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SMU MBAHCS ASSIGNMENT SEMESTER III MB0052 HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING ASSIGNMENT SET: I SUBMITTED BY: J.JERALD JEYAPRAKASH MBAHCS ROLL NO :- 531010671

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Q.1 a. Explain the differences between formal and informal organizations,b. What are the characteristics of a hospital organization,Q2. Explain hospital administration.,Q3. Hannah Healthcare is planning to open a hospital in North Bangalore region. For this purpose they have brought together a team of experts,A. Who are the team of experts who constitute the hospital planning?,B. What are the principles of hospital planning?,Q.4. Explain the various ward designs. Explain them with diagrams.,Q5. Write short notes on:i. OPD ,ii. Accident and emergency services,Q6. If you are called be the infrastructural consultant for setting up a NICU in a 5 year old multispecialty hospital, what are the planning considerations of NICU that you would present to the Managing Board?,

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Page 1: MH0052 Solved Assignment

SMU

MBAHCS ASSIGNMENT

SEMESTER – III

MB0052

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING

ASSIGNMENT SET: I

SUBMITTED BY:

J.JERALD JEYAPRAKASH

MBAHCS

ROLL NO :- 531010671

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SMU- MBA Semester III

Reg. No: 531010671

HOSPITAL ORGANIZATION, OPERATIONS AND PLANNING-MH0052

INDEX

Q.No

QUESTION

Page No

Q.1

A. EXPLAIN THE DIFFERENCES BETWEEN FORMAL AND

INFORMAL ORGANIZATIONS.

B. WHAT ARE THE CHARACTERISTICS OF A HOSPITAL ORGANIZATION?

3

4

Q.2 EXPLAIN HOSPITAL ADMINISTRATION 5

Q.3 HANNAH HEALTHCARE IS PLANNING TO OPEN A HOSPITAL IN NORTH BANGALORE REGION. FOR THIS PURPOSE THEY HAVE BROUGHT TOGETHER A TEAM OF EXPERTS.

A. WHO ARE THE TEAM OF EXPERTS WHO CONSTITUTE THE HOSPITAL PLANNING?

B. WHAT ARE THE PRINCIPLES OF HOSPITAL PLANNING?

10

12

Q.4 EXPLAIN THE VARIOUS WARD DESIGNS. EXPLAIN THEM WITH DIAGRAMS.

13

Q.5 WRITE SHORT NOTES ON:

I. OPD

II. ACCIDENT AND EMERGENCY SERVICES

20

25

Q.6 IF YOU ARE CALLED BE THE INFRASTRUCTURAL CONSULTANT FOR SETTING UP A NICU IN A 5 YEAR OLD MULTISPECIALTY HOSPITAL, WHAT ARE THE PLANNING CONSIDERATIONS OF NICU THAT YOU WOULD PRESENT TO THE MANAGING BOARD?

29

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Q.1.A) EXPLAIN THE DIFFERENCES BETWEEN FORMAL AND INFORMAL

ORGANIZATIONS.

Answer

Formal organization:

A formal organization is one which consists of a group of people working together

cooperatively, under authority, towards goals that mutually benefit the participants and the

organization. In this system, well defined jobs bearing a clear measure of

authority,responsibility and accountability are found.

Formal organizations have an intentional structure of roles in a formally organized

enterprise.

The structure must be flexible; there should be room for discretion, for advantageous

utilization of creative talents, and for recognition of individual likes and capacities. The

Structure should be organized in such a manner that the people involved and the resources

are able to accomplish the purpose for which the organization was set up. That is why it is

very important for a healthcare organization to set its organization structure based on its

objectives. Hospitals however may share some of their objectives, but, there may be

objectives that are unique to a particular organization only. The spectrum of objectives

determines the organization structure, its scope and volume of activities, the required

departments and their sizes, staff requirement, etc.

Informal Organizations:

Chester Barnard, author of The functions of executive, described informal organization as

any joint personal activity without conscious joint purpose, even though contributing to

joint results.

Keith Davis of Arizona State University described the informal organization as a network of

personal and social relations not established or required by the formal organization but

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arising spontaneously as people associate with one another. Thus in informal organizations,

relationship that does not appear on an organizational chart, might include the machine-

shop group; the sixthfloor crowd; the Friday evening bowling gang; the morning coffee or

tea club members etc. Both formal and informal types are found in organizations.

Table 1.1: Formal Organization Vs Informal Organization

Characteristics Formal Organization Informal Organization

Origin Deliberately created Formed spontaneously Goal Reflects organizational

goals Individual and group goals

Structure Has definite hierarchy Structure less

Integrating mechanisms

Held together by rules, regulations and procedures

No rules, held together by feelings of friendship, mutual help and trust

Communication channels

Formal official channels of communication

No defined communication channels

Q.1.B) WHAT ARE THE CHARACTERISTICS OF A HOSPITAL ORGANIZATION?

Answer

Characteristics of Hospital Organization

Every organization has a head. In every organization there should be a clear line of

authority for every individual. In a hospital, there are dual lines of authority. The

Administrators are responsible for solving management problems while Doctors are

involved in patient care.

Hospitals are characterized by having wide diversity of objectives and goals for different

personnel, professional groups and subsystems. For example: The house keeping

department works towards maintaining cleanliness and sanitation, the clinical team focus

on patient care, the Administration team works on problem solving and hospital

betterment, the marketing team works towards brand building and better marketing of

services.

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The hospital is in continuous operation which requires high operating costs and substantial

personnel and scheduling problems.

The diversity of personnel ranges from highly skilled and educated administrators and

doctors to unskilled and uneducated employees like the staff involved in sanitary functions.

The hospital organization is characterized by interdependence. Every person involved in

patient care is dependent on other departments or individuals in order to accomplish their

tasks or fulfill their responsibilities. For example: An orthopedic surgeon cannot perform an

orthopedic surgery without the findings from the radiology department and the assistance

of the nurses and technicians.

Hospitals deal with problems of life and death. This has psychological and physical stress on

personnel at all levels in the hierarchy.

Measuring the quality of product (healthy and satisfied patient) is a problem because

patient care delivered has no precise measurement.

Hospitals provide services. Unlike the production industry where productivity and quality

may be easily defined, hospitals productivity and quality cannot be quantified easily.

Hospitals should always comply by the medical ethics. (eg: patient confidentiality).

Q2. EXPLAIN HOSPITAL ADMINISTRATION

Answer

Hospital Administration

What is hospital administration?

Hospital administration is the management of the hospital business. Hospital

administration is made up of many healthcare managers and executives who take care of

individual departments.

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They are in charge of all the administrative or management functions of their respective

departments. These various managers or assistant administrators will report to the Hospital

Administrator.

Need for hospital administration:

A hospital like any other business entity may function for purposes of profits too. With the

burgeoning numbers of private / corporate hospitals, private nursing homes, the need for

specialized managers for hospitals become evident. The stiff competition necessitates

specialists to handle difficult situations. Well informed decision makers have become a

necessity. Gone are the days when a highly skilled physician would also take care of the

administrative functions.

With the enormous challenges pressing the healthcare industry people with special and

specific education are required. Hence, the presence of hospital Administrators is the need

of the hour.

The primary function of a hospital administrator would be to manage the resources of the

hospital. The resources of a hospital are: people, methods, measurements, materials,

machinery and equipment, money, time and information. Some of these resources may be

scarce, like the availability of specialist doctors, or nurses, availability of diagnostic

equipment, etc.

A hospital organization may seem a lot like any other organization. It has many business

features common to that of other businesses; however, there are certain qualities in a

hospital that make it unique. These unique characteristics were already discussed in unit 1.

You may read that again.

Besides being an interdependent entity, a hospital is an organization of high accountability.

The community looks up to the hospital for all of its healthcare needs. Hospitals deal with

life and death, making it all the more a sensitive place. Hospitals mostly intervene at the

time of greatest mental agony. Its clients are a lot sensitive, therefore every service

provided must ensure the utmost care. Hospital Administrators are people who have

understood this situation very well.

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They should bear this in mind while taking decisions.

Who is a Hospital Administrator?

A hospital Administrator is the overall head of the business operation and managerial

functions in the hospital. The Hospital Administrator is vested with the responsibility of

running the hospital operations. He / she acts as a liaison between the Governing Board,

medical staff and other management staff. They play a major role along with the Governing

Board in making the hospital policies. They take up human resources function also such as,

recruiting, staffing, evaluation, etc. They have an active participation in the hospitals public

relations. He / she is also responsible for contributions during budgeting and allocation of

resources. They are involved constantly in training programs that would enhance their

managerial skills and helps them to know new management trends and techniques enabling

them to be on the edge. The Administrators role is very crucial in the effective and efficient

running of a hospital.

Roles and functions of a Hospital Administrator:

Hospital Administrator is the chief executive in the hospital. A hospital may have a number

of executives in various departments to handle the administrative or managerial functions.

All these executives are accountable to the Hospital Administrator. Figure 2.3 represents

the various major duties of the Hospital Administrator.

The major functions of the Hospital Administrator are enlisted below:

Functions of the Hospital Administrator:

1. Acts as a legal representative of the Hospital. The Hospital Administrator is responsible to

ensure whether the hospital is complying with the government rules and whether all the

statutory requirements are met.

2. Is a part of the Governing Board. He / she has the responsibility of supervising all the

activities in the hospital

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3. Should ensure that all staff is aware of the hospitals mission, vision and objectives. He

/she is instrumental in getting information on mission, vision and objectives down to all the

staff.

4. Implements all the management decisions in the hospital

5. Formulates major rules, regulations and procedures and ensures their implementation

6. Ensures that the rules formulated are in line with the hospitals policies

7. Coordinates and participates in devising short term and long term plans for the hospital

8. Submits annual reports to the Governing Body

9. Ensures financial viability of the hospital

10. Acts as a link in between the management and the employees. Therefore participates in

deciding the salary structure, benefits, etc.

11. Is responsible for a good employer employee relations

12. Works closely with other important executives in the hospital such as the Medical

Superintendent, nursing Superintendent, etc.

13. Ensures that all the departments function smoothly and efficiently.

14. Is responsible for outsourcing services, contracts, hiring, etc.

15. Acts as an official representative of the hospital

16. Maintains contacts with the government, community and media.

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Fig. 2.3: Duties of a Hospital Administrator

Characteristics of an effective Hospital Administrator:

An effective Hospital Administrator should possess all the managerial skills. Besides, he or

she should also be outstanding in the following qualities:

1. Should show competence at work

2. Should be sensitive to organizations and staffs problems and needs

3. Should possess the ability to analyze, synthesize and integrate various information

Duties of Hospital

Administrator

Needs Assessment of

the organisation /

Clients

Hospital operations,Public Relations

functions

Human Resources Function

Formulation of policies

and implementati

on

Ensure complience

with law,rules,regulations,ethics

Contributes to devising annual

budgets

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4. Has the ability to foresee and plan

5. Has the ability to bring forth new and creative ideas

6. Has the ability to coordinate, organize, control and allocate resources

7. Should be able to delegate work and make efficient use of his or her own time

8. Ability to motivate and develop people

9. Should be able to introspect and evaluate

10. Should be an able communicator

Q3. HANNAH HEALTHCARE IS PLANNING TO OPEN A HOSPITAL IN NORTH

BANGALORE REGION. FOR THIS PURPOSE THEY HAVE BROUGHT TOGETHER A

TEAM OF EXPERTS.

A. WHO ARE THE TEAM OF EXPERTS WHO CONSTITUTE THE HOSPITAL

PLANNING?

B. WHAT ARE THE PRINCIPLES OF HOSPITAL PLANNING?

Answer

The Hospital Planning Team

The hospital planning team should ideally consist of the following members:

1. Hospital Administrator

The Administrator is the chairman of the planning team. He is mainly involved in putting up

hospital requirements to his team in terms of, facilities for the hospital, design

consideration, orientation of interrelated departments and service facilities. He also

oversees and coordinates the various activities involved in planning.

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2. Hospital Engineer

The engineer appointed to prepare the plan of the hospital should have previous

experience in constructing hospitals. He works in close coordination with the administrator

and the architect.

3. Hospital Architect

The hospital architect should have knowledge of the work flow involved in a hospital setup

so as to suggest the design considerations of the hospital. The experience and expertise of

the architect and the hospital engineer helps in planning a good hospital.

4. Financial Expert

The financial expert helps the administrator to study the feasibility of the project. He can

advice on the funds required for the project and the sources available for the same. The

estimates given by the finance expert helps in drawing up a smooth plan.

5. Health Statistician

The health statistician also contributes to the study of the feasibility of the project. He helps

the team by providing vital information on the demographic picture of the region, disease

related statistics, socio-economic condition of the people, all of which helps the

administrator in deciding the type of facilities required and charges to be levied.

6. Representatives of government or local bodies

The representatives of the government or local bodies help in the coordination of the

project.

They form a link between the community and the hospital

7. Nursing Director/Superintendent

The nursing director can give valuable inputs to the project team, especially in ward

planning.

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8. Social scientist

The social scientist helps in identifying the felt needs and real need of the community. His

suggestions during the planning process helps in fulfilling the communitys expectations of

the project.

9. Consultant representative from user department

The success of everything planned in the hospital depends on whether it is user friendly. It

is therefore necessary for the planning team to take into consideration the suggestions of

the consultant representative from the user department. The design and functioning should

be user friendly.

Principles of Hospital Planning

High Quality Patient Care:

The hospital must be designed, staffed and equipped to meet the stated objectives in

addition to providing high quality medical care. There must be a good organizational

structure. The quality of patient care delivered should be strictly monitored through

continuous review of existing facilities, services offered etc. The hospital should have

adequate number of competent staff who would ensure a high quality patient care. The

medical staff should be provided continuous medical education that keeps them informed

about the latest trends and technology.

Community Orientation:

The needs of the population should be borne in mind while planning the hospital. The

hospital should be located at a convenient and easily accessible location. While outlining

the charges for the healthcare facilities, the following factors should be taken into

consideration i.e. the population mix, social status, education and earning capacity of the

target population. The hospitals Governing Board may have people representatives from

the community. The hospital should also involve itself in community outreach programs

that might not only promote the hospital services, but will also help in developing goodwill

and helps in understanding the needs of the community.

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Economic Viability:

The hospital may not be profit making at all times. Hence there should be a sound financial

management system in place. The healthcare facility should be able to identify and adopt

means to be self sustaining. Any renovation and expansions planned should be done

rationally, taking the views of the community into consideration.

Sound Architecture:

The design adopted in putting up a hospital should consider efficient use of the facility and

personnel. Flexibility should be adopted during designing, ensuring proper circulation space

for movement of staff, patients, relatives and friends. The space should also accommodate

movement of goods and materials used for patient care. Identifying areas prone to

infection and adopting infection control measures at preliminary stage of planning

contribute to a sound architecture. In short Design should follow function and not vice

versa. Design should accommodate and consider future expansion. Disaster planning

should be done simultaneously with the planning and design of the hospital structure.

Q.4. EXPLAIN THE VARIOUS WARD DESIGNS. EXPLAIN THEM WITH DIAGRAMS.

Answer

Design and Layout

Size: The size of the wards depends on several factors. It can vary from as low as 10 beds to

as high as 90 beds in a single ward. Some of the parameters influencing the design and

layout of the wards are:

1. Severity of the patient condition The more the severity, smaller the ward. E.g.: ICU, CCU,

T.B Sanatorium etc.

2. Category of the ward General wards has more number of beds than special room or

deluxe wards.

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Location: The location of the wards depends on the activities taking place, services

rendered, movement of patients, relatives of patients, doctors, nurses, paramedical staff,

visitors etc.

Example: It is desirable to have the surgical wards close to operation theater and post op;

antenatal wards close to labour theater; ICU close to the Accident & Emergency centre etc.

Ward Areas: the various areas that need to be included while designing the wards are:

Patient space: it includes: Multibed bays, patient rooms

Day space: serves as a space for reading, writing, watching TV, etc.

Patient relatives area

Visitors waiting area

Corridor space that would allow movement of man, machines and trolleys, stretchers, etc.

Ward Design

Nightingale Ward:

The nightingale ward is named after Florence Nightingale. This pattern came into existence

after the Crimean war during the 19th century. Each ward has a total of 40 beds. Schematic

picture of this plan is given below. This arrangement has the following advantages;

1) excellent crossventilation, 2) good lighting, 3) clear and unimpeded view of all patients.

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Fig. 4.1: Nightingale Ward

The disadvantages are:

1) No privacy for the patients,

2) Lot of traffic (food cart, patient trolley,ward stock etc) moving through the patient care

areas causing inconvenience and disturbance to patients admitted,

3) Nurses/ other staff fatigue factor, due to the distance to be covered for rendering

services located in separate areas.

Variant Nightingale:

To overcome some of the disadvantages faced in the Nightingale pattern, a variant of the

same was created. Even in this pattern there are 40 beds. The Variant Nightingale pattern is

also called Cruciform Shape. The length of the ward is 26 meters. This concept gave rise to

the evolution of having single bed room/double bed room wards. A sketch of this type of

layout is illustrated below.

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Fig. 4.2: Variant Nightingale Pattern

Advantages of this design is:

1) Privacy for patients

2) Reduction in noise levels

3) Reduced incidence of cross-infection

4) Attached toilets making it convenient for patient attenders/visitors

5) Flexibility in usage of wards among different departments.

This pattern was not free of defects as it had a few disadvantages;

1) Reduced view from the nursing station

2) Patients found it difficult to communicate to nurses and doctors

3) Cost of construction, maintenance, overheads etc was more with high capital costs

4) Maintenance also was difficult as this pattern increased the floor area.

Rigs Design:

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The Rigs pattern of ward was first designed in 1910 and implemented in Denmark. The

length was reduced and width was increased as compared to the Nightingale pattern. A

schematic representation of this layout is given below.

Fig. 4.3: Rigs Design

Some of the special features incorporated in this design are as follows:

1. There was a major shift in the earlier concept of spacing of beds.

2. Privacy in general wards was enhanced due to wall partition of 5 ft height.

3. The distance walked by the nurses for rendering service was reduced

4. Patient beds are arranged parallel to the main corridor, in order to reduce traffic

disturbances in the ward

Some of the other patterns worth mentioning are:

Nuffields ward:

A lot of research was done on hospital design during 1950s. Nuffields study (1949-1955)

deserves special mention. Based on the findings, an experimental ward was constructed.

The design is represented below.

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Fig. 4.4: Nuffields Ward

Race track design/deep plan:

This concept arose during 1950s in the United States. Also called double corridor system,

this design has 36 beds with two nursing stations.

Fig. 4.5: Rack Track Design

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Harness type ward:

Also known as the crossed type, this design is known to have different types of rooms with

single, double, four and even eight beds.

Fig. 4.6: Harness type Ward

Other ward types:

Courtyard ward:

This type of wards makes provisions for natural light and ventilation. This also helps in

saving costs and hence contributes towards the hospitals economy.

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Q5. WRITE SHORT NOTES ON:

I. OPD

II. ACCIDENT AND EMERGENCY SERVICES

Answer

Out-Patient Department

Introduction

The outpatient services of the hospital are significant. It is the first point of contact with the

hospital. The reputation of the hospital thus, depends on how good the out-patient service

is. It is also considered as the window of the hospital. It helps in reducing inpatient

admissions and facilitates day care services. This helps the hospital management in

reducing managing costs and as for as the patient is concerned, it benefits in terms of

convenience and also reduced healthcare expenditure.

Objectives:

After reading this section you will be able to:

Define outpatient facility

Explain the importance of outpatient services

Illustrate the work flow in the department

List the minimum facilities required in the outpatient department.

Definition:

The outpatient department is a part of the hospital with allotted physical facilities; medical

and paramedical staff in sufficient numbers, with regular scheduled hours of work to

provide care for patients who are not registered as in-patients.

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Functions:

Provides wide range of treatment, diagnostic tests and minor procedures.

Eliminates the need for hospital stay/reduction in hospitalization rates.

Reduces the cost burden on both hospital and patients.

Imparting education to professional staff and patients.

Benefits medical students, physicians and other healthcare professionals in terms of

diversified clinical experience.

Importance of Outpatient department:

The outpatient department is the first point of contact with the hospital.

Forms an entry point into the healthcare delivery system.

Inseparable link in the hierarchical chain of healthcare facilities.

Stepping stone for health promotion and disease prevention.

Contributes to the reduction in mortality and morbidity rates.

Reduces the number of admissions (IP), conserving hospital bed

Filters the inpatient admissions, ensuring admission to patients who necessarily require it.

Outpatients:

Outpatients are those persons who are given diagnostic, therapeutic or preventive services

through the hospitals facilities, who have not registered themselves as inpatients the

hospital.

Categories of outpatients:

1. Emergency outpatient:

Emergency care is given in case of sudden severe illness or accident

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Emergency can be from the patient point of view or from the physicians point of view

2. Referred outpatient:

Generally referred from outside hospitals or general physician For specific investigations or

minor procedures

3. General outpatient:

Usually form the bulk of the outpatient attendance

For follow-up care rendered by the consultants in the hospital.

Source of origin of OP cases:

The various sources of outpatient case can be listed as

Direct walk in patients to the hospital

Referred case from outside hospitals, local doctors etc.

Attendance in casualty on an emergency basis

Follow-up cases or repeat visits

Flow pattern of work:

Reception and enquiry i.e. first point of contact in the hospital

Registration

Moves to sub-waiting area

Visits the doctor at OPD

Subjected to number of clinical investigations

Patient sent home based on clinical findings

Patient is admitted (if required) for further evaluation and treatment.

Planning of outpatient services:

It is important to note that the outpatient department which is a part of the hospital has

functional and administrative links with the hospital. There are health centers, satellite

clinics and dispensaries dependent on the outpatient services. As a matter of policy,

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preventive and promotive care should be provided along with curative care. In short, better

services attract more patients.

The demand for outpatient services depends on number of factors like, expenses to the

patient; distance to reach the OPD; transportation facilities available; socioeconomic status

of the target population; degree of urbanization in the population and quality of care

provided at the hospital.

Planning considerations:

At the time of planning the outpatient department, the following points are worthy of

consideration -

1. Range of outpatient services to be provided; defining the functions.

2. Number of staff required by rank and the tasks to be performed by them.

3. Possible service time per patient, depending on daily and hourly capacity.

4. Flow of patients

5. Requirement of furniture and equipment

6. Layout of the department.

Facilities available at OPD:

1. Public areas and administration

o Trolley bay

o Reception and Help desk

o Registration counter

o Lobby and waiting lounge

o Toilet and drinking water facilities

o Public telephone

o Coffee shop, gift/flower shop

o Bank extension counter

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o Security out post and fire alarms

2. Clinical facilities

o General examination rooms

o Special examination rooms i.e. for ENT, EYE, etc.

o Treatment/procedure rooms

o Nursing station

o Injection room

o Laboratory and sample collection area

o Pharmacy outlet

o Radiology services

o Common problems encountered by patients at the OPD:

o Long waiting time to consult the doctor

o Non availability of lab investigation reports on time

o Interruptions during patient consultations because of telephone calls to doctors

o Poor designing of facilities

o Breaking the queue in the appointment system

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Q5. WRITE SHORT NOTES ON:

II. ACCIDENT AND EMERGENCY SERVICES

Answer

Accident and Emergency Services

Introduction:

The emergency department has become a key point in patient care in the healthcare

delivery system, serving the market that demands modern, efficient facilities, trained staff

and state-of-art healthcare. The volume of patients seeking routine care in emergency

departments has grown considerably, since there is a large pool of mobile citizens who

have no family physicians.

Furthermore, the emergency department remains one of the few places where provision of

healthcare unequivocally takes precedence over financial and legal considerations. Round

the clock availability of services is another aspect that is characteristic of emergency

departments.

The emergency department is required to render a comprehensive range of services right

from the elementary first-aid and general outpatient services to sophisticated management

of surgical and medical emergencies and full-scale trauma care. This service, like OPD has a

lot of public impact and as a result helps strengthen the image of the hospital.

Maintaining a 24-hour service with its high fixed costs and periods of low utilization can be

costly. A well designed and efficiently managed emergency department is an important

source of revenue to the hospital. It can be noted that patients in emergency use diagnostic

and supportive services of the hospital to a considerable extent and this brings in a lot of

revenue.

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Objectives:

At the end of this section you will be able to:

Define accident and emergency service

Describe the phases of emergency medical care

Explain the importance of accident and emergency services

Identify the planning considerations of an emergency unit

Factors contributing to increased demand:

Rapid urbanization and industrialization

Increased diagnostic facilities in the hospital

Team approach to medical care

Medico-legal cases not attended by general practioner

Increased recognition of the hospital as a place of healing

Definition:

A patient who requires immediate treatment, which if not given would mean loss of

life/limb or result in any other disability.

An emergency as understood by the patient and his relatives is any illness/injury for which

patient requires/desires immediate attention of the physician.

Phases of emergency medical care:

There are 3 phases of emergency medical care, they are1.

Pre-hospital care:

Prevention i.e. by public education

Detection

Establishing communication network

Notification i.e. trained technical manpower

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Rescue operation

Initial stabilization: The trauma team should reach out to the accident scene quickly as the

treatment initiated during the first one hour also called Golden Hour is of importance in

clinical outcome in such cases.

Transportation to hospitals

Continuous advance life support measures enroute the hospital.

2. Emergency department care:

The hospital accident and emergency unit is activated from the time the mobile unit arrives

at the site of accident till the patient is transferred either to the in-patient area or to

another hospital where facilities are available.

3. Hospital care:

This refers to general or specialized care received at the hospital in ICU/CCU/Burns/Trauma

centre etc. This phase extends up to the rehabilitation stage of the patient.

Importance of A & E services:

The accident and emergency unit is a very sensitive area in public relations. Its services

form the mirror image of the hospital and for some patients, the first point of contact with

hospital care.

The promptness exhibited in attending to the patients by the healthcare personnel reflects

the hospital services. It is often an area for criticism

Trauma and cardiovascular diseases are the two leading causes of sudden death.

India accounts for nearly 6-8% of total road traffic accidents in the world.

Location:

The ideal location for the accident and emergency unit would be the ground floor, with

direct and easy access for patients and ambulance from the main road. There should be a

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separate entrance to this unit and there should be clearly visible sign boards directing

towards the entrance, with proper lighting (during night).Parking area should be spacious

with a drive in for vehicles and transferring of patients from the ambulance comfortably.

Other services to be located near the accident and emergency unit is, the admission

counter; medical records department; laboratory services; radiology services; blood bank;

intensive care unit; operation theater etc.

Physical facilities

1. Administrative and public areas:

o Reception

o Entrance should be wide enough to move stretcher, trolley

o Public waiting area with toilet; drinking water; public phone facilities

o Room for security; police out post; ambulance driver; patient bystanders

o Office for the night supervisor

o Coffee shop and snack bar in the vicinity

2. Clinical facilities:

o Trauma room

o Examination/treatment room

o Scrub room

o Space for triage/observation room

o Storage space for equipments

o Room for duty doctors/nurses

o Patients toilet

o Soiled linen room; janitors closet

o Locker room

Categories of staff:

The various categories of staff working in the accident and emergency unit include, casualty

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medical officer; consultants on call; nursing staff; attenders and orderlies; receptionist;

medicosocial workers; security staff; radiographers; laboratory and ECG technicians on call.

The hospital management should ensure that adequate security is provided to the various

categories of staff from manhandling, as casualty is a highly sensitive and emotional area.

Adequate measures to be taken in providing the staff with personal protective equipment

to protect staff against infection.

Q6. IF YOU ARE CALLED BE THE INFRASTRUCTURAL CONSULTANT FOR SETTING

UP A NICU IN A 5 YEAR OLD MULTISPECIALTY HOSPITAL, WHAT ARE THE

PLANNING CONSIDERATIONS OF NICU THAT YOU WOULD PRESENT TO THE

MANAGING BOARD?

Answer

Neo-natal ICU

Introduction

Childbirth is an occasion for joy. However, on some occasions this joy is tainted with

concern about the health of the newborn. The threat of serious illness or death of a

newborn places serious responsibilities on health care providers to respond appropriately

with effective therapy.

Disorders and diseases in the neonatal period pose a greater risk to life and health than

which occur during any other period of postnatal life. This burden of illness is measured not

only in terms of neonatal mortality and morbidity but also in terms of disability and

handicap among survivors and in terms of high economic costs for acute and continuing

medical care, special education and other supportive services. The recognition of the need

for provision of intensive care to the newborn, led to the birth of the concept of Neonatal

Intensive Care Units/ Special Care Neonatal Units/ Intensive Care Nurseries.

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The idea of having a special intensive care unit for newborns represented a

developmentalmilestone in the field of neonatology. The establishment of the first

premature infant center at Sara Morris Hospital in Chicago in 1920s marked a new era of

concern for the sick newborn. Dr.Louis Gluck established the first newborn center at Grace

New Haven Hospital at New Haven,Connecticut in 1960. At the turn of the 20th century, a

French physician named Pierre Constant Budin discovered that incubator care was

associated with improved survival of premature infants. Martin Couney is credited with

advances in incubator design as well as premature feeding techniques. The use of

ventilators in infants with respiratory distress began in 1961.

Much of what is now known as intensive care, the use of intravascular catheters; blood gas

monitoring; arterial pressures; heart rate; temperature monitoring and a myriad of other

facets of care were developed as a result of research, after the success of assisted

ventilation.

Objectives:

After going through this section you will be able to:

o Define a neo-natal intensive care unit

o Classify the NICU

o Explain the design considerations of NICU

o List the policies and procedures followed in NICU

Definition

Newborn intensive care is defined as care for medically unstable or critically ill newborns

requiring constant nursing, complicated surgical procedures, continual respiratory support,

or other intensive interventions.

Neonatal Intensive Care Unit (NICU) is a special unit of the hospital set up to provide

extraordinary surveillance and support of vital functions and definitive therapy for infants

having acute or potentially reversible life threatening impairment of a vital system.

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Classification of Neo-natal Intensive Care Unit

There is a lack of consistent definition of levels of care in neonatal care units. The

advantages of having uniform definition would include the ability to compare outcomes,

utilization, and costs among institutions; develop NICU standards; inform the public of NICU

capabilities; minimize the perceived need for businesses to develop NICU standards.

The proposed levels of care are:

Level 1. Newborn Nursery

- Can perform neonatal resuscitation at every delivery

- Care for healthy term newborns and for infants 35-37 weeks gestation who remain

physiologically stable.

- Other newborns would be stabilized and transported to a unit with the appropriate higher

level of care.

Level 2a. Special Care Nursery

- Can provide Level 1 care plus can care for infants > 32 weeks gestation and > 1500 grams

birth weight.

- Have physiologic immaturity (apnea, poor feeding, temperature instability), but not

requiring mechanical ventilation or Continuous Positive Airway Pressure (CPAP)

- Have medical problems that are anticipated to resolve rapidly and not require urgent

subspecialty care

- Are convalescing after intensive care.

Level 2b. Special Care Nursery

- Can provide Level 2a care, and

- Can provide mechanical ventilation for brief duration (<24 hours) or CPAP.

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Level 3a. Neonatal Intensive Care Unit.

Can care for infants > 28 weeks gestation and > 1000 grams birth weight.

Can provide sustained life support with conventional mechanical ventilation.

May perform minor surgical procedures, such as placement of central venous catheters or

repair of inguinal hernias.

Level 3b. Neonatal Intensive Care Unit

Can provide comprehensive care for infants < 28 weeks gestation and

< 1000 grams birth weight.

Can provide advanced respiratory support such as high-frequency ventilation or inhaled

nitric oxide.

Can perform major surgical procedures on neonates (excluding ECMO and repair of

complex congenital heart defects requiring cardiopulmonary bypass).

Requires prompt and on-site access to a full range of paediatric sub-specialty consultants,

as well as paediatric surgeons and anesthetist.

Requires availability of advanced imaging support on an urgent basis, including CT, MRI, and

echocardiography.

Level 3c. Neonatal Intensive Care Unit.

Has the capabilities of a level 3b NICU

Can provide ECMO and surgical repair of complex congenital heart defects requiring

cardiopulmonary bypass.

The rationale for this three-tier approach is:

A reasonable geographic coverage is ensured.

A high throughput for the level III units enables the maintenance of clinical skills.

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High levels of bed occupancy in level III units permits efficient use of expensive resources.

In our country, 80-85% of all babies need only primary or level I care,15-20% needs level II

care and only 5% need level III care. Level II and level III care are woefully inadequate, in

both the government and non-government sectors and level I care, though available, is of

very poor quality. If newborn care has to improve, all three levels of care have to be well

developed and a good referral system should be in place.

Neonatal Intensive Care Unit Environment:

The environment within the NICU is completely new to the preterm infant, who until the

time of birth, has been protected within an intra-uterine environment. Increasing amount

of research shows a relationship between the NICU environment and the physiological and

neurological development of the infants. An environmentally sensitive unit can enhance

growth, shorten the duration of mechanical ventilation, lead to early oral feeding, reduce

incidence of complications, shorten hospital stay and reduce hospital costs.

Giving birth to a premature or sick infant is not usually the familys expectation, and the

intimidating environment of the NICU can provide reassurance to the shock and sense of

loss that families feel. Therefore in planning and designing a neonatal unit, the goal should

be to provide an environment which is conducive to family-centered developmental care of

sick newborns, decreasing stress for the family and the healthcare providers, improving

short and long-term outcomes.

Physical Facilities and Space Requirements:

Core physical requirements include, continuous supply of running water, uninterrupted

power supply, central supply of medical gases and suction facilities.

Geographic access:

Level III neonatal intensive care services should be available within 2 hours by road, under

normal traffic conditions for 90 % population in a district.

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Location within the hospital:

The NICU should be in a distinct area within the health care facility, with controlled access.

Movement to other services should not pass through this unit. It should be located close to

the labour room and operation theatre, to facilitate prompt transfer of sick and high-risk

infants. It is suggested that units receiving babies from other hospitals should have ready

access to the hospitals transport receiving area or hospitals ambulance entrance. NICU

should be easily accessible from emergency room, laboratories and radiology suite.

NICU Unit configuration:

Hospitals proposing a level III NICU should propose a unit of at least 15 beds and should

have 15 or more level II NICU beds. According to Putsep concept, a 28 bassinet unit might

have 3 intensive care spaces (10.7%), 20 intermediate care spaces (71.4 %) and 5

transitional care spaces (17.9 %) for short-term observation. The unit should be in a square

area so that open, unencumbered space is available. A split-unit, on either side of the

hospital corridor should be avoided for ease of mobility and prevention of infections.

The NICU design may range from an open ward to an individual cubicle or room

configuration.

Open unit configuration offers maximum flexibility for patients, staff, equipment movement

and better patient view; individual cubicles design gives less noise and patient movement

and reduced cross-infection rate.

Size of the unit

The size of the unit planned, depends on the number of deliveries in the hospital per year;

whether it is a referral maternity center or babies born in other hospitals are admitted. At

present the recommendation is that 1.5-2 intensive care beds and 2 special care beds

should be provided for every 1000 births (can be modified according to the workload of the

unit). Extra provision has to be made for babies in other hospitals.

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Infant care space

Each infant care space should contain a minimum of 11.2 square meters, excluding sinks

and aisles. Intensive care beds may require 14 square meters per infant. An estimated 50

square feet of floor space is needed per patient bed, for intermediate care.

There may be an aisle adjacent to each infant care space with a minimum width of 1.2

meters in multiple bedrooms and 2.4 meters in case of single patient rooms or fixed cubicle

partitions. This is to facilitate easy movement of all equipment, which may be brought to

the babys bedside.

In multiple bedrooms, there should be a minimum of 2.4 meters between infant care beds.

This is because the provision of less than 8 feet between beds limits the ability of a family to

stay at a babys bedside without interfering with staff activities. Each room should have a

minimum of one door of width 48 inches, for X-ray equipment.

Electrical, Gas supply and Mechanical Needs:

Mechanical requirements at each infant care bed, such as electrical and gas outlets, must

be organized to ensure safety, easy access and maintenance. There should be a minimum

of 20 simultaneously accessible electrical outlets for intensive care infants positioned to

maximize access and flexibility. Standard duplex electrical outlets are not suitable, as each

outlet may not be simultaneously accessible for oversized equipment plugs. The outlets

must be installed at a height of three feet. There should be a mix of AC power supply and

UPS for all electrical outlets.

At least fifty percent of the outlets should be connected to an uninterrupted power supply.

All life support and monitoring equipment should be connected to UPS. In addition, the

area needs a special outlet to power portable X-ray machines. The use of adaptors and

extension boards should be discouraged. The electrical equipment must be checked, at

least once a month for leakage of power supply and grounding adequacy. Voltage supply to

the NICU must be stabilized with a voltage stabilizer.

Minimum number of accessible gas outlets recommended is: Air; Oxygen; Vacuum; 3 out

lets per infant bed. In case of intermediate care infants, two oxygen outlets, two

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compressed air outlets and two suction outlets should be provided for each bed. A flow

rate of 20 liters per minute, at a pressure of 3.5 to 4.0 bars is satisfactory for oxygen supply.

Each vacuum pointshould allow free airflow of 40 liters per minute at vacuum pressure of

500 mm of mercury. The suction outlets should be equipped with a unit alarm to signal loss

of vacuum. Installations should be at a height of 3 feet.

Airborne Infection Isolation Room(s)

It is desirable to have an isolation room for every 6-10 beds. In most of the cases, this is

ideally situated within the NICU; but, in some circumstances, utilization of a similar isolation

room elsewhere in the hospital (example, in a pediatric ICU) would be suitable. Infants with

open sepsis should be cared for by different nursing and resident staff. A work-area for

hand washing, gowning and storage of clean and soiled materials, may be provided near

the entrance to the room. The room must have a minimum of 150 square feet of clean

space, excluding the entry work area. Single and multiple bed configurations are

appropriate based on use. Ventilation systems for isolation room(s) should be engineered

to have negative air pressure with 100 % air exhaust. There should be a minimum

ventilation of 12 air-changes per hour in the isolation room and 10 air-changes per hour in

the work-area.

The walls, ceiling, floor must be sealed tightly so that air does not infiltrate the environment

from outside or from other air spaces. An emergency communication system should be

provided within the room and remote monitoring of an isolated infant should be

considered. When not used for isolation, these rooms may be utilized for care of non-

infectious infants and other clinical purposes.

Procedure room

A procedure room may be incorporated into the NICU but is preferably sectioned off to

reduce patient traffic and to allow better control of techniques such as exchange

transfusion, umbilical vessel catheterization. This room should be a minimum of 120 square

feet in size, equipped with a hand washing section, oxygen outlet and vacuum outlet and

about 4 electrical switches. The ventilation of the room should provide a minimum of 6 air-

changes per hour.

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Entrance

The entrance to the neonatal unit should be planned as a lobby with double doors; an

airlock, which allows some control of the airflow within the unit. Corridors in NICU should

be at least 1.8 meter wide.

Scrub area

At least 150 square feet of space at the main entrance, must be assigned as a scrub area

with provision for hand-washing, hanging coats, stethoscopes and for leaving footwear. It

should have hands-free sinks large enough to contain splashing. Blade handles at the sink

should be minimum six inches long. Space must be provided, for donning of protective

clothing and a bench to facilitate wearing of over-boots. About ten air-changes per hour are

recommended for this area.

General support space

Storage areas A three level storage system is desirable. The first storage area should be the

central supply department of the hospital. The second storage zone is the clean utility area

for the storage of supplies frequently used in the care of newborns. It should be adjacent to

or within the infant care area. There should be at least 0.22 cubic meters of space for each

infant, for secondary storage of syringes, needles, intravenous infusion sets and sterile

trays.

A medical equipment store should be provided; 1.7 square meters of floor space for

equipment storage per infant in intermediate care and 2.8 square meters per infant in

intensive care. Easily accessible electrical outlets are desirable in this area for recharging

equipment. All supply and medical equipment rooms should have convenient access to at

least one sink. A minimum of 4 air-changes per hour are recommended for the clean utility

and equipment storage rooms.

The third storage zone is for items frequently used at the newborns bedside. There should

be shelf space available for placing respirators, monitors, infusion pumps and feeding

pumps.

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Bedside cabinet storage should be 0.45 cubic meters per infant in intermediate care area

and 0.67 cubic meters per infant in intensive care area.

Family entry and reception area

The NICU should have a clearly identified entrance and reception area for families. Families

shall have immediate and direct contact with staff when they arrive at this entrance and

reception area. The design of this area should be impressive. Facilitating contacts with staff

will also enhance security for infants in the NICU. This area should have storage facilities

with a lock for families personal belongings.

Floor surfaces

Floor surfaces should be such that they can be easily cleaned, should minimize growth of

microorganisms and should be highly durable to withstand frequent cleaning and heavy

traffic.

Floors should be slip resistant. Consideration should also be given to the density of

materials used and acoustical properties. Materials suitable to these criteria are resilient

sheet flooring (medical grade) and carpeting with an impermeable backing, chemically

welded seams with antimicrobial and antistatic properties.

Walls and surfaces

As with floors, the ease of cleaning, durability and acoustical properties of wall surfaces

must be considered. Acceptable materials include scrub paint, vinyl wall covering, vinyl

covered sound absorbing panels and sheet materials that have fused joint systems. Walls

may also be made of washable glazed tiles. There should be protection at points where

contact with movable equipment is likely to occur. Walls must be painted white or slightly

off-white to permit prompt detection of jaundice and cyanosis.

Glossy finish create glare that is harmful to newborn eyes; matt finish in dark colors absorb

too much light, increasing the need for artificial light sources. Doors should be provided

with automatic door closers.

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Ceiling

Ceiling should be cleaned easily and should prohibit the passage of particles from the cavity

above the ceiling into the clinical environment. It should either be a monolithic ceiling or

have ceiling tiles that are clipped down and washable. It should have a noise reduction

coefficient

(NRC) of at least 0.903. Standard hospital tiles have a NRC of 0.6519.

Ambient temperature and ventilation:

The NICU should be designed to provide an air temperature of 22-26oC and a relative

humidity of 30-60 %. This is best achieved by air-conditioning with small package units

rather than centralized air-conditioning. Portable radiant heater and infrared lamp can be

used to provide additional heat to an individual infant.

Effective ventilation is essential to reduce nosocomial infections. The most satisfactory

ventilation is achieved with laminar airflow. In a vertical type system, the air flows from

above downwards and it is recommended for use in NICU. A constant positive air pressure

should be maintained, to prevent contaminated air entry from the corridors into the NICU;

the vertical flow of filtered air maintains positive pressure of 15 mmHg. Millipore filters

(0.5m) or high efficiency particulate aggregate (HEPA) filter may be used (to filter out

bacteria). Air delivered to the NICU should be filtered with at least 90 % efficiency. A

minimum of 6 air changes per hour is required, with a minimum of 2 air changes from

outside air. The ventilation pattern should

prevent particulate matter from moving freely in the space; intake and exhaust outlets

should be situated as to minimize drafts near infant beds. Fresh air intake should be located

at least 25 feet (7.6 meters) from the exhaust outlets of ventilating systems, combustion

equipment stacks, plumbing vents, or areas that may collect vehicular exhaust or other

noxious fumes.

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Noise abatement

The noise level in a NICU affects the infants, staff and families. Excessive noise may lead to

hearing loss, physiological and behavioral disturbances like sleep disturbances, crying,

hypoxia, tachycardia and increased intracranial pressure. Equipment should be selected

with a noise criterion (NC) rating of 40 or less. However, once the unit is in operation, much

of the transient sound in a nursery is under the control of personnel. Hence, the personnel

should devise simple strategies to reduce noise in the nursery (no tapping / writing on

incubator hoods, careful closing of incubator doors, soft shoes, etc.).

Communication system

The NICU should be provided with an intercom system. A direct external telephone is

mandatory for parents to inquire about their infants.

Infant security

The NICU should be designed to minimize the risk of infant abduction. Care should be taken

to limit the number of exits and entrances to the unit. Control station / clerical area should

be located in close proximity and direct view of the entrance to the newborn area, so that

all visitors will have to pass in front of the nursing station to enter the unit. In addition, for

security reasons, parent-infant room(s) should be situated within an area of controlled

public access.

Ancillary services

Distinct support space should be provided for respiratory therapy, laboratory, pharmacy,

radiology and other ancillary services when these activities are routinely performed in the

unit.

Satellite facilities may be required to provide these services. Hospitals providing Level III

neonatal intensive care services should provide at the site, X-ray and clinical laboratory

services capable of performing micro studies. This requirement is essential in order to carry

out investigations on blood samples in small quantity from preterm babies in whom,

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frequent biochemical investigations are needed, collecting venous blood is difficult and

hazardous.

Anesthetist should be available. There should also be access to ECG, EEG and blood bank

services.

Equipment requirements

During the last decade, a large number of devices for diagnostic and therapeutic application

for the high-risk newborn infants have evolved. The fundamental needs of the unit are

availability of adequate space, presence of sufficient number of trained nurses and

continuous in-service training. It should be ensured that company supplying the equipment

undertakes to train all staff in the unit.

Maintenance of existing equipments in proper working condition is more important than

acquiring new ones. After expiry of warranty period, yearly maintenance contract must be

made for preventive maintenance and emergency repairs. Essential spares must be

purchased and kept in stock. Photocopies of working and service manuals should be

available in the NICU.

Equipments must be charged when not in use. The in-charge nurse should maintain a

register with equipment name, company address and contact number, date of installation,

warranty period, problems and repairs pertaining to all the equipments, along with record

keeping of equipment quality assurance. There should be a budget for purchasing,

maintaining, replacing and upgrading of equipments for neonatal care.

Equipments needed may be classified into following groups:

Supportive systems: incubator, open care systems, transport incubator, infusion pump,

phototherapy unit, ventilator, nebulizer.

Monitors: The monitors with facility to display, heart rate, respiratory rate, blood pressure,

oxygen saturation,

Laboratory and imaging equipment

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The various equipments in the neonatal unit are listed below

Emergency tray( containing Ambu bag and mask, infant laryngoscope, oral airways and

tracheal tubes of different sizes, connectors for tracheal tubes, sterile suction catheters,

oral mucus suction, emergency drugs like epinephrine 1:10,000, naloxone hydrochloride,

sodium bicarbonate, IV fluids and pediatric stethoscope); Bag and mask resuscitator;

Suction equipment;

Catheters, syringes and needles; Weighing machine; Bassinets; Incubators; Perspex heat

shield;

Oxygen head box / Oxygen hood; Oxygen analyzer/ambient oxygen monitor; Heart rate

monitor;

Respiratory rate and apnea monitor; Thermometers; Blood pressure monitor; Invasive

blood gas monitoring; Non-invasive blood gas monitoring; Pulse-oximeter; Transcutaneous

blood gas monitor; Capnography or End Tidal CO2 (EtCO2) monitor; Multi-channel vital sign

monitor;

Ventilator; CPAP (Continuous Positive Airway Pressure) apparatus; Infusion pump;

Phototherapy unit; Transcutaneous bilirubinometer; Portable X-ray and ultrasound

machine; Laboratory equipment; Feeding equipment; extra corporeal membrane

oxygenator (ECMO)

Discharge policy in a neonatal unit

The discharge policy statement is put forward by the first formal statement of the American

Academy of Pediatrics on the issue of hospital discharge of the high-risk neonate. It has

been developed, on the basis of scientifically derived information.

Four categories of high risk neonate are identified:

Preterm infant

Infant who requires technological support

Infant primarily at risk because of family issues

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Infant whose irreversible condition will result in an early death.

The unique home care issues for each are reviewed within a common framework.

Recommendations are given for four areas of readiness for hospital discharge: infant,

home care planning, family and home environment, community and health care system.

The need for individualized planning and physician judgment is emphasized..