULTANT OPD
o
o
o
o
Patient properly evaluated at general OPD be referred to consultant OPD
Record of referral be kept at general OPD & a copy sent to consultant OPD
Patient should be given time & date to see a consultant with intimation to the consultant
Investigations advised by consultant should be reported upon before 1.0 PM so that patient
does not have to come back the second time to get treatment.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
SOPS FOR WARD ROUND
o Medical staff up to SR level would start seeing patients at the start of their working
hours(8.0AM)
o Consultant along with the whole team would start ward round at 9.0 AM
o Senior most consultant ( Prof. / I/C of unit) in the team would conduct the ward round
o Other consultant of the team would extend help in the management by giving their opinion on
the signs & symptoms of the patient
o Evening ward round would be conducted at 8 PM
o Evening ward round would be conducted by Asstt. Prof. alternating with Assoc. Prof. with SR
present
o In the evening ward round, the following will be ensured
1. Instruction in the morning ward round are carried out
2. In the light of new findings, does the treatment to be changed on emergency basis or it
can wait till next morning when the whole team is around
3. If the patient has improved & ready to be discharged , instruction regarding discharge
given so that discharge summary is ready in the morning
SOPS FOR G.I. ENDOSCOPIES
o
o
o
o
o
o
o
o
o
o
o
o
Patient to be reviewed by consultant/SR for the need for endoscopy
If indicated, Registrar/ TMO/ concerned HO to make arrangements for the endoscopy.
A written / informed consent to be taken from the patient/relative
Screening for Hepatitis B, C & HIV must be done
Any preparation required to be given as advised by the consultant/SR
Any pre medication required to be given as advised by the consultant/ SR.
On the morning of the endoscopy, the patient should be shifted to endoscopy suit with an IV
access.
The responsibility of shifting to Endoscopy suit lies with the concerned HO/TMO/ Registrar.
The endosopist should review the patient’s condition and the need for Endoscopy again at the
Endoscopy suit & make sure that the patient is fully prepared with a written consent,
screening done & pre- medication given before proceeding with the endoscopy
Endoscopy finding should be clearly written on the patient chart & biopsy if any taken, should
be properly labelled & processed.
Any post-procedure orders should be clearly written on the chart
The post-procedure care if any advised by the endoscopist, is the responsibility of the
concerned HO/TMO/Registrar, who should receive the patient in the unit after the procedure
& go through the endoscopy findings & instructions.
DEPARTMENT OF SURGERY
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
INTRODUCTION
The Deptt. Of Surgery, KMC Peshawar consists of five General Surgical Units, Orthopedic &
Trauma Unit, Casualty, Plastic Surgery & burn unit, SICU & a Pediatric Unit. Each unit has 46
beds. Patient care means that the doctors & ancillary staff are not only doing so in the wards but
also are using the OPDs, major OT for doing so. It may be mentioned that the major OT not only
has operating rooms but also a recovery room & endoscopy suite besides other areas such as
staff rooms.
Managing patients does not only mean treating disease but involves making sure that this is
done in a way which comfortable both for the patients and relatives, ethical, logical & cost
effective. It must be kept in mind that all medical personnel are part of a team each having their
own roles in patient care. In dealing with patients & relatives medical personnel should be polite
at all times. White coat, name tags & a professional turnout is emphasized for all doctors.
A concerted effort is needed to prevent errors. Standardized systems are needed to minimize
the need to rely on human nature, which is rather imperfect. Legal issues can come up in patient
management. Following a set protocol can go a long way in protecting medical personnel from a
legal view point.
The following are some guidelines that should be followed by the Medical
personnel while
managing patients:
ATTENDANCE, PUNCTUALITY AND LEAVE:
o Senior Registrar should maintain an attendance register of the House Officers, Medical Officers
and Registrar
o The Registrar must ensure the presence of nursing staff, dispensers and auxiliary staff.
o Habitual late comers or absenteeism should be reported by the SR to the MS who should warn
such doctors and later on after the recommendation of the Professor in charge either be
transferred of his/her services terminated. The Dean PGMI should additionally be informed in
case trainees.
o Leave if needed should be applied for two days in advance. This should be signed by a
substitute and Registrar and forwarded by the SR to the MS. Leave for unforeseen
emergencies must be communicated to the Registrar.
o A House Officer is allowed a total of ten days leave during a six month period. A trainee is
allowed
days per year. A Medical Officer is allowed 25 casual leaves per year. A House
Officer and Trainee is allowed days per year. A Medical Officer is allowed 25 casual leaves per
year. A House Officer and Trainee will have to compensate by leaves per year. A House Officer
and Trainee will have to compensate by additional days in their training should their leave
exceed the allotted number of days aloe\wed.
1. The leave Register must be maintained by the SR.
ADMISSION TO SURGICAL UNITS:
o All patient needing admission should be offered admission irrespective of whether they have
been seen in a private clinic or in OPD. Emergency patients will take priority as well as those
needling urgent surgery eg. Cancer patients.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o Elective admission should be done after the patient is seen by a person of SR level and above.
The admission should be justifiable
o Should a consultant see a patient in his / her private clinic & refer him/her to the casualty as
an emergency case, the patient should be managed accordingly whether the particular
consultant belongs to that ward or not. The patient may be shifted to the ward the consultant
belongs to , only if he/she has requested to
ADMISSION TO PRIVATE ROOMS
o Medico legal cases & emergency cases should not be admitted to private rooms
o No patient should be admitted to the private room without the approval of a member of the
teaching staff of the ward
o Patients with cardiopulmonary problems, if admitted to private rooms should stay in the ward
for at least 24 hours post op
HISTORY SHEETS
o Patient clerking must be done by the house officer at the earliest possible time following
admission. This should include proper examination of relevant systems & a note of chest
findings, BP, Pulse
o TMO notes & plans in writing are mandatory, especially in emergency cases. However
resuscitation of the patient will take priority
o Daily morning & evening progress report should be recorded by the HO & TMO
DUTY ROTAS
o These should be made by the SR or Assistant Professor of the ward & should include duties in
minor OT, recovery room & ward
o The doctors on duty have to be physically present in the ward
o The HO & TMO can leave the ward after their duty is over only when the next doctor on duty
has arrived. However doctors on duty in the afternoon & night shift should all be present in
the evening round.
1. Doctors should communicate with each other at the time of change of duty ie they
should inform the next doctor on duty the status of serious patients etc
ACADEMIC ACTIVITIES:
o The SR will prepare a list of academic activities to be held on “free days” in liaison with the
professor of the unit
o The HO & TMO must attend classes & demonstrations/ seminars being held in the ward
EMERGENCY PATIENTS
o The registrar should ensure that the emergency drugs, disposables & equipments is available
at all times & in working condition
o Emergency patients should be promptly attended by the HO & TMO. The registrar should see
all emergency admission & record important observations. Should he/she be busy in OT, he/
she should be informed.
SOPs KTH 2010
P&D Cell-M&E
14
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o
o
o
o
Every effort should be made to resuscitate patients if indicated according to ABC protocol
Emergency patients should be closely monitored & findings recorded & dealt with.
Only stable patients can be shifted out of the ward for important investigations.
Important surgical interventions should be done on the same day if the condition of the pt
permits
o TMOs can perform emergency surgeries according to their year of training only under the
supervision of the registrar SR. Should the SR face difficulty he/she should call his next senior.
PATIENT PREPARATION FOR SURGERIES;
o A written , informed consent is a must, duly signed by the pt. his/her immediate relative & the
HO or MO
o Certain aspect must be made in writing , for eg amputations, mastectomy, the need for
permanent stoma etc.
o Common complications should also be mentioned in the consent form
o Should the patient refuse surgery this should be in writing in the presence of a relative &
signed by the pt , relative & doctor.
o The side to be operated upon should be marked.
o The nurse should make sure that the site to be operated on is shaved, jewelry & dentures
removed & all valuables left to a relative. She should know which patients are due for surgery
& that they are shifted to the OT in time. All pre medications & investigations such as fasting
blood sugar & early morning KUB should be positively done & sent with patients. The HO
concerned should make sure that the patient are prepared properly. The HO staying in the
ward on OT day should be present early in the ward & make sure that all these steps are
carried out.
o During the evening round before the OT day, the registrar should make sure that the patient
has the necessary requirements for surgery and calls to any department made if necessary.
o Ideally a copy of the OT list should be intimated to the OT after OPD and one of the
anesthetists concerned with the ward, should carry out a round on the day before surgery, so
that necessary requirements are fulfilled. The anesthetist should ideally carry out his round
with the registrar at a time convenient to all.
o All preoperative investigations including hepatitis and HIV screening should be carried out
before the patient is admitted so that they are ready for timely intervention if needed. They
would prevent unnecessary delays, and wastage of time as well as resentment on the part of
patients for having to be admitted only to be deferred or have a delay.
o Containers for specimens should be available with patients and should be properly marked
beforehand by the House Officer concerned showing the name, bed number, ward and
specimen name.
OPD
o All doctors should be available in the OPD.
o The Dispenser should make sure that the OPD is clean, the instruments sterilized, disposables
available and all equipment and lights etc in working order.
SOPs KTH 2010
P&D Cell-M&E
15
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o The staff should make sure that patients are asked to wait for their turn to prevent
unnecessary chaos.
o Relevant information should be written on the OPD chit and signed.
o All patients due for surgery should be assessed for co morbid conditions, their BP and pulse
noted and chest examined. They should be referred for an assessment for fitness if needed.
Two or three doctors can use a separate room in the OPD for patient workup etc.
o All patients due for surgery should be advised investigations before admission. These should
be seen and corrected if possible, before the patient is admitted.
o A waiting list should be maintained by each ward ideally mentioning the patients contact
number and address. Unforeseen delays should preferably be communicated to the patient.
SOPs KTH 2010
P&D Cell-M&E
16
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
OPERATION THEATRE:
o All OT notes should be complete and then recorded in an OT register.
o The House Officers should ensure that all specimens are sent and received in the ward.
o The chief OT tech is responsible for the cleanliness and discipline of the OT.
o Swab count should be maintained at all times by one member of the operating team and the
same nurse of OT tech. ideally this should be written on a board.
o A House Officer and Trainee of the ward should be present in the recovery room and ward to
respond to unforeseen mishaps.
o All post op patients should be monitored.
o Patients with Hepatitis B or C should be operated according to set protocol which should be
developed by the Surgical Department and the administration.
MINOR OT:
o Two trainees should be present in the minor OT on OPD days to carry out minor procedures
like biopsies, nail avulsions etc.
WARD ROUNDS:
o All morning rounds must be done by a consultant at a set time, preferably starting before 9 am
so as to have time for carrying out orders like investigations, calls etc.
o The evening round must be done daily by the Registrar and important entries made.
o The post of and emergency evening round should be done by the senior registrar/Assistant
professor with the registrars, medical officers and house officers.
o The nurse and dispenser should be present in the round.
o The Head Nurse should make sure that the ward is cleaned and the bedding done before the
round. The nurse should make sure that ward decorum is maintained 24 hours. The attendants
should be asked to leave. One attendant must be present the patient who needs one.
o The Registrar should ensure that all orders of the senior teaching staff regarding patients have
been carried out including referrals to medical and other related specialties.
SOPs KTH 2010
P&D Cell-M&E
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DURG ADMINISTRATION:
o Nurse should make sure that proper drug is given, through proper route at proper time, after
test dose if needed. Expiry dates must be checked. Entries in writing should be made as well as
any reason for not administering the drug. Any confusion, any delays in administering the drug
should be communicated to the Medical Officer or Registrar.
o The House Officer and Medical Officer concerned should make sure that the drugs are
properly and timely administered.
INDENT BOOK:
o The Registrar shall sign the indent book and check all the drugs and IV fluids supplied to the
ward.
SAFETY MEASURES:
o At no time shall any anaesthetic drug be either kept with the other drugs or emergency drugs.
They should preferably be available in the OT and if need to be bough by the patient should be
kept separately.
o All used syringes and IV fluid bottles should be immediately destroyed by the nurse. The Head
Nurse and Registrar should be vigilant about this issue.
WARD CLEANLINESS AND MAINTAINANCE:
o The Head Nurse should make sure that the ward is kept clean at all times. This includes the
floors, windows, beds, toilets, galleries, cupboards, side tables etc. The Registrar should ensure
that this done.
o All equipment or lights etc that needs replacement must be immediately reported to the
Registrar by the Head Nurse and Dispenser.
This protocol should be reviewed every six months and changes/additions made accordingly.
SOPs KTH 2010
P&D Cell-M&E
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DEPARTMENT OF GYNAE &OBSTETRIC
INTRODUCTION
The Department of Gynecology/Obstetric KMC Peshawar consists of 3 Gynae Units and a Labour
Room. Each Unit has 40 beds, Labour Room has 20 beds & gives 24hrs emergency cover.
Managing patients does not only mean treating disease but involves a coordinated approach to
diagnosis, treatment & care services of all patients. This should be done in such a way which is
comfortable both for the patients and relatives and is ethical, logical & cost effective. It must be kept
in mind that all medical personnel are part of a team each having their own roles in patient care. In
dealing with patients & relatives medical personnel should be polite at all times and should have
professional attitude. White coat, name tags & a professional turnout is emphasized for all doctors.
A concerted effort is needed to prevent errors. Standardized systems are needed to minimize the
need to rely on human nature, which is rather imperfect. Legal issues can come up in patient
management. Following a set evidence based protocols will protect medical personnel from medico
legal issues.
The following are some guidelines that should be followed by the Medical personnel while managing
patients:
ATTENDANCE, PUNCTUALITY AND LEAVE:
o Senior Registrar should maintain an attendance register of the House Officers, Medical Officers
and Registrar
o The Registrar must ensure the presence of nursing staff, dispensers and auxiliary staff.
o Habitual late comers or absenteeism should be reported by the SR to the MS who should warn
such doctors and later on after the recommendation of the Professor In-charge either be
transferred or his/her services terminated. The Dean PGMI should additionally be informed in
case of trainees.
o Leave if needed should be applied for two days in advance. This should be signed by a
substitute and Registrar and forwarded by the SR to the MS. Leave for unforeseen
emergencies must be communicated to the Registrar.
o A House Officer is allowed a total of ten days leave during a six month period. A trainee is
allowed
days per year. A Medical Officer is allowed 25 casual leaves per year. A House
Officer and Trainee will have to compensate by additional days in their training should their
leave exceed the allotted number of days aloe\wed.
o The leave Register must be maintained by the SR.
ADMISSION TO GYNAE UNITS & LABOUR ROOM:
o All patient needing admission should be offered admission irrespective of whether they have
been seen in a private clinic or in OPD. Emergency patients will take priority as well as those
requiring urgent surgery eg. C-Section & Gynae emergency.
o Elective admission should be done after the patient is seen by a person of SR level and above.
The admission should be justifiable
SOPs KTH 2010
P&D Cell-M&E
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o Patients who have undergone major surgery should stay in ward for 24hrs postoperative,
before being shifted to private room.
o Should a consultant see a patient in his / her private clinic & refer him/her to the casualty as
an emergency case, the patient should be managed accordingly whether the particular
consultant belongs to that ward or not. The patient may be shifted to the ward the consultant
belongs to, only if he/she has requested to shift that patient.
ADMISSION TO PRIVATE ROOMS
o Medico legal cases & emergency cases should not be admitted to private rooms.
o No patient should be admitted to the private room without the approval of a member of the
teaching staff of the ward.
o Patients with cardiopulmonary problems, if admitted to private rooms should stay in the ward
for at least 24 hours post op.
HISTORY SHEETS
o Patient clerking must be done by the house officer at the earliest possible time following
admission. This should include proper examination of relevant systems, Obstetric &
Gynecological examination
o TMO notes & plans in writing are mandatory, especially in emergency cases. However
resuscitation of the patient will take priority
o Daily morning & evening progress report should be recorded by the HO & TMO
DUTY ROTAS
o These should be made by the Registrar/SR or Assistant Professor of the ward & should include
duties in Ward, Labour Room, O.T, OPD, ANC
o The doctors on duty have to be physically present in the ward
o The HO & TMO can leave the ward after their duty is over only when the next doctor on duty
has arrived. However doctors on duty in the afternoon & night shift should all be present in
the evening round.
o Doctors should not only communicate, with each other at the time of change of duty ie they
should inform the next doctor on duty the status of serious patients etc but should also
maintain a hand over & take over register
ACADEMIC ACTIVITIES:
o The SR will prepare a list of academic activities to be held on “free days” in liaison with the
professor of the unit
o The HO & TMO must attend classes & demonstrations/seminars /journal club/ long cases
being held in the ward
o Regular rehearsal drill of obstetric and Gynaecological emergencies should be done in ward by
the TMO, H.O and supervised by registrar.
SOPs KTH 2010
P&D Cell-M&E
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
EMERGENCY PATIENTS
o The registrar should ensure that the emergency drugs, disposables & equipments are available
at all times & in working condition
o Emergency tray should be regularly updated & maintained by the registrar
o Emergency patients should be promptly attended by the HO & TMO. The registrar should see
all emergency admission & record important observations. Should he/she be busy in OT, he/
she should be informed.
o Every effort should be made to resuscitate patients if indicated according to ABC protocol
o Emergency patients should be closely monitored & findings recorded & dealt with.
o Only stable patients can be shifted out of the ward for important investigations.
o Important surgical interventions should be done on the same day if the condition of the pt
permits
o TMOs can perform emergency surgeries according to their year of training only under the
supervision of the registrar SR. Should the SR face difficulty he/she should call his next senior.
PATIENT PREPARATION FOR SURGERIES;
o A written , informed consent is a must, duly signed by the pt. his/her immediate relative & the
HO or MO
o Certain aspect must be made in writing, eg tubal ligation, high risk consent etc.
o Common complications should also be mentioned in the consent form
o Should the patient refuse surgery this should be in writing in the presence of a relative &
signed by the pt , relative & doctor.
o The site to be operated upon should be marked.
o The nurse should make sure that the site to be operated on is shaved, jewelry & dentures
removed & all valuables & mobiles left to a relative. She should know which patients are due
for surgery & that they are shifted to the OT in time. All pre medications & investigations such
as fasting blood sugar should be positively done & sent with patients. The HO concerned
should make sure that the patients are prepared properly. The HO staying in the ward on OT
day should be present early in the ward & make sure that all these steps are carried out.
o During the evening round before the OT day, the registrar should make sure that the patient
has the necessary requirements for surgery and calls to any department made if necessary.
o Ideally a copy of the OT list should be intimated to the OT after OPD and one of the
anaesthetists concerned with the ward, should carry out a round on the day before surgery, so
that necessary requirements are fulfilled. The anaesthetist should ideally carry out his round
with the registrar at a time convenient to all.
o All preoperative investigations including hepatitis and HIV screening should be carried out
before the patient is admitted so that they are ready for timely intervention if needed. They
would prevent unnecessary delays, and wastage of time as well as resentment on the part of
patients for having to be admitted only to be deferred or have a delay.
o Containers for specimens should be available with patients and should be properly marked
beforehand by the House Officer concerned showing the name, bed number, and ward and
specimen name.
SOPs KTH 2010
P&D Cell-M&E
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
POSTOPERATIVE CARE:
o One house officer and TMO must be available in the ward 24hrs a day for care of the patient.
o The TMO Batch on call must come after O.T for postoperative round.
o The registrar on call should do a postoperative round after O.T.
o Postoperative round must be documented with date and time by H.O /T.M.O , registrar &
consultant on call.
o There must be protocol for resuscitation in case of any complication & immediate contact of
senior as per protocol.
OPD & ANC:
o All doctors should be available in the OPD.
o The Dispenser & Khala should make sure that the OPD is clean, the instruments sterilized,
disposables available and all equipment and lights etc in working order.
o The staff should make sure that patients are asked to wait for their turn to prevent
unnecessary chaos.
o Relevant information should be written on the OPD chit and signed.
o All patients due for surgery should be assessed for co morbid conditions, their BP and pulse
noted and chest examined. They should be referred for an assessment for fitness if needed.
Two or three doctors can use a separate room in the OPD for patient workup etc.
o All patients due for surgery should be advised investigations before admission. These should
be seen and corrected if possible, before the patient is admitted.
o A waiting list should be maintained by each ward ideally mentioning the patients contact
number and address. Unforeseen delays should preferably be communicated to the patient.
OPERATION THEATRE:
o All OT notes should be complete and then recorded in an OT register.
o The House Officers should ensure that all specimens are sent and received in the ward.
o The chief OT tech is responsible for the cleanliness and discipline of the OT.
o Swab count should be maintained at all times by one member of the operating team and the
same nurse or O.T tech. Ideally this should be written on a board.
o A House Officer should be present in the recovery room and ward to respond to unforeseen
mishaps.
o All post op patients should be monitored.
o Patients with Hepatitis B or C should be operated according to set protocol which should be
developed by the Gynae Department and the administration.
WARD ROUNDS:
o All morning rounds must be done by a consultant at a set time, preferably starting before 9 am
so as to have time for carrying out orders like investigations, calls etc.
o The evening round must be done daily by the Registrar and important entries made.
o The post and emergency evening round should be done by the senior registrar/Assistant
professor with the registrars, medical officers and house officers.
o The nurse and dispenser should be present in the round.
SOPs KTH 2010
P&D Cell-M&E
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o The Head Nurse should make sure that the ward is cleaned and the bedding done before the
round. The nurse should make sure that ward decorum is maintained 24 hours. The attendants
should be asked to leave. One attendant must be present the patient who needs it.
o The Registrar should ensure that all orders of the senior teaching staff regarding patients have
been carried out including referrals to medical and other related specialties.
SOPs KTH 2010
P&D Cell-M&E
23
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DURG ADMINISTRATION:
o Nurse should make sure that proper drug is given, through proper route at proper time, after
test dose if needed. Expiry dates must be checked. Entries in writing should be made as well as
any reason for not administering the drug. Any confusion, any delays in administering the drug
should be communicated to the Medical Officer or Registrar.
o The House Officer and Medical Officer concerned should make sure that the drugs are
properly and timely administered.
DISCHARGE:
o The discharge slip should be prepared a day before the expected discharge of the patient by
the H.O & checked & counter signed by T.M.O, so that undue delay and discomfort of the
patient is avoided.
o Decision of discharge should be done by the registrar, S.R or Consultant.
LABOUR ROOM
o 3rd year TMO & House officer Batch on call will do labour room round at 8:00am along with
Registrar. 1st year PG and H.O batch will stay in the labour room from 8:00am ––– 2:00pm. A
4th year PG along with her batch on call will do round at 1:00pm along with the Registrar
o A 1st year PG along with H.O’s will stay in the labour room and 3rd year / 4th year PG will do
round at 6:00pm. The Registrar /S.R and assistant Prof will do round at 7:00pm on
emergencies & will be on call at night.
o The decision of surgery should be taken only after discussion with registrar.
o All high risk patients should be discussed with the consultant on call.
o The consultant on call should also inform about the progress of high risk patient.
o The Head nurse should make sure that the labour room is clean all the times as it is a place of
quick patient turn over. This includes the delivery rooms, instruments, Autoclave, Drugs,
linens, floors, beds, toilets etc. The registrars of the three units should work in collaboration
for maintenance and cleanliness of the labour room.
o The Head nurse and the registrar of the Gynae unit on call should make sure that the
emergency tray in the labour room is completed and updated all the times in order to face any
sort of emergency.
SOPs KTH 2010
P&D Cell-M&E
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
CLINICAL AUDIT:
o Statistical record of the ward should be maintained and regularly checked by the registrar /
S.R.
o Fortnightly or monthly clinical audit meeting should be conducted in the ward & supervised by
the Professor in charge of the ward.
o Adverse events & near miss events should be discussed in no blame environment to improve
patient outcome & should be notified to the administration.
o Protocols for Obstetric & Gynaecological emergencies should be displayed in the Gynae Units
& Labour rooms & regularly updated.
DOCUMENTATION:
o Adequate documentation should be maintained in the charts. All findings & orders should be
legibly written & signed with date & time. This should be regularly checked by the registrar on
call.
INDENT BOOK:
o The Registrar shall sign the indent book and check all the drugs and IV fluids supplied to the
ward.
SAFETY MEASURES:
o At no time shall any anaesthetic drug be either kept with the other drugs or emergency drugs.
They should preferably be available in the OT and if need to be bought by the patient should
be kept separately.
o All used syringes and IV fluid bottles should be immediately destroyed by the nurse. The Head
Nurse and Registrar should be vigilant about this issue.
WARD CLEANLINESS AND MAINTAINANCE:
o The Head Nurse should make sure that the ward is kept clean at all times. This includes the
floors, windows, beds, toilets, galleries, cupboards, side tables etc. The Registrar should ensure
that this done.
o All equipment or lights etc that needs replacement must be immediately reported to the
Registrar by the Head Nurse and Dispenser.
SOPs KTH 2010
P&D Cell-M&E
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
RESEARCH AND CLINICAL TRIALS:
o Research projects will be allowed to the PGs and the teaching staff after being permitted by
the In-charge of the unit and after fulfilling ethical issues.
o There must be at least three research project going on in each gynaecology ward
This protocol should be reviewed every six months and changes/additions made accordingly.
.
SOPs KTH 2010
P&D Cell-M&E
26
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DEPARTMENT OF OTO-RHINO-LARYNGOLOGY (ENT)
ATTENDANCE, PUNCTUALITY AND LEAVE:
o Senior Registrar should maintain an attendance register of the House Officers, Medical Officers
and Registrar
o The Registrar must ensure the presence of nursing staff, dispensers and auxiliary staff.
o Habitual late comers or absenteeism should be reported by the SR to the MS who should warn
such doctors and later on after the recommendation of the Professor in charge either be
transferred of his/her services terminated. The Dean PGMI should additionally be informed in
case trainees.
o Leave if needed should be applied for two days in advance. This should be signed by a
substitute and Registrar and forwarded by the SR to the MS. Leave for unforeseen
emergencies must be communicated to the Registrar.
o A House Officer is allowed a total of ten days leave during a six month period. A trainee is
allowed
days per year. A Medical Officer is allowed 25 casual leaves per year. A House
Officer and Trainee is allowed days per year. A Medical Officer is allowed 25 casual leaves per
year. A House Officer and Trainee will have to compensate by leaves per year. A House Officer
and Trainee will have to compensate by additional days in their training should their leave
exceed the allotted number of days aloe\wed.
o The leave Register must be maintained by the SR.
ADMISSION TO ENT UNITS:
o All patient needing admission should be offered admission irrespective of whether they have
been seen in a private clinic or in OPD. Emergency patients will take priority as well as those
needling urgent surgery eg. Cancer patients.
o Elective admission should be done after the patient is seen by a person of SR level and above.
The admission should be justifiable
o Should a consultant see a patient in his / her private clinic & refer him/her to the casualty as
an emergency case, the patient should be managed accordingly whether the particular
consultant belongs to that ward or not. The patient may be shifted to the ward the consultant
belongs to , only if he/she has requested to
SOPs KTH 2010
P&D Cell-M&E
27
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
ADMISSION TO PRIVATE ROOMS
o Medico legal cases & emergency cases should not be admitted to private rooms
o No patient should be admitted to the private room without the approval of a member of the
teaching staff of the ward
o Patients with cardiopulmonary problems, if admitted to private rooms should stay in the ward
for at least 24 hours post op
HISTORY SHEETS
o Patient clerking must be done by the house officer at the earliest possible time following
admission. This should include proper examination of relevant systems & a note of chest
findings, BP, Pulse
o TMO notes & plans in writing are mandatory, especially in emergency cases. However
resuscitation of the patient will take priority
o Daily morning & evening progress report should be recorded by the HO & TMO
DUTY ROTAS
o These should be made by the SR or Assistant Professor of the ward & should include duties in
minor OT, recovery room & ward
o The doctors on duty have to be physically present in the ward
o The HO & TMO can leave the ward after their duty is over only when the next doctor on duty
has arrived. However doctors on duty in the afternoon & night shift should all be present in
the evening round.
o Doctors should communicate with each other at the time of change of duty ie they should
inform the next doctor on duty the status of serious patients etc
ACADEMIC ACTIVITIES:
o The SR will prepare a list of academic activities to be held on “free days” in liaison with the
professor of the unit
o The HO & TMO must attend classes & demonstrations/ seminars being held in the ward
EMERGENCY PATIENTS
o The registrar should ensure that the emergency drugs, disposables & equipments is available
at all times & in working condition
o Emergency patients should be promptly attended by the HO & TMO. The registrar should see
all emergency admission & record important observations. Should he/she be busy in OT, he/
she should be informed.
o Every effort should be made to resuscitate patients if indicated according to ABC protocol
o Emergency patients should be closely monitored & findings recorded & dealt with.
o Only stable patients can be shifted out of the ward for important investigations.
o Important surgical interventions should be done on the same day if the condition of the pt
permits
SOPs KTH 2010
P&D Cell-M&E
28
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o TMOs can perform emergency surgeries according to their year of training only under the
supervision of the registrar SR. Should the SR face difficulty he/she should call his next senior.
PATIENT PREPARATION FOR SURGERIES
o A written , informed consent is a must, duly signed by the pt. his/her immediate relative & the
HO or MO.
o Common complications should also be mentioned in the consent form
o Should the patient refuse surgery this should be in writing in the presence of a relative &
signed by the pt , relative & doctor.
o The side to be operated upon should be marked.
o During the evening round before the OT day, the registrar should make sure that the patient
has the necessary requirements for surgery and calls to any department made if necessary.
o Ideally a copy of the OT list should be intimated to the OT after OPD and one of the
anesthetists concerned with the ward, should carry out a round on the day before surgery, so
that necessary requirements are fulfilled. The anesthetist should ideally carry out his round
with the registrar at a time convenient to all.
o All preoperative investigations including hepatitis and HIV screening should be carried out
before the patient is admitted so that they are ready for timely intervention if needed. They
would prevent unnecessary delays, and wastage of time as well as resentment on the part of
patients for having to be admitted only to be deferred or have a delay.
o Containers for specimens should be available with patients and should be properly marked
beforehand by the House Officer concerned showing the name, bed number, ward and
specimen
name.
OPD
o All doctors should be available in the OPD.
o The Dispenser should make sure that the OPD is clean, the instruments sterilized, disposables
available and all equipment and lights etc in working order.
o The staff should make sure that patients are asked to wait for their turn to prevent
unnecessary chaos.
o Relevant information should be written on the OPD chit and signed.
o All patients due for surgery should be assessed for co morbid conditions, their BP and pulse
noted and chest examined. They should be referred for an assessment for fitness if needed.
Two or three doctors can use a separate room in the OPD for patient workup etc.
o All patients due for surgery should be advised investigations before admission. These should
be seen and corrected if possible, before the patient is admitted.
o A waiting list should be maintained by each ward ideally mentioning the patients contact
number and address. Unforeseen delays should preferably be communicated to the patient.
OPERATION THEATRE:
o All OT notes should be complete and then recorded in an OT register.
o The House Officers should ensure that all specimens are sent and received in the ward.
SOPs KTH 2010
P&D Cell-M&E
29
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o The chief OT tech is responsible for the cleanliness and discipline of the OT.
o Swab count should be maintained at all times by one member of the operating team and the
same nurse of OT tech. ideally this should be written on a board.
o A House Officer and Trainee of the ward should be present in the recovery room and ward to
respond to unforeseen mishaps.
o All post op patients should be monitored.
o Patients with Hepatitis B or C should be operated according to set protocol which should be
developed by the Surgical Department and the administration.
WARD ROUNDS:
o All morning rounds must be done by a consultant at a set time, preferably starting before 9 am
so as to have time for carrying out orders like investigations, calls etc.
o The evening round must be done daily by the Registrar and important entries made.
o The post of and emergency evening round should be done by the senior registrar/Assistant
professor with the registrars, medical officers and house officers.
o The nurse and dispenser should be present in the round.
o The Head Nurse should make sure that the ward is cleaned and the bedding done before the
round. The nurse should make sure that ward decorum is maintained 24 hours. The attendants
should be asked to leave. One attendant must be present the patient who needs one.
o The Registrar should ensure that all orders of the senior teaching staff regarding patients have
been carried out including referrals to medical and other related specialties.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DURG ADMINISTRATION:
o Nurse should make sure that proper drug is given, through proper route at proper time, after
test dose if needed. Expiry dates must be checked. Entries in writing should be made as well as
any reason for not administering the drug. Any confusion, any delays in administering the drug
should be communicated to the Medical Officer or Registrar.
o The House Officer and Medical Officer concerned should make sure that the drugs are
properly and timely administered.
INDENT BOOK:
o The Registrar shall sign the indent book and check all the drugs and IV fluids supplied to the
ward.
SAFETY MEASURES:
o At no time shall any anesthetic drug be either kept with the other drugs or emergency drugs.
They should preferably be available in the OT and if need to be bough by the patient should be
kept separately.
o All used syringes and IV fluid bottles should be immediately destroyed by the nurse. The Head
Nurse and Registrar should be vigilant about this issue.
WARD CLEANLINESS AND MAINTAINANCE:
o The Head Nurse should make sure that the ward is kept clean at all times. This includes the
floors, windows, beds, toilets, galleries, cupboards, side tables etc. The Registrar should ensure
that this done.
o All equipment or lights etc that needs replacement must be immediately reported to the
Registrar by the Head Nurse and Dispenser.
Note: This protocol should be reviewed every six months and changes/additions made
accordingly.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DEPARTMENT OF OPHTHALMOLOGY
INTRODUCTION
The Deptt. Of Ophthalmology, KTH Peshawar consists of 2 units. Each unit has 46 beds. Patient care
means that the doctors & ancillary staff are not only doing so in the wards but also are using the
OPDs, major OT for doing so. It may be mentioned that the major OT not only has operating rooms
but also a recovery room besides other areas such as staff rooms.
Managing patients does not only mean treating disease but involves making sure that this is done in a
way which comfortable both for the patients and relatives, ethical, logical & cost effective. It must be
kept in mind that all medical personnel are part of a team each having their own roles in patient care.
In dealing with patients & relatives medical personnel should be polite at all times. White coat, name
tags & a professional turnout is emphasized for all doctors.
A concerted effort is needed to prevent errors. Standardized systems are needed to minimize the
need to rely on human nature, which is rather imperfect. Legal issues can come up in patient
management. Following a set protocol can go a long way in protecting medical personnel from a legal
view point.
The following are some guidelines that should be followed by the Medical personnel while managing
patients:
ATTENDANCE, PUNCTUALITY AND LEAVE:
o Senior Registrar should maintain an attendance register of the House Officers, Medical Officers
and Registrar
o The Registrar must ensure the presence of nursing staff, dispensers and auxiliary staff.
o Habitual late comers or absenteeism should be reported by the SR to the MS who should warn
such doctors and later on after the recommendation of the Professor in charge either be
transferred of his/her services terminated. The Dean PGMI should additionally be informed in
case trainees.
o Leave if needed should be applied for two days in advance. This should be signed by a
substitute and Registrar and forwarded by the SR to the MS. Leave for unforeseen
emergencies must be communicated to the Registrar.
o A House Officer is allowed a total of ten days leave during a six month period. A trainee is
allowed
days per year. A Medical Officer is allowed 25 casual leaves per year. A House
Officer and Trainee is allowed days per year. A Medical Officer is allowed 25 casual leaves per
year. A House Officer and Trainee will have to compensate by leaves per year. A House Officer
and Trainee will have to compensate by additional days in their training should their leave
exceed the allotted number of days aloe\wed.
o The leave Register must be maintained by the SR.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
ADMISSION TO UNITS
o All patient needing admission should be offered admission irrespective of whether they have
been seen in a private clinic or in OPD. Emergency patients will take priority as well as those
needling urgent surgery eg. Trauma etc..
o Elective admission should be done after the patient is seen by a person of SR level and above.
The admission should be justifiable
ADMISSION TO PRIVATE ROOMS
o Medico legal cases & emergency cases should not be admitted to private rooms
o No patient should be admitted to the private room without the approval of a member of the
teaching staff of the ward
HISTORY SHEETS
o Patient clerking must be done by the house officer at the earliest possible time following
admission. This should include proper examination of ophthalmic system & a note of chest
findings, BP, Pulse
o TMO notes & plans in writing are mandatory
o Daily morning & evening progress report should be recorded by the HO & TMO & should be
checked by SR
o All emergency cases admitted should have arrival report by TMO & duty with plans of
management
DUTY ROTAS
o These should be made by the SR or Assistant Professor of the ward & should include duties in
OPD, OT,& ward
o The doctors on duty have to be physically present in the ward
o The HO & TMO can leave the ward after their duty is over only when the next doctor on duty
has arrived. However doctors on duty in the afternoon & night shift should all be present in
the evening round.
o Doctors should communicate with each other at the time of change of duty ie they should
inform the next doctor on duty the status of serious patients etc
ACADEMIC ACTIVITIES
o The SR will prepare a list of academic activities to be held on “free days” in liaison with the
professor of the unit
o The HO & TMO must attend classes & demonstrations/ seminars being held in the ward
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
EMERGENCY PATIENTS
o The registrar should ensure that the emergency drugs, disposables & equipments is available
at all times & in working condition
o Emergency patients should be promptly attended by the HO & TMO. The registrar should see
all emergency admission & record important observations. Should he/she be busy in OT, he/
she should be informed. SR should be on call on every emergency day, if JR feels any difficulty
he can call SR any time.
o Emergency patients should be closely monitored & findings recorded & dealt with.
o Only stable patients can be shifted out of the ward for important investigations.
o Important surgical interventions should be done on the same day if the condition of the pt
permits
o TMOs can perform emergency surgeries according to their year of training only under the
supervision of the registrar SR. Should the SR face difficulty he/she should call his next senior.
PATIENT PREPARATION FOR SURGERIES
o A written , informed consent is a must, duly signed by the pt. his/her immediate relative & the
HO or MO
o Certain aspect must be made in writing , for eg enucleation, evisceration, exentration & should
be explained to patient & relatives.
o Common complications should also be mentioned in the consent form
o Should the patient refuse surgery this should be in writing in the presence of a relative &
signed by the pt , relative & doctor.
o The side to be operated upon should be marked.
o The nurse should make sure that the site to be operated on is shaved, jewelry & dentures
removed & all valuables left to a relative. She should know which patients are due for surgery
& that they are shifted to the OT in time. All pre medications & investigations such as fasting
blood sugar & early morning KUB should be positively done & sent with patients. The HO
concerned should make sure that the patient are prepared properly. The HO staying in the
ward on OT day should be present early in the ward & make sure that all these steps are
carried out.
o Any patient who is absent from bed or have no medicines/ IOL etc. shall be dropped from list.
o During the evening round before the OT day, the registrar should make sure that the patient
has the necessary requirements for surgery and calls to any department made if necessary. SR
shall supervise all these on pre op evening round
o Ideally a copy of the OT list should be intimated to the OT after OPD and one of the
anesthetists concerned with the ward, should carry out a round on the day before surgery, so
that necessary requirements are fulfilled. The anesthetist should ideally carry out his round
with the registrar at a time convenient to all.
o All preoperative investigations including hepatitis and HIV screening should be carried out
before the patient is admitted so that they are ready for timely intervention if needed. They
would prevent unnecessary delays, and wastage of time as well as resentment on the part of
patients for having to be admitted only to be deferred or have a delay.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o Containers for specimens should be available with patients and should be properly marked
beforehand by the House Officer concerned showing the name, bed number, ward and
specimen name in case of biopsy, AC tape for C/S & corneal scraping for microscopy & C/S.
OPD
o One doctor preferably JR should start OPD at 9.00 AM
o All doctors should be available in the OPD.
o The teaching staff (SR & above) on duty along with the HOs/TMOs etc. should be present in
their respective rooms till end of OPD timing
o The technician should make sure that the OPD is clean, the instruments sterilized, disposables
available and all equipment and lights etc in working order.
o The staff should make sure that patients are asked to wait for their turn to prevent
unnecessary chaos.
o Relevant information should be written on the OPD chit and signed with clearly written name
of doctors
o All patients due for surgery should be assessed for co morbid conditions, their BP and pulse
noted and chest examined. They should be referred for an assessment for fitness if needed.
Two or three doctors can use a separate room in the OPD for patient workup etc.
o All patients due for surgery should be advised investigations before admission. These should
be seen and corrected if possible, before the patient is admitted.
o A waiting list should be maintained by each ward ideally mentioning the patients contact
number and address. Unforeseen delays should preferably be communicated to the patient.
This process should be supervised by SR
OPERATION THEATRE
o All doctors should be present in concerned OT room as per duty rota
o All OT notes should be complete and then recorded in an OT register.
o The House Officers should ensure that all specimens are sent and received in the ward.
o The chief OT tech is responsible for the cleanliness and discipline of the OT.
o All post op patients should be monitored.
o EUA will be done by consultant who has seen the patient before.
o Surgery of a particular case will be given to particular trainee according to his seniority & level
of competence.
o Patients with Hepatitis B or C should be operated according to set protocol which should be
developed by the Surgical Department and the administration.
WARD ROUNDS
o All morning rounds must be done by a consultant at a set time, preferably starting at 8.30 am
so as to have time for carrying out orders like investigations, calls etc. except on Wednesday
which should be at 9 am(Hospital CPC day)
o The evening round must be done daily by the Registrar and important entries made & pre op it
should be supervised by SR.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o The post op and emergency evening round should be done by the senior registrar/Assistant
professor with the registrars, medical officers and house officers.
o The nurse and dispenser should be present in the round.
o The Head Nurse should make sure that the ward is cleaned and the bedding done before the
round. The nurse should make sure that ward decorum is maintained 24 hours. The attendants
should be asked to leave. One attendant must be present the patient who needs one.
o The Registrar should ensure that all orders of the senior teaching staff regarding patients have
been carried out including referrals to medical and other related specialties.
DURG ADMINISTRATION
o Nurse should make sure that proper drug is given, through proper route at proper time, after
test dose if needed. Expiry dates must be checked. Entries in writing should be made as well as
any reason for not administering the drug. Any confusion, any delays in administering the drug
should be communicated to the Medical Officer or Registrar.
o The House Officer and Medical Officer concerned should make sure that the drugs are
properly and timely administered.
INDENT BOOK:
o The Registrar shall sign the indent book and check all the drugs and IV fluids supplied to the
ward. He will also check all the maintenance items supplied & used/ installed in the ward.
SAFETY MEASURES:
o At no time shall any anesthetic drug be either kept with the other drugs or emergency drugs.
They should preferably be available in the OT and if need to be bough by the patient should be
kept separately.
o All used syringes and IV fluid bottles should be immediately destroyed by the nurse. The Head
Nurse and Registrar should be vigilant about this issue.
WARD CLEANLINESS AND MAINTAINANCE:
o The Head Nurse should make sure that the ward is kept clean at all times. This includes the
floors, windows, beds, toilets, galleries, cupboards, side tables etc. The Registrar should ensure
that this done.
o All equipment or lights etc that needs replacement must be immediately reported to the
Registrar by the Head Nurse and Dispenser.
o This protocol should be reviewed every six months and changes/additions made accordingly.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DEPARTMENT OF PEDIATRICS & CHILD HEALTH
ADMISSION POLICY
o There will be alternate emergency cover of each unit
o Patients will be admitted from 9 AM to 2 Pm from OPD while emergency admission through
emergency pediatric services will be open for 24 hours
o Two trainee MOs & 4 HOs will be on duty in such a manner that at any given time , one TMO &
2 HOs have to be present in the ward
o One SR & 2 JRs will be on call for 24 hours for the Department of Pediatrics covering both
units. Evening round on every emergency day will be done by consultant on call .
o Patients will be admitted on assurance that only one female attendants will be allowed in the
ward & the compliance will be checked by staff nurse on duty
o All histories should be completed & signed by the HO on duty, & the arrival rep[ort with full
assessment has to be taken immediately & signed by the TMOs/Mo on duty
o SR & consultant on duty will be informed depending on the nature of the illness if the child
needs to be seen before ward rounds
o Admission can be decided by the MO on duty in all urgent cases
o When the pediatric unit on call becomes full, the EPS beds can be utilized by the unit on call
for every admission except for very sick patients. ( This is done to prevent doubling in the unit)
WARD DISCHARGE POLICY
o Patients only be discharged after consultation of SR & above level
o All patients data is entered in to the ward computerized database by the concerned HO
o All patients on discharge are issued discharge slips
o Every discharge slip is countersigned by a consultant before handing over to the patients
o Hospital computerized data form is filled for every patients & entered into the data base by
computer operator
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
WARD ROUND POLICY
o Beds are not distributed per professor/ Assoc. Prof/ Asstt. Prof etc. All these cadres of
consultants do the rounds based on rota & equally distributed. Consultants are required to
write their clinical findings & decisions in the notes or at least dictate it to the MO
o MO or HO of the respective bed present the patient
o Round book is kept to write in the ‘jobs” & for hand over purpose
o Printed history note books are designed & issued for patients records
o On call cover is provided by a single consultant out of routine duty hours to peads A/B units &
SCBU, assisted by a senior registrar
o Continuous notes are written & even reporting is the principle. Once or twice daily DPR is
discouraged. All instruction about the patient care must be given in writing. Doctors/ nurses
must write their names in block letters & just signatures are not acceptable
PATIENTS INVESTIGATIONS & PROCEDURES POLICY
o Where applicable & appropriate all tests must be sent to the hospital laboratory. Tests not
available in hospital are sent to recognized private laboratories.
o Lumber puncture is done by MO or by senior house officer under supervision of the MO.
Lumber puncture is deferred & always done in the morning . CSF will be sent to by the ward
lab. Technician
o Other invasive procedures e.g. chest drainage is carried by consultant or MO under supervision
o All procedures shall be recorded in the notes.
INJECT ABLE DRUG POLICY
o Only recognized brands of the drugs agreed upon in the unit are allowed to be prescribed.
Junior doctors & consultants are not allowed to prescribe other than authorized trade names.
Head Nurse is expected to counter check the inject able given by inspecting the empty the
empty vials daily
o IV valium , IV KCL & other drugs like digoxin should be checked by the house officer & nurse
together
WARD REFERRAL POLICY
o Inter unit referral & inter hospital referral is always done through the consultant. Head of the
Department sets the example by personally writing the referral notes. It is expected that the
counterpart unit consultant or at least SR should respond in writing. Patient suitability for
transport to other hospital must be taken in to account. Any medical need e.g Oxygen /IV
fluids/ ambulance arrangement must be met
WARD EMERGENCY POLICY
o There is written plan present for all common emergencies which is available round the clock
on ward counter. Doctors on duty are required to follow these plans.
o Consultant on call must be notified & advised taken for critically ill children.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o Emergency drugs are placed in emergency cupboard with all necessary life saving drugs
available round the clock
o Emergency drugs used have to be constantly replenished either through indent from A&E
Services or by patient attendants
o Resuscitation Equipment is daily checked & kept in emergency cupboard.
o Proper hand over/ take over of emergency cupboard is done every day under supervision of
registrar
o Resuscitation equipment is daily checked & kept in emergency cupboard.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
ACCIDENT & EMERGENCY SERVICES DEPARTMENT
STANDARD OPERATIVE PROCEDURES
DOG BITE
o Wound should be washed with copious amount of saline and antiseptic solution.
o Wound should not be sutured.
o Tetanus prophylaxis should be given accordingly.
1. TiG (Tetanus immunoglobulin 250 units) in non immunized patients and 0.5 ml Tetanus
Toxoid at separate sites with separate syringes.
2. Tetanus Toxoid only in previously immunized patients.
o Wound is classified as under:
Category 1: touching or feeding suspect animals, but skin is intact
Category 2: minor scratches without bleeding from contact, or licks on unbroken
skin
Category 3: one or more bites, scratches, licks on broken skin, or other contact
that breaks the skin; or exposure to bats
o Post-exposure care to prevent rabies includes cleaning and disinfecting a wound, or point of
contact, and then administering anti-rabies immunizations as soon as possible. Anti-rabies
vaccine is given for Category 2 and 3 exposures. Anti-rabies immunoglobin, or antibody, should
be given for Category 3 contact in non-immunized patient, or to people with weaker immune
systems.
o If possible, the full dose of Anti-rabies immunoglobin should be infiltrated around any
wound(s) and any remaining volume should be administered IM at an anatomical site distant
from vaccine administration. Also, RIG should not be administered in the same syringe as
vaccine. Because RIG might partially suppress active production of antibody, no more than the
recommended dose should be given.
Dosage of Lyssovac (Berna) post exposure
0-3-7-14—48(booster) ---1.0 ml I/M
Only first dose of Anti Rabies vaccine (ARV) will be issued from hospital for dog bite cases provided
the patient:
o Has an evident puncture wound.
o Presents within 24 hours of dog bite.
o Did not receive any other ARV after dog bile.
o Belongs to the area allocated to Khyber Teaching Hospital.
o Submits photocopy of his computerized national identity card.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
The dose will be issued with permission of I/C Casualty, shift DMS and RMO. It will be administered in
the casualty and record be maintained. The site will be marked and documented by the CMO to
prevent mis-use of vaccines.
STANDARD OPERATIVE PROCEDURES
GENERAL INSTRUCTIONS:
o All patients coming to emergency will be attended by the CMO.
o Record of medico legal patients will be maintained in MLC register.
o Elective patients coming to emergency department by mistake or intention will be politely
directed to the concerned Outpatient department.
o Chief complaints and provisional diagnosis of the patients should be clearly mentioned on the
prescription chit and vital signs recorded on the same.
o Medicines prescribed and administered in the casualty should be recorded on the chit.
o After initial treatment and resuscitation, all patients will be shifted to the concerned unit for
definitive care when the vital signs are stabilized.
o In case of serious emergencies when the patient is not stable enough for shifting, the doctor
from concerned unit will be called for opinion.
o In case of any ambiguity or administrative problem I/C Casualty or shift DMS will be
immediately informed.
o All drugs in the casualty will be prescribed by the CMO and will be administered in the casualty
and record be maintained.
o Carbon copy of the prescription chit will be retained in Casualty for record.
o No drugs will be given to the patient for administration/use elsewhere.
o Doctors on duty in casualty should refrain from prescribing unregistered drugs, drugs not
meant for the sign symptoms and provisional diagnosis of the patient or drugs on patient
preference not indicated otherwise.
o All the medical claims and bills will be dully checked and signed by the I/C Casualty.
MEDICINES IN CASUALTY:
o
Victims of bomb blast and terrorist activities will be provided all medicines
including
implants from hospital.
o Red patients (i.e. serious emergencies needing admission) will be provided with fee medicines
excluding implants, from hospital for first 24 hours subjected to availability.
o Yellow patients (sub acute emergencies needing observation only) will be provided with some
of medicines from hospital subjected to availability.
o
Green patients (outpatients) will be provided with free consultation only.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
STANDARD OPERATIVE PROCEDURES
TRAUMA/FIRE ARM INJURY/ROAD TRAFFIC ACCIDENT
o Patients presenting with major trauma should be given priority in management and primary
survey of the patient with treatment should start immediately at arrival without wasting time
in taking long histories.
o The standard treatment protocols should be followed according to ATLS/ESS-BLSPTC programs
i.e. ABCDE.
1. A for Airway and Cervical spine.
2. B for Breathing and ventilation.
3. C for Circulation.
4. D for Disability and Deformity.
5. E for Exposure, Environment and Evacuation.
AIRWAY
o Talk to the patient to assess his airway, breathing and consciousness at the same time.
o Start with chin lift and jaw thrust manoeuvre if not responding.
o Oral cavity is examined for foreign bodies and secretions.
o Gödel’s airway of appropriate size should be passed and suction done.
o ETT and tracheotomy/ cricothyroidotomy are reserved for cases unable to maintain their
airway like unconscious patients or GCS less than 8.
o Cervical spines should be immobilized with spine board or hard collar if the slightest double of
spinal injury exists.
BREATHING:
o All trauma patients should be given supplemental oxygen by face mask till confirmed to have
adequate peripheral oxygen saturation.
o Chest should be auscultated bilaterally.
CIRCULATION:
o Two wide bore canolas should be passed in accessible veins in arms or fore arm. (Like 18 G n
adults, 20 G in adolescents and 22 G in children).
o Venous cut down, central venous lines or interosseus lines can be used wherever indicated by
the attending physician.
o Ring lactate is the fluid of choice for initial resuscitation.
o Blood pressure and pulse rate should be regularly checked and properly recorded.
o Any evident bleeding should be stopped with pressure dressing.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DISABILITY AND DEFORMITY:
o Patients should be properly exposed for examination preventing hypothermia and overexposure.
o All suspected fractures should be simply splinted and open wounds washed and dressed.
o Neurological status of the patient should be assessed according to AVPU or GCS.
AVPU SYSTEM
o
o
o
o
A
V
P
U
Alert
Responds to verbal command
Responds to pain only
Unresponsive
Glasgow Coma Scale
Eyes
1
Does not
Open eyes
2
Opens eyes
Response to
Painful stimuli
Verbal
Makes
sounds
Motor
Makes no Extension to
movements Painful stimuli
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no Incomprehensible
Sounds
3
Opens
eyes
in
response
to voice
Utters
inappropri
ate words
4
5
Opens eyes N/A
spontaneously
6
N/A
Confused,
disoriented
N/A
Abnormal
flexion to
painful
stimuli
Flexion/With Localizes
drawal
to painful
painful
stimuli
stimuli
Oriented,
converses
normally
Obeys
commands
43
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
EXPOSURE AND ENVIRONMENT
o After initial treatment and resuscitation, all patients will be shifted to the concerned unit for
definitive care when the vital signs are stabilized.
o The relevant documents should accompany the patient and the doctor in concerned
department should be priory informed to make necessary arrangements.
o In case of serious emergencies when the patients are not stable enough for shifting, the doctor
from concerned unit will be called for opinion.
o The environment and temperature should be conductive for the patient.
ADJUNCTS
o Following investigations should be generously utilized where ever needed:1. Radiographs lf chest and pelvis and cross table lateral view of cervical spines
2. ECG
3. FAST (Focal assessment sonography in trauma)
4. CT Scan for Head injury
5. Pulse oximetry
6. DPL (Diagnostic peritoneal lavage)
o Nasogastric tube and urinary catheter help in preventing aspiration of gastric contents and
measuring urinary output and should be used
o After completing primary survey the doctor should start secondary survey only if the vital signs
of the patient are within normal limits.
o At this stage AMPLE history should be recorded as following
A
M
P
L
E
Allergies (Whether allergic to any medicines?)
Medication (Was taking any medicine?)
Past illnesses/pregnancy
Last Meal
Events/Environment leading to injury
VITAL SIGNS include the heart beat, breathing rate, temperature, and blood pressure. These signs
may be watched, measured, and monitored to check and individual level of physical functioning.
Normal vital signs change with age, sex, weight, exercise and condition.
Normal ranges for the average healthy adult vital signs are:
o Blood Pressure: 120/80 mm/Hg
o Breathing: 12-18 beats per minute (at rest)
o Temperature: 97.8-99.1 degrees Fahrenheit / average 98.6 degrees Fahrenheit.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
MASS EMERGENCIES/BOMB BLAST INJURY/TERRORIST ACTIVITIES
o The mass emergencies will be dealt according to the revised Disaster Management Plan
already published.
o Patients will be received and shifted after resuscitation as mentioned on page 2-3 of Disaster
Management Plan.
o The Medical Superintendent will be the focal person for dealing with Media, VIP’s/visitors and
Relatives of the patient.
o In absence of Medical Superintendent the DMS (Admin) and DMS (P&D) will be the focal
person respectively.
o The senior most surgeon available at the scene will triage the patient and label them with tags
as under for further management.
Grey
Dead or Insolvagable
Red
Patient with Life threatening injuries
Yellow
Patient with Non-life threatening major injuries.
Green
Walking wounded patients with minor injuries
o Patients will be treated according to ATLS protocols as simplified above for Poly-trauma
patients.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
CCU CARDIOENT OF ACUTE MYOSPITAL - SOPS
GATE PASS SOPS
o Visitor pass must be issued to the attendant accompanying patients admitted in the CCU.
o Rupees 100 (refundable) deposited for each pass with the charge nurse and document in the
register
o Visitor pass collected by charge nurse when patient is discharged,
o Refund Gate pass fee of Rs 100 and clearly document in the register.
1. INFECTION CONTROL:I/V LINE
1. Wash hands
2. Pass by staff nurse/4th year nurse
3. Explain procedure to the patient
4. Take consent
5. Clean area with spirit swab
6. Share the area if needed
7. Spread plastic sheet
8. Pass I/V line in sterilized way, check with saline and stabilize with nichban sticking
9. Change after three days
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION ADMITTED TO CCU
Tasks
 Comfortable position
 Maintain IV line
 02 inhalation
IMMEDIATE Rx
 Aspirin 300m
Chew orally
 Clopidogral 300mg
Orally

Inj.Morphine+Metchlorpromide
I/V

ß-Blocker if BP is high

Nitrates (Exclude Contra Ind.)

Consider Thrombolytic therapy
1). Consent from the patient
2). Exclude Contraindications
Preparation of streptokinase
Time
Duration
Within 5Min
Do
Written order
Action
By
MO/TMO/SMO/ H.O
Cons
Nurse
Do
Do
Do
Staff
Nurse
Do
Consider
Within
15m
Do
MO
(See SOP).
(Immediate Rx (Continued)
MO
Staff
Nurse
3). Monitoring
4). Prognosis
MO
MO
Documentation
 Arrival report
 BP record chart
 Risk factor
 Rx chart
 Nursing entry sheet
 ECG pasting
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Within
20-30
minutes
HO/TMO/MO/SMO/Consultant
MO
MO
HO/N
MO/HO
Nurse
Nurse
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
Investigation






Baseline (see app)
Post St. Kinase ECG
Documentation of any
Adverse events
Post SK notes
Treatment adjustment
Reassurance to patients &
relatives
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Within
20-30
minutes
MO/TMO/SMO
Staff Nurse
Do
Do
Do
Staff Nurse
Do
Do
Do
MO
MO
MO
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
SOPS FOR SURGICAL ICU
ADMISSION CRITERIA
o Pre-post of patient in shock (Hypovolumic &Shock)
o For total parental nutrition
o Post of major surgery e.g. total colostomies, Esophegectomies, gastrectomy
o Patient with multiple injuries (e.g. FAI)
o DIC
o Delay recovery from GA
o Ventilator support
ON ARRIVAL IN SICU
o Patient will be examined by both HO and M.O.
o Documentation by the HO,M.O separately encompassing time of arrival in the SICU,
o History of illness/injuries/surgery, Past History, drug allergies, drug history, family history,
clinical findings, investigations required and management plan.
o To discuss the new admissions with the Registrar and senior registrar.
o To follow the treatment plans according to the treatment protocols and guidelines.
o To start the management ASAP but not later than 15 minute after the arrival of the patients.
o Ensure to utilize the hospital resources a much as possible and to send all investigations to the
hospital laboratory if available.
o To counsel/inform relatives/attendants of patient and take proper detailed consent with
explanation of any possible procedures if needed as part of the patient’s management.
MORNING ROUNDS
o The HO,MOs and TMOs working (inclusive of those on rotation) will take daily progress report
of the patient after proper examination of the patients and proper documentation with time
and date written clearly.
o The morning round will be supervised by the Sr. Reg. and M.O will present beds, if beds are
allotted then MOs will present their respective beds. HO should be encouraged to present
beds and supervised.
o During rounds The patient, his relatives attendants should be properly informed about the
disease, state/ condition of the patient and prognosis
o If a procedure or referral is planned during the round it must be explained to the patient or his
relatives.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
EVENING ROUNDS
o Evening round to be done on regularly basis irrespective of any holidays.
o Senior Rg. must supervise the evening round.
o HO and MO on duty must be present in the evening round and present their respective
patients per SICU protocols.
o All orders, examination findings, unusual findings and treatment plans must be clearly
documented and singed. Name of the responsible doctor should be written clearly under the
signature.
o Any new development or change of plans must be explained to the patient or his relatives.
o Proper handover and take over to be undertaken with clear documentation on the chart of the
patient. This applies to doctors and nursing staff.
o Any defaulters from the rounds must be report per protocol of the hospital.
INFECTION CONTROL
o All entering the SICU must take off their shoes and over alls before entering the SICU.
o Wash hands before examining patients and relatives must wash hands before touching their
patients.
o After examination and procedure, all health care providers must wash their hands.
o Relatives and attendants accompanying the patients must be discouraged and clearly told not
to bring any unnecessary personnel belongings to the SICU.
o Hospital timings regarding visiting hours and rounds must be observed.
I/V LINE
1. Wash hands
2. Pass by staff nurse/4th year nurse
3. Explain procedure to the patient
4. Take consent
5. Clean area with spirit swab
6. Share the area if needed
7. Spread plastic sheet
8. Pass I/V line in sterilized way, check with saline and stabilize with nichiban sticking
9. Change after three days
GATE PASS SOPS
o Visitor pass must be issued to the attendant accompanying patients admitted in the SICU.
o Rupees 100 (refundable) deposited for each pass with the charge nurse and document in the
register.
o Visitor pass collected by charge nurse when patient is discharged
o Refund Gate pass fee of Rs 100 and clearly document in the register.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
SOPS FOR MEDICAL ICU
10 bedded ICU for most serious patients of the hospital, subject to availability of beds
HIERARCHY
o Senior Registrar
o Registrar
o 6 Medical Officers
o 2 House officers on rotation from medical wards
o 2 staff nurses in each shift
o One student nurse
CRITERIA FOR ADMISSION IN MICU
o Patient requiring mechanical support e.g. ventilator, dialysis
o Patient with metabolic crisis or electrolyte imbalance, organ failure, shock(septicemia,
hypovolumic)
o Comatose Patients, CVA, Infections, Meningitis, Encephalitis, Poisoning etc.
o 2 beds for tetanus patients
1. The patients are admitted in MICU from medical & allied as well as surgical & allied
wards with medical problems
2. In MICU the staff present on duty is responsible for all the orders given for medication
& nursing care
DOCUMENTATION
o As soon as the patient is shifted to the MICU, the MO on duty reviews the treatment of the
patient, fully understands the purpose of the patient admission in the ICU and along with the
HO present on duty documents the patient( history taking by the HO while the MO writes the
arrival reports clearly) with in the 30 minutes of the patients arrival
o If already prescribed with any investigations & treatment, the orders must be carried out as
soon as possible. HO being on the front line is fully supervised by the MO & registrar. If the SR
is present then he must supervise all the staff present in MICU and review all the work done
by the staff junior to him
o When a doctor/ consultant from the parent ward visits the ICU , the MO & the HO must
present & discuss the relevant patient in detail with the visiting doctor & properly document
their notes.
o A proper treatment plan to be notified on the chart of the patient, so as to elaborate the line
of action
o Proper , clear, compassionate explanation of what is being done for the patient should be
communicated by the HO/ MO/ Registrar/ SR to the patient after as per protocol of the MICU
& the prognosis dicussed with the relatives with in the ethical limits.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o While changing shifts the doctors, nurses & other staff must ensure proper well documented
hand over & take over
GATE PASS SOPS
o Visitor pass must be issued to the attendant
o accompanying the patient admitted in MICU
o Rs 100 ( refundable) deposited for each pass with the
o charge nurse & document in the register
o Visitor pass collected by charge nurse when patient is discharged
o Refund gate pass fee of Rs 100 & clearly document in register
INFECTION CONTROL
IV LINE
a.
b.
c.
d.
e.
f.
g.
h.
i.
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Wash hands
Pass by staff nurse/ 4th year student nurse
Explain procedure to the patient
Take consent
Clean area with spirit swab
Shave the area if needed
Spread plastic sheet
Pass IV line in sterilized way, check with saline & stabilize with nichiban sticking
Change after 3 days
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
PULMONOLOGY UNIT
STANDING OPERATING PROCEDURE FOR BRONCHOSCOPY
DUTIES OF BRONCHOSCOPY TECHNICIAN/REG/TMO
o Patient should be NBM for at least 4-6 hrs.
o Check P.T. It should not be more than 3 sec from control.
o Check, document & share B.P, PULSE, SaO2, and any ECG abnormality. Patient
o Hemodynamically stable and SaO2 at least >90%.
o Check procedure items. (Technician & MO/TMO on duty)
o Explain procedure to the patient. (Duty of MO/TMO responsible for bed in case of admitted
patient and also TMO on duty in OPD cases).
o Take written informed consent from patient/relative.
o Ensure patient / working i/v access (Cannula).
o Re-confirm the indication for bronchoscopy and side of pathology.
o Recheck working oxygen cylinder, oxygen gauge and new/sterilized nasal cannula.
o Properly operating suctioning machine and sterilized bronchoscope confirmed before each
bronchoscopy.
o Re- confirms the availability & expiry date of all possible medications in the resuscitation
trolley.
o Must always checked sputum for AFB result (if available) before bronchoscopy.
o Identify the name, CXR, check relevant investigations and correlate clinically.
o Hand over the valuable of patient like watch, gold rings, bangles etc. to relative.
o Particularly, remove nose ring or clip in female patient.
o Perform procedure in accordance with guidelines.
o Operator must be SR or above to perform procedure independently.
o Specimen must be labeled legibly before handing it over to the patient.
o Document procedure notes.
o Re-check and document post procedure BP, Pulse & SaO2.
o In case of TBB obtain CXR (PA view) & exclude pneumothorax.
o Bronchoscopy call must be discussed with the consultant before giving date and then
animate the date to the bronchoscopy technician well in time to enable him to prepare list.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
STANDING OPERATING PROCEDURE FOR ASPIRATION & BIOPSY
DUTIES OF TECHNICIAN, REG/TMO/MO
o Check procedure items. (Technician & MO/TMO assistant).
o Check and document B.P, PULSE, SaO2 and any ECG abnormality. Patient hemodynamically
stable and SaO2 at Least > 90%.
o Take written informed consent from patient / relative.
o Explain procedure to the patient.
o Re- Confirm patient I/V access.
o Hand over the valuables of patient like watch, gold rings, bangles etc. to relative.
o Correlate clinical findings and site of pathology with latest CXR/CT scan/Chest U/S.
o Identify the name & date on CXR.
o If TMO is main operator, he must have authorization from SR/AP/Prof. All others must do
under supervision of consultant/ year 3 trainee of Pulmonology.
o Perform procedure in accordance with the guidelines.
o Send pleural fluid for R/E and Pleural biopsy for H/P.
o Specimen must be labeled before handing it over to the patient.
o Send the specimen only to hospital/specified laboratory.
o Document procedure notes and any specific order.
o Check chest X-ray post procedure.
o Presence of close relative/ female staff should be ensured if procedure is undertaken on
female patient.
o OPD cases should be admitted for proper care.
STANDARD OPERATING PROCEDURE FOR CHEST INTUBATION
DUTIES OF TECHNICIAN, REG TMO/MO
o Check procedure disposables sterilized equipments & other required items.
o Check and document B.P, pulse & SaO2.
o Take consent from patient/relative.
o Explain procedure to the patient.
o Correlate clinical findings and site of pathology with latest CXR/CT scan /Chest U/S.
o Identify the name & date on CXR.
o Re – confirm identification for chest intubations & document authorization.
o Re – confirm patient IV access (IV line).
o If TMO is main operator, he must have authorization from SR/AP/Prof. All others must do
under supervision of consultant /year 3 trainee of Pulmonology.
o Perform procedure in accordance with the guidelines.
o Re – check proper working of chest tube, all connections and under water seal bottle.
o Check Chest X- ray post procedure.
o Document all the procedure notes and any specific order.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o Explain precautions regarding tube care to the patient &/attendant as well.
o Re – check & document post procedure BP, Pulse & SaO2.
o Presence of close relative/female staff should be ensured if procedure is undertaken on female
patient.
o OPD case should be admitted for proper care.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
STANDARD OPERATING PROCEDURES
PATIENT’S HISTORY, MANAGEMENT AND TRAINING OF JUNIOR
DOCTORS.
The following rules should be observed and followed. (Duty of Registrar, TMO/MO will look after
to continue implementation).
o Time of arrival and treatment should be written on the treatment charts (Reg /TMO/MO on
duty).
o Patient should get admission number within an hour of arrival (duty of staff nurse and ward
technician) but this should not delay the treatment.
o Medical officers should write medication within half and hour and arrival reports within one
hour of receiving the patient.
o House Officers should write detailed history of the patients within three hours of admission
and all the histories must be completed till 2.00 pm.
o Medical Officers and House Officers on Evening Duty should write Arrival Reports and Detailed
histories of all the patients admitted through Casualty.
o Any medication written on Treatment Charts should be in clear and eligible writing with name
of the advising doctor mentioned.
o
o
o
o
o
o
o
M or Dr.Mukhtiar Zaman Afridi
S for Dr. Saadia Ashraf
R for Dr Rukhsana Farooqi
Rest all should write their full names.
Generic Names of drugs should also be written in Capital Letters.
First dose of all I/V antibiotics must be given by the TMO/MO/ on duty and properly
document.
All the required information should be entered in appropriate pages & ensure all pages
including investigation pages should be duly filled in by the discharge of the patient. (Duty of
HO/TMO/MO).
All CXR of the patients should be labeled and dated serially.
All orders/ investigations ordered in morning round must be fulfilled till 1.00 pm and delay
should be noted in notes & communicated to the next on call team.
All investigations received back should be checked by respective MO/TMO, signed & any
action arising should be taken & documented on history sheet. If needed, discuss with senior
and take appropriate action but document properly.
Three samples of sputum must be sent for patients having suspicion of Pulm TB. (Duty by
MO/TMO’s).
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o Evening Rounds should be documented in the Register by the nurse, signed by the MO and
report should be written in the evening round register and separate report submitted the
Dr.Mukhtiar Zaman Afridi.
o All investigations advised must be sent to the lab on the register and sign should be taken from
the appropriate person from lab. (MEMO needs to go from management of ward to lab for
cooperation.)
o Beds allotted to each HO/TMO/Rotation TMO must be properly displayed on the beside (duty
of registrar) and all needs to be aware of the case and DPR.
o Registrar should ensure that DPR and ward is ready before starting morning round.
o All HO’s should bring their own stethoscope and BP apparatus.
o All patients’ diagnosis and their ICD 10 coding must be clearly written on their history sheets
as well as on their discharge cards.
o It is the duty of the Reg /MO/TMO to ensure patient is getting all medications as prescribed.
o No discharge card is given to the patient unless it is checked and duly signed by the chest ward
permanent TMO/MO & /Registrar.
o On OPD days chest ward TMO/MO who’s duty is in ward is supposed to see and manage
admitted patients and prepare them for post OPD round.
o Bed numbers and important orders of all serious patients should be clearly written on the
lounge notice board (duty by relevant MO/Registrar).
o Call from other wards should be noted and attended by Reg /Senior MO/TMO and if needed
consult the senior on duty. Call specifically written for the consultant should be noted and
timely informed to the consultant on call. Call register should be maintained by Reg /MO on
duty.
o Bronchoscopy call must be discussed with the consultant before giving date and then intimate
the date to the bronchoscopy technician well in time to enable him to prepare list.
o All MO/TMO should perform their duties in respective places in accordance with the duty Rota
displayed in the ward and doctor’s lounge.
o Monthly morbidity and mortality meetings will be held in last week of the month (SR duty)
and doctors should present all respective cases. List of cases will be developed during the
month.
o All TMO’s should keep their log book updated and get it signed within 1 week of the activity.
o All MO’s keep a record of the procedures performed and their outcome and report will be
presented in the monthly meeting along with record of short cases, long cases and CPC
presented or attended. Etc.
o Any new appointee should go through induction, orientation programme within 1 week of
arrival & all protocols & guidelines will be shared ( duty 0f SR & JR).
SOPS FOR ANESTHESIA DOCTORS
PRE OPERATIVE EVALUATION / ASSESSMENT
(BOTH ELECTIVE & EMERGENCY CASES)
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
o To anticipate potential risk involved by taking a thorough history, physical examination &
laboratory investigations
o To ensure that the patient is prepared to decrease the risk of adverse outcome
o To provide appropriate information to the patient & to obtain consent for a planned anesthetic
technique.
o To prescribe pre medication and prophylactic measure if required.
o To provide satisfactory pre operative care
o Consultation with relevant professional & seniors where required.
CHECKING ANESTHESIA EQUIPMENTS
o Checking anesthesia machine, oxygen supply, anesthesia circuits, laryngoscope, suction
machine, monitors etc.
o Labeling syringes of anesthesia drugs
o Stand-by supply of oxygen cylinder, emergency drugs, ambu bag, defibrillator etc.
ANESTHETIZING A PATIENT
o Setting I/V line & starting I/V fluids
o Setting monitors-SpO2, BP, ECG etc.
o Pre medication
o Induction & maintenance of anesthesia as planned
o Recovery of patient
o Shifting the patient from the recovery to ward or ICU according to the patient clinical status
o Consultation with seniors in difficult situation/complication
DOCUMENTATION / RECORD KEEPING
o Pre operative assessment record
o Anesthesia plan.( GA or regional technique)
o Intra operative events & monitoring: Blood loss, IV fluid & drug given
o Record vital signs
o Signs of recovery noted
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
SOP’S FOR UTILIZATION OF ZAKAT FUND
o
o
Budget to be distributed (Month wise)
Medicine to be issued to;
1. Indoor patient (Valid Istehqaq from whole province)
2. Out door patient (Valid Istehqaq, Pesh. Distt: & referred cases only)
INVESTIGATIONS:
o MRI, CT-Scan to indoor patient on the sign of the consultant only.
o Routine investigations to Zakat patient (free)
1. Ailments i.e. diabetic, Asthmatics, HTN, osteoporosis, Thalecemic etc.
o OPD patient, from KTH surrounding area properly referred by district Zakat officer will be
entertained.
o Medicine received must be defaced before issue and sign/thumb impression taken in the LP
ledger for Zakat.
o Zakat indent must be signed & stamped by a consultant;
o Three days dose will be issued to indoor patients and 7-15 days dose to be issued to
o Outdoor patients as per short/long illness in the allowed allocation to ensure
o judicious utilization for effective therapy & quick disposal
o Brand of common drugs will be selected to avoid complications/ ensure judicious utilization of
funds for effective therapy and quick disposal.
a).
b)
c)
d)
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60% of total budget will be used for Bulk purpose of some common
facilitate the patients
20% of total budget will be for investigations.
30% of total budget will be for outdoor patients.
50% of total budget will be for indoor patients.
drugs to
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DISASTER/ CRISIS MANAGEMENT FLOW CHART
Casualty KTH
Reception + Resuscitation
Neurosurgery +
Cardiothoracic
Trauma unit near
Orthopedic
Minor Injuries
Resuscitation
Lady Reading Hospital
Peshawar
Major Injuries
Casualty O.T
Minor O.T
Main O.T
Transfer to Surgical/
Orthopedic Wards etc
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
IBP Block
Reception
Resuscitation
Major Operations
In Main O.T
Minor Operations in
IBP Block O.T
Transfer to Surgical/
Orthopedic etc
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DECISIONS
1.
PROTOCOL FOR RECEIVING INJURED/SERIOUS PATIENTS.
The Disaster management team which comprises the doctors to be present on the premises in
Casualty KTH and Trauma Unit adjacent to Orthopaedic ward will assess and
proceed to treat the
patient. Patient requiring resuscitation will be resuscitated in Casualty
and Trauma area. Patients
requiring any minor surgical procedure shall be shifted to the Minor O.T which has been upgraded
with facilities for anaesthesia and sterilization.
Patients requiring major surgical procedure shall
be shifted to the Main O.T and the surgeons present at the site shall operate. ENT and Eye cases will
be taken care of by the
respective. These patients after having been operated and treated will
be admitted back to the units on call. If the unit on call has become full with patients the other units
should be used for admitting the patients and the staff of that unit will be responsible for their care
and further management of complications.
PETCOT building will be developed as soon as possible to become the designated area for
Emergency reception and treatment. However till such time that PETCOT is not functional
the above protocol mentioned shall be in vogue. PETCOT is being developed
for mass emergency
so as to exclude the main hospital as much as possible from the influx of attendants and public
coming with the injured patients.
An area for reception of emergency will be designated in Petcot, and a resuscitation area
will
also be designated. The team of doctors and paramedics designated for being present at the site of
emergency shall then function in this area.
The theatre in Petcot will be fully developed with anaesthesia cover and all minor and major cases
which can be operated there will be taken care of in this operation theatre. The cases of serious
nature requiring major surgery will be operated in the Main O.T of KTH. These patients will then be
shifted to the wards on call and if their numbers
increase will go to the other allied wards.
2.
One TMO from the surgical wards and Medical Wards should be posted to the casualty on
daily basis from the unit on call.
3.
The provision of all necessary items like Oxygen Cylinders, masks, suckers, I/C Canulas, I/V
Fluids emergency drug shall be present at the site of emergency resuscitation and
these shall
be checked by the focal person i.e the Medical Superintendent.
4.
Bulk Store in the basement with resuscitation material for fifty patients shall be present at all
times and will be checked by the focal person.
5.
The Operation Theatre in Casualty shall be fully functional.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
6.
Resuscitation items for at least twenty patients shall be available in the Casualty of KTH and
the focal person shall check its availability.
DISASTER …………………BE PREPARED -A GENERAL REVIEW
Disaster is a sudden great incidence causing massive destruction and casualties like Bomb blast, Road
Side Accidents, Fire Arm Injuries, Riots and violence, Building Collapse and out break of epidemic
diseases.
Disasters have been classified as natural and man made. There is a complex relationship between the
two.
In order to cope with all sorts of emergencies effectively, all health care institutions must devise an
institutional disaster plan of action. Because in the crisis situation, the failure of the authority to warn
people adequately and of people to respond promptly can contribute to the increase loss of life and
damages. Therefore a plan of action should be worked out to effectively manage crisis situation. Every
health care institution must be prepared and ready to tackle the crisis situation developing as a result
of the disaster in its area. The hospital administration must anticipate the crisis. It can save death and
misery. The sudden increase in demand on the services of the health care must be met. Absence of a
plan will add to chaos and confusion, which come on when ever large numbers of people are affected.
That will paralyze the services to be provided by the institution- what would have been possible
ordinarily would be come almost impossible. All the concerned people, the hospital administration,
doctors, nurses and other paramedical staff, the victims, the relatives and the public become
frustrated. Lives may be lost unnecessarily because of lack of preparedness.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
1.
STEPS TO BE TAKEN
Nomination of a focal person
In all kind of crisis situation there is need for a unified authority. One focal person should be
identified, who will issue instructions. These instructions must be followed otherwise there will be
confusion and conflict.
It is also necessary to decide before hand who will be the next focal person in the absence of the
designated focal person. The focal person should be available at the control room always. His duty is
to coordinate and supervise the activities, ensuring that the plan is being carried out efficiently. He
should be available to give advice and instructions. The focal person motivates and encourages the
crisis team to give their best.
The focal person should ensure that there is proper communication:
 Between the members of the team
 With the anxious relatives of the victims
 With the public
 With the authority and
 With the media
 The Focal person will submit the daily situation report to the Chief Coordinator for onward
submission to the higher authorities.
2.
Formation of Disaster Management Groups (DMGs)
The hospital administration must develop disaster management groups. The members of the groups,
consisting of doctors, nurses, paramedical and other supportive staff should be carefully selected and
trained. Each one must be aware of his / her responsibilities, what to do and whom to contact, should
they need assistance.
These groups should be capable of being assembled quickly, at any time of day or night, hence, in he
selection of people, priority should be given to those who are available easily and live close by in the
campus, in the neighbor hood , having telephone connections and own transport.
3.
Medicines
All kind of life saving drugs should always be made available in the accident and emergency
department insufficient quantity to provide emergency care to a maximum of 500 patients.
4.
Equipments
Certain equipments and materials should be earmarked for dealing with disasters. They must
be checked periodically. It must be ensured that they can be used without any delay.
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
5.
Blood
About 500 bags of screened blood should be made available in the blood bank all the time. A
donor list of people willing to donate blood at short notice be ready, with their correct address and
telephone numbers. Formation of donors desk in the hour of need .
6.
Instruments
To ensure the availability of sterile instruments for mass emergency use.
7.
Ambulances
Ambulances must be well equipped with emergency drugs , equipments and trained medical
staff.
8.
Establishment of information and Registration Desks at Accident and Emergency Department
9.
During Natural calamities, the tele-communication system is usually disrupted. It is therefore
necessary for every mega health institution to establish its own wireless system for the purpose.
10.
Arrangements for preservation of unknown dead bodies.
11.
The focal person who is the Medical Superintendent should check the medicines and
relevant equipment on weekly basis to be ready for emergency situations.
SOPs KTH 2010
P&D Cell-M&E
65
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
CRISIS MANAGEMENT TEAM (CMT)
OBJECTIVE
To ensure timely organized Trauma care in order to decrease mortality, morbidity & disability due to
injury.
-CMT will hold regular meetings to check the preparations of the hospital in order to cope with all
sorts of emergencies effectively.
1.
Dr. Mohammad Zafar
Chief Coordinator
Chief Executive KTH/KMC/KCD
Office: 091-9216362
Resident: 091-5861627
Cell No. 0300-5949517
2.
Dr. Khizar Hayat Khan
Medical Superintendent
Focal Person
Office: 9216832
Residence: 9211196
Cell No. 03339155129
3.
Dr. Farman Ali
Coordinator DMGs
DMS (P&D)
Office: 1208
Mobile: 0333-9166402
4.
Dr. Mohammad Zafar Afridi
Dy: Medical Superintendent (Admn)
Coordinator DMGs
Office: 2003
Mobile:03339120753
4.
Dr. Ghulam Rasool
Main Operation Theatre Coordinator
Office No.
Cell No. 03219093747
6.
7.
8.
9.
10.
Dr. S.Mujtaba
Resident Medical Officer
Office: 2004
Mobile 0300-5940821
Dr. S. Asad Maroof
Senior Registrar Casualty/Trauma
Office No. 2042
Dr. Akbar Shah
I/C A & E Deptt.
Contact #
Office: 9216363
Mobile: 03465114449
Mr. Jalil Anwar
Chief Pharmacist
Contact #03339138784
Mrs. Naseem Himayat
Chief Nursing Supdt:
Office No. 2167
SOPs KTH 2010
P&D Cell-M&E
Member
Member
Member
Member
Member
66
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
GROUP OF SURGEONS / ANESTHETIST
S. No.
Name of Group Leaders
1.
Assoc. Prof. Dr. Atta Ur Rehman
2.
Assoc. Prof. Dr. Rooh Ul Muqim
SNo
Name of Surgeon/Supervisors
1
Prof. Mia Asadullah Jan
2
Prof. Attaullah Jan
3
Prof Zafar Durrani
4
Prof. Parhaizgar
S. No.
Name of Doctors to be present at site
of mass Emergency
1.
Prof. Dr. Mustafa Iqbal Supervisor
2.
Assoc. Prof. Dr. Mushtaq
3.
Assoc. Prof. Dr. Attaur Rahman
4.
Assoc. Prof. Dr. Ijaz Ahmad
5.
Assoc. Prof. Dr. Zahid Askar
6.
Assoc. Prof. Dr. Inayat
8.
Assoc. Prof. Dr. Zakir Ullah
9.
Assoc. Prof. Dr. Hashimuddin Azam
10.
Assoc. Prof. Dr. Hamza Khan
11.
Assist. Prof. Dr. Qutbi Alam
12.
Assist. Prof. Dr. Abid Haleem
13.
Assist. Prof. Dr. Zareen SR
S.No.
Name of Anesthetists to be present in
O.T in case of mass emergency
1.
Asstt:Prof. Dr. Tahira Hakim Shah
2.
Assist. Prof. Dr. Nighat Aziz
3.
Dr. Asmatullah
4
Dr. Neelam
5
Dr. Aniqa
6
Dr. Zarmina Javed
7
Dr. Ghulam Rasool
Department Coordinator
8
Dr. Nirgus
9
Dr. Talat
S.No.
Name of Nurses
1.
Mrs. Shaheena Rehmat
3
Mrs. Akhter Shah
4
Mrs. Sabia Bukhari
5
Mrs. Robina Sultan
6
Mrs. Aqila Shaheen
8
Mrs. Gul Naz
SOPs KTH 2010
P&D Cell-M&E
Contact Numbers
03339106767
03005974985
Contact No
03339168781
5812860
5841800-03008582838
0333-5974985
Contact Numbers
03005957528
03339143130
5844501 / 0303-7866927
272817 / 0300-5908006
5843457
0300-5920492
5860561/03339169366
03005949920
03009012710
5704519 / 0333-9125829
811716
851640 / 0300-5980301
Contact Numbers
5812582/03349672447
03339156221
5825309
03349145229
5811831
0300-9598319 / 840194
5815466
5812632
5851007 / 0333-9113680
Contact Numbers
5850072
5840738
5703510
5842636
67
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
S.No.
1
2
3
4
5
6
7
8
9
10.
S.No.
1
2
3
4
5
6
7
8
9
S.No.
1
2
3
4
5
6
7
8
9
10
SOPs KTH 2010
P&D Cell-M&E
Name of OTAs
Mr.Liaqat Khan
Waheed Ahmad
Qayum Jan
Irshad Ali
Ibrahim Khan
Rashid Khan
Khair Ul Bashar
Younis Khan
Jehanzeb
Subhan
Name of Anaesthesia Technicians
Saleem Shah
Khan Sher
Muslim Khan
Safiullah
Ikhtiar Alam
Mujahid Azam
Nishad Ali
Shabir
Khan Said
Name of Ward orderlies
Viqar Khan
Hidayat Ullah
Mukhtiar Khan
Attaullah Shah
Riaz Khan
Misal Khan
Gul Bahar
Azad Khan
Samin Jan
Javed
Contact Numbers
2573708 / 0333-9165453
0300-5929584
0921- 645251
2211241
2285374
0333-9150917
0333-9127748
2990304
Contact Numbers
241549 / 0300-5983938
0300-5977229
2572828
0333-9122437
0300-5973879
611418
0300-5939088
0300-5727031
Contact Numbers
0300-5975765
5700880
5702944
870091
833463
5702079
68
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DOCTORS TO BE PRESENT AT SITE OF MASS EMERGENCY
S.No.
Name of Surgeons / Doctors
Contact Numbers
1.
Assoc. Prof. Dr. Ibrar Eye
845550 / 0300-5864732
2.
Assist. Prof. Dr.Tariq Waheed
0300-5940788
3.
Assist. Prof. Dr. Inayat E.N.T
0333-9115307
4.
Dr. Awal Hakim Orthopedic
Ext: 2235
5.
Dr. Zahid Khan
6.
Dr. Jamshed
Ext: 2117
7.
Dr. Ajmal Registrar
03339146350
8.
Dr. Azhar Shah Registrar
03005928386
9.
Dr. Sayed Asif Shah S.R Burn
0321-9046656
10.
Assist. Prof. Dr. Attaullah
03339143511
11.
Assist. Prof. Dr. Qutbe Alam
12.
Assist. Prof. Dr. Tariq Saeed
03025524826
13.
Assist. Prof. Dr. Zarin
03339414477
14.
Assist. Prof. Dr. Abid Haleem
15.
Assoc. Prof. Dr. Zahid Askar
16.
Assoc. Prof. Dr. Ayaz
17.
Assist. Prof. Dr. Wazir Mohammad
18.
Assist. Prof. Dr. Jamila Javed Shah
19.
Dr. Muslim Senior Registrar SBW
Resident Supervising Coordinator
SOPs KTH 2010
P&D Cell-M&E
03005933101
03005937571
69
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DIAGNOSTIC SERVICES MANAGEMENT GROUP
This group will manage the affairs of Blood Bank, the Clinical Laboratory, Radiology Deptt: and ECG .
The Blood Bank of KTH has a capacity to store 500 bags of blood.
S.No.
1
2
3
4
5
Name of Doctor
Dr. Azeem Afridi
Dr. Fayaz Naeem Assoc. Prof.
Radiology
Dr. Inam Pathologist
Contact Numbers
Mr. Hanif Chief Blood Bank Tech:
2670044 / 0300-5943981
5701909
MEDICINE AND SURGICAL DISPOSABLE MANAGEMENT GROUP
All the emergency drugs have been stocked in the Casualty Satellite pharmacy. These are sufficient to
provide health care to a maximum of 500 patients. (List of medicine is given below):
S.No.
1
2
3
4
DMG-6
Name of Pharmacist / Store keeper
Jalil Anwar Chief Pharmacist
Coordinator
Mr.Javed Senior Pharmacist
Badri Zaman Store Keeper
Zahir Ali Dispenser
Contact Numbers
0333-9138784
03469218509
842687
0300-5962257
INFORMATION AND REGISTRATION GROUP
S.No.
Name of officers /officials
Contact Numbers
1
:Mr. Farhad Khan PRO
03339109847
2
Mr. Mumtaz Khan Protocol Officer
03219009657
3
Safdar Khan
9216363
4
Ayub Khan Head Ward orderly
0333-9166288
SOPs KTH 2010
P&D Cell-M&E
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
MASS EMERGENCY AREAS (RED ZONES)





Disaster Cell in Trauma unit ------30 beds
Casualty Department
------12 beds
Eye A & B , ENT A&B units
-----184 beds
Surgical Wards A,B,C&D
------184 beds
Surgical ICU
------8 beds
Total
------418 beds
All these areas have been equipped with beds, linens, staff, emergency trays and medicines.
LOGISTICS
 In case of power failure alternate mechanisms have been ensured working in collaboration
with WAPDA authorities.
 Stand by diesel generators along with sufficient diesel for emergency ensured.
 Provision for continuous supply of water.
 Fire extinguishers to all vulnerable areas.
 Emergency Nos have been provided to the telephone operators.
 Hot line No. 9216348 communicated to Police and DCO Peshawar.
 Measures taken to ensure that the hotline is not kept busy.
 Six Ambulances have been equipped for Primary Care with sufficient Diesel and round the
clock provision of drivers.
 At least ten trolleys and Ten Wheel Chairs are available for patient transport.
 Blood Bank Officer and Social Welfare Officer are working in close liaison with Social welfare
society of KMC to ensure sufficient blood.
SOPs KTH 2010
P&D Cell-M&E
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STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
TELEPHONE NUMBERS OF PROFESSORS
S.NO
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
NAME OF PROFESSOR
Prof. Mia Asadullah Jan
Prof.Dr.Sultan Mahmood
Prof. Balqis afridi
Prof.Sadeeq U Rahman
Prof. Attaullah Jan
Prof. Inayat Shah Roghani
Prof.Zafar Hayat
Prof.Niamatullah Kundi
Prof. Nadeem Khawar
Prof.Zafar Durani
Prof. Azer Rashid
Prof.Shah-e-Din
Prof. M. Aziz Wazir
Prof. Nisar Anwar
Prof. Dr. Noor Ul Iman
Prof. Dr. M. Hamayun
Prof. Dr. Mukhtiar Zaman
Prof. Mehmud Aurangzeb
Prof.Dr. Mustafa Iqbal
20. Assoc. Prof. Atta Ur Rehman
21. Assist. Prof. Dr.Arif Raza
SOPs KTH 2010
P&D Cell-M&E
OFFICE
2212
2216
2205
2197
2187
2236
2186
2184
2199
2188
2182
2201
2174
2126
RESIDENCE MOBILE
5841894
0333-9168781
5841628
0333-9166220
5841894
0300-5922472
5813092
0300-5949951
5812860
0333-9123391
5828011
0304-9006447
5815651
0300-5980159
5844561
0300-5920463
5817773
0345-9043892
5841800
03008582838
5276747
0300-5942418
5812513
0333-9103887
576326
0300-8595551
03339131322
03005956027
03339135316
03339141114
03005957528
03339259091
5844501
03339106767
5836199
0333-9167305
5825861
2573042
72
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
SOPS FOR LABORATORY INVESTIGATIONS








All the samples must be properly labeled
All the routine/ baseline investigations which do not need the orders of the Professor I/C of
the concerned unit ( like blood complete, urine exam, blood urea, blood sugar etc.), may be
sent in time to the laboratory before 10.00 am
Specialized investigations or any other test advised may be sent to the laboratory up to 12. 0
Noon. These investigations will be completed & reported up to 2. PM
Emergency investigations will be entertained any time up to 2 PM in the morning shift & round
the clock afterwards
All the pre operative patients must be screened by Elisa . The ICT quick method may be utilized
only for dire emergencies.
Samples for Elisa tests must reach laboratory from 9 AM -- 4 PM
Blood for P.T/ APTT must be sent in citrated tube in proper volume in the ratio of 0.2 ml
reagent & 1.8 ml blood
Patient for fasting blood sugar must have 12 hrs fasting & random glucose checked after lunch/
dinner
SOPs KTH 2010
P&D Cell-M&E
73
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR
DEPARTMENT OF RADIOLOGY
INTRODUCTION
Radiology department is now changed into an imaging department and gives services round the clock.
Department has facilities of conventional X-ray, fluoroscopic examinations, ultrasound and Doppler
studies. The endowment fund has provided CT and MRI.
GUIDELINES FOR THE PATIENTS
Patient coming to radiology department has investigation forms duly filled in and advised by treating
physician, gets his examination form registered at the counters manned/controlled by MS KTH along
with the payment of dues and gets receipt. A few examination services are on appointment bases,
where the patient is given date by the clerk in room No 6. the money so collected is deposited with
the almoner of the hospital by the respective data entry operator.
ULTRASOUND
Department runs in three shifts. Morning: 8am to 1pm. It is for all cold cases of the OPD, wards and
also for emergency cases. Ward cases are by appointment. Evening: 1pm to 8pm. Night: 8pm to 8am.
Evening and night shifts provide cover to casualty and ward emergency cases.
X-RAY
X-ray are done round the clock and the shifts are the same as for the ultrasound.
CT SCAN
CT scan is done up to 3pm and reported daily. After this the emergency services are provided round
the clock.
MRI
MRI is done daily up to 3pm and reported on the same day except few cases kept for teaching
purpose.
STAFF
There are different cadres of staff working in the department, the included are
 KMC teaching staff.
 Provincial Health Services Doctors.
 Provincial Health Services Paramedics.
 Clerical and supporting services of dais ward orderlys, sanitary.
 Doctors of all cadres work under the supervision of head of radiology department, who is
Professor of KMC. JR/SR is designated staff of MS KTH and is responsible for liaison between
department and administration of KTH. They are the administrative local heads.
SOPs KTH 2010
P&D Cell-M&E
74
STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR




Doctors perform all the procedures and examinations of patients and report the images of
different modalities.
Paramedics mostly the X-ray, CT and MRI technicians responsible for acquiring images.
A few minor procedures of general radiology are also performed by paramedics.
Dais are present in ultrasound section and responsible for assisting the doctors on duty in
handling the female patients and also fulfill the requirement of female attendant at the time
of examination
REVENUE
Radiology department is also the earning hand of the institution. Most of the services provided are on
charge basis.
The revenue then generated is deposited with the Almoner of KTH. Revenue generated from CT and
MRI is deposited in the account of Endowment fund project and later distributed between Provincial
Endowment fund, KTH and staff of radiology department.
DUTY ROTA
Duty Rota is made by registrar in consultation with the head of department. The doctor on duty has to
be present in the department. House officers and TMO’s also perform the duties on rotation bases.
Duties are assigned in three shifts.
Registers are maintained in the department by senior technician and supervised by JR/SR along with
head of department.
CLEANLINESS
Department cleanliness and maintenance is checked daily.
SOPs KTH 2010
P&D Cell-M&E
75