NABH- OBJ Element HAT -2, COP 2

Policy on Emergency services.

Purpose: to ensure that emergency services are guided by policies, procedures,applicable laws and regulations.

1. General Initial assessment of patient at Emergency:

1. Actions to be initiated at Hospital Emergency Section before the arrival of thepatient:1. Before arrival of the patient if possible an attempt should be made to collect the

following information by the receptionist in charge of emergency.( Referencemight have come from a referring hospital, or a patient attendant from a house orfrom a stranger).

2. Record the basic details of the person giving details about the arrival of thepatient to the emergency unit. The name of the caller, telephone number, addressof the caller, name of the patient, address of the patient must be recorded inwriting by the receptionist at the Emergency.

3. Use available resources to attempt to determine the chief complaint of thepatient, so that available specialists can be lined up.

4. Attempt to determine the mechanism of injury or the nature of illness of thepatient.

5. If the services probably required by the patient are not within the scope of thehospital services, it is better to inform the position to the caller and suggestsuitable alternatives.

6. Determine the number of patients that can be expected at the emergency sectionespecially to deal with vehicle accident cases, or house collapse or burns cases.

7. Inform and keep adequate number of Emergency nurses for triage, if required.8. Determine if there is any need for special units or additional resources.

2. Triage

1. This hospital will provide emergency medical screening and stabilizingtreatment, as necessary, to all individuals coming to the EmergencyDepartment, without delaying care to inquire about the patient's ability to pay.

2. All patients will be evaluated by the Triage Nurse at Emergency prior to beingseen by an Emergency Department Registration Clerk/ duty doctor.

3. The triage area is a room at the entrance to emergency. It has direct access toemergency room. It has a telephone. Triage room is managed by Triage Nurse.

4. All patients being brought to the emergency section are first examined by theTriage nurse. Completion of patient registration and patient identification isnot a pre condition for triage.

5. The registered nurse will evaluate and categorize each patient upon arrival tothe Emergency Department into following categories.

1. Black / Expectant: They are so severely injured that they will die oftheir injuries, possibly in hours or days (large-area burns, severe

trauma, lethal radiation dose), or in life-threatening medical crisis thatthey are unlikely to survive given the care available (cardiac arrest,septic shock, severe head or chest wounds); they should be taken to aholding area and given painkillers as required to reduce suffering.

2. Red / Immediate: They require immediate surgery or other life-savingintervention, and have first priority for surgical teams or transport toadvanced facilities; they "cannot wait" but are likely to survive withimmediate treatment.

3. Yellow / Observation: Their condition is stable for the moment butrequires watching by trained persons and frequent re-triage, will needhospital care (and would receive immediate priority care under"normal" circumstances).

4. Green / Wait (walking wounded): They will require a doctor'sobservation in several hours or days but not immediately, may wait fora number of hours or be told to go home and come back the next day(broken bones without compound fractures, many soft tissue injuries).Such patients will be given symptomatic treatment.

5. White / Dismiss (walking wounded):They have minor injuries; first aidand home care are sufficient, a doctor's care is not required. Injuriesare along the lines of cuts and scrapes, or minor burns.

6. All patients presenting to the Emergency Department will be triaged andcategorized as either Non- Resuscitative, Resuscitative, Emergency, Urgent,Semi-Urgent or Routine cases. The patients are tagged with black, red,yellow, green and white tags for further course of treatment as mentionedabove.

3. Registration by Emergency Admission assistant:

1. The Emergency Registration Assistant will not do any clinical work on thepatient.

2. Registration Assistant will get basic demographic data of the patient or hisfamily members , identify the patient correctly, registers the patients andcollects data for EMR.

3. Once registered the patient is tagged as per the hospital procedures.4. Identifying the patient through a identification band is a must before following

any procedure or providing a treatment. If the band has been lost or mutilatedpatient will have to be identified and a new band will have to be tagged to thepatient. Nursing staff is responsible for providing the new band.

i. The patient can remove the identification band after discharge. In theevent of death, the identification band shall remain on the patient’sbody.

ii. Use ----- (registration module) for registering the patient at Emergencysection. The module allows registering of patients at Emergencysection.

iii. The mandatory fields must be filled up.

5. The “ Patient Examination” form in -------------- (T.Sol) be used for thispurpose. Fill up all text boxes with whatever information available.

6. The box” Presenting Complaints” must be used to record the observations ofdoc tor on a patient at Emergency.

7. The Duty doctor --------------- (or nurse at emergency section) will enter datain the EMR.

8. If the patient is unconscious or not in a position to give data, the person whobrought the patient must be asked to give details required for EMR.

9. No treatment be rejected on the ground that basic data of the patient was notavailable.

4. Actions after the arrival of the patient:

1. This protocol is meant to provide an outline for completing an initialassessment of all category of patients at emergency. Regarding the specificprocedures to be conducted for certain type of cases Emergency Clinicalprotocols given at the end of this policy and procedure document be referred.

2. On arrival at emergency the Duty doctor will assess the patient.3. Once the patient arrives on scene, begin by forming a general impression of

the patient. If by first assessment if it appears that the services immediatelyrequired by the patient are beyond the scope of services for which the hospitalis equipped, without wasting time the patient must be referred to a suitablecenter.

4. In case the patient has been brought in a vehicle which has no life supportsystems the patient must be shifted to ambulance of the hospital and shifted toa suitable and nearest hospital which has the facilities that the patient requires.

5. During the transfer all required first aid and resuscitation activities must beperformed.

6. If it appears to the duty doctor that the services immediately required by thepatient are provided by the hospital then the duty doctor must follow thefollowing guidelines for assessment of patient at emergency.

7. All Emergency Department patients must sign consent for treatment in theEmergency Department form. If the patient is unable to sign, the significantother may sign. If no one available is authorized to sign the consent, documentthe reason for not being able to obtain consent and proceed with the treatment.

5. Patient assessment ( In general) at emergency:1. Continuously assess the need for spinal immobilization given available

information.2. Determine the patient's level of consciousness using the AVPU scale.

1. A-Alert2. V - Responsive to verbal stimuli3. P - Responsive to painful stimuli4. U - Unresponsive

3. Ensure the patient has a patent airway.1. If the patient is not maintaining a patent airway on his or her own,

move the patient so that he or she can be laid flat on his or her

back, and open the patient's airway by performing the head-tiltchin-lift maneuver.

4. If spinal injury is suspected, maintain in-line stabilization and open the airwayusing jaw thrusts.

5. If the patient is choking and cannot clear the obstruction on his or her own,perform the Heimlich maneuver.

6. OPA to be attempted first before NPA as it has the added benefit of holding thetongue out of airways.

7. Use NP A and/or OP A devices as necessary to ensure continued airway patency.8. Assess and assure adequate breathing.

1. Evaluate respiratory rate, quality and effort.2. Observe the skin for signs of hypoxia.3. Assess for life threatening breathing problems (flail chest, etc) and

treat as appropriate.4. If the patient's tidal volume appears to be inadequate, begin

ventilations with bag-valve mask.9. Ensure patent IV line using a cannula. Initiate patient stabilising measures for eg.

Volume expanders.10. Ensure adequate circulation and manage major bleeding and assess for signs of

shock.11. Attempt to control all sources of major bleeding as soon as they are discovered.12. Evaluate pulse quality, BP, blood sugar level, Oxygen saturation levels.13. Evaluate Sodium and potassium levels using blood gas analyzer14. Observe for signs of perfusion, such as capillary refill.15. Treat for shock when indicated by placing the patient in shock position with feet

raised, or Trendelenberg position if patient is immobilized.16. Complete a medical exam or trauma exam, as appropriate, according medical and

trauma protocols.17. The initial assessment of the patient at Emergency must be completed within one

hour of arrival at the hospital.18. In the meanwhile the duty doctor will identify the specialist/ specialists who are

required for providing further services and ensures their availability.19. The consultant will determine the patient's chief complaint and take further

action appropriately. It could be admission to ward, or shifting to a differentreferral hospital or shifting of the patient to Intensive Care Units or to Operationsuits or labour wards on the advice of the consultant physician.

6. Action in case of Medico legal cases:1. No treatment can be rejected because an emergency case is probably a medico

legal case.2. In case a patient who is brought to emergency is not provided services on the

ground of the case being a Medco-legal case the person rejecting services thenthe duty doctor is personally liable and the hospital cannot held responsible.

3. The treatment protocol is same for all categories of cases irrespective of thecase being medico-legal or not.

4. Cases of poisoning, grievous hurt, accidents of all categories, domesticviolence, MTP on minor, burns often turn out to be medico legal cases and the------------------------ ( jurisdictional police officer) be informed of such caseswhich land in emergency.

7. Vital signs tracking at emergency:1. Fundamental Emergency Department nursing interventions include, but

are not limited to the following:a. Vital signs every 30 minutes on triage- Black, Red and Yellow

patients, unless ordered more frequently. If available use Patientmonitors.

b. Vital signs every one to two hours on triage- green IV patients,unless ordered more frequently

c. Vital signs on admission and PRN on Level V patients, unlessordered more frequently

d. Vital signs will be repeated if not within normal limits, as follows:e. Adult ranges: Temp: 96 to 101 degrees F BP: 100/60 - 140/90

mm/Hg Pulse: 60-100 beats per minute Respirations: 12-24respirations per minute.

f. Vital signs will be repeated after administration of medicationswith potential side effects IV hydration or IV access, if needed

8. Neurological Assessment1. Every patient will undergo neurological assessment at the emergency. The

assessment will include1. Level of orientation,2. Response to Stimulation:3. Alertness to voice, touch, noxious pain stimuli ,4. Motor response,5. Motor strength ( Upper extremities and lower extremities ,6. Seizure activity,7. Ataxia,8. Pupils,9. Cranial Nerve Assessment.

9. Cervical Traction or C-Spine Immobilization

1. Suspect C-Spine injury in Traffic collision cases, Falls, Assault to head orneck, Change in LOC with unknown mechanism of injury, especiallywhen a non medical person brings the patient in a personal vehicle.

2. Apply cervical neck collar.3. Rescuer moves to the top of the patient's head. Reassures patient verbally.

Axial stabilization is maintained by staff member placing his/her hands oneither side of the head with the palms over the patient's ears. Staff membermaintains a steady forward pull to implement cervical traction until c-spineis cleared by x-ray or replaced by full immobilization equipment.

4. Do not hyperextend neck.

10. Patient Requiring Psychiatric Evaluation

1. Hospital is ----------------- (a non-psychiatric receivinghospital). Any patient accessing care at this facility whorequires psychiatric treatment will be managed through referraland transfer to a psychiatric receiving facility and/ormanagement through consultative psychiatric services on atemporary basis, until the patient's clinical condition hasstabilized to allow for psychiatric facility transfer.

2. For Patients Accessing the Hospital Through the EmergencyDepartment: The Emergency Department physician willevaluate the patient and determine the need for a psychiatricevaluation. (If the hospital has Emergency PsychiatricEvaluation Team cal them for evaluation.

3. Maintain patient safety. Utilize restraints only if patient is adanger to self, staff or others refer to restraint policy.

4. Call local law enforcement agency, if there is potential dangerto patient, staff or others.

5. Assessment and documentation shall include: Patient historyPatient complaint Observation of signs and symptoms ofmental, emotional, behavioral or suspected substance abuse.

6. Any medication to be given is only on instructions ofconsultant.

11. Pain Assessment, Reassessment and Management

1. The hospital is aware that effective pain assessment and managementcan remove the adverse psychological and physiological effects ofunrelieved pain.

2. All patients , including the ones who are terminally ill are assessed forpain. In Surgical wing every patient is assessed for pain.

3. Apart from medication for pain management other pain managementtechniques utilized in the care of patients are

i. Control or relief of anxiety through medication.ii. Repositioning of the patient

iii. Ambulation of the patientiv. Mild patient exercisev. Therapeutic massage i.e., back rub Bathing or sitz bath

vi. Diversion techniques i.e., television or video tapeviewing, reading

vii. Therapeutic communicationviii. Spiritual counseling

ix. Visitation from family/significant others Any patientcare provider, from any department.

12. Adult Pain Scale.

For assessing pain of patients use the following Mankoski scale

0 - Pain Free

1 - Very minor annoyance - occasional minor twinges.No medication needed.

2 - Minor Annoyance - occasional strong twinges. Nomedication needed.

3 - Annoying enough to be distracting. Mild painkillerstake care of it. (Aspirin, Ibuprofen.)

4 - Can be ignored if you are really involved in yourwork, but still distracting. Mild painkillers remove painfor 3-4 hours.

5 - Can't be ignored for more than 30 minutes. Mildpainkillers ameliorate pain for 3-4 hours.

6 - Can't be ignored for any length of time, but you canstill go to work and participate in social activities.Stronger painkillers (Codeine, narcotics) reduce pain for3-4 hours.

7 - Makes it difficult to concentrate, interferes withsleep. You can still function with effort. Strongerpainkillers are only partially effective.

8 - Physical activity severely limited. You can read andconverse with effort. Nausea and dizziness set in asfactors of pain.

9 - Unable to speak. Crying out or moaninguncontrollably - near delirium.

10 - Unconscious. Pain makes you pass out.

13. Pain Assessment in Children

1. A screening assessment is conducted to determine the presence orabsence of pain in the pediatric patient.

2. Pain is assessed to understand how much pain a child isexperiencing and to understand if what is being done to relievepain is working.

3. Information can be provided to parents to help them identify achild's pain.

4. Infants and children will be screened for the presence or absence ofpain. Identified pain in infants and children will be assessed andaddressed. Hospital shall use pain scale for children.

5. Infants and children under three 3 years of age. Pain scale is asshown below;

i. Child cry is high-pitched, tense, irregularii. Child is crying, but gently or whimpering

iii. Child is screamingiv. Child will not stop crying when picked up and

comforted6. Children three or four 3 or 4 years of age:

i. May become quiet and inactiveii. May curl into a fetal position

iii. May become hyperactiveiv. May only be able to express pain in single wordsv. Parents recognize pain through changes in behavior

and communicate what word is used at home forpain

7. Children five 5 to 10 years of age: Can tell about the extent of pain.They can compare.

14. Assessment of Trauma patients as per Glasgow Trauma Scale:1. A trauma patient is assessed as per Glasgow scale.

1 2 3 4 5 6

EyesDoes notopen eyes

Opens eyes inresponse to

painful stimuli

Opens eyesin response to

voice

Openseyes

spontaneously

N/A N/A

VerbalMakes no

soundsIncomprehensibl

e sounds

Uttersinappropriate

words

Confused,

disoriented

Oriented,conversesnormally

N/A

MotorMakes nomovement

s

Extension topainful stimuli(decerebrate

response)

Abnormalflexion to

painfulstimuli

(decorticateresponse)

Flexion /Withdrawal topainfulstimuli

Localizespainfulstimuli

Obeyscommands

15. Procedures for Assessment of the Trauma Patient

1. Establish and maintain airway2. Immobilize c-spine3. Control bleeding,4. Monitor heart rate/ respiration/ oxygenation.5. Evaluate neurological status6. Undress patient and assess for other injuries7. Maintain patient body temperature8. Take initial vital signs9. Frequently assess and monitor vital signs

10. Make head-to-toe evaluation

16. Authorization for Autopsy

1. It is the policy of Hospital that a consent for autopsy must be obtainedfrom the person nearest of kin to the deceased, unless the medicalexaminer has jurisdiction because of the circumstances or cause of death(when ordered by the law enforcement arm of government or Courts).

2. The attending physician or Nurse approaches the family regarding theirrequest or consent for an autopsy.

3. Consent for autopsy is not legal if signed before the patient expires.4. If the nearest of kin should consent/request an autopsy, the Pathology

Department will be notified.5. Authorization for Autopsy consent will be completed, signed by the

nearest of kin.The person signing the consent will indicate his/herrelationship to the deceased. The patient's name will be completelywritten. The date and time the authorization is signed will be indicated.The consent will be witnessed by two 2 persons other than the nearest ofkin.

6. The original copy of the consent remains with the hospital.

17. Blood/Blood Components Transfusion at Emergency.

1. It is the policy of Hospital to have a uniform method of transfusing bloodproducts.

2. The blood transfusion information pamphlet shall be signed by the patientand if the patient is not conscious by the kin who accompanied the patientto the hospital.

3. If the patient is unconscious and no relatives/ friend/ acquaint is presentthe Duty Doctor may clearly record the reason for not being able to informthe patient and obtain the consent.

4. A consent form shall be signed prior to blood transfusion by the patient.. ifthe patient is not conscious consent of the kin who accompanied thepatient to the hospital shall be obtained.

5. Blood or blood components must be obtained from authorised blood banksonly. It must have been tested for HIV.

6. Blood grouping and cross matching must be performed prior to theadministration of blood.

7. Use blood warmer, if multiple units will be infused.8. Observe for transfusion reactions like ------------------ (Rash Flushed

feeling, hot Chills, Shortness of breath ,Headache ,Fever, Decreased bloodpressure, Hematuria, Pharyngeal edema ,Wheezing ,Pain in lower backand legs and Other reactions) up to one 1 hour after infusion of blood.

18. Blood Transfusion - Type-Specific Blood or Blood from a Universal Donor

1. It is the policy of Hospital that in order to support a patient with severehypovolemia due to blood loss, usually over a short period of time, apatient may need to receive type-specific blood or blood from a universaldonor. This does pose some danger to the patient since the blood is notcross-matched and some unexpected incompatibilities may be present. Butat the same time, the threat to life from the hypovolemia due to blood lossfar outweighs the other problems that could be encountered byadministering the blood.

2. An informed consent shall be signed prior to infusion.3. Make out the appropriate requisitions for type and crossmatch with the

number of units necessary.4. Notify the Blood Bank Technologist of the urgency of the order.

19. Blood/Blood Components - Transfusion Reactions

1. It is the policy of Hospital that a transfusion reaction requires immediaterecognition and prompt nursing intervention to prevent furthercomplications and possible death. All transfusion reactions must be treatedas serious in nature until proven otherwise. The proper procedure must befollowed and a transfusion reaction form completed when indicated.Notification of the physician must take place for the following types ------------------ (of transfusion reactions).

20. Legal Evidence - Chain of Custody

1. A chain of custody will be established for physical evidence so that it maybe used by law enforcement agencies.

2. Physical evidence, i.e., bullets, fragments, drugs, will be properlypreserved and documented. Emergency Department staff will beinserviced on guidelines for forensic evidence collection, preservation anddocumentation.

3. The physician will pass the evidence to the Emergency Department nurse.4. The nurse will place the evidence, as is, in a container and label the

container with the patient's name, medical record number, location whereevidence was collected, date and time collected and name of the physicianwho removed the object.

5. The nurse will turn over the evidence to the law enforcement officer afterchecking proper ID.

6. The law enforcement officer will sign the proper document detailing itemsand confirming possession of the evidence. This will include the LawEnforcement office name, officer's name and badge number, date andtime, and a description of the evidence.

7. The Emergency Department nurse will also sign this form.8. The evidence document will be placed in the patient's medical records.

21. Organ/Tissue/Eye, Body Donation - Nursing Staff Responsibilities

1. It is the policy of Hospital to identify all potential donors of organs and tissuesfor transplantation according to the -------------- (Transplantation of HumanOrgans Act, 1994).

2. Hospital has an agreement with the ----------------- (Tissue Bank and the EyeBank) to cooperate in the retrieval, processing, preservation, storage anddistribution of organs, tissues and eyes.

3. All deaths at Hospital shall be reported to the Tissue Donation Hotlinehereinafter referred to as the Tissue Donation Hotline for evaluation ofdonation potential. At the time that the Tissue Donation Hotline is notified of adeath, a donor number shall be contacted by the Tissue Donation Hotline.

4. If the family requests that the Hotline not contact them, this information willbe given to the Hotline by the nurse.

5. In consideration of the family's cultural structure, an ethnically similar staffmember will conduct the conversation about Tissue Donation Hotline contact.Because the death of a loved one can be a very emotional time for the familyand the decision to donate the organs or tissues of a loved one can add to theemotional disturbance. Hospital has no desire to complicate lives of familieswho are emotionally stretched.

6. For donating a body for studies to a medical college, the procedures to befollowed are the same as above. The family may be permitted to perform ritesand can accompany the body only up to the entrance of the institution.

22. Care of The Dying Patient at Emergency.

1. A dying patient needs intensive physical support as he/she develops the signsof impending death: Reduced respiratory rate and depth, Decreased or absentblood pressure, Weak or erratic pulse rate, Lowered skin temperature,Decreased level of consciousness, Diminished senses and neuromuscularfailure.

2. Every effort is made by the members of the hospital team to save the patient.3. With all the efforts to save the patient when it is obvious that nothing more

can save the life it is the policy of Hospital to care for the dying patient withrespect, dignity and consideration by providing physical, emotional andspiritual comfort for the patient and his/her family.

4. Care of the dying patient aims to provide physical, emotional and spiritualcomfort.

5. But, at this final stage such support most often means simple reassurance,someone's physical presence to ease any fear and loneliness, or familiarprayers if desired, to help give him/her support and strength as he/she preparesfor the end of life.

6. More intense emotional support is important at earlier stages, especially in thepatient with long term progressive illness who can work through the stages ofdying.

7. It is the policy of Hospital to assist those patients who are facing end of lifeconditions to proceed through the death process with comfort, dignity andrespect, with minimal pain and suffering.

8. As death is viewed as the final act of living, generated from within the person,all efforts will be set forth by the organization to identify, address and

positively respond to the patient's needs, related to all primary and secondarydiagnosis and symptoms, and those of their families as they relate topsychological, social, emotional and spiritual issues.

9. In case a patient wants to write a dying declaration available assistance willhave to be provided.

23. Assessment and management of specific category of emergency cases.

1. Assessment of Victims of Domestic Abuse (Spouse/Partner).

1. Upon arrival to the Emergency Department, all patients are triagedby the emergency nurse. If the nurse suspects or observes signs andsymptoms of abuse to either the adult or pediatric patient, it shallbe reported to the local law enforcement agency.

2. A call shall also be placed to the hospital social worker.3. Patients brought to the Emergency Department by law enforcement

agencies for evaluation of alleged rape shall be escortedimmediately to the OB/GYN room:

4. The nurse who performs the rape exam must not leave the patientuntil assessment and specimen collection is completed.

5. While assessing a victim of domestic abuse and rape look for oldinjuries, repeated injuries, ingestions, non-substantiatedcomplaints, delay in seeking care, discrepancy between historyand injury, third-party or object blamed for injury and alleged selfinjuries.

6. As part of physical examination look for presenting problems likesigns of high anxiety and chronic stress, agitation hyperventilation,Panic attacks, Gastrointestinal disturbances. hypertension.

7. Observe children for signs of stress caused by family violence.8. Record heart palpitations, severe crying spells and suicidal

tendencies, miscarriages, depression, stress-related conditions, i.e.,insomnia, violent nightmares, anxiety, extreme fatigue, eczema orhair loss.

9. Talk of having problems with spouse/partner, description of him orher as very jealous or impulsive or as an alcohol or drug abuser

2. Management of a Patient Under the Influence of Alcohol and Drugs

1. The patient arriving at the Emergency Department under theinfluence of drugs will receive the following care

i. Obtain IV accessii. Obtain urine specimen

iii. Draw blood to screen for alcohol and other drugsaccording to --------------------(state's laws andregulations).

iv. Use breath analyser to record the alcohol level.v. Monitor airway and give respiratory support, as

necessary

vi. Administer ---------------- ( intravenous Narcan orany other detoxicant either as bolus, intramuscularor continuous intravenous infusion drip), as perphysician's orders.

vii. Assume other mixed drug intoxications.viii. Monitor heart rate on cardiac monitor

ix. Monitor respiratory status; administer oxygen, asappropriate

x. Monitor ingestions.xi. Gastric lavage is used if the patient is comatose or

has an absent gag reflex. Use a cuffed endotrachealtube. Lavage with a large-bore Ewald tube or Levintube with the patient in the left lateral decubitusTrendelenburg position, with the patient's headlowered approximately 15 degrees.

xii. Use a tidal wash volume of 150-200 mL in adultsand 10 mL per kg in children. Activated charcoalper physician order: Adults: 50 to 100 g Infantsyounger than one 1 years: 1 g per kg of weight.

3. Immediate Intervention of a Patient Under the Influence of Alcohol

1. The patient arriving at the Emergency Department under theinfluence of alcohol will receive the following care:

i. Obtaining a urine specimenii. Draw blood to obtain blood glucose level and screen

for alcohol (see your state's laws and regulations)iii. IV - Establish Normal Saline as per physician

orderiv. Give 50% Dextrose 50 mL IV or IM,v. if hypoglycemia is present as per per physician

order Give ------------------(Thiamine 100 mg IM.0,Dilantin Folic Acid Librium Lorazepam MagnesiumSulfate - 50% IM or IV MVI - 12, IV PhenobarbitalThorazine.

vi. Call Security for assistance when needed.vii. Documentation shall include, but is not limited to:

Initial assessment of patient, including history andduration of use Initial vital signs Medications andallergies Initial LOC; any changes in LOC Seizuresand treatment Signs and symptoms of deliriumtremens.

4. Initial assessment and management of Abdominal Pain patients

1. The patient arriving at the Emergency Department with abdominalpain will receive the following care:

a. Assure patient airway.b. Obtain vital signs.c. IV - establish Normal Saline (or as per physician

preference).d. Draw blood for Clinical Laboratory.e. Obtain clean-catch urine sample for tests. Male patients

presenting with STD symptoms should see a physician first,before a urine specimen is obtained. If available, do HCGwith urine sample.

f. Keep patient NPO.g. Obtain stool sample, as applicable.h. Documentation shall include, but not be limited to:

Mechanism of injury, if trauma Past injury details.i. Assessment of pain: Location, Quality, Radiation, Onset,

Severity 1-10 pain scalej. Intake and outputk. Rigidity or guardingl. Any abdominal tenderness or distentionm. Any nausea, vomiting, diarrhea or constipation, fevern. Any Bowel soundso. Last bowel movementp. Color and consistency of stoolq. Color and consistency of emesisr. Any weight loss, fever.s. Details of any Previous abdominal surgeriest. Any Vaginal bleeding/dischargeu. Last menstrual periodv. Pregnancy detailsw. Any shortness of breath, chest pain

5. Initial assessment and management of Acute Status Asthmatics1. The patient arriving at the Emergency Department with acute

status asthmatics will receive the following care:i. Assure a patent airway.

ii. Assist with ventilation, as needed.iii. Recognize the need for potential intubation.iv. Administer oxygen high-flow.v. Establish IV access.

vi. Place on pulse oximetry and cardiac monitor.vii. Prepare patient for respiratory breathing

treatments, ABGs and medication.viii. Monitor respiratory status continuously.

ix. Documentation shall include, but is not limitedto: Initial lung sounds Initial vital signs Skincolor; use of accessory muscles. Oxygensaturation.

x. Nebulisation ( as per -------------).

6. Management and assessment of Paediatric Asthma

1. A patient who arrives at the Emergency Department with pediatricasthma will receive the following care:

i. Monitor and maintain open airway.ii. Obtain initial SaO2 reading.

iii. Obtain, if possible, initial peak flow.iv. Monitor cardiac status.v. Hold IV access, unless severe distress.

vi. Respiratory treatments every 15 minutes x 3.vii. Documentation shall include, but is not limited to:

Initial SaO2 reading and vital signs, Initial lung sounds,Initial peak flow and peak flow following treatment,Response to respiratory treatments, Environmentalfactors at home i.e., smoking, animals Dischargeinformation.

7. Initial assessment and Management of Allergic Reaction or Anaphylaxis -

1. The patient arriving at the Emergency Department with an allergicreaction or anaphylaxis will receive treatment depending on severity ofallergic reaction:

i. Assist to gurney.ii. Assess and maintain patent airway.

iii. Recognize potential need for intubation, if airwayimpaired.

iv. Place on cardiac monitor; obtain initial rhythm strip.v. Place on pulse oximetry.

vi. Place on oxygen two to six 2-6 liters per minute pernasal cannula, or by mask at 10-15 liters per minute.

vii. Establish intravenous access with 1000 mL NormalSaline.

viii. Anticipate physician order for medications ( BenadrylIM or IV Epinephrine Solu-Medrol, prednisone,antihistamines, aminophylline).

ix. Documentation shall include, but not be limited to:Initial vital signs Assessment of airway Lung soundsSkin assessment/urticaria Any changes in airway statusResponse to medication Medical history Currentmedications Allergies Changes in vital signs.

8. Initial Assessment and management of Animal Bites

1. Patients arriving at the Emergency Department with animal bites willreceive the following care:

i. Control all bleeding.ii. Wash with high-pressure irrigation using large amounts

of Normal Saline.iii. If appropriate, set-up for suture of wound.iv. If appropriate, set-up for debridement of wound.v. If appropriate, give tetanus toxoid or diphtheria tetanus,

per physician order.vi. Assess for risk of rabies.

vii. IV access for antibiotics, when applicable.viii. Report all animal bites to (----------------- Municipality).

ix. Documentation shall include, but is not limited to Timeof bite, Location and severity of bite; size, shape Typeof animal.

x. Antirabies vaccine or sera as appropriate.

9. Initial assessment and management of Burns at emergency:

1. A patient who arrives at the Emergency Department with burns willreceive the following care:

a. Minor burns second-degree burns less than 10% in age fragile, lessthan 15% total body surface area in adults: Apply cool saline steriledressings for no longer than 15 minutes at a time. Obtain vitalsigns. Notify physician. Assess and manage pain. Document thelocation and percent of burn. Apply Silvadene cream dressing toburn, per physician order.

b. Second-degree burns 15% - 25% TBSA in adults or 10% - 20% inchildren; Apply cool saline sterile dressings for no longer than 15minutes at a time. Obtain vital signs. Notify physician. Assess andmanage pain. Document the location and percent of burn. ApplySilvadene cream dressing to burn, per physician order. Obtain vitalsigns. Monitor pain.

c. Third-degree burns less than 10% TBSA: Monitor and maintainairway. Apply oxygen supplement. If respiratory compromise,prepare for intubation.

d. Third-degree burns greater than 10% TBSA: Monitor and maintainairway; apply oxygen supplement. If respiratory compromise,prepare for intubation. Place on cardiac monitor and obtain rhythmstrip. Obtain vital signs. Notify physician. Evaluate and monitorpain. Establish IV access. Draw labs from IV access. Document thelocation and percent of burn. Cover burn area with cool sterilesaline towels.

2. Except for minor burns all other category of burns are shifted to Burnsward ( Or to a suitable hosipital).

10. Initial assessment and management of Chest Pain or MyocardialInfarction

1. A patient who arrives at the Emergency Department with chest pain ormyocardial infarction will receive the following care:

a. Maintain a patent airway.b. Place on cardiac monitor and obtain baseline rhythm.c. Place on pulse oximetry.d. Obtain room air SaO2.e. Place patient on oxygen two to six 2-6 liters per minute via nasal

cannula, or 10-15 liters per minute with mask.f. Obtain vital signs, blood pressure in both arms and apical heart

rate.g. Establish IV access, two if suspected MI in progress.h. Draw bloods with IV access, draw for PT, PTT and type and cross

if suspected MI infraction.i. Medication------------ (NTG Heparin IV, as per physician order or

Heparin drip or Tridil drip, titrate to chest pain Asystole:j. If needed do CPR/ACLSk. Intubatel. Establish IV accessm. Confirm in two 2 leadsn. Consider possible causes: (Hypoxia Hyperkalemia Hypokalemia

Preexisting acidosis Drug overdose Hypothermia Consider TCPtranscutaneous pacing).

o. Documentation shall include, but is not limited to:i. Time of onset

ii. Severity of pain on 1-10 scaleiii. Provocation, Location, Description of pain.

2. With the earliest opportunity shift the patient to the Cardiac emergency .

11. Management of Cardiac Arrest - Code Blue at emergency

1. All Emergency Department staff will be CPR certified.2. All physicians and nursing staff within the Emergency

Department will be ACLS certified.3. On establishing the patient to be pulseless and apneic, the staff

will initiate CPR and ACLS protocols ( code blue).4. The following list of personnel will respond to Code Blue

announcements in the hospital: The Emergency Departmentphysician, one ICU/CCU Nurse, One Emergency DepartmentNurse, One ------------- ( Respiratory Therapist) HouseSupervisor of the section where code blue has been called.

5. Do CPR and ACLS.6. Prepare the defibrillator's paddles. Use adequate lubricant or

place prepared pads under the paddles, to prevent electricalburns of the skin. One paddle shall be placed at the uppersternal area.

7. Deliver wattage to the patient only after everyone is standingclear of the bed. The person defibrillating the patient shouldstate, loudly and clearly, All clear. Look to see if all personnelare away from the bed, prior to defibrillation.

8. All registered nurses must understand the operation of thedefibrillator prior to its use.

9. The Emergency Department Nurse is responsible for theeducation of all new personnel. In the event of a cardiac arrest,a physician is called for duty immediately.

12.Management and assessment of CVA or Stroke - Standard of Care

1. A patient who arrives at the Emergency Department with CVA or strokewill receive the following care:

1. to gurney.2. Obtain history of onset of complaint.3. Obtain medical history.4. Place on cardiac monitor; obtain initial rhythm strip.5. Place on pulse oximetry.6. Maintain airway.7. Administer oxygen via nasal cannula at two to six 2-6 liters per

minute, or via mask at eight 8 to 10 liters per minute.8. Obtain ABGs as ordered.9. Maintain patient safety; siderails up.10. Document neurological deficit.11. Monitor LOC.12. Monitor for seizure activity.13. Establish IV access.14. Obtain blood sample for analysis.15. Observe the patient for bleeding a side effect of t-PA therapy at IV

sites, urinary catheter site, endotracheal tube, nasogastric tube, urine,stool, intracranial bleed.

16. Patient will be admitted to the ICU as soon as possible.17. Patient diagnosed with an ischemic stroke and who is not a candidate

for t-PA therapy: Administer anticoagulants per physician orderAdminister osmatic diuretics per physicians order The patient's PaCO2will be maintained between 30 - 35 mm Hg.

13. Assessment and management of Diarrhea at emergency.

1. A patient who arrives at the Emergency Department with diarrhea willreceive the following care:

i. Assess vital signs for orthostatic changesii. Assess skin turgor

iii. Assess for dehydrationiv. Assess LOCv. Establish IV access 1000 mL Normal Saline or Lactated

Ringers, (as per Emergency Department physicianpreference)

vi. Obtain blood samples with IV accessvii. Monitor fluid resuscitation

viii. Documentation shall include, but is not limited to: Vitalsigns ( BP being most important), Onset of diarrhoea,

How many times has patient had episode of diarrhoea, Skinturgor, First episode of voiding post fluid resuscitation,Any other episodes of diarrhoea while in the EmergencyDepartment

14. Management of Active labour cases and abortions at Emergency

1. Establish criteria for the emergency delivery of the pregnantwoman in active labor on arrival in the Emergency Department.

2. On arrival to the Emergency Department, any patient who is inactive labor and is 16 to 18 weeks or more pregnant, shall beescorted directly to Labor and Delivery for evaluation.

3. Asses whether delivery is to be normal or by caesarean section.4. Notify Labor and Delivery of patient arrival and estimated date of

delivery.5. Transport patient either by wheelchair or gurney.6. If the patient is suspected to be PET – Eclamsia then put the patient

on a cot with railings.7. Any patient who is in active labor on arrival to the Emergency

Department, and time does not allow safe transportation to Laborand Delivery, conduct the delivery at the Emergency Departmentitself.

8. Request infant warmer be brought to the Emergency Department.9. Contact the patient's obstetrician or, if patient has no obstetrician,

contact the obstetrician on-call.10. Prepare for possible resuscitation.11. Trauma patients who are pregnant will be evaluated in the

Emergency Department before being sent to Labor and Deliveryfor assessment of the fetus.

12. When applicable, request an labor and Delivery nurse to come tothe Emergency Department to assess and evaluate any Trauma andpregnant patient.

15. Assessment and management of Epistaxis

1. The patient presenting to the Emergency Department with epistaxis nosebleed will receive the following care:

i. Escort to ENT Roomii. Apply nasal clamp

iii. Maintain patent airwayiv. Utilize standard precautionsv. Obtain medical history

vi. Set up nasal trayvii. Documentation shall include, but not be limited to: Vital

signs, Response to treatment, Approximate amount ofblood loss, Local anesthetic Sedation, if used Nasalpacking; which nares ,

viii. Any vomiting Referral to ENT

16. Assessment and management of Eye Emergencies

1. The patient arriving at the Emergency Department with an eye injury willreceive the following care:

i. Visual acuity if possible; use Snellen chart with and withoutcorrective lenses

ii. Immobilize impaled objectsiii. Ocular anesthesiaiv. Irrigate eye with Normal Saline using Morgan lensv. Documentation shall include, but not be limited to: Chief

complaint, Mechanism of injury, Visual acuity, Appearanceof eye Bleeding, tearing, redness Pupils, Past medicalhistory Medications/allergies.

17. Assessment and management Head Injury

1. A patient who arrives at the Emergency Department with a head injurywill receive the following care:

a. Maintain a patent airway, apply oxygen supplement.b. If the patient has convolutions then treat appropriately and use

cots with railings.c. Place on cardiac monitor and obtain rhythm strip.d. Place on pulse oximetry.e. Obtain initial vital signs; then obtain vital signs every 15

minutes for one 1 hour; then every 30 minutes or as needed byassessment.

f. Obtain initial neuro checks; then obtain neuro checks every 15minutes for one 1 hour; then every 30 minutes or as needed byassessment. Follow Glasgow scale for neuro check.

g. Apply c-spine precautions.h. Notify Emergency Department physician.i. Establish IV.j. Observe for signs and symptoms of increased intracranial

pressure i.e., Raccoon eyes, Battle's sign.k. Prepare patient for x-rays and/or CT Scan as ordered by the

physician.l. Documentation shall include, but is not limited to: Mechanism

of injury, Initial assessment, Vital signs, Neuro checks anddocumentation of neurological changes, Initial LOC, and anychanges, Obvious trauma Pupil reaction, Repetitivequestioning..

18. Assessment and management Hypothermia

1. The patient arriving at the Emergency Department with hypothermiacondition in which the body core temperature falls below 95 degrees F 35degrees C, shall receive the following care:

i. Assess and maintain airway.ii. Obtain history of incident, length of time of exposure.

iii. Obtain rectal core temperature.

iv. Place on cardiac monitor; obtain baseline rhythm.v. Assess degree of hypothermia.

vi. Draw blood for Clinical Laboratory testsvii. Mild Hypothermia: Remove wet clothing; dry the patient.

Apply warm blankets; cover the patient's head. Initiateintravenous line, use warm IV solution

viii. Heavy Hypothermia: Assess for frostbite. Prepare forpossible intubation if decreased level of consciousness.Monitor for life-threatening arrhythmias. Follow AdvanceCardiac Life Support (ACLS) protocols. Remember, ifasystole due to long immersion in cold water, patient maystill be resuscitated.

ix. Documentation shall include, but not be limited to: Chiefcomplaint/mechanism of injury Initial vital signs Updatedvital signs every hour until the patient is stable.

19. Assessment and management of Hypovolemic Shock:

1. The patient presenting to the Emergency Department in hypovolemicshock will receive the following care:

i. Assess and maintain a patent airway.ii. Place oxygen via mask at 10-15 liters per minute.

iii. Assess level of consciousness.iv. Assess Glasgow Coma Scale.v. Place on cardiac monitor and obtain baseline rhythm.

vi. Obtain initial vital signs.vii. Control obvious external bleeding.

viii. Initiate intravenous lines with large-bore catheters usingNormal Saline.

ix. Obtain venous blood for Clinical Laboratory. Type andcross for possible transfusion. If available, check glucoseand H&H using -------------- (Glucometer).

x. Obtain baseline electrocardiogram.xi. If applicable, prepare for surgery.

xii. Documentation shall include, but not be limited to:Mechanism of injury, Initial vital signs, Initial level ofconsciousness and any changes, Any changes in vital signs,Obvious bleeding, internal and/or external, Response tofluid resuscitation.

20. Assessment and management of Lacerations and/or Abrasions

1. The patient arriving at the Emergency Department with lacerationsand/or abrasions will receive the following care:

i. Assess airway status.ii. Assess bleeding.

iii. Assess neurological and sensory status distal to theinjury.

iv. Control bleeding.v. Clean wound with hospital accepted solutions.

vi. Set-up suture equipment.vii. If applicable, give tetanus booster.

viii. Documentation shall include, but not be limited to:Mechanism of injury, Initial vital signs, Description andlocation of injury, Any obvious deformity, Approximateblood loss, Type of suture used, Medical history,Tetanus status, Medication/allergy Dressing used

21. Assessment and management of Orthopedic Emergencies (Extremities)

1. The patient arriving at the Emergency Department with an orthopedicemergency to an extremity will receive the following care:

i. Assess and maintain a patent airway.ii. Immobilize the extremity.

iii. Elevate the extremity.iv. Apply ice to area of injury.v. Assess circulation to area distal to injury.

vi. Assess sensation to area distal to injury.vii. Cover open wounds with Normal Saline dressing.

viii. Initiate intravenous line with Normal Saline, if obviousdeformity or open fracture.

ix. Documentation shall include, but not be limited to:Mechanism of injury, if trauma, Initial vital signs,Position of injured limb, Obvious deformity, Anycirculatory or sensory abnormality, Frequent circulatoryand sensory exams, Any associated injuries, Anydiagnostic test, What time orthopedist was notified andarrival time, Type of splinting or casting.

22. Initial assessment and management of Paediatric Fever

1. Establish criteria for care of the paediatric patient presenting to theEmergency Department with fever over 101 degrees F.

2. Infants 12 weeks of age or younger who present with a fever greaterthan 100.4 degrees F rectally will be evaluated immediately.

3. Paediatric patients under the age of five 5 will have rectal temperaturesobtained.

4. Obtain weight.5. Assess hydration.6. Obtain history of onset of fever and home care.7. For fever more than 1000F do tepid sponging.8. For fever over -----------degrees F, obtain order from Emergency

Department physician for: Tylenol per weight, if none given withinfour 4 hours of arrival to Emergency Department.

9. Ibuprofen per weight, if Tylenol has been given within four 4 hours.10. Escort patient, with parent or guardian, to room; remove excessive

clothing from patient.11. Documentation shall include, but is not limited to: Initial vital signs,

Response to medications, Retake temperature and document, if initial

temperature is greater than 102 degrees F, Discharge instructions forhome care of fever

23. Assessment and management of Seizures

1. A patient who arrives at the Emergency Department with seizures willreceive the following care:

a. Establish and maintain a patent airway.b. Prepare to assist with ventilation, if necessary.c. Maintain patient safety.d. Suction airway, as needed.e. Apply oxygen, high flow.f. Monitor cardiac status.g. Establish IV access with 1000 mL Normal Saline.h. Obtain venous bloods for Clinical Laboratory from IV access.i. Obtain history of seizure activity.j. Keep siderails up for patient protection. Pad siderails for patient

protection.k. Have medication available to stop seizure, per physician's

order.l. Prepare the patient for CT scan, MRI or EEG as required.m. Documentation shall include, but is not limited to: Initial vital

signs, Time and length of seizure, Time and length of anyseizure activity in the Emergency Department, History ofseizure activity or activity prior to seizure

24. Assessment and management of Vaginal Bleeding at Emergency:1. A patient who arrives at the Emergency Department with vaginal

bleeding will receive the following care:2. Escort to OB/GYN gurney.3. Evaluate bleeding, extent, clots, tissue.4. Save all tissue and send to Pathology.5. Record Date of LMP.6. Establish the reason for bleeding.7. Obtain initial vital signs.8. Obtain orthostatic vital signs.9. Establish IV access with 1000 mL Normal Saline.10. Obtain venous blood for Clinical Laboratory with IV access.11. Initiate treatment medical or interventional.12. Perform HCG or BHCG.13. Documentation shall include, but is not limited to: Initial vital signs and

orthostatic vital signs Amount of bleeding, tissue, clots while inEmergency Department, LMP/Gravida and Para status Onset of bleeding

25. Assessment and management of Vomiting at Emergency:1. A patient who arrives at the Emergency Department vomiting will receive the

following care:a. Establish and maintain patent airway.

b. Obtain initial vital signs and/or orthostatic vital signs.c. Assess frequency of vomiting.d. Assess causative factor.e. Assess Levels of Conciousness..f. Documentation shall include, but is not limited to: Initial vital signs

and/or orthostatic vital signs Documentation of vomiting while in theEmergency Department Monitor and document I&O Documentresponse to antiemetic therapy

GENERAL:

26. Emergency Service Access1. Emergency and Urgent Care Services will be clearly identified and

easily accessible from the road. Signage will be posted in clear viewand at regular intervals. Signs will be well lighted and maintained.

2. Signs will be prominently posted from the main vehicle roadwaythroughout the property to the Emergency Department entrance.

3. Security will keep the limited Emergency Department parking clear forauthorized vehicles only.

4. Security will patrol Emergency Department parking and ambulancereceiving areas as part of regular hospital rounds. Security will be onhand for traffic control and will attempt to clear area of any infractions,if unsuccessful local police will be contacted for assistance.

27. Transportation of Emergency Department Patient Within the Hospital1. Patients admitted to a monitored bed will be transported with a

licensed nurse and a monitor.2. All patients will be transported within the hospital accompanied by

qualified staff members. Siderails or seat belts will be used to maintainpatient safety when transporting patients.

3. The patient will be assessed prior to transport by a licensed staffmember, to determine the method of transport i.e., wheelchair orgurney.

4. All patients will be transported with admitting orders and patientbelongings lists or Property Sheet

28. Visitors in the Emergency Department1. The ------------- (Emergency Security) will control visitation in the

Emergency Department in coordination with the EmergencyDepartment attending physician.

2. Visitors will be limited to two 2 at a time, depending on the patient'scondition.

3. All visitors must wear a visitor's pass to enter the EmergencyDepartment. The visitor's pass must be visible at all times.

4. The Patient Liaison will remain in contact with families in the waitingroom on a frequent basis.

5. Family member/significant other should be included in the dischargeteaching process, as applicable. Wherever appropriate, allow thepatient's other should be included in the discharge teaching process, asapplicable.

6. Wherever appropriate, allow the patient's family/significant other to bepresent during resuscitation and invasive procedures

7. Facility staff who are not directly involved in the care of the patientmust comply with this policy as a visitor.

8. No external materials including food items are allowed into theemergencies.

29. Patient and Visitor Safety1. The following criteria will be utilized to maintain safety within the

Emergency Department for staff, patients and visitors.2. Patients will be protected from injury: Siderails up, Padded siderails

for seizure patients3. Assist with ambulation Escort to admitted patients to their room via

wheelchair or gurney4. Clean up all spills immediately.5. Paediatric patients shall be accompanied by parent or guardian.6. Visitors are permitted in the Emergency Department at the discretion

of the emergency nurse. To monitor traffic and maintain a safeenvironment, no more than two 2 visitors per patient at any given time.

7. To maintain patient privacy, visitors will be requested to leave duringpatient evaluation.

8. Offer visitors a chair versus a stool to sit on.9. Keep doorways clear of items.

30. Emergency Department Security1. These procedures address the safety and security of patients, personnel

and visitors will be followed by all personnel working in theEmergency Department.

2. Only authorized personnel and visitors will be allowed access to theEmergency Department.

3. All Emergency Department and Security Department personnel shallreceive aggression management training and special training onhandling disruptive and violent persons during orientation and annuallythereafter.

4. Emergency Section consumables like intravenous needles, hypodermicneedles, scissors and oxygen bottles shall be stored in an areainaccessible to public.

5. All prisoners or patients under custody will be treated wheneverpossible in a secured area.

6. The main entrance to the Emergency Department can be locked duringwhatever hours necessary by the triage nurse.

7. The Emergency Department personnel shall be able to release the lock.

8. Video will allow for screening of incoming persons.9. A Security Officer will be available at entrance to Emergency on 24X

7 basis.

Emergency safety protocol.

31. General:1. --------------------------- (The emergencySupervisor) is responsible

for maintaining safety standards, developing safety rules,supervising and training personnel in departmental standards.

2. --------------- is responsible for notifying the -----------------------(Safety Officer) in case of any safety hazard.

3. All department employees shall report defective equipment, unsafeconditions, acts or safety hazards to ---------------------.

4. All employees shall be trained in emergency protocol.

32. Employee responsibilities:1. Obey established safety rules.2. Use personal protective equipment, as required.3. Inform your supervisor of: Any symptoms of overexposure that

may possibly be related to hazardous chemicals, missing labels oncontainers, Malfunctioning safety equipment, any damagedcontainers or spills must be reported immediately.

4. Don’t use equipment for which you have not been trained.5. Follow safety precautions.6. Keep electrical cords clear of passageways.7. Do not use electrical extension cords without written approval of

the Engineering Department.8. Check for frayed cords.9. Do not attempt to remove stoppers on glass tubing by force. If they

are stuck, cut them off.

33. Fire Safety1. The proper response to fire or smoke is RACE. R = Rescue patients

immediately from fire or smoke area. A = Pull fire alarm stationand call emergency number give exact location. C = Contain thesmoke or fire by closing all doors to rooms and corridors. E =Extinguish the fire when safe to do so.

2. Rescue individuals from the immediate fire or smoke area. Alwaysrescue people before pulling the fire alarm.

3. Pull the fire alarm and call -------- (emergency number) to reportthe fire.

4. Turn off all electrically operated equipment. Assist nursing staff inclosing.

5. Be sure to take this step immediately after rescuing, so that theappropriate emergency response personnel arrive at the spotquickly. Stand by for orders.

6. If the fire is not in your area, be alert, be guided by the instructionsof your area fire marshal or ----------------.

7. Clear hallways to permit safe passage of emergency responders.8. -------------------------, -------------------------- & ---------------- have ,

functioning with in Emergency section have been trained in the useof fire extinguishers. These persons have to take fire extinguishersand report to scene of the fire.

9. Fire Extinguisher Class C Type must be used.

34. Electrical Safety:1. Safety precautions shall be followed at all times when electrical

devices are utilized.2. Electrical devices shall be protected from wet floors.3. The frames of all electrically operated machinery shall be

grounded.4. Brass light sockets within reach shall be replaced with non-

conducting material.5. Extension lights shall be equipped with rubber handles, sockets and

lamp guards.6. The cords shall be of approved rubber-covered type.7. Non-conducting links shall be inserted in brass pull chains.8. Prompt repairs shall be made to any electrical equipment from

which a shock is felt.9. Equipment must be always in switch off position.10. Ensure Switch to off position before connecting or disconnecting.11. Do not disconnect the plug from the wall by grasping the power

cord. Grasp the plug itself and disconnect.12. Report and remove from service any device that has been dropped,

abused, had liquid spilled on it or had evidence of overheating.13. Discontinue use of equipment that has any wire or power cord that

shows fraying, extreme wear, a cut or crack in insulation orevidence of burning.

35. Equipment Safety:1. ------------------------- will be responsible for assessing the condition

of electrical equipment utilized.2. The assessment will be done ------------ ( once a month)3. Electrical equipment and devices with electronic components shall

be evaluated as follows:a. Electrical connectors, such as jacks, receptacles or plugs,

must be of an approved type, free of cracks or breaks andproperly attached to the line cord or cable.

b. Mechanical indexing mechanisms must be free of wear ordamage to prevent improper alignment or mating of plugsand receptacles.

c. Cables, cords and internal wiring must be of an approvedtype and of proper wire size.

d. No brittle insulation to be used.e. Cables, clips, studs and terminals must be free of dirt, rust,

corrosion and other deposits.f. Switches, circuit breakers, relay points and selectors must

not be dirty, corroded, excessively worn or pitted.g. Grounding systems must be of an approved type and

properly installed. All electrical components, such as relays,transformers, capacitors, electron tubes and resistors, mustoperate without overheating.

h. Heating elements must be checked for electrical safety.

36. Emergency Instrument Maintenance:

1. Daily instrument maintenance logs are kept in each department in theClinical Emergency.

2. Maintenance will be done as required and properly documented in theinstrument log. Any minor maintenance not requiring a service callwill be documented in the instrument log.

3. Specific instructions for daily maintenance can be found in theinstrument operation manuals located in each Clinical EmergencyDepartment.

4. Records of major scheduled preventive maintenance and unscheduledrepairs are located in the ------------------- (Chief MedicalTechnologist's) office.

37. Hazard Surveillance Detection Survey

The hospital will conduct Hazard Surveillance survey once a year. Thesurvey is conducted to collate information on the following:

1. Ability of the staff to demonstrate knowledge and skill of their roleand expected participation in the safety management program.

2. Ability of the staff to demonstrate knowledge and skill of their roleand expected participation in the security management program.

3. Ability of the staff to demonstrate knowledge and skill of their roleand expected participation in the hazardous materials and wastemanagement program.

4. Ability of the staff to demonstrate knowledge and skill of their roleand expected participation in the emergency management program

5. Ability of the staff to demonstrate knowledge and awareness aboutthreat in Emergency.

6. Ability of the staff to report a security incident7. About usefulness ID badge and dosimeter if appropriate.8. Marking of Emergency reagents9. About marking of Emergency specimens10. About Visitor management.11. About correctness in reporting.

38. Material Safety Data Sheet ( MSDS):1. A Material Safety Data Sheet supplies detailed information on a

chemical and its hazards. The following information is listed on thesheet, if applicable to the product:

1. Product name2. Chemical name3. Manufacturer's name,4. Address and telephone number5. Formula Trade name6. Appearance7. Odor8. Hazardous ingredients9. Physical and chemical characteristics

10. Fire and explosion data11. Physical hazards12. Health hazards including acute and chronic health

effects13. Any other related information14. Primary routes of entry15. Any Carcinogen impact?16. Emergency and first aid procedures17. Special protection information18. Special precaution and spill/leak procedures

Applicable.19. Control measures including engineering controls

2. The MSDS Manual is kept in the -------------------------'s office.

39. Emergency Management:

1. Apart from fire, floods and natural disasters the hospital identifiesthe following situations as emergency situations.

i. Handling of contagious disease ( like H1N1 Fever)ii. Handling of unknown equipment errors detected

subsequently.iii. Mixing of blood or blood components.iv. -----v. -----

2. Upon recognizing the emergency the --------------- (Administrator)will notify in priority order the -----------------, -------------------- and-------------.

3. ----------------------------- will initiate emergency response. ------------ may obtain additional help from the Emergency Pool as needed.

4. --------------- may direct personnel as needed until someone morequalified arrives.

5. The ------------------------ (Duty doctor determines the necessity toevacuate the area due to an emergency or imminent emergencywithin the department.

40. Workplace Violence Prevention Plan1. This hospital will provide a means of addressing workplace violence.2. The safety and security of hospital personnel, patients and visitors is of

vital importance. Therefore, acts or threats of physical violence,including intimidation, harassment or coercion, which in yourjudgment affects the hospital or which occurs on hospital property willnot be tolerated. This prohibition against threats and acts of violenceapplies to all persons involved.

3. All incidents of abuse, verbal attacks or aggressive behavior includinguse of force not connected to medical treatment of a person areconsidered as violent incidents.

4. When violent incidents occur within the hospital either betweenservice providers and patients or when violent incidents occur amongthe hospital staff members or when violent incidents occur within thehospital without any involvement of hospital staff, the Security willtake immediate steps to prevent further escalation of violence.

5. The security will take up all necessary measures within the limits oflaw to safeguard the loss of life and property. The first attempt is topacify the violent persons and force to restrain violent behavior willhave to be used only when necessary. The force used must be aimed atrestraining the violent person and not to cause any more harm to theviolent person.

6. With the first opportunity the incident must be brought to the notice of---------------- who will take steps to ensure the operation of legalmachinery.

41. Latex Sensitivity:1. Latex exposure can cause a local allergic reaction. Symptoms of a local

reaction might be itching, redness or urticaria.2. Latex exposure may cause a systemic anaphylactic reaction. A

systemic reaction might manifest as difficulty in breathing, anxiety,palpitations, chest tightness and pain, hypotension, facial andperipheral edema and shock. Even a trivial exposure may result in acardiorespiratory arrest.

3. Persons with a history of asthma, hay fever, allergy to bananas,avocados, pears or chestnuts and patients that have experienced ananaphylactic reaction during surgery, urinary catheterization, rectal orvaginal examination must declare their latex sensitivity.

4. Persons who are sensitive to latex should not be allowed to function atthe Emergency.

5. While dealing with latex sensitive patients non- latex alternativematerials are to be used.

Infection Control at the Emergency.

42. Handling of Biomedical Waste at the Emergency.

1. All waste in the Emergency must be handled as per_____________________ rules.

2. Dispose of all biomedical wastes as per ----------------- rules.

43. Transmission-Based Precautions (Isolation Precautions)

1. Emergency patients come from highly unsterile areas. Hence one mustexercise all precautions against Transmission based diseases.

44. Hand Hygiene

1. Observe Hand Hygiene practices as indicated in the infection controlmanual in order to prevent the transmission of bacteria, germs andinfections.

2. Alcohol-Based Hand Rub: An alcohol-containing preparation designed forapplication to the hands for reducing the number of viable microorganismson the hands.

3. Antimicrobial Soap: Soap containing an antiseptic agent.4. Antiseptic Agent: Antimicrobial substances that are applied to the skin to

reduce the number of microbial flora. Use alcohol, chlorhexidine,quaternary ammonium compounds and triclosan.

5. Plain Soap: Detergents6. Bacillus anthracis is suspected or proven.7. The action of washing and rinsing hands under these circumstances is

recommended because alcohols, chlorhexidine, iodophors and otherantiseptic agents have poor activity against spores.

45. Asepsis

1. Aseptic technique refers to all efforts that the Emergency team makes toprevent contamination of a surgical wound by bacteria by maintaining thesurgical field.

2. Moisture may cause contamination.3. Gloved hands must be kept at waist level or above. Below the waist is

contaminated.4. Keep away from mask.5. Arms are not to be folded under axillae.6. Always keep gloved hands in sight.

46. Infection Control Measures

1. All staff in the Emergency must observe continuous infection controlsurveillance measures, as outlined in the hospital Infection Control Policyand Procedure Manual.

2. Any staff with an infectious or communicable disease process shall not beassigned to the Emergency work.

47. Disposal of Sharps

1. Sharps include any device having acute rigid corners, edges orprotuberances capable of cutting or piercing including: hypodermicneedles, syringes, blades, needles with attached tubing, pipettes and bloodvials which are contaminated with other medical waste.

2. Sharps waste shall be contained in Sharps Containers which are rigid,puncture resistant when sealed.

3. No sharps be discarded into waste or trash containers.4. Bare needles will not be left anywhere.5. Do not recap needles. This is the single most important cause of needle

puncture injury.6. Sharp containers shall be filled to three quarters filled and taped closed or

tightly lidded.7. Sharps shall be disinfected by keeping for 20 min in 1% freshly prepared

Sodium hypochlorite solution and then stored.8. Sharps containers are placed in red bags by Environmental Services staff

for processing.

48. Sharps Injury Protection Plan

1. The main purpose of engineered sharps safety is to increase protectionfrom sharps injuries, which can transmit HIV, hepatitis B, hepatitis C andother bloodborne pathogens.

2. This is accomplished by stronger requirements for employers to useneedles and other sharps which are engineered to reduce the chances ofinadvertent needlesticks or other sharps injuries.

3. Also required is for employers to keep a sharps injury log, which recordsthe date and time of each sharps injury, as well as the type and brand ofdevice involved in the exposure incident.

4. The confidentiality of the staff member shall be protected.5. All cases shall be entered on the --------------- Form as an injury.6. Do not include the staff member's name. Show it as Employee code.

49. Sharps Injury Log

1. Whenever an employee Exposure Incident Involving a Sharp takes palce thedetails of the incident and actions taken are to be employed in the log.

i. Employee Name:ii. Date of Injury:

iii. Procedure Being Performediv. When Injury Occurredv. Did the Exposure Incident Occur:

vi. While drawing venous bloodvii. While putting sharp into disposal container

viii. Unknown/not applicableix. Sharp left in inappropriate place table, bed, etc.x. Heparin/Saline

xi. Flush Disassembling Cuttingxii. Other:

xiii. known exposure to patient?xiv. Body Partxv. Check all that apply

xvi. Identify Sharp Involvedxvii. If known

xviii. Did the device being used have engineered sharps injuryprotection?

xix. FingerType:xx. Description of the Exposure Incident

xxi. Job Classificationxxii. Department/Location Where Exposure Occurred

xxiii. Whether Injury report form given to ----------(Surgical ServicesManager) .

xxiv. Whether the employee seen by ED and by physician.xxv. Whether injury report forwarded to Human Resources Dept.

50. Surveillance, Prevention and Control of Infection:

1. Standard Precautions combine the features of universal precautionsand body substance isolation. Standard Precautions apply to allpatients regardless of their diagnosis or suspected infection status.Standard Precautions apply to the following:

i. Bloodii. All body fluids,

iii. secretions and excretions except sweat whether ornot they contain visible blood

iv. Nonintact skin Mucous membranes2. All personnel will use the hand-hygiene techniques, as set forth in

the infection control manual of the hospital.3. Exposure Control Plan: The staff of the Emergency will follow all

the exposure control precautions laid out in the Hospital InfectionControl manual.

4. Sharps Injury Protection Plan : The staff of the Emergency willfollow all the Sharps Injury protection plan laid out in the HospitalInfection Control manual.

51. Personnel Injury and Illness1. For assistance in the event of injury or illness to personnel during

duty hours at the surgical department initiate first aid.2. Seek medical treatment Emergency Department, physician's office

or nursing unit.3. Notify the --------------------- (Emergency Director) of the situation

as soon as possible.4. All on-the-job injuries must be reported on the Incident Report

Form.5. In addition, the --------------------- Department must be notified of

any on-the-job injury.

52. Training of Emergency Staff in Emergency safety:

New Employee Orientation

1. Each new employee shall be employed on an initial three 3 months 90calendar days probationary period.

2. During this period of time, the employee is not considered to be onpermanent status.

3. In order to assure successful completion of the probationary period, eachemployee will be oriented to all facets of his or her job, as well as workingconditions, the organization's mission, vision, values and goals, theorganization's policies and procedures and all employee benefits.

4. During this orientation phase the employee will be given a copy of themost recent Employee Handbook and sign acknowledging its receipt.

5. The employee will also receive pertinent handbooks which explain themedical and dental programs as well as other information in force at thetime of employment.

6. There will be an induction training for all the new entrants and an annualrefresher training for all the staff. Training for personnel will include, at aminimum, the following areas:

1. The Hazard Communication/Right of workers involved inroutine tasks such as in the cleaning, maintenance and repair ofequipment

2. List all jobs and associated occupations that handle hazardouschemicals

3. Right of workers involved in emergency procedures4. Identification of hazardous chemicals used in the Emergency,

by name and location of the chemicals.5. Providing specific training for individual jobs.6. Identifying any areas where an industrial hygiene or

occupational health evaluation may be needed and training theconcerned staff for ensuring Emergency safety.

7. The employee will be assessed for his/her ability to carry out assigned responsibilitiessafely, competently and in a timely manner upon completion.

8. No activity on a patient will be done by a new incumbent without supervision.

Inservice Orientation to the Staff at Emergency section:

1. Continuing educational programs will reflect and meet the developmentalneeds of the Emergency Services staff and will be offered as internalprograms or available through community resources.

2. Continuing educational programs will reflect and meet the evolving needsof the hospital, i.e., they will reflect education needs arising fromhealthcare associated activities.

3. The deputed staff must attend all mandatory inservice education andtraining programs offered, to meet the performance standard forEmergency Services.

4. External educational program offerings are made available to staff throughthe use of their education time.

5. Information concerning external programs is posted on the ------------(Emergency Services Bulletin Board).

6. In-service training for Emergency staff will be imparted annually coveringthe following areas.

1. Organization's Mission and Values2. Performance Improvement Program3. Safety4. Patient Safety in general as well as at Emergency .5. Radiation Safety6. Hazardous Materials and Waste Management, including

Pharmaceutical Waste7. Attire at Emergency8. Infection Control in general as well as at Emergency.9. Healthcare Associated Infections,10. Surgical Site Infections11. Aseptic Technique12. Standard Precautions, including Hand Hygiene, Personal

Protective Equipment, Transmission-Based Precautions13. Surgical Site Infection Prevention Measures14. Code Blue practices.15. Use of CSSD16. Material distribution network.17. Using of Time Clock/Cards18. Using of Crash Carts19. Using of Stock Carts20. Using of Scrub Sinks21. Using of Autoclave22. Using of communication systems like Intercom,

Pager/Beeper,,Phone System. Computer23. Reporting Fire Codes24. Emergency Call-Back Procedure

25. Description and Tour of Emergency with details of zones,facilities, fixtures, movement and traffic.

26. Location and facilities at Clinical Emergency.27. Equipment case and cart system28. MSDS29. Proper Emergency attire30. Staff Organization: Department organization chart Emergency

staff31. Aseptic techniques32. Surgery & documentation of care33. oral and written communication,34. Record keeping documentation, etc.35. Physician's orders36. equipment and supply needs37. Fire & Electrical safety protocol at Emergency.38. Job Description of each Emergency personnel.39. Surgical Department manuals40. Physician Reference Cards41. Clinical Emergency protocols.42. Staff Schedules, Assignments43. Staff Meeting Minutes44. Surgical Rules and Regulations