Guideline For Establishing Emergency Medical and Trauma Centers

Guideline for Establishing
Emergency Medical and Trauma

Centers
1st Edition
2020
Emergency Medical Services Division

Department of Medical Services
Ministry of Health
Guideline for Establishing Emergency Medical and Trauma Centers
Table of Contents
Foreword ................................................................................. 3
Acknowledgement .................................................................. 4
Abbreviations .......................................................................... 5
Scope ....................................................................................... 6
Objective ................................................................................. 6
Definition of EMTC................................................................ 6
Levels of EMTC ..................................................................... 6
Workflow and Design - Planning consideration for EMTC ... 7
Establishment of EMTC ....................................................... 13
Monitoring and Evaluation ................................................... 14
ANNEXURE 1: Assessment Tool for Identifying EMTC ... 15
ANNEXURE 2: Check list for EMTC .................................. 22
References ............................................................................. 32
Emergency Medical Services Division Page 2

Foreword
Globally, trauma is one of the leading causes of death between 1-44
years. About 5.8 million people die each year as a result of
trauma/injuries. In Bhutan, trauma cases are increasing which require
prompt and standard care. In addition, medical emergencies are becoming
a serious burden for the health system. NCDs like stroke, acute coronary
syndrome, respiratory, diabetic complications and alcohol liver diseases
are some of the conditions requiring immediate care. The effort to reduce
the burden of trauma and medical emergencies is one of the challenges
faced by Ministry of Health (MoH). As such, Emergency Medical
Services Division is mandated to improve trauma care and emergency
services in Bhutan.
Initially, based on the Health Emergency and Disaster Contingency Plan

2016, MoH had identified 10 hospitals (Dewathang hospital, Trashigang
hospital, Riserboo hospital, Trongsa hospital, Yebilaptsa hospital,
Damphu hospital, Wangdue hospital, Phuentsholing hospital, Samtse
hospital and Gedu hospital) as Emergency Medical and Trauma
Centers (EMTC). However, there was no formal specific guideline for
the same. Establishing achievable and affordable standards for trauma
care and appropriate utilization of health resources, including human
resources with clear job responsibilities in the country is important.
In this guideline, EMTCs are classified into three levels based on services
availability criteria. It intends to strengthen referral hospitals as level I,
identified hospitals as level II and other districts as level III and it shall
provide as a guiding document for the Ministry to upgrade the existing
hospitals and establish new ones as EMTC. It also aims at making
significant improvements at various levels of health facilities in providing
trauma, emergency medical services in a coordinated manner. This
guideline has been developed in consultation with our various experts
involved in care of trauma/injured patients and approved by 2nd High-
Level Committee Meeting for Health Sector held on 13th January 2020.
Dr. Ugen Dophu

Secretary

Acknowledgement
We would like to extend our heartfelt gratitude to the following
individuals for providing your technical support in developing this
guideline:
1. Dr. Tashi Tenzin, MD, Consultant General and Neurosurgeon,
JDWNR Hospital. Professor of Surgery, Dean of Faculty of
Postgraduate Medicine, Khesar Gyalpo University of Medical
Sciences of Bhutan, Thimphu, Bhutan
2. Dr. Ugyen Tshering, Emergency Physician, JDWNRH
3. Dr. Sona Pradhan, Emergency Physician, Head of Department,
Emergency, JDWNRH
4. Yonten Jamtsho, Staff Nurse, Phuenthsoling hospital
5. Sangay Dorji, SN, Trongsa hospital
6. Tashi Chophel, SN, ERRH
7. Karma Jurmin, Sr, PO, HCDD
8. Kinzang Chedup, Nurse, Trauma Focal, JDWNRH
9. Kunzang Thukten, EMRO, Trauma Focal, ERRH
10. Nima Wangchuk, Nurse, Trauma Focal, ERRH
11. Sither Dorji, Clinical Nurse, Trauma Focal, Phuentsholing hospital
12. Sangay Dorji, EMRO, Trauma Focal, CRRH
13. Budha Bir Rai, Nurse, Trauma Focal, Phuentsholing hospital
14. Chimi Lhdon, Nurse, Trauma Focal, Trashigang hospital
15. Neeta Gurung, Nurse, Trauma Focal, Riserboo hospital
16. Tika Devi Dhungana, Clinical Nurse, Trauma Focal, CRRH
17. Jamtsho, Program Analyst, EMSD
18. Som Bdr Darjee, Dy. CPO, HCDD, DMS
19. Tashi Duba, Sr. PO, HCDD, DMS
20. Sanjay Puwar, HRO, HRD
21. Ugyen Tshering, PO, EMSD
22. Kinzang Galey, Engineer, HIDD
23. Yangdon, PO, EMSD
24. Jamyang Choden, PO, EMSD
25. Sonam Dorji, APO, EMSD
26. Tshewang Dorji, Dy. CPO, EMSD
27. Khina Maya, Dy. CPO, HCDD
28. Wangchuk Dukpa, Dy. CPO, EMSD
29. Sangay Wangdi, APO, EMSD
30. Krishna S. Monger, Chief Nurse, Wangdue Hospital
31. Rinchen Dema, Asst. Nurse, Damphu, Hospital

32. Pem Gyem, SN, Gedu Hospital

33. Chimi Wangchuk, SN, Trashigang hospital
34. Rinzin Pemo, CN, ERRH
35. Kencho Wangmo, Chief Nurse, JDWNRH
36. Dorji Penjor, Trauma Nurse, JDWNRH
Abbreviations
ACLS- Advanced Cardiac Life Support
ATLS- Advanced Trauma Life Support
BLS- Basic Life Support
CME- Continue Medical Education
DMS- Department of Medical Services
EmNOC- Emergency Neonatal and Obstetric Care
EMS- Emergency Medical Services
EMR- Emergency Medical Responder
EMRO- Emergency Medical Response Officer
ED/ER- Emergency Department/Room
EMSD- Emergency Medical Services Division
EMTC- Emergency Medical and Trauma Centers
FAST- Focused Abdominal Sonogram for Trauma
HCDD- Health Care and Diagnostic Division
HRD- Human Resource Division
HIDD- Health Infrastructure Development Division
HLC- High Level Committee
ICU- Intensive Care Unit
MoH- Ministry of Health
NCD- Non-Communicable Diseases
PALS- Pediatric Advanced Life Support
PHTLS- Prehospital Trauma Life Support
PPD- Policy and Planning Division

Scope
● This guideline shall apply to MoH, Dzongkhag Health Sectors and
health care professionals involved in emergency medical and trauma
care services.
Objective
● To serve as a standard guide for the establishment of EMTC
including up-gradation of existing hospitals and building new
infrastructure.
Definition of EMTC
EMTC is a health facility with resources and capability to provide timely
emergency medical and trauma care services on 24x7 to critically injured
patients. Although international definition of trauma center is of high
standard demanding sophisticated resources requirement, in this guideline
the definition is customized for Bhutan’s context and resources
availability. Accordingly, the EMTC is classified into three levels (level
III as lowest and level I as highest) based on the staffing, specialist and
services availability.
Levels of EMTC
Level III
• Provide all aspects of immediate care, including some definitive care
for non-major trauma patients according to patient needs and
available resources
• It will have a general surgical service which also provides most
aspects of definitive care to severely injured patients. Its principal
function, with respect to major trauma, is to provide initial
resuscitation and operative stabilization, prior to appropriate early
transfer of major trauma patients to the higher center
• It may be small and isolated hospitals or medical centers, with no
immediately available specialist, and minimal radiology or acute care
facilities
• Provide 24X7 on-call consultation including pre-hospital services
• Refer patients requiring comprehensive care to Level I & II centers
as necessary
• Target- District hospitals with a capacity of 20-40 beds
Level II

• Provide comprehensive clinical care for the severely injured patient.

• The clinical aspects of care for the injured patient should be identical
to that of a Level I service without the additional leadership, research
and education components
• A Level II service must have a surgeon available
• It provides an appropriate and expeditious transfer of major trauma
patients to Level I centers when required
• Provide 24X7 on-call consultation including pre-hospital services
• The center should be equipped with Emergency unit, Surgical,
Orthopedic services, EmNOC, OT services, Blood bank,
Physiotherapy services, Diagnostic facilities (lab, x-ray, USG), and
other supportive services
• Target- Strategic hospitals with a capacity of 60 beds
Level I
• Provide highest level of care for emergencies and trauma patients
• Capable of providing the full spectrum of care for the most critically
injured patient, from initial reception and resuscitation through to
discharge and rehabilitation
• Provide services of all specialties (orthopedic surgery, neurosurgery,
anesthesiology, emergency medicine, radiology, internal medicine,
reconstructive surgery, oral and maxillofacial, pediatric and critical
care) associated with trauma and emergency care
• Provide leadership in injury prevention, surveillance and public
education
• Provide CME on trauma care and medical emergency
• Conduct research on trauma care and medical emergency
• Target- Referral hospitals with bed strength of or more than 150
beds
Workflow and Design - Planning consideration for EMTC

The health facility providing EMTC services shall be designed in such a
way that patients have easy access to the health care services with good
room space, proper ventilation and dust free. There shall be designated
patient care areas, diagnostic and clinical services and other facilities
depending on the level of centers. These services must have access to
each other for transferring patients. It is to be noted that EMTC can be a
specialized service strengthened within the existing hospital building or
build new infrastructure in an identified area.

Figure 1: Workflow consideration for EMTC

Patient
Entry
Waiting Area
Ambulance Bay
Minor Care Triage Area

Treatment/
Observation
Lab, Radiology, Area
Blood Bank,
Pharmacy
Resuscitation
Room
ICU Operation
(Only for L-I) Theatre
Ward
Discharge/Referral
Trauma Morgue/Body
Registry Rehab/Follow up holding area
Core areas of EMTC:

1. EMS services
2. Patient access and Ambulance entrance
3. Resuscitation room
4. Treatment room
5. Observation room
6. Minor OT/Procedure room
7. Isolation room
8. Triage area
9. Green area/minor care
10. Ambulance bay
11. Intensive Care Unit

12. Operation theatre

13. Burn care room
14. Trauma registry
15. Pharmacy
16. Laboratory
17. Radiology
18. Blood Bank
19. Morgue/Body Holding Area
EMS Services
All the EMTC shall provide basic and advanced pre-hospital care services
24 hours a day. The pre-hospital care team shall be manned by trained
professionals such as EMRs, EMROs, Nurses and Doctors depending on
the nature of call. These providers are trained in pre-hospital care, scene
management, rescue, stabilization and the transport of ill and injured
people. In addition, they should be also trained in advanced courses like
ACLS, PALS, ATLS and PHTLS. For pre-hospital services and
transportation ambulance and helicopter guidelines should be followed.
Entrance Area
The EMTC shall be easily accessible to ambulance and walking patients,
including persons with disabilities and wheelchair users. The ambulance
transfer area should be one-way entrance. There shall be a direct access
from public roads for ambulance and vehicles, with the “entrance” and
“driveway” clearly marked with yellow ink on red background. In an
existing health facility, the entrances can be common with the current
entry and exit providing easy access.
The air-lifted patients are likely to be in a real time critical condition. It is

important that the time taken to transfer them between the helicopter and
the ED is as short as possible. There are primarily three options for
helicopter landing site: at surface (ground) level; at elevated (rooftop)
level; or a built structure above the level of the surrounding surface. The
best locations for a helicopter landing site are deemed to be on a roof
above ED or, where practical, in an open area adjacent to it.
Waiting Area
The waiting area shall provide sufficient space for patients as well as
patient escorts. It should be preferably open and nearer to the Triage area.

Seating facilities should be comfortable and adequate. Priority seats

should be allowed for persons with disabilities.
Triage Area
Triage may occur before or instantaneously upon patient arrival, within
minutes of arrival, at the bed-side or in a designated area. The Triage area
may not necessarily need the separate room but shall be located where
staff can observe and control access to treatment areas, entrances, and
waiting areas. Triage shall be stationed by triage nurse accompanied by
other health care staff 24 hours a day. It should be accessible to trolley
and wheelchair. There shall be basic equipment such as blood pressure
device, pulse oximeter, thermometer, stethoscope, trauma registry form,
glucometer, weighing device, extra patient’s trolleys, triage tags and
alarm system as required for triaging.
Resuscitation Room (Red Area)

The resuscitation area is the specific area where most of the critical and
lifesaving interventions are done after reaching hospital. The size and
number of the resuscitation area largely depends on the level of centers
and the frequency of resuscitation done. Resuscitation area should not be
too far from the entrance (Triage area). At a minimum, two nurses per
shift shall be there to perform primary assignment for the resuscitation
area.
There shall be 360-degree circumferential access to the patient,

monitoring equipment and defibrillator, suction, oxygen and wash basin.
If more than one resuscitation beds are used, there should be enough work
space between the two resuscitation beds. Resuscitation equipment,
ventilator, infusion device, cannulation, etc. must be checked and kept
ready for all the time. Unnecessary attendant shall not be entertained in
resuscitation area.
Treatment Room (Yellow Area)

The treatment room shall provide a private and controlled environment
for patient consultations, examinations, treatments and minor procedures.
Treatment room is also called acute medical care room. At a minimum,
1:2 beds per nurse ratio per shift shall be there at all times. The number of
treatment beds may depend upon the level of centers and frequency of
number of emergency and trauma patients. All the beds must be equipped

with monitoring devices and other necessary facilities such as suction,

oxygen, infusion device, infection control bins, hand rub, wash basin,
screen, etc. Only up to one attendant per patient may be allowed if
required in treatment area.
Operating Room
The trauma center shall have at least one adequately staffed operating
room immediately available for trauma patients and post-anesthesia
recovery (the surgical intensive care unit is acceptable). The operating
team shall consist minimally one scrub nurse or technician, one
circulating staff nurse, one anesthesiologist immediately available.
Ideally, the operating room should be located near or adjacent to the
resuscitation area to minimize transportation time for an unstable
emergency and trauma patients. There shall be enough space in operating
room to accommodate most surgical procedures required in emergency
and trauma care with portable operating light, portable imaging
equipment and others. Room shall be clean with separate bins for
biohazard waste and others as per the standard. The walls and ceiling
should be free of fissures, open joints and cracks.
Observation Room (green area)

It is the room for the continued treatment and evaluation process for
patients prior to leaving the ER or admitted to the ward. Observation
room shall be equipped with all the basic medical and non-medical
equipment required in functional mode. The number of observation beds
may depend on the level of center and frequency of patients. Each bed
shall have enough space (at least 1.5 meters) for the smooth and
comfortable working environment for staff.
Isolation Room
EMTC shall have one designated room to keep trauma patients those who
are diagnosed with highly contagious disease such as tuberculosis,
measles, or chickenpox that need isolation from other patients and staff in
the hospital. It should be maintained under negative room
pressure technique used in hospitals and medical centers to prevent cross-
contaminations from room to room. It includes a ventilation system that
generates negative pressure to allow air to flow into the isolation room
but not escape from the room, as air will naturally flow from areas with
higher pressure to areas with lower pressure, thereby preventing

contaminated air from escaping the room. This technique is used to

isolate patients with airborne contagious diseases.
Intensive Care Unit (ICU)

The critically ill trauma patient requires continuous and intensive
multidisciplinary assessment and intervention to restore stability, prevent
complications, and achieve and maintain optimal outcomes. The EMTC
(level I) shall provide ICU care for the patients as long as the patient
remains critically ill. A minimum of 1:2 beds per nurses ratio shall be
there at all time and may increase above this as dictated by patient acuity.
Level II and III EMTC may not have a separate standard ICU but there
shall have trauma ward with enough bed capacity for the care of critically
ill trauma patients.
Trauma Registry
A system of timely data collection that aids in the evaluation of trauma
care for injured patients is called trauma registry. EMTC shall have a
trauma registry unit with necessary equipment such as desk top computer
with internet connectivity, file rack, table and chairs.
Morgue/Body Holding Area

The Morgue/Body holding area is a facility for the temporary holding /
storage of dead bodies prior to transfer to a destination. The area should
allow for the following:
 Direct access from the facility for delivery of the body
 It should allow easy and discrete access to deliver and/or remove
bodies
 Consider away from public area to ensure that is appropriately
screened from visibility
Store
EMTC shall have separate room to store all kind of medical supplies and
equipment.
Other Facilities for Patient Relatives

The center should provide enough facilities for the patient families and
relatives such as toilets, waiting area with seating facilities and
entertainments as required.

Facilities for Staff

EMTC shall have enough facilities for staff including nurse station,
changing room, and toilet and administrative office.
Establishment of EMTC
There are two aspects to the establishment of EMTC in this guideline.
While one is the establishment of EMTC by strengthening services in
existing hospitals, the other is by building new structure. For the former,
since the hospitals being identified for up-gradation will already be
functional with most of the facilities in place, it is intended to fill the
deficiencies and gap identified under this guideline, while for the later it
intends to provide as guidance.
Process for up-gradation of Existing hospitals as EMTC

The selection of existing hospitals to be upgraded as EMTC shall be
based on the set criteria, preferably in maximum trauma case, regionally
balanced area, vulnerability to accidents and difficult access due to hilly
terrain, hazard-profile including accident prone areas, highway, industries
and mines. The priority shall be accorded to those existing hospitals,
where there is high mortality due to trauma and injuries.
MoH will carry out a need assessment of existing hospitals using health
facility need assessment tool for EMTC (annexure 1). The EMTC will be
classified into three levels based on the findings of the assessment, which
will be presented to HLC for approval.
After identifying the health facilities, an individual health facility shall be

responsible to submit the duly filled requirement form (annexure 2:
checklist for EMTC). The program shall verify and a detailed field study
shall be done by the team for infrastructure, space and size, entrance,
equipment, other supplies and costing. The processes are shown in
Figure 2. The assessment team shall comprise of the following members:
1. Representative, EMSD (Lead)
2. Representative, HCDD
3. Representative, HRD
4. Representative, HIDD
5. Representative, PPD
6. Emergency Specialist/Trauma Focal
7. Others will be based on need.

Figure 2: Process for up-gradation of Existing hospitals as EMTC

1. Carry out Need Assessment for EMTC
2. Analyze Report
3. Present to HLC/DMS for Approval
4. Implementation
5. Continuous Monitoring and Evaluation
Building New EMTC

For the construction of new EMTC, the relevant division/department shall
refer workflow and design - planning consideration for EMTC of this
guideline.
Monitoring and Evaluation

Continuous monitoring and evaluation of overall emergency and trauma
management system shall be done by the team lead by EMSD. However,
individual health facility’s administration shall be responsible for
conducting all kind of indenting and requisition of supplies and
equipment. They shall also facilitate in building capacity of human
resources by training relevant health staff in relevant field. Any issues
related to emergency medical and trauma services shall be reported to
EMSD and further to MoH. EMSD shall report overall status and
improvement of EMTC to High Level Committee annually or during
annual review meeting.

ANNEXURE 1: Assessment Tool for Identifying EMTC

Section A: General Information
1. Name of Facility 5. Type of Facility 6. Number of Beds
________________ □ NRH
2. Address ___________________ □ RRH
3. E mail_____________________ □ District hospital ……………
4. Telephone no.__________________ □ Military hospital
□ BHU
Section B: Infrastructure and Services
Type Definition s Yes/No Remarks
1. Triage area Designated area where the sorting of patients for prioritization
according to clinical acuity is done.
2. Resuscitation Room The specific room where most of the critical and lifesaving
(Red) interventions are done in ED/ER.
3. Treatment Room A room for patient consultations, examinations, treatments and minor
(Yellow) procedures in ED/ER. Treatment room is also called acute medical care
room.
4. Observation Room A room for the continued treatment and evaluation process for patients
(green) prior to leaving the ER or admitted to the ward.
5. Intensive Care Unit A unit in the hospital where intensive treatment care is provided to
patients with severe or life threatening injuries and illnesses, which
require constant care and close supervision from life support equipment
and medication.
6. Operating theater A room or facility within a hospital where surgical operations are
with post anesthetic carried out in an aseptic environment.

recovery zone
7. Isolation Room A designated room to keep patients those who are diagnosed with
highly contagious disease such as tuberculosis, measles, or chickenpox
that need isolation from other patients and staff in the hospital.
8. Central Sterile Integrated place in hospital that performs sterilization and other actions
Supply Department on medical devices, equipment and consumables.
(CSSD)
9. Ambulance A vehicle equipped for taking sick or injured people to and from
hospital especially in emergencies. Here it denotes only functional
ambulances in the hospital.
10. Waiting area A space near triage area for patients as well as patient escorts can sit
until they receive the services.
11. Oxygen supply Readily available number of oxygen cylinders.
12. Running water Readily available water supply to the hospital.
13. Backup Power Backup power supply to the hospital such as generator, solar, etc. that
supply is capable to power surgical machines and life-saving equipment.
14. An internet Hospital that has accessible to high bandwidth internet connection.
connectivity
15. Hospital emergency Emergency contingency plans available and in place.
contingency plans in
place
Section C: Strategic location:
Type Definitions Number Remarks

1. Number of Catchment Total number of population that the hospital is currently

Population providing services.
2. Distance from highway Total distance in km to the nearest highway from the hospital.
(km)
3. Road network in the Total length of road in km covering the catchment area of the
catchment area/district hospital or district.
4. Number of Projects, Mines Total number of hydropower projects, mining, quarries,
and Industries industries within the catchment area.
5. High risk areas (landslides, High risk area is defined as the sum of all hazards that have
flood, etc.) potential threat to population in that catchment area.
6. Number of referring health Total number of health centers that the hospital is currently
centers serving as referral center for. Only BHU-II and above will be
considered to be counted as referring centers.
7. Distance to higher level of Total distance in km from the hospital to the nearest higher
center (km) referral center.
Section D: Mortality and Morbidity
Type of cases Definition Number Remarks
1. Caseload Total number of cases (IPD and OPD) in the past one year.
2. No. of patients admitted Total number of patients admitted to the hospital in the past one
year.
3. No. of trauma cases Total number of trauma cases (drowning and submersion,
accidental falls injury, road traffic accidents, work related
injuries, burns and other injuries) admitted to the hospital in the
past one year.

Name and Designation of Respondent: _______________________
Name and Designation of Assessor: __________________________
Format to Calculate the Final Score (to be used by Assessor)

Name of Hospital………………………………………………………..
CRITERIA PARAMETER TOTAL SCORE SCORE REMARKS
1. Bed capacity (16 %)

> 151 beds 16
61-150 beds 14
21-60 beds 12
<20 beds 10
2. Infrastructure and Services (30 %)
2.1. Triage area Yes 2
No 0
2.2. Resuscitation Room (Red) Yes 2
No 0
2.3. Treatment room/Acute Medical Yes 2
Care (Yellow) No 0

2.4. Observation Room (green) Yes 2

No 0
2.5. Intensive Care Unit Yes 2
No 0
2.6. Operating theater with post Yes 2
anesthetic recovery zone No 0
2.7. Isolation Room Yes 2
No 0
2.8. CSSD Yes 2
No 0
2.9. Ambulance (functional) Yes 2
No 0
2.10. Waiting area Yes 2
No 0
2.11. Oxygen supply Yes 2
No 0
2.12. Running water Yes 2

No 0
2.13. An electricity Yes 2
No 0
2.14. An internet connectivity Yes 2
No 0
2.15. Disaster contingency and plans Yes 2
in place
No 0
3. Strategic Location (28 %)
3.1. Number of Catchment Population >50,000 5
20,001-49,999 3
<19,999 1
3.2. Distance from highway (km) ≤1 km 3
>1 km 2
3.3. Road network in the catchment ≥1000 4
area/district
<999 2
3.4. Number of Projects, Mines and >3 4

Industries 1-3 2
0 0
3.5. High risk areas (landslides, flood, Yes 4
etc.)
No 0
3.6. Number of referring health center ≥10 5
<10 3
3.7. Distance to higher level of center ≥70 km 3
(km)
<70 km 1
4. Type of Cases (26 %)
4.1. Caseloads >100,000 8
50,001-99,999 6
<50,000 4
4.2. No. of patients admitted >6000 8
3001-5999 6
<3000 4
4.3. No. of trauma cases including >2000 10
burns
1001-1999 8
<1000 6
* Region – If there is more number of health facilities from the same region, the Ministry will use its privilege
to prioritize the health facilities as EMTC for regional balance and equity.

ANNEXURE 2: Check list for EMTC
Name of Health Facility: _________________________________________________________

Sl. SERVICES Requirement Status Remarks/Justifications
No. Level I Level Level III Available Not Available
(Highest) II (Lowest) (Number)
Infrastructure
1 Resuscitation room E E E
2 Treatment room E E E
3 Observation room E E E
4 Minor OT/Procedure room E E E
5 Isolation room E E D
6 Triage area E E E
7 Green area/minor care E E E
8 Ambulance bay E E E
9 Intensive Care Unit E D -
10 Operation theatre E E E
11 Burn care room E D D
12 Trauma registry E E E
13 Pharmacy E E E
14 Laboratory E E E

Prehospital Care services

1 Emergency Medical E E E
Response Officer
2 Emergency Medical E E E
Responder
3 Advanced life support E E D
ambulance
4 Basic life support E E E
ambulance
5 Communication system E E E Radio or mobile phone
with ED/ER
6 Emergency Aeromedical E D D
Retrieval
7 Automatic External E E E
Defibrillator (AED)
8 Standard Emergency E E E Developed by EMSD
Medical Kits
Emergency Department
1 Emergency Physician E D -
2 Nurses (Emergency, E E E
Critical
care/Trauma/Triage Nurse)
3 GDMO/MO with training E E E
in ATLS/ACLS

4 Patient Triage protocols E E E SOP for training trauma and

emergency patients
5 Communication system E E E
with prehospital responder Radio/Phone
6 24hrs Consultant on call E E E
7 GDMO/MO available E E E
24hrs
9 Trauma/Emergency alert E E E
system
10 Refrigerator – pharmacy E E E
and blood purpose
11 Full range of splints E E E
12 ECG 12 lead E E E
21 Arterial Blood Gas (ABG) E E D
Machine
22 Portable mechanical E E E
ventilator
23 Laryngoscope: Adult, E E E
paediatric and neonate
24 Defibrillator system: E E E
biphasic, cardio version,
defibrillation, AED,
pacing, and monitoring

25 Emergency crash cart ABS E E E

trolley body
26 Infusion pump E E E
27 Blood/Fluid warming set E E E
28 Suction machine E E E
29 Mayo Table E E E
30 Operation theatre light E E E
31 Oxygen cylinder – type A, E E E
B and D with accessories
32 FAST scanning E E E
33 Chest drainage set E E E
15 Blood/Fluid warming set E E E
12 Patient transfer system: E E E
Easy move or pat slide;
Full body length
34 Bedside screen, 4 folds E E E
13 Photocopier & fax, E E E
Internet, Email
Anesthesia/OT Services
1 Anesthesiologist (General) E E E
2 Nurse anesthetist E E E
3 Arterial Blood Gas (ABG) E E E

Machine
4 BiPAP Machine: Portable E D D
5 Mechanical Ventilator E E E
6 Anaesthesia machine E E E
Vaporiser
7 Anaesthesia monitor for E E E
patient
8 Laryngoscope, Blade size: E E E
Adult, paediatric and
neonate
9 Monitor for post anesthesia E E E
care unit
10 Defibrillator system E E E
Facilities: biphasic, cardio
version, defibrillation,
AED, pacing, and
monitoring
11 Emergency crash cart ABS E E E
trolley body
12 Patient transfer system: E E E
Easy move or pat slide;
Full body length
13 Recovery trolley E E E
14 Infusion pump E E E

16 Suction machine E E E
17 Mayo Table, SS E E E
18 Operation theatre light E E E
19 Retractor, Collin' (pediatric E E E
and adult)
Orthopedic Services
1 Orthopedic Surgeon E E E
2 Ortho Technicians E E E
3 Pneumatic tourniquet E D -
system
4 Bone drill set E E E
5 Traction, braces and E E E
accessories
6 General orthopedic E E E
instruments set
7 Traction bed E E D
Laboratory Services
1 Lab technologist/technician E E E
3 Blood gases and pH E E E
analyzer
4 Coagulation studies E E E
5 Drug and alcohol screening E E E

6 Microbiology E E E
7 Serum and urine osmolality E E E
8 Blood typing, screening, E E E
and cross matching
9 Blood for transfusion E E E
Hemodialysis Services
1 Concentrate mixing system E D -
Concentrate mixer for
preparation of dialysis
solution with complete set
2 Hemodialysis machine E D -
3 Dialyser reprocessing E D -
system
4 Hemodialysis chair E D -
5 Reverse osmosis system, E D -
portable
Radio Imaging Services
1 Radiologist E D -
2 X-Ray/Ultrasound E E E
Technician
3 CT/MRI Technicians E - -
4 Computer Tomography E D -
(CT) Scanner

5 X-Ray machine E E E
6 X-Ray machine, Portable E E D
7 MRI machine E* - - * Depending on situation
8 Ultrasound machine E E E
9 Ultrasound machine, E E D
Portable
Other Specialities and Services
1 Burns cradle Foldable; E E D
Whole body SS
2 Nebulizer machine with E E E
tubings and mask, Adult
and child
3 Stretcher E E E
4 Weighing scale E E E
5 Autoclave E E E
6 Wheel chair (Adult and E E E
child)
7 Endoscopy machine E D -
8 In-service training for ward E E E
nurses on
Trauma/Emergency
9 Trauma registry E E E

10 Up to date disaster plans E E E

for in & out of hospital
disasters
11 Regular tests of the disaster E E E
planning – including
multidisciplinary
involvement
12 Intensive Care Unit E D -
13 Neuro Surgeon E D -
14 General Surgeon E E E
15 Therapist (Physio and E E E
occupational)
16 Medical Specialist E E D
17 General Duty Medical E E E
Officer (GDMO)
18 Gynecologist E E D
19 Pediatrician E D D
20 ENT/Maxillofacial E D D
21 Urology E D D
22 Cardiothoracic E D D
23 Pharmacist/technician E E E
24 Emergency Eye Care E E E
Services

25 Electricity back up system E E E

26 General surgical instrument E E E
27 Thoracotomy instrument E E -
28 Spinal surgery instrument E D -
29 Facio-maxillary instrument E D -
30 Craniotomy instrument E D -
31 Physiotherapy equipment E E D

References
1. Capacity Building for Developing Trauma Care Facilities on

National Highways, Operational Guidelines, Government of India,
Ministry of Health & Family Welfare.
2. Trauma Center Standard, State Of Florida, Department Of Health,
January 2010.
3. Guidelines for Essential Trauma Care, World Health Organization,
2004.
4. Model Resource Criteria for Level I, II, III & IV Trauma Services In
Australasia, Royal Australasian College of Surgeons, August 2009.
5. Emergency Medicine and Trauma Services Policy, Medical
Development Division, Ministry of Health, Malaysia, 2012.

Guideline For Establishing Emergency Medical and Trauma Centers

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What are the different levels of EMTC defined in the guideline?

What are the different levels of EMTC defined in the guideline?

What are the minimum requirements for an EMTC of level I?

What are the minimum requirements for an EMTC of level I?

Guideline for Establishing

Emergency Medical and Trauma

Emergency Medical Services Division

Emergency Medical Services Division Page 2

Initially, based on the Health Emergency and Disaster Contingency Plan

Dr. Ugen Dophu

Emergency Medical Services Division Page 3

Emergency Medical Services Division Page 4

32. Pem Gyem, SN, Gedu Hospital

Emergency Medical Services Division Page 5

Emergency Medical Services Division Page 6

• Provide comprehensive clinical care for the severely injured patient.

Workflow and Design - Planning consideration for EMTC

Emergency Medical Services Division Page 7

Figure 1: Workflow consideration for EMTC

Minor Care Triage Area

Core areas of EMTC:

Emergency Medical Services Division Page 8

12. Operation theatre

The air-lifted patients are likely to be in a real time critical condition. It is

Emergency Medical Services Division Page 9

Seating facilities should be comfortable and adequate. Priority seats

Resuscitation Room (Red Area)

There shall be 360-degree circumferential access to the patient,

Treatment Room (Yellow Area)

Emergency Medical Services Division Page 10

with monitoring devices and other necessary facilities such as suction,

Observation Room (green area)

Emergency Medical Services Division Page 11

contaminated air from escaping the room. This technique is used to

Intensive Care Unit (ICU)

Morgue/Body Holding Area

Other Facilities for Patient Relatives

Emergency Medical Services Division Page 12

Facilities for Staff

Process for up-gradation of Existing hospitals as EMTC

After identifying the health facilities, an individual health facility shall be

Emergency Medical Services Division Page 13

Figure 2: Process for up-gradation of Existing hospitals as EMTC

3. Present to HLC/DMS for Approval

5. Continuous Monitoring and Evaluation

Building New EMTC

Monitoring and Evaluation

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ANNEXURE 1: Assessment Tool for Identifying EMTC

Emergency Medical Services Division Page 15

Emergency Medical Services Division Page 16

1. Number of Catchment Total number of population that the hospital is currently

Emergency Medical Services Division Page 17

Name and Designation of Respondent: _______________________

Name and Designation of Assessor: __________________________

Format to Calculate the Final Score (to be used by Assessor)

1. Bed capacity (16 %)

Emergency Medical Services Division Page 18

2.4. Observation Room (green) Yes 2