STANDARD PROTOCOLS FOR EMERGENCY DEPARTMENT

The following protocols have been enumerated in the standard protocols for Emergency Department -

1.      Receiving of the patient

ü  Receiving area at emergency department is ensured of the availability of wheelchairs and stretchers.

ü  Whenever a non-ambulatory patient reaches near the emergency door, on duty staff on the gate shifts the patient on stretcher or wheelchair depending on patients condition and shift the patient inside to the consultation area.

ü  In case of walk-in patients, patients walk in directly to the consultation area.

2.      Registration of the patient

·        Out Patient Registration

ü  In case of critical patients, they are immediately directed to the consultation area and registration is done afterwards at the emergency registration counter.

ü  All critical patients coming to emergency are registered at emergency registration counter.

ü  During OPD working hours if a non-critical patient walks into emergency he is directed to go to concerned OPD after registration at the general OPD registration counter of the hospital, whereas during odd hours and holidays all patients walking into hospital are registered at the emergency registration counter except in those hospitals where evening OPD is functional.

ü  Following parameters are captured during emergency registration: Name, age, sex, address and time of admission.

ü  For referred in patients same is mentioned on the OPD card along with details of facility from where referred and reason for referral. Referral slip if available is retained in hospital record.

ü  For medico legal cases MLC is mentioned on the OPD card.

ü  After registration an OPD number is given to the patient.

ü  In addition to OPD number, all the medico-legal cases are separately identified by a centralized MLC number. MLC number is provided either manually at the registration counter or generated by computer.

ü  Police information is sent for all the medico legal cases by the doctor on duty.

ü  All unidentified patients are registered as medico legal cases and the information regarding this is sent to police and once the patient is identified, information is updated in the records.

ü  After doctors assessment a provisional or actual diagnosis is entered on the OPD card by concerned doctor both for MLC and non MLC cases.

·        In Patient Registration

ü  Treatment is started without waiting for registration in case of critical patients.

ü  If it is decided by the treating doctor that the patient needs to be admitted then patient’s attendants are directed to emergency registration counter where admission file is prepared and another number is generated.

ü  Following information is captured on patient file- Name, age, sex, address, speciality under which admitted, provisional diagnosis, date and time of admission.

3.      Identification of the patient

·        Out –Patient Identification

ü  The patient is identified by dual identifiers; one is patient’s name and other is OPD Number.

ü  The hospital uses sound clinical judgement to ensure the patient identification at all the times before :

o   Consultation

o   Before administering medicine

o   Giving sample in the phlebotomy area

o   Before any procedure

·        In-Patient Identification:

ü  Identification bands are provided to all the patients at the time of admission with the help of which he/she is identified during his/her stay irrespective of the condition (conscious /unconscious).

ü  Different types of coding is followed to avoid any error that is

o   White colour band for all patients

o   Pink colour band for baby girl

o   Blue colour band for baby boy

o   V is written on white band by staff for Vulnerable patient

ü  Identification band is non-transferable and affixed on the patient’s wrist.

ü  ID band consists of : Patient’s Name, Age, Sex and Registration Number

ü  Patient and his/her family members are educated about the importance of the band and not to remove the band.

ü  ID band is checked before any consultation, investigation, procedure and administration of medication. Patient name is also asked to confirm the patient identification.

4.      Initial assessment of patient

·        Out Patient Assessment:

ü  All the patients coming to A&ED are assessed by doctor on duty.

ü  In case doctor is not immediately available the patient is assessed by staff nurse on duty and then seen by doctor as soon as possible.

ü  Vital signs are recorded by the doctor/ nurse within five minutes and then every 30 minutes or as the patient’s condition warrants.

ü  Treatment is given according to the doctor’s orders.

ü  Specialist consultation is sought by doctor on duty, if required. Consultation may be provided in person or telephonically.

ü  In case of verbal or telephonic orders, they are duly verified prior to implementation.

ü  Initial assessment includes-

o   Detailed patient history

o   Vital examination

o   History of any allergy or drug reactions

o   Systemic examination as indicated from history

ü  Initial assessment leads to a working diagnosis.

ü  A documented plan of care is made after initial assessment.

ü  In case the patient needs referral to higher centre, findings of initial assessment are captured in the OPD record and patient is stabilised before referral.

ü  All the patient records are dated, timed, named and signed by the concerned person.

·        In Patient Assessment

ü  All the patients admitted under a particular speciality are examined by a specialist within 12 hours of admission.

5.      Reassessment of patient

·        Out Patient Reassessment:

ü  All the critical patients are kept under observation in the observation area/room.

ü  These patients are reassessed by the doctor on duty every 30 minutes or as and when required.

ü  All the non-critical patients are reassessed every 4 hours or as and when required.

ü  Decision to refer is taken in consultation with the specialist, however in life threatening conditions the doctor on duty can refer the patient on his own and then inform the concerned specialist.

·        In-Patient Reassessment:

ü  All the admitted patients are reassessed by doctor on duty at least twice during each shift or more frequently if the patient is critical.

ü  All the admitted patients are reassessed by specialist of concerned department at least once during each shift.

ü  If an admitted patient is to be referred, decision to refer is taken in consultation with the concerned specialist, however in life threatening conditions the doctor on duty can refer the patient on his own and then inform the concerned specialist.

ü  All the notes on patient’s records are to be dated, timed, named and signed by the concerned doctor.

6.      Shifting/ transfer of patient within hospital

ü  All the admitted, stable patients are shifted to respective wards within 24 hours if a bed is available.

ü  All the concerned specialists take round of A&ED at least twice a day and shift all the stable patients to respective wards.

7.      Referral of patients

·        Referred –In

ü  All the patients referred from periphery and other institutes are promptly treated at the hospital if the services required are within scope of A&ED of hospital.

ü  If the services required are not in the scope of hospital then these patients/ attendants are explained the same and also guided about the alternatives. The protocol for referred out patient is followed.

ü  All the referred in patients are registered in the hospital and their record is maintained separately.

·        Referral Out

ü  Once doctor on duty decides that the patient requires referral to higher centre for further treatment he/she contacts the concerned specialist on telephone or through a written call. If required specialist doctor visits the patient and assess condition of patient and then take the decision to refer the patient.

ü  If the patient is critical and any delay in treatment may endanger life of patient, he/she is referred by doctor on duty.

ü  If the patient’s condition is unstable, he should be stabilized in the emergency department before referring out.

ü  Doctor on duty ensures availability of bed in the hospital where patient is being referred.

ü  In case of non-availability of beds alternatives are explained to the relatives of the patient and decision is made accordingly.

ü  EMT accompanies the patient in case of critical patient.

ü  Fully filled referral card is provided to the patient at the time of referral with details like reason for referral, investigations done if any.

ü  Ambulance used is fully equipped with resuscitation equipment and with trained staff who has training in BLS.

ü  Entry is made in the refer-out register.

8.      Discharge of the patient

ü  Discharge process is discussed with patient and family.

ü  The concerned doctor, discharging the patient documents the discharge instructions in the file at the time of discharge.

ü  Discharge summary is prepared on a standardised format and signed by the concerned doctor.

ü  The discharge summary contains :

o   Diagnosis

o   Brief progress notes

o   Significant findings

o   Investigations results

o   Procedures performed (if any)

·        Discharge Against Medical Advice/ Discharge On

ü  In case the patients and relatives wish to get discharged from the hospital before complete recovery, the provision of the same is made.

ü  The doctor on duty/ specialist discusses the consequences and risk to the patient and relatives. The patient, relatives, concerned doctor and the nurse on duty sign the consent for discharge against medical advice.

ü  A discharge summary is handed over to the patient/relative with the medical advice and it is mentioned on the discharge card that patient is being discharged against medical advice.

·        Absconded

ü  If a patient absconds from hospital without informing any concerned staff member then this information is mentioned in the patient record.

9.      Patient care protocols

ü  Patient as classified in the Triage section are given care as per different care protocol.

ü  The Category-I patients are referred to Resuscitation Room. Patients are managed as per the resuscitation protocol.

ü  Initial Assessment of the patient is done as per the initial assessment protocols already described.

ü  The doctor on duty reassesses the patient every 30 minutes or more frequently as per patient’s condition.

ü  Decision is taken to admit, shift, discharge or refer the patient within four hours.

ü  The staff nurse on duty also monitors the patient as per doctor’s instructions.

ü  All the investigations (Laboratory, Radiology, etc.) are done as soon as possible and reports are made available on priority.

ü  Doctors and nurses follow ethical code of conduct and universal precautions.

ü  Proper written handover of patients is done as the shift changes.

ü  Drugs and equipments are checked and monitored at the start of every shift.

ü  Hygiene and sanitation is maintained at all times. Infection control and waste management protocols are strictly followed.

ü  A medico legal case is a case of injury /illness where the attending doctor after eliciting history and examining the patient, thinks that some investigation by law enforcement agencies are essential to establish and fix responsibility for case in accordance with the law.

10. Medico-Legal Cases

ü  A medico legal case is a case of injury /illness where the attending doctor after eliciting history and examining the patient, thinks that some investigation by law enforcement agencies are essential to establish and fix responsibility for case in accordance with the law.

ü  The police needs to be informed when a patient is brought to the hospital/admitted and there is a history of:

ü  Accident, homicide, suicide, infanticide, poisoning, machinery related injury (industrial and vehicular accidents), assault, strangulation, sexual offences, criminal abortion, burns, mass casualty , other cases brought by police and the cases in which foul play is suspected.

·        Intimation Of Medico-Legal Cases To The Police:

ü  The privacy of the patient should be ensured first.

ü  The doctor on duty examines the patient and prepares medico legal report in computerized format. In case doctor is unable to provide computerised report immediately, manual report is provided to the patient and computerised report is provided within one week.

ü  The police authorities are intimated giving brief details of the case in a written format.

ü  The reporting time and date is also mentioned in the police information.

ü  MLC police information form is filled in duplicate and one copy is handed over to the police person and one copy is retained in the hospital record.

ü  Receiving is taken from police person who receives the information.

ü  Wherever required various specimens are collected, sealed and handed over to the police authorities after sealing the same. A receipt of the items sealed and handed over to the police is taken. Patient case file is stamped as medico-legal case.

11. Safety of the patient belongings:

ü  Patients are advised to leave all valuables at home or send them home upon admission to the hospital; this includes jewellery, cash etc. That would be considered a loss if misplaced

ü  Signature of the relative is taken upon handing over of patient belongings

ü  If attendant is not available the nurse on duty keeps the valuables under lock and key. They are not kept at patient bedside

ü  A receipt is provided for collection of the items upon discharge.

     ü  Patient is informed to take care of their belongings that they bring along such as mobile etc.