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GUIDE BOOK TO NABH STANDARDS FOR HOSPITALS

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Guide Book To Nabh Standards For Hospitals

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NABH Guide Book to Accreditation Standards for Hospitals (4th edition) December Orientation to NABH Eye Care Organization Accreditation Standards. EYE CARE HOSPITAL (ECO) ACCREDITATION – PROJECT By: Mr. .. of Eye Care Standards + Guide book (From NABH office) Get accustomed to the. hospitals under 50 beds, and the other using NABH standards for hospitals This Guidebook for Pre-Accreditation Entry-Level Standards for SHCOs contains.

The organisation is aware of the availability of alternate organisations where the patients may be directed in case of non-availability of beds.

In case the organisation admits these patients in a temporary holding area it shall ensure that there is adequate infrastructure to take care of these patients.

Further, the organisation shall define as to how long patients are kept on temporary beds before a decision to transfer out is taken. The documented procedure also addresses managing patients when bed space is not available in the desired bed category or unit and the financial implications explained to the patient of the same. Access to the healthcare services in the organisation is prioritised according to the clinical needs of the patient.

Patients with clinical problem which warrant an earlier response are identified and prioritised in all care settings. For eg. A patient waiting in the OPD who complains of giddiness, is seen as soon as possible. The staff are aware of these processes. All the staff handling these activities should be oriented to the applicable policies and procedures.

Documented policies and procedures guide the transfer-in of patients to the organisation. This shall address both planned and unplanned transfers.

For unplanned transfers and in case of suspected unstable patients, the organisation could send a suitably trained person with the ambulance. However, this shall be guided by the information received by the organisation.

Patients needing transfer include those who have come to the emergency but need to be transferred to another organisation or those already admitted but who now require care in another organisation. It also includes patients being shifted for diagnostic tests. The organisation shall define who is an unstable patient. This shall be defined based on physiological criteria.

The documented procedure should address the methodology for safe transfer of the patient in a life-threatening situation like those who are on ventilator to another organisation. There should be availability of an appropriate ambulance fitted withlife support facilities and accompanied by trained personnel.

Patients not in a life threatening situation stable should also be transported in a safe manner. Further, the staff identified should be aware of the transfer procedure.

A doctor should accompany an unstable patient. The organisation gives a summary of patients condition and the treatment given. This shall also include patients being transferred for diagnostic and therapeutic purposes. In case of a patient being discharged from the organisation, a discharge summary is given to all patients including those patients going against medical advice.

A copy of the same shall be retained by the organisation. The organisation defines and documents the content of the initial assessment for the outpatients, in-patients and emergency patients. The organisation shall have a format using which a standardised initial assessment of patients is done in the OPD, emergency and in-patients.

The initial assessment could be standardised across the hospital or it could be modified depending on the need of the department. However, it shall be the same in that particular area, e. In emergency department, this shall include recording the vital parameters. The format shall be designed to ensure that the laid-down parameters are captured.

Every initial assessment shall contain the presenting complaints, vital signs and salient examination findings especially of the system concerned. This shall incorporate initial assessment by doctors and nursing staff in case of in-patients. Abridged documentation may be used for day care as appropriate. The organisation determines who can perform the initial assessment.

The assessment could be done by various categories of staff. The organisation determines who can do what assessment and it should be the same across the organisation. Assessments are performed by each discipline within its scope of practice, registration and applicable laws and regulations.

The organisation defines the time frame within which the initial assessment is completed based on patients needs. The time frame shall be from the time that the patient has registered or it is the arrival time to the emergency department till the time that the initial assessment is documented by the medical and nursing team. Patients may be assessed earlier depending upon the clinical need. The initial assessment for in-patients is documented within 24 hours or earlier as per the patients condition, as defined in the organisations policy.

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This should cover history, examination including vital signs and documentation of any drug allergies. It should mention the provisional diagnosis. For an admitted patient, if a detailed assessment has been done earlier either in OPD or emergency on the same day , it need not be written in detail again. Note that the maximum time allowed for documentation is 24 hours. However, the organisation shall define and document the appropriate time depending on the patients condition and the scope of its services.

Initial assessment of in-patients includes nursing assessment which is done at the time of admission and documented. This shall identify the nursing needs and also help identify any special needs of the patient. It shall be completed within a defined time frame.

This assessment shall help in identifying the nursing needs of the patient. A checklist or template could be used for the same. Initial assessment includes screening for nutritional needs. This is only a screening for nutritional needs and not a complete assessment. Nutritional screening shall be done for all patients including OP and IP for relevant parameters.

Nutritional screening could result in a need for a detailed nutritional assessment which shall be done wherever necessary.

The initial assessment results in a documented care plan. This shall be documented by the treating doctor or by a member of his team in the patient record. Care plan is prepared and documented based on initial assessment and result of diagnostic tests if available. The care plan shall be subject to modifications or changes at reassessments. The care plan reflects desired results of the treatment, care or service.

The care plan is countersigned by the clinician in-charge of the patient within 24 hours. The treatment of the patient could be initiated by a junior doctor but the same should be countersigned and authorised by the treating doctor within 24 hours. The clinician in charge implies the treating doctor. Patients are reassessed at appropriate intervals. After the initial assessment, the patient is reassessed periodically and this is documented in the case sheet. The frequency may be different for different areas based on the setting and the patient's condition, e.

Reassessments shall also be done in response to significant changes in patients condition. Every patient shall be reassessed at least once every day by the treating doctor. Out-patients are informed of their next follow-up, where appropriate.

This may not be applicable in cases where patient has come for just an opinion or the patients condition does not warrant repeat visits. For in-patients during reassessment the care plan is monitored and modified, where found necessary.

The care plan shall be dynamic and modified where necessary by the treating doctor according to the patients condition. The changing care plan is documented in the medical record.

This could be evidenced in different sections such as progress notes, doctors orders or medication charts. Staff involved in direct clinical care document reassessments. Actions taken under reassessment are documented. The staff could be the treating doctor or any member of the team as per their domain of responsibility of care. At a minimum, the documentation shall include vitals, systemic examination findings and medication orders.

The nursing staff can document patients vitals. Only phrases like patient well; condition better would not be acceptable. Patients are reassessed to determine their response to treatment and to plan further treatment or discharge.

The organisation lays down guidelines and implements processes to identify early warning signs of change or deterioration in clinical conditions for initiating prompt intervention.

The organisation trains the staff to use defined physiological parameters to identify clinical deterioration. The organisation has a mechanism whereby this information is made available to appropriate medical personnel to initiate prompt and appropriate actions.

Scope of the laboratory services commensurate to the services provided by the organisation. The organisation should ensure availability of laboratory services commensurate with the healthcare services offered by it.

The organisation shall ensure that these services are available round the clock and patient care does not suffer. For example, a cardiac care organisation must necessarily have facilities for cardiac enzyme.

The infrastructure physical and equipment is adequate to provide the defined scope of services. Laboratory shall have adequate space and equipment to meet its defined scope of services which shall include. Equipment required to conduct these tests including suitable backup plan internal or external. The manpower is adequate to provide the defined scope of services. The number of laboratory personnel should be commensurate with the work load with sufficient staff for each shift and emergencies.

Reports should not get delayed due to lack of adequate manpower including personnel authorised to report results. The staff employed in the lab should be suitably qualified appropriate degree and trained to carry out the tests.

Pathologist, microbiologist and biochemist supervise the staff. Documented procedures guide ordering of tests, collection, identification, handling, safe transportation, processing and disposal of specimens. The organisation has documented procedures for ordering, collection, identification, handling, safe transportation, processing, and disposal of specimens, to ensure safety of the specimen till the tests and retests if required are completed observing standard and special precautions.

The organisation shall ensure that the unique identification number is used for identification of the patient. In addition, it could use another number for example, lab number to identify the sample. The disposal of waste shall be as per the statutory requirements Bio-medical waste management and handling rules. Laboratory results are available within a defined time frame.

The organisation shall define the turnaround time for all tests. The organisation should ensure availability of adequate staff, materials and. The turnaround time could be different for different tests and could be decided based on the nature of test, criticality of test and urgency of test result as desired by the treating doctor.

Critical results are intimated immediately to the personnel concerned. The laboratory shall establish its biological reference intervals for different tests. The laboratory shall establish and document critical limits for tests which require immediate attention for patient management and the same shall be documented. The critical test results shall be communicated to the personnel concerned and this shall be documented.

This shall include critical results of outsourced investigations. If it is not practical to establish the biological reference interval for a particular analysis the laboratory should carefully evaluate the published data for its own reference intervals.

Relevant staff are made aware and trained on the critical values and its reporting process through suitable mechanism. Results are reported in a standardised manner. At a minimum, the report shall include the name of the organisation or in case of outsourced laboratory, the name of the same , the patients name, the unique identification number, reference range of the test where applicable and the name and signature of the person reporting the test result.

In case of outsourced test results, the same shall be either on the outsourced laboratorys letter head or on the organisations letter head. If it is done on organisations letter head it should include atleast the name of the outsourced laboratory, date and reference number of the report given by the outsourced laboratory.

These could include recall for errors due to pre analytical, analytical and post analytical factors. If already issued to the patient, the amended report is made available to the patient with the caution to ignore the earlier one. The same shall be documented. Placement of corrected report in all these areas is also evidenced. Corrective and preventive action is implemented as appropriate based on detailed analysis. Laboratory tests not available in the organisation are outsourced to organisation s based on their quality assurance system.

The organisation has documented procedure for outsourcing tests for which it has no facilities. This should include: Identity of personnel in the outsourced facilities to ensure safe and timely transportation of specimens and completing of tests as per requirements of the patient concerned and receipt of results at organisation.

Manner of packaging of the specimens and their labelling for identification and this package should contain the test requisition with all details as required for testing. A methodology to check the performance of service rendered by the outsourced laboratory, as per the requirements of the organisation. The laboratory quality assurance programme is documented.

The organisation has a documented quality assurance programme. Quality assurance includes internal quality control, external quality assurance, pre-analytic phase, test standardisation, post-analytic phase, management and organisation.

The laboratory shall participate in external quality assurance programme when available. When such programmes are not available, the laboratory could exchange samples with another laboratory for purposes of peer comparison. There is a mechanism to obtain feedbacks from various stakeholders to evaluate the laboratory services. Verification of an analytical procedure is the demonstration that a laboratory is capable of replicating with an acceptable level of performance a standard method.

Verification of Standard method performance can be defined for two situations: The first use of a standard method within the laboratory. Verification under conditions of use is demonstrated by meeting the specifications established for that method as well as a demonstration of accuracy and precision or other method parameters for that method.

Eg If the Laboratory introduces a new methodology of testing Blood Glucose levels, in addition to meeting the specifications established by that particular method recommended by the manufacturer in case of a commercial kit , it should also demonstrate accuracy and precision by alternate established methods either within the laboratory or from outside laboratory.

Validation of method: Non-standard and laboratory-developed methods need method validation. Methods requiring validation include: Modified official methods In-house developed methods Methods extended to a component, analysis or matrix not previously tested or included in validation Changes involving new technology or automation Verification usually includes accuracy, precision and linearity.

Validation in addition includes sensitivity and specificity. This also holds true for any laboratory-developed methods. The programme addresses surveillance of test results. Surveillance of laboratory results like controls, external and internal quality assurance results, non-conformances etc shall be periodically assessed by the designated individual s.

This shall be done in a structured manner. The programme includes periodic calibration and maintenance of all equipment. Traceability certificate s of all calibration done shall also be documented and maintained.

This shall also include point of care equipment wherever feasible. The programme includes the documentation of corrective and preventive actions. The laboratory safety programme is documented. A well-documented laboratory safety manual is available in the lab.

This takes care of the safety of the workforce as well as the equipment available in the laboratory. It shall be in consonance with the risks and hazards identified. This programme is aligned with the organisations safety programme. Laboratory safety programme is aligned with the safety programme of the organisation. The broad principles shall be the same as that of the organisations safety programme.

Written procedures guide the handling and disposal of infectious and hazardous materials. The lab staff should follow standard precautions. The disposal of waste is according to Biomedical Waste management and handling rules.

Material safety and data sheets MSDS-where applicable shall be available and staff well versed in the same. Laboratory personnel are appropriately trained in safe practices. All the laboratory staff undergo training regarding safe practices in the laboratory. The training need identification has to be done commensurate with the job description of the staff.

Adequate safety devices are available in the lab, e. PPE, eye wash facilities, dressing materials, disinfectants, fire extinguishers etc. It should. All laboratory personnel shall adhere to standard precautions at all times. All lab staff shall be appropriately immunised.

Imaging services comply with legal and other requirements. The organisation is aware of the legal and other requirements of imaging services and the same are documented for information and compliance by all concerned in the organisation. The organisation maintains and updates its compliance status of legal and other requirements in a regular manner. The organisation shall have a Radiation Safety Officer of appropriate level.

Scope of the imaging services is commensurate to the services provided by the organisation. The infrastructure physical and equipment and manpower is adequate to provide for its defined scope of services. Imaging services shall have adequate space and equipment to meet its defined scope of services which shall include. Equipment required to conduct these tests including suitable backup internal or external.

Reports should not get delayed due to lack of adequate equipment or manpower including personnel authorised to report results. Adequately qualified and trained personnel perform, supervise and interpret the investigations. AERB guidelines could be used as a reference document for radiation based imaging. Documented policies and procedures exist to ensure correct identification and safe and timely transportation of patients to and from the imaging services.

The aim is to ensure patient identification at all times so that correct procedure is carried out for a patient and correct report is handed over. Procedure addresses the safe and timely transportation to and from the imaging services. This should also address transfer of unstable patients. Imaging results are available within a defined timeframe. The organisation shall document turnaround time of imaging results for all modalities.

The organisation shall monitor the waiting times, time taken to perform the tests and time taken to prepare the reports of the tests for all modalities; for in-patient, outpatient and emergency. The defined timeframes could be different for different type of tests and could be decided on the basis of the nature of the test, modality, and criticality of the test and the urgency of the test result as required by the treating doctor.

The organisation shall define and document the critical results which require immediate attention of clinician, e. At a minimum, the report shall include the name of the hospital or in case of outsourced imaging centre, the name of the same , the patients name, the unique identification number, and the name and signature of the person reporting the test result. In case of tele-radiology, there shall be the name of the reporting doctor and a remark to that effect.

It should also include the name of the reporting organisation if outsourced to an organisation. The report should be in prevailing context taking into account the clinical details and results of any previous imaging.

These could include recall for errors at all levels. Whenever there is a recall of a particular report, withdrawal from clinical areas, medical records, RIS and HIS should be ensured. Imaging tests not available in the organisation are outsourced to organisation s based on their quality assurance system.

The quality assurance programme for imaging services is documented. The QA programme for imaging should involve all stakeholders. It should be a comprehensive programme addressing equipment QA, Protocols, safety, education and surveillance.

In addition, AERB requirement will have to be met. Some examples for QA of radiation equipment include congruence of optical and radiation field, focal spot size, output consistency, leakage rate, etc. A peer review system will be in place to review the reports and outcomes of interventional procedures performed. This shall be done in a structured manner, and the sample size, periodicity for each modality shall be defined. The results of such reviews shall be discussed with all stake holders in "discrepancy meetings" and the same shall be documented.

The peer review can be performed by the head of department or by a group of peers, with or without blinding of the original reports. Discrepancies in the reports will be graded on the. The purpose is to prevent errors in future, and continuous quality improvement rather than computation or error rates of the individuals. Structured peer review of the imaging protocols and procedures shall be periodically performed and they should be modified in accordance of the current best practices.

Surveillance of the quality of images, and completeness of the imaging procedures should be performed to ensure that they are appropriate for the indications for which the imaging has been performed. For example: CT for acute renal colic requires only a low dose non-contrast CT and a multiphase CT urography would expose the patient to unnecessary radiation and contrast media injection; while for Obstructive uropathy with urosepsis will require it to be tailored for identifying abscesses, and hence would be multiphase CT.

A system is in place to ensure the appropriateness of the investigations and procedures for the clinical indication. The investigation orders are screened prior to performing of the imaging or interventional procedure to ensure that they are appropriate investigation as per current best practice guidelines and patient safety based on for the clinical indication, otherwise alternate investigations are offered in consultation with the treating doctor.

Mammography for a lactating 25 yrs old lady with fever and a lump is inappropriate, and will never reveal the breast abscess; Ultrasound scan of the breast will be the best investigation. Quality Assurance including calibration and maintenance of all equipment will be performed as per AERB guidelines, as well as the manufacturer's recommendations and records of the same shall be maintained. All such activities will be performed by persons who are appropriately trained and certified by the regulatory authorities for this purpose.

Traceability certificates of all Calibrations done by calibrated equipment shall be maintained. In case of any deviations noted from the laid down quality assurance programme, the organisation shall institute corrective and preventive actions as may be appropriate.

The radiation-safety programme is documented. Refer to AERB guidelines. Imaging safety programme is aligned with the safety programme of the organisation. Informed consent should be taken for contrast injection, moderate-deep sedation, interventional procedures and whenever higher risk of imaging is found on risk screening.

Handling, usage and disposal of radio-active and hazardous materials are as per statutory requirements. Document on safe use of radioactive isotopes for imaging services shall be available and implemented. Radioactive and hazardous materials shall be disposed of as per guidelines laid down by competent bodies.

Imaging personnel and patients are provided with appropriate radiation safety and monitoring devices where applicable. Shielding of body parts of staff and patients, attendants shall be adhered to using appropriate aprons and shields. The number of such devices shall be adequate to ensure that all workers have proper protection. Radiation-safety and monitoring devices are periodically tested and results are documented. Protective devices, e. This is done periodically. It is preferable that the image of the same be stored either physical or electronic.

This shall be done at least once a year. Imaging and ancillary personnel are trained in imaging safety practices and radiation-safety measures. Imaging safety practices include training of imaging and ancillary personnel on MRI safety, kinking of tubes, fall prevention and handling patients in the imaging areas.

Radiation safety measures refer to the steps taken to protect the patient and staff from unwanted radiation. These staff may include Nurses, Helper staff, stretcher bearers, housekeeping, security, etc. Imaging signage are prominently displayed in all appropriate locations. This includes safety signage and display of signage as required by regulatory authorities.

During all phases of care, there is a qualified individual identified as responsible for the patients care. Although care may be provided by a team, the hospital record shall identify a doctor as being responsible for patient care.

Care of patients is coordinated in all care settings within the organisation. The organisation shall ensure that there is effective communication of patient requirements amongst the careproviders in all settings. Information about the patients care and response to treatment is shared among medical, nursing and other care-providers.

The organisation ensures periodic discussions about each patient covering parameters such as patient care, response to treatment, unusual developments if any, etc.

This could be done on the basis of entries either on case sheet or on electronic patient records EPR. For example 1. The organisation shall ensure that intra-organisation transfers are done adhering to safe practices. The patients shall be transported in a safe manner and a proper handover and takeover shall be documented.

The patients record s is available to the authorised care-providers to facilitate the exchange of information. The record could be kept in the nursing station for that area. The organisation has clearly defined and documented the procedures to be adopted to guide the personnel dealing with referral of patients to other departments or specialties.

The organisation shall ensure that where appropriate a multi-disciplinary team shall provide care. Established criteria or policies should be used to determine the appropriateness of transfers within the organisation.

Referral could be for opinion, co-management and takeover. It could be graded into immediate, urgent, priority or routine category. All referrals shall be based on clinical significance and for better outcome. All referrals shall be seen in a defined time frame. This could be different based on the urgency of referral. The organisation has defined timelines eg: Patients are informed of the same.

The organisation shall also inform the caregiver so as to ensure that the continuity of care is not compromised. The organisation has a mechanism in place to monitor whether adequate clinical intervention has taken place in response to a critical value alert. The attending clinician shall respond immediately to a critical value alert. The organisation has a mechanism to periodically review the intervention to assess for timeliness and appropriateness of response.

In case of outpatient, efforts will be taken to alert the patient or family about the critical values. The patient's treating doctor determines the readiness for discharge during regular reassessments. The same is discussed with the patient and family.

Documented procedures exist for coordination of various departments and agencies involved in the discharge process including medico-legal and absconded cases. For medico-legal cases MLC the organisation shall ensure that the police are informed. Documented policies and procedures are in place for patients leaving against medical advice and patients being discharged on request. The organisation has a documented policy for such cases. A discharge summary is given to all the patients leaving the organisation including patients leaving against medical advice and on request.

In LAMA cases,. Terminology used to refer to such patients may differ, but the intent of issuing the discharge summary with reports remains the same. The organisation defines the time taken for discharge and monitors the same. The hospital defines discharge time and monitors delay if any.

The organisation shall make an effort to ensure that all steps involved in the discharge process are completed in timely manner and delays are avoided. Discharge summary is provided to the patients at the time of discharge. Discharge summary contains the patients name, unique identification number, date of admission and date of discharge. Discharge summary contains the reasons for admission, significant findings and diagnosis and the patients condition at the time of discharge.

Discharge summary contains information regarding investigation results, any procedure performed, medication administered and other treatment given. In addition it could also have the name of the primary physician and other consultants involved in the treatment. Discharge summary contains follow-up advice, medication and other instructions in an understandable manner.

The organisation ensures that the follow-up advice, medication and other instructions are explained to the patient and or relatives in a language and manner that they understand. Discharge summary incorporates instructions about when and how to obtain urgent care. The organisation should outline conditions regarding when to obtain urgent care.

The organisation ensures that instructions about when and how to obtain urgent care are explained to the patient and or relatives in a language and manner that they understand. In case of death, the summary of the case also includes the cause of death. In case the cause of death is not clear and a post mortem is being performed Eg MLC , the same shall be documented. The organisation provides uniform care to all patients in different settings. The different settings include care provided in outpatient units, various categories of wards, intensive care units, procedure rooms and operation theatre.

When similar care is provided in these different settings, care delivery is uniform.

Policies, procedures, applicable laws and regulations guide emergency and ambulance services, cardio-pulmonary resuscitation, use of blood and blood components, care of patients in the intensive care and high dependency units. Pain management, nutritional therapy and rehabilitative services are also addressed with a view to providing comprehensive health care. The standards aim to guide and encourage patient safety as the overall principle for providing care to patients. Uniform care to patients is provided in all settings of the organisation and is guided by the applicable laws, regulations and guidelines.

Emergency services are guided by documented policies, procedures applicable laws and regulations. The ambulance services are commensurate with the scope of the services provided by the organisation. The organisation plans for handling community emergencies, epidemics and other disasters. Documented policies and procedures guide the care of patients requiring cardio-pulmonary resuscitation.

Documented policies and procedures define rational use of blood and blood components. Documented policies and procedures guide the care of patients in the intensive care and high dependency units. Documented policies and procedures guide the care of patients undergoing moderate sedation. Documented policies and procedures guide the care of patients undergoing surgical procedures.

Documented policies and procedures guide organ transplant programme in the organisation. Care delivery is uniform for a given health problem when similar care is provided in more than one setting. The organisation shall ensure that patients with the same health problems and care needs receive the same quality of health care throughout the organisation, irrespective of the category of the ward.

Further, in case the organisation has separate OPDs for a different category of patients the methodology for care delivery shall be uniform in all OPDs. Uniform care is guided by documented policies and procedures. These reflect applicable laws, regulations and guidelines. MTP Act or any such similar legislation. For example, consent before surgery, providing first aid to emergency patients and police intimation in cases of medico-legal cases.

The organisation adapts evidence-based medicine and clinical practice guidelines to guide uniform patient care. For definitions of evidence-based medicine and clinical practice guidelines, refer to the glossary.

Emergency services are guided by documented policies, procedures, applicable laws and regulations. There shall be an identified area in the organisation which is easily accessible to receive and manage emergency patients. The identified area to treat emergency patients should be easily accessible for initiation of care.

Policies and procedures for emergency care are documented and are in consonance with statutory requirements. It shall address both adult and paediatric patients. The procedure shall incorporate at a minimum identification, assessment and provision of care.

The organisation shall also define the minimum number of beds based on its scope of services. Emergency services should have adequate manpower.

All patients coming to the hospital shall be provided with first aid before transferring them to another centre. This also addresses the handling of medico-legal cases.

The policy shall be in line with statutory requirements w. The organisation shall also define as to what constitutes an MLC in accordance with statutory guidelines. The patients receive care in consonance with the policies. Poisoning cases, road-traffic accidents, patients with coronary disease, etc. Documented policies and procedures guide the triage of patients for initiation of appropriate care. This should be based on good clinical practices.

The triage should be part of routine day-to-day functioning of the emergency department and not only from a disaster point of view. For triage refer to the glossary. Staff are familiar with the policies and trained on the procedures for care of emergency patients. Admission or discharge to home or transfer to another organisation is also documented.

In case of discharge to home or transfer to another organisation, a discharge note shall be given to the patient. The discharge note shall incorporate salient features of investigations that were done and treatment given.

Quality assurance programmes are documented and implemented. The quality and safety programme should be documented and involve all aspects of the functioning in the Emergency department. Processes should be in place to ensure the patient safety. The Emergency department should collect data on key performance indicators as part of its quality improvement programme. The collected data should be collated, analyzed and. The improvements should be monitored for sustenance.

The documented policies and procedures guide management of patients found dead on arrival to the hospital. There are clear policies and guidelines for managing situations where a patient is either found dead on arrival to the Emergency department or dies on arrival to the Emergency department. The policies and procedure in case of patient found dead on arrival to the Emergency department address:. Due diligence to be exercised by the organisation to ensure that the policies laid down are in accordance with the local laws.

In case of death on arrival the policies and procedure shall address: There is adequate access and space for the ambulance s. The organisation shall demarcate a proper space for the ambulance s. This shall be demarcated keeping in mind easy accessibility for receiving patients and to enable the ambulance s to exit quickly. The ambulance adheres to statutory requirements. This is in the context of Motor Vehicle Act.

The ambulance s is appropriately equipped. This shall be done based on the organisations scope. It is expected that any ambulance shall be equipped with at least basic life support. Equipment for both adult and paediatric patients shall be present. The ambulance s is manned by trained personnel. Personnel shall be trained in basic cardiopulmonary resuscitation. The ambulance s is checked on a daily basis. The check shall also clearly indicate the functioning status of the ambulance like lights, siren, beacon lights, etc.

In addition, the ambulance shall undergo servicing as per the set schedule. Equipments are checked on a daily basis using a checklist. The check shall clearly indicate the functioning status of the equipment.

Emergency medications are checked daily and prior to dispatch using a checklist. This also includes checking the expiry date of drugs.

In case a rapid turnaround of the ambulance is required where checking may not be possible prior to dispatch , only the medications used could be topped up or the organisation could keep an additional set of drugs as standby. The ambulance s has a proper communication system.

The communication system should encompass the whole process of patient transport. There should be laid down policy by the organisation as to how a call for patient transport is received, who are the people expected to respond and organise the transport. The communication ensures that ambulance leaves the hospital within predefined timeframe based upon the patients needs.

The emergency department identifies opportunities to initiate treatment at the earliest when the patient is in transit to the organisation. This information is used by the ambulance personnel of the receiving hospital to be better prepared to assess, initiate interventions during transit and transport the patient safely.

During the transit, when required, there is an exchange of information between the ambulance personnel and the medical professional at the receiving hospital.

This will help the doctor at the receiving hospital guide the ambulance personnel National Accreditation Board for Hospitals and Healthcare Providers. When the patient is being shifted by an external agency, where possible, an attempt is made by the doctor of the receiving hospital to communicate with the ambulance personnel of the external agency to ascertain the clinical situation and make appropriate suggestions.

However, the medical professional in the ambulance would be responsible for decision making regarding the interventions during the transit.

The organisation identifies potential emergencies. The organisation has a documented plan and procedure for handling the situations like sudden rush of victims of i. The organisation has a documented disaster management plan. The disaster plan must incorporate essential elements of alert code, information and communication, action cards for each of the staff, availability and earmarking of resources, establishment of command nucleus, training and mock drills, managing clinical activities during the event.

Refer to. Emergency room could follow triage policy according to NDMA guidelines. Provision is made for availability of medical supplies, equipment and materials during such emergencies. Resource availability should be according to threat perception. The quantity of resources, i. Staff are trained in the hospitals disaster management plan. The training shall include the various elements of the disaster plan. The plan is tested at least twice a year. This shall test all the components of the plan and not just awareness.

Simulated patients not real shall be used. This is only the minimum frequency and this may be increased. Documented policies and procedures guide the uniform use of resuscitation throughout the organisation. The organisation shall document the procedure for same.

This shall be in consonance with accepted practices. Where appropriate, it shall address adult, paediatric and neonatal patients. The organisation shall ensure. Basic life support should be initiated as soon as a condition requiring CPR is identified. This is implemented in all areas of the hospital. Staff providing direct patient care are trained and periodically updated in cardiopulmonary resuscitation.

These aspects shall be covered by hands-on training which could be done by trainers from within or outside the organisation using established evidence-based protocols. If the organisation has a CPR team e.

All doctors, rehabilitation staff and nursing staff must at least be trained to provide basic life support. The events during a cardiopulmonary resuscitation are recorded. In the actual event of a CPR or a mock drill of the same, all the activities along with the personnel attended should be recorded.

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At the minimum, it will include timeliness of response, availability of manpower, equipment, drugs, and barriers if any. This could be done using the pre-defined procedural checklist and by monitoring whether the prescribed activity has been performed properly and in the right sequence.

A post-event analysis of all cardiopulmonary resuscitations is done by a multidisciplinary committee. The analysis shall focus on the initiation of CPR, time of arrival of the team, availability of suitable resources, recording of the sequence of events during CPR including technique and the overall coordination.

The organisation shall also monitor the outcomes. The multidisciplinary committee shall be. The analysis should be completed within a defined time frame. Corrective and preventive measures are taken based on the post-event analysis. Corrective and preventive measures should be completed within a defined time frame. During subsequent resuscitations, it is preferable that implementation of these actions is noted and training be modified, if necessary. There are documented policies and procedures for all activities of the nursing services.

This could be in the form of a nursing manual incorporating all nursing procedures. These reflect current standards of nursing services and practice, relevant regulations and purposes of the services.

Nursing practice is in accordance with nationally accepted standards and shall include: Documented individualised patient-focused nursing care plan for each patient to achieve appropriate outcomes;. Planning and follow-up, to include discharge planning that reflects the continuity of care. Assignment of patient care is done as per current good practice guidelines. Assignment shall be based on the patients clinical requirements and shall incorporate the guidelines laid down by regulatory and professional bodies.

Nursing care is aligned and integrated with overall patient care. This shall be provided as per the nursing Care plan. The nursing Care plan shall be aligned with the Care plan of the patient. Uniformity and continuity of care should be practised.

Care provided by nurses is documented in the patient record. This includes all nursing-related care and not just monitoring of vitals and documentation of medication administration. Nurses are provided with adequate equipment for providing safe and efficient nursing services. There shall be an adequate number of sphygmomanometers, thermometers, weighing scale s , etc. Nurses are empowered to take nursing-related decisions to ensure the timely care of patients.

Documented procedures are used to guide the performance of various clinical procedures. This is a broad guideline which is common to all the procedures. It shall incorporate as to who will do the procedure, the pre-procedure instructions, the conduct of the procedure and post-procedure instructions. Only qualified personnel order, plan, perform and assist in performing procedures. The organisation could conduct a clinical audit of various procedures especially with respect to indications.

Documented procedures exist to prevent adverse events like a wrong site, wrong patient and wrong procedure. At least two identifiers should be used to identify the patient out of which one method should the unique hospital ID.

In addition, the organisation should have a procedure to identify the site of the procedure, where appropriate. Informed consent is taken by the personnel performing the procedure, where applicable. In case the procedure is being done by a person in training, it shall specify the same. All such procedures shall be supervised by the treating doctor. Adherence to standard precautions and asepsis is adhered to during the conduct of the procedure. This shall include standard precautions, appropriate use of PPE, preparation and disinfection of body parts, high-level chemical disinfection and sterilisation of reusable equipment and instruments.

Patients are appropriately monitored during and after the procedure. At a minimum this shall include pulse, blood pressure and respiratory rate which shall be monitored for at least two hours after the procedure or as clinically required. Procedures are documented accurately in the patient record. The documentation shall mention the name of the procedure, the person who performed the procedure, salient steps of the procedure, key findings and the post-procedure care.

All documentation shall have name, date, time and signature. Documented policies and procedures are used to guide the rational use of blood and blood components. This shall address the conditions where blood and blood components can be used. It shall also address inventory and ordering schedules planned and unplanned.

This shall at a minimum include how the orders are written including pre-medications if any rate needs to be mentioned for paediatric. A good reference guide is the NABH standards for blood banks. Verification, transportation, cold chain and delivery at the right source should be taken care of.

Blood shall be transported from the external blood bank in a safe and proper manner. The transfusion services are governed by the applicable laws and regulations. Refer to Drugs and Cosmetics Act. Informed consent is obtained for donation and transfusion of blood and blood components.

Consent should be taken for transfusion of blood or blood components when there is a requirement for transfusion. In case of patients who are transfusion dependent e.

Such consent shall have a defined validity period but not more than 6 months. The consent should include risks, benefits and possible complications of multiple transfusions. Informed consent also includes patient and family education about the donation. This has to be given along with the consent form.

The organisation shall define as to what constitutes use in an emergency situation and accordingly develop procedures. This is applicable even if the organisation doesnt have the blood bank facility inhouse. It is preferable that the organisation also define the time frame within which blood must be available for use in an emergency situation.

Use in emergency includes both for emergency stand-by and use in an emergency. Post-transfusion form is collected, reactions if any identified and are analysed for preventive and corrective actions.

The organisation shall ensure that any transfusion reaction is reported. It is preferable that the organisation capture feedback regarding every transfusion including the ones without reaction as this would enable it to capture all transfusion reactions. The organisation shall maintain a record of transfusion reactions. For transfusion reactions refer to the glossary.

Staff are trained to implement the policies. Records of the same should be available. Documented policies and procedures are used to guide the care of patients in the intensive care and high dependency units. At a minimum this should include as to how care is organised, how patients are monitored and the nurse-patient ratio. The organisation has documented admission and discharge criteria for its intensive care and high dependency units.

The organisation should develop criteria based on physiologic parameters and adhere to it. A good starting point could be various national and international critical care society guidelines. Staff are trained to apply these criteria. Adequate staff and equipment are available.

The ICU should be equipped with all necessary life-saving and monitoring equipment as well as suitably manned by trained staff. The exact requirements shall be decided by the organisation based on the scope and complexity of its services. However, the organisation is expected to follow best clinical practices.

Defined procedures for the situation of bed shortages are followed. As and when there are no vacant beds in the ICU and there is a requirement of such bed, a detailed policy and procedure should be in place to address the situation. Infection control practices are documented and followed. These could be developed individually or it could be a part of the infection control manual.

The organisation shall ensure that the practices are in consonance with good clinical practices. A quality assurance programme is documented and implemented. These could be developed individually or it could be a part of the organisations quality-assurance programme. The organisation shall ensure that the programme is in consonance with good clinical practices. Good clinical practices include monitoring infection rates, re-admission rates, re-intubation rates, etc.

Imaging services comply with legal and other requirements. The organisation is aware of the legal and other requirements of imaging services and the same are documented for information and compliance by all concerned in the organisation. The organisation maintains and updates its compliance status of legal and other requirements in a regular manner. The organisation shall have a Radiation Safety Officer of appropriate level.

Scope of the imaging services is commensurate to the services provided by the organisation. The infrastructure physical and equipment and manpower is adequate to provide for its defined scope of services. Adequately qualified and trained personnel perform, supervise and interpret the investigations. AERB guidelines could be used as a reference document for radiation based imaging.

Documented policies and procedures exist to ensure correct identification and safe and timely transportation of patients to and from the imaging services. The aim is to ensure patient identification at all times so that correct procedure is carried out for a patient and correct report is handed over.

Procedure addresses the safe and timely transportation to and from the imaging services. This should also address transfer of unstable patients. Imaging results are available within a defined timeframe. The organisation shall document turnaround time of imaging results for all modalities.

The organisation shall monitor the waiting times, time taken to perform the tests and time taken to prepare the reports of the tests for all modalities; for in-patient, outpatient and emergency. The defined timeframes could be different for different type of tests and could be decided on the basis of the nature of the test, modality, and criticality of the test and the urgency of the test result as required by the treating doctor. The organisation shall define and document the critical results which require immediate attention of clinician, e.

In case of tele-radiology, there shall be the name of the reporting doctor and a remark to that effect. It should also include the name of the reporting organisation if outsourced to an organisation. The report should be in prevailing context taking into account the clinical details and results of any previous imaging.

These could include recall for errors at all levels. Whenever there is a recall of a particular report, withdrawal from clinical areas, medical records, RIS and HIS should be ensured.

Imaging tests not available in the organisation are outsourced to organisation s based on their quality assurance system. The quality assurance programme for imaging services is documented. The QA programme for imaging should involve all stakeholders. It should be a comprehensive programme addressing equipment QA, Protocols, safety, education and surveillance. In addition, AERB requirement will have to be met.

Some examples for QA of radiation equipment include congruence of optical and radiation field, focal spot size, output consistency, leakage rate, etc. A peer review system will be in place to review the reports and outcomes of interventional procedures performed. This shall be done in a structured manner, and the sample size, periodicity for each modality shall be defined. The results of such reviews shall be discussed with all stake holders in "discrepancy meetings" and the same shall be documented.

The peer review can be performed by the head of department or by a group of peers, with or without blinding of the original reports. Discrepancies in the reports will be graded on the The purpose is to prevent errors in future, and continuous quality improvement rather than computation or error rates of the individuals.

Structured peer review of the imaging protocols and procedures shall be periodically performed and they should be modified in accordance of the current best practices. Surveillance of the quality of images, and completeness of the imaging procedures should be performed to ensure that they are appropriate for the indications for which the imaging has been performed.

For example: CT for acute renal colic requires only a low dose non-contrast CT and a multiphase CT urography would expose the patient to unnecessary radiation and contrast media injection; while for Obstructive uropathy with urosepsis will require it to be tailored for identifying abscesses, and hence would be multiphase CT.

A system is in place to ensure the appropriateness of the investigations and procedures for the clinical indication. The investigation orders are screened prior to performing of the imaging or interventional procedure to ensure that they are appropriate investigation as per current best practice guidelines and patient safety based on for the clinical indication, otherwise alternate investigations are offered in consultation with the treating doctor.

Mammography for a lactating 25 yrs old lady with fever and a lump is inappropriate, and will never reveal the breast abscess; Ultrasound scan of the breast will be the best investigation. Quality Assurance including calibration and maintenance of all equipment will be performed as per AERB guidelines, as well as the manufacturer's recommendations and records of the same shall be maintained.

Traceability certificates of all Calibrations done by calibrated equipment shall be maintained. In case of any deviations noted from the laid down quality assurance programme, the organisation shall institute corrective and preventive actions as may be appropriate.

The radiation-safety programme is documented. Refer to AERB guidelines. Imaging safety programme is aligned with the safety programme of the organisation. Informed consent should be taken for contrast injection, moderate-deep sedation, interventional procedures and whenever higher risk of imaging is found on risk screening.

Handling, usage and disposal of radio-active and hazardous materials are as per statutory requirements. Document on safe use of radioactive isotopes for imaging services shall be available and implemented.

Radioactive and hazardous materials shall be disposed of as per guidelines laid down by competent bodies. Imaging personnel and patients are provided with appropriate radiation safety and monitoring devices where applicable.

Shielding of body parts of staff and patients, attendants shall be adhered to using appropriate aprons and shields.

The number of such devices shall be adequate to ensure that all workers have proper protection. Radiation-safety and monitoring devices are periodically tested and results are documented. Protective devices, e. This is done periodically. This shall be done at least once a year.

Imaging and ancillary personnel are trained in imaging safety practices and radiation-safety measures. Imaging safety practices include training of imaging and ancillary personnel on MRI safety, kinking of tubes, fall prevention and handling patients in the imaging areas. Radiation safety measures refer to the steps taken to protect the patient and staff from unwanted radiation. These staff may include Nurses, Helper staff, stretcher bearers, housekeeping, security, etc.

Imaging signage are prominently displayed in all appropriate locations. This includes safety signage and display of signage as required by regulatory authorities. Although care may be provided by a team, the hospital record shall identify a doctor as being responsible for patient care. Care of patients is coordinated in all care settings within the organisation. The organisation shall ensure that there is effective communication of patient requirements amongst the care- providers in all settings.

The organisation ensures periodic discussions about each patient covering parameters such as patient care, response to treatment, unusual developments if any, etc. This could be done on the basis of entries either on case sheet or on electronic patient records EPR. For example 1 Structured Clinical handover by doctors and nurses has to be done and documented 2 Transfer summary.

The organisation shall ensure that intra-organisation transfers are done adhering to safe practices. The patients shall be transported in a safe manner and a proper handover and takeover shall be documented.

The record could be kept in the nursing station for that area. The organisation has clearly defined and documented the procedures to be adopted to guide the personnel dealing with referral of patients to other departments or specialties. The organisation shall ensure that where appropriate a multi-disciplinary team shall provide care. Established criteria or policies should be used to determine the appropriateness of transfers within the organisation. Referral could be for opinion, co-management and takeover.

It could be graded into immediate, urgent, priority or routine category. All referrals shall be based on clinical significance and for better outcome.

All referrals shall be seen in a defined time frame. This could be different based on the urgency of referral. The organisation has defined timelines eg: Patients are informed of the same. The organisation shall also inform the caregiver so as to ensure that the continuity of care is not compromised i.

The organisation has a mechanism in place to monitor whether adequate clinical intervention has taken place in response to a critical value alert. The attending clinician shall respond immediately to a critical value alert.

The organisation has a mechanism to periodically review the intervention to assess for timeliness and appropriateness of response. In case of outpatient, efforts will be taken to alert the patient or family about the critical values. The patient's treating doctor determines the readiness for discharge during regular reassessments. The same is discussed with the patient and family. Documented procedures exist for coordination of various departments and agencies involved in the discharge process including medico-legal and absconded cases.

The discharge procedures are documented to ensure coordination amongst various departments including accounts so that the discharge papers are complete well within time. For medico-legal cases MLC the organisation shall ensure that the police are informed. Documented policies and procedures are in place for patients leaving against medical advice and patients being discharged on request.

The organisation has a documented policy for such cases. A discharge summary is given to all the patients leaving the organisation including patients leaving against medical advice and on request. In LAMA cases,. Terminology used to refer to such patients may differ, but the intent of issuing the discharge summary with reports remains the same.

The organisation defines the time taken for discharge and monitors the same. The hospital defines discharge time and monitors delay if any. The organisation shall make an effort to ensure that all steps involved in the discharge process are completed in timely manner and delays are avoided. Discharge summary is provided to the patients at the time of discharge. Discharge summary contains information regarding investigation results, any procedure performed, medication administered and other treatment given.

In addition it could also have the name of the primary physician and other consultants involved in the treatment. Discharge summary contains follow-up advice, medication and other instructions in an understandable manner. This shall also incorporate preventive aspects, where appropriate. The organisation ensures that the follow-up advice, medication and other instructions are explained to the patient and or relatives in a language and manner that they understand.

Discharge summary incorporates instructions about when and how to obtain urgent care. The organisation ensures that instructions about when and how to obtain urgent care are explained to the patient and or relatives in a language and manner that they understand.

In case of death, the summary of the case also includes the cause of death. In case the cause of death is not clear and a post mortem is being performed Eg MLC , the same shall be documented. The organisation provides uniform care to all patients in different settings. The different settings include care provided in outpatient units, various categories of wards, intensive care units, procedure rooms and operation theatre.

When similar care is provided in these different settings, care delivery is uniform. Policies, procedures, applicable laws and regulations guide emergency and ambulance services, cardio-pulmonary resuscitation, use of blood and blood components, care of patients in the intensive care and high dependency units.

Pain management, nutritional therapy and rehabilitative services are also addressed with a view to providing comprehensive health care. The standards aim to guide and encourage patient safety as the overall principle for providing care to patients.

Uniform care to patients is provided in all settings of the organisation and is guided by the applicable laws, regulations and guidelines. COP 2: Emergency services are guided by documented policies, procedures applicable laws and regulations. COP 3: The ambulance services are commensurate with the scope of the services provided by the organisation.

COP 4. The organisation plans for handling community emergencies, epidemics and other disasters. COP 5: Documented policies and procedures guide the care of patients requiring cardio-pulmonary resuscitation. COP 6: Documented policies and procedures guide nursing care. COP 7: Documented procedures guide the performance of various procedures. COP 8: Documented policies and procedures define rational use of blood and blood components. COP 9: Documented policies and procedures guide the care of patients in the intensive care and high dependency units.

COP Documented policies and procedures guide the care of vulnerable patients. Documented policies and procedures guide obstetric care. Documented policies and procedures guide paediatric services. Documented policies and procedures guide the care of patients undergoing moderate sedation. Documented policies and procedures guide the administration of anaesthesia. Documented policies and procedures guide the care of patients undergoing surgical procedures.

Documented policies and procedures guide appropriate pain management. Documented policies and procedures guide appropriate rehabilitative services. Documented policies and procedures guide all research activities. Documented policies and procedures guide nutritional therapy. Documented policies and procedures guide the end of life care. Care delivery is uniform for a given health problem when similar care is provided in more than one setting. The organisation shall ensure that patients with the same health problems and care needs receive the same quality of health care throughout the organisation, irrespective of the category of the ward.

Further, in case the organisation has separate OPDs for a different category of patients the methodology for care delivery shall be uniform in all OPDs. Uniform care is guided by documented policies and procedures.

These reflect applicable laws, regulations and guidelines. MTP Act or any such similar legislation. For example, consent before surgery, providing first aid to emergency patients and police intimation in cases of medico-legal cases. The organisation adapts evidence-based medicine and clinical practice guidelines to guide uniform patient care. Emergency services are guided by documented policies, procedures, applicable laws and regulations.

There shall be an identified area in the organisation which is easily accessible to receive and manage emergency patients. The identified area to treat emergency patients should be easily accessible for initiation of care.

Policies and procedures for emergency care are documented and are in consonance with statutory requirements. It shall address both adult and paediatric patients. The procedure shall incorporate at a minimum identification, assessment and provision of care. The organisation shall also define the minimum number of beds based on its scope of services. Emergency services should have adequate manpower. All patients coming to the hospital shall be provided with first aid before transferring them to another centre.

This also addresses the handling of medico-legal cases. The policy shall be in line with statutory requirements w. The organisation shall also define as to what constitutes an MLC in accordance with statutory guidelines. The patients receive care in consonance with the policies.

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Poisoning cases, road-traffic accidents, patients with coronary disease, etc. Documented policies and procedures guide the triage of patients for initiation of appropriate care. This should be based on good clinical practices.

The triage should be part of routine day-to-day functioning of the emergency department and not only from a disaster point of view. Staff are familiar with the policies and trained on the procedures for care of emergency patients. Admission or discharge to home or transfer to another organisation is also documented. In case of discharge to home or transfer to another organisation, a discharge note shall be given to the patient. The discharge note shall incorporate salient features of investigations that were done and treatment given.

Quality assurance programmes are documented and implemented. The quality and safety programme should be documented and involve all aspects of the functioning in the Emergency department.

Processes should be in place to ensure the patient safety. The Emergency department should collect data on key performance indicators as part of its quality improvement programme.

The collected data should be collated, analyzed and The improvements should be monitored for sustenance. The documented policies and procedures guide management of patients found dead on arrival to the hospital. There are clear policies and guidelines for managing situations where a patient is either found dead on arrival to the Emergency department or dies on arrival to the Emergency department.

The policies and procedure in case of patient found dead on arrival to the Emergency department address: Due diligence to be exercised by the organisation to ensure that the policies laid down are in accordance with the local laws.

In case of death on arrival the policies and procedure shall address: There is adequate access and space for the ambulance s. The organisation shall demarcate a proper space for the ambulance s. This shall be demarcated keeping in mind easy accessibility for receiving patients and to enable the ambulance s to exit quickly.

The ambulance adheres to statutory requirements. This is in the context of Motor Vehicle Act. The ambulance s is appropriately equipped. It is expected that any ambulance shall be equipped with at least basic life support.

Equipment for both adult and paediatric patients shall be present. The ambulance s is manned by trained personnel. Personnel shall be trained in basic cardiopulmonary resuscitation. The ambulance s is checked on a daily basis. The check shall also clearly indicate the functioning status of the ambulance like lights, siren, beacon lights, etc. In addition, the ambulance shall undergo servicing as per the set schedule. Equipments are checked on a daily basis using a checklist. The check shall clearly indicate the functioning status of the equipment.

Emergency medications are checked daily and prior to dispatch using a checklist. This also includes checking the expiry date of drugs. In case a rapid turnaround of the ambulance is required where checking may not be possible prior to dispatch , only the medications used could be topped up or the organisation could keep an additional set of drugs as standby. The ambulance s has a proper communication system. The communication system should encompass the whole process of patient transport. There should be laid down policy by the organisation as to how a call for patient transport is received, who are the people expected to respond and organise the transport.

This information is used by the ambulance personnel of the receiving hospital to be better prepared to assess, initiate interventions during transit and transport the patient safely. During the transit, when required, there is an exchange of information between the ambulance personnel and the medical professional at the receiving hospital. This will help the doctor at the receiving hospital guide the ambulance personnel When the patient is being shifted by an external agency, where possible, an attempt is made by the doctor of the receiving hospital to communicate with the ambulance personnel of the external agency to ascertain the clinical situation and make appropriate suggestions.

However, the medical professional in the ambulance would be responsible for decision making regarding the interventions during the transit. Standard COP.

The organisation identifies potential emergencies. The organisation has a documented plan and procedure for handling the situations like sudden rush of victims of i. These plans and procedures cover ensuring adequacy of medical supplies, equipment, materials, identified-trained personnel, transportation aids, communication aids and mock-drill methodology.

The organisation has a documented disaster management plan. The disaster plan must incorporate essential elements of alert code, information and communication, action cards for each of the staff, availability and earmarking of resources, establishment of command nucleus, training and mock drills, managing clinical activities during the event. Refer to Emergency room could follow triage policy according to NDMA guidelines. Provision is made for availability of medical supplies, equipment and materials during such emergencies.

Resource availability should be according to threat perception. The quantity of resources, i. The training shall include the various elements of the disaster plan. The plan is tested at least twice a year. This shall test all the components of the plan and not just awareness. Simulated patients not real shall be used. This is only the minimum frequency and this may be increased. Documented policies and procedures guide the uniform use of resuscitation throughout the organisation.

The organisation shall document the procedure for same. This shall be in consonance with accepted practices. Where appropriate, it shall address adult, paediatric and neonatal patients. The organisation shall ensure Basic life support should be initiated as soon as a condition requiring CPR is identified. This is implemented in all areas of the hospital. Staff providing direct patient care are trained and periodically updated in cardio- pulmonary resuscitation.

These aspects shall be covered by hands-on training which could be done by trainers from within or outside the organisation using established evidence-based protocols. If the organisation has a CPR team e. All doctors, rehabilitation staff and nursing staff must at least be trained to provide basic life support. The events during a cardiopulmonary resuscitation are recorded. In the actual event of a CPR or a mock drill of the same, all the activities along with the personnel attended should be recorded.

At the minimum, it will include timeliness of response, availability of manpower, equipment, drugs, and barriers if any. This could be done using the pre-defined procedural checklist and by monitoring whether the prescribed activity has been performed properly and in the right sequence.

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A post-event analysis of all cardiopulmonary resuscitations is done by a multidisciplinary committee. The analysis shall focus on the initiation of CPR, time of arrival of the team, availability of suitable resources, recording of the sequence of events during CPR including technique and the overall coordination. The organisation shall also monitor the outcomes. The multidisciplinary committee shall be The analysis should be completed within a defined time frame.

Corrective and preventive measures are taken based on the post-event analysis. Corrective and preventive measures should be completed within a defined time frame.

During subsequent resuscitations, it is preferable that implementation of these actions is noted and training be modified, if necessary. There are documented policies and procedures for all activities of the nursing services. This could be in the form of a nursing manual incorporating all nursing procedures. These reflect current standards of nursing services and practice, relevant regulations and purposes of the services. Nursing practice is in accordance with nationally accepted standards and shall include: Documented individualised patient-focused nursing care plan for each patient to achieve appropriate outcomes; ii.

Monitoring of the patient to assess the outcome of the care; iii. Modifying the care when necessary; iv. Completing the care; v. Planning and follow-up, to include discharge planning that reflects the continuity of care.

Assignment of patient care is done as per current good practice guidelines. Nursing care is aligned and integrated with overall patient care. This shall be provided as per the nursing Care plan.

The nursing Care plan shall be aligned with the Care plan of the patient. Uniformity and continuity of care should be practised. Care provided by nurses is documented in the patient record. This includes all nursing-related care and not just monitoring of vitals and documentation of medication administration. Nurses are provided with adequate equipment for providing safe and efficient nursing services. There shall be an adequate number of sphygmomanometers, thermometers, weighing scale s , etc.

Nurses are empowered to take nursing-related decisions to ensure the timely care of patients. Documented procedures are used to guide the performance of various clinical procedures. This is a broad guideline which is common to all the procedures.

It shall incorporate as to who will do the procedure, the pre-procedure instructions, the conduct of the procedure and post-procedure instructions. Only qualified personnel order, plan, perform and assist in performing procedures. The organisation could conduct a clinical audit of various procedures especially with respect to indications. Documented procedures exist to prevent adverse events like a wrong site, wrong patient and wrong procedure.

At least two identifiers should be used to identify the patient out of which one method should the unique hospital ID. In addition, the organisation should have a procedure to identify the site of the procedure, where appropriate. Informed consent is taken by the personnel performing the procedure, where applicable.

In case the procedure is being done by a person in training, it shall specify the same.

All such procedures shall be supervised by the treating doctor. Adherence to standard precautions and asepsis is adhered to during the conduct of the procedure. This shall include standard precautions, appropriate use of PPE, preparation and disinfection of body parts, high-level chemical disinfection and sterilisation of reusable equipment and instruments.

Patients are appropriately monitored during and after the procedure. At a minimum this shall include pulse, blood pressure and respiratory rate which shall be monitored for at least two hours after the procedure or as clinically required. Procedures are documented accurately in the patient record. The documentation shall mention the name of the procedure, the person who performed the procedure, salient steps of the procedure, key findings and the post-procedure care.

All documentation shall have name, date, time and signature. Documented policies and procedures are used to guide the rational use of blood and blood components.

This shall address the conditions where blood and blood components can be used. It shall also address inventory and ordering schedules planned and unplanned. This shall at a minimum include how the orders are written including pre-medications if any rate needs to be mentioned for paediatric A good reference guide is the NABH standards for blood banks.

Verification, transportation, cold chain and delivery at the right source should be taken care of. Blood shall be transported from the external blood bank in a safe and proper manner.

The transfusion services are governed by the applicable laws and regulations. Refer to Drugs and Cosmetics Act. Informed consent is obtained for donation and transfusion of blood and blood components. Consent should be taken for transfusion of blood or blood components when there is a requirement for transfusion.

In case of patients who are transfusion dependent e. Such consent shall have a defined validity period but not more than 6 months. The consent should include risks, benefits and possible complications of multiple transfusions. Informed consent also includes patient and family education about the donation. This has to be given along with the consent form. It is preferable that the organisation also define the time frame within which blood must be available for use in an emergency situation.

Use in emergency includes both for emergency stand-by and use in an emergency. Post-transfusion form is collected, reactions if any identified and are analysed for preventive and corrective actions. The organisation shall ensure that any transfusion reaction is reported. It is preferable that the organisation capture feedback regarding every transfusion including the ones without reaction as this would enable it to capture all transfusion reactions.

The organisation shall maintain a record of transfusion reactions. Staff are trained to implement the policies. Records of the same should be available. Documented policies and procedures are used to guide the care of patients in the intensive care and high dependency units.

At a minimum this should include as to how care is organised, how patients are monitored and the nurse-patient ratio. The organisation has documented admission and discharge criteria for its intensive care and high dependency units. The organisation should develop criteria based on physiologic parameters and adhere to it. A good starting point could be various national and international critical care society guidelines.

Staff are trained to apply these criteria. Adequate staff and equipment are available. The ICU should be equipped with all necessary life-saving and monitoring equipment as well as suitably manned by trained staff.

The exact requirements shall be decided by the organisation based on the scope and complexity of its services. However, the organisation is expected to follow best clinical practices. A good reference guide for nursing manpower is the Indian Nursing Council recommendations. Defined procedures for the situation of bed shortages are followed.

As and when there are no vacant beds in the ICU and there is a requirement of such bed, a detailed policy and procedure should be in place to address the situation. Infection control practices are documented and followed. These could be developed individually or it could be a part of the infection control manual.

The organisation shall ensure that the practices are in consonance with good clinical practices. A quality assurance programme is documented and implemented. The organisation shall ensure that the programme is in consonance with good clinical practices.

Good clinical practices include monitoring infection rates, re-admission rates, re-intubation rates, etc. Further, a good starting point could be various national and international critical care society guidelines on quality assurance in ICUs.

Patients and families are counselled by the treating medical professional at periodic intervals and when there is a significant change in the condition of the patient, and same is documented. Patients and families need to be counselled at periodic intervals at-least once a day by any doctor of the treating team to inform them and answer queries related to the changing condition of the patient.

The periodicity should be at least once a day or more often, based on the clinical condition of the patient and same needs to be documented. Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines.

The organisation shall identify the vulnerable patients. The procedure shall also include who is responsible for identifying these patients, risk management in these patients and monitoring of these patients at least twice a day.The organisation gives a summary of patients condition and the treatment given.

Informed consent for administration of anesthesia is obtained by the anesthetist e. Our With this being said, I recommend that the PETH exam be taken strictly from knowledge without the use of any physical or electronic assistance. Each patients postanesthesia status is monitored and documented g. Patients that match the organisations resources are admitted using a defined process. For eg: The minimum positive pressure recommended is 15 Pascal 0. Based on the pattern of drinking I described, many websites would lead you to believe that a Peth test is only valid for two, maybe up to three weeks after significant drinking.

Clipping is a handy way to collect important slides you want to go back to later.