EMERGENCY DEPARTMENT MANUAL

DATE OF ISSUE

ISSUE NO

APPROVED BY
MEDICAL DIRECTOR
 CONFIDENTIALITY NOTICE AND DISCLAIMER

These documents are confidential and a property of SRM Hospitals, Ramapuram, Chennai. These policies
and guidelines have been prepared specifically for stakeholders, process owners and other staff of SRM
Hospital, to enable them to carry out their day today duties.

SRM Hospital has exercised reasonable care in the preparation of contents. These policies and procedures
cannot replace a physician’s independent judgment about the appropriateness of risks of a procedure but
is intended to serve only as process guidelines.

Any photocopying or duplication of this manual by a third party person is strictly prohibited and shall be
liable for legal action.

ISSUE NO

ISSUE DATE

AMMENDMENT NO

Preparation Approval Issue

SIGNATURE SIGNATURE SIGNATURE

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Table contents:

s.no particulars page no

amendment log
definitions and abbreviations
abbreviations
introduction- policy on emergency services
scope of services
staffing
organogram
departmental work flow
initial assessment & reassessment of patients in emergency department
policy on ambulance
policy on emt duties
policy on ambulance driver duties
policy on ambulance equipment checklist
triage
handling cardiac arrest in emergency department
handling post rosc care in emergency department
handling mlc patients in emergency deaprtment
handling of brought dead cases in emergency department
handling death of patient in emergency department
receiving, registration & billing of patient in emergency department
admission process from emergency department
criteria for admission to icu from emergency department
admission of unknown patient in emergency department
procedure for ordering / reporting of diagnostic investigations
safety of patients and healthcare workers during transfers
transfer-in of stable and unstable patients to the organization
transfer out of stable and unstable patient who does not match the organizational
resources
procedure for discharge of patient from emergency department
leaving against medical advice from emergency department
obtaining blood for transfusion
procedure to obtain medications not listed in the hospital drug formulary
storage & labelling of medication
policy for storage, prescription and issue of narcotics
policy on use of medications nearing expired or outdated
breaking of bad news in emergency department
infection control guidelines in emergency department
quality assurance in emergency department
occupational health and safety in emergency department

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 disaster management in emergency department
patient record & ed record completion
management of trauma related emergencies
management of diabetic ketoacidosis
management of septic shock
management of acute coronary syndrome
management of bradycardia
management of tachycardia
management of cva/stroke
management of acute exacerbation of copd
management of acute ingestion of poison
management of anaphylaxis
management of seizures/ status epilepticus

Amendment sheet:

S.N PAGE SECTION/ DATE OF AMENDME REASONS AMEND SIGNAT

O NO. CLAUSE/ AMENDME NT MADE OF MENT URE OF
PARA/LINE NT AMENDM MADE THE
ENT BY PERSO
N
AUTHO
RIZING
AMEND
MENT

1. Guideline For Using Amendment Record Sheet:

Amendments made in QSM/ Quality Improvement Manual / Departmental manuals from time to time will be
traced through the Amendment Record sheet maintained in the respective Department manuals. Amendment
Record sheet will show the current Amendment No. & Amendment date. The arrangement of the Amendment
details would be such that the latest amendment (decided by Date) will be mentioned first followed by the other
Amendments arranged in the reverse chronological order and the first Amendment will be shown as the last
item. Whenever the issue changes for any of the reasons mentioned above, the Amendment Record Sheet will

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start afresh, not indicating the amendments made in the previous issue. The previous issued document will be
stamped as obsolete and retained under the custody of the NABH Coordinator.

1.1 Control of Issue Number & Amendment Number

a. Any new document like QSM, Quality Improvement Manual, and Departmental Manual issued for
the first time shall have ‘Issue No. 01’ and ‘Amendment No. 00’ with an ‘Issue Date’ only and no
‘Amendment date’. Any change in the document will be reflected in ‘Amendment Number’. The
‘Issue No.’ and ‘Issue date’ will remain the same.
b. The Cover page / Top Sheet of such a manual shall have the same ‘Issue No. 01’ with the same
Issue Date
c. For Example, whenever there is a change in a document or a complete section of the document,
having an ‘Issue No. 01’ and ‘Amendment No. 00’, the new amended document will have the
same ‘Issue No. 01’ but, the ‘Amendment No.’ becomes 01, indicating the ‘Date of Amendment’.
d. The detail of the amendment is recorded in the respective amendment record sheet.
e. Whenever any document is re-issued, the issue number is increased incrementally by 1. For
example, if ‘Issue No. 01’ is re-issued, the next issue will be ‘Issue No. 02’. The Amendment No.
reverts to Amendment No. 00 in such cases. The circumstance under which there is fresh issue of
documents is mentioned below. This is only an illustrative one and the issuing authority has
powers to define a new issue.
f. The ‘Issue No.’ of any Manual or Document will change only whenever:
There is a change in the requirements of the NABH standard, either in part or whole.

Periodical review of manual / document (once in a year)

Major change in the scope of accreditation

Major Change in the document control procedure

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Abbreviations:

S.No Abbreviations Expansion

ED EMERGENCY DEPARTMENT
OTC OVER THE COUNTER
MO MEDICAL OFFICER
CTC COMPRESHENSIVE TRAUMA CARE
BID BROUGHT IN DEAD
MLC MEDICOLEGAL CASE
NPO NIL PER ORAL
ECG ELECTROCARDIOGRAM
CBC COMPLETE BLOOD COUNT
LOC LEVEL OF CONSCIOUSNESS
CVA CEREBRAL VASCULAR ACCIDENT
RBS RANDOM BLOOD SUGAR
USG ULTRASOUND
GCS GLASGOW COMA SCALE
PT PROTHROMBIN TIME
PTT PARTIAL THROMBOPLASTIN TIME

1) INTRODUCTION:
An Emergency Department (ED), also known as Accident or Emergency Department is a medical
treatment facility, specializing in acute care of patients who present without prior appointment, either by
their own means or by ambulance.

The emergency departments of operate 24 hours a day.

Most vital department to triage, stabilize and provide treatment to the patient round the clock on all the
days.

ED is situated at one end of the hospital, easily accessible.

Approach is very easy and easy shifting of patients from the ambulance to emergency is possible.

Near security table there is an intimation bell to alert emergency staff about the receipt of the patient.

The ED is also supported by EMS- Emergency Medical Services which provides Pre hospital Emergency
Care.

2) Goals:
1. To provide priority care for individuals who require immediate medical attention as per triage
guidelines.

2. To provide rapid resuscitation, stabilization and referral of critically ill patients.

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3. To provide necessary definitive medical care to stabilize an emergency condition within discretion of
the doctor doing screening of patients.

4. To provide continuity in care through mechanisms for admission, treatment, discharge and or referral
to another facility.

5. To ensure that all the patients coming to emergency are assessed by qualified individuals.

6. To provide Pre-hospital care by serving as base station for referral transport services

STAFFING:

 ER HEAD
 ER PHYSICIANS
 ER INCHARGE NURSE
 ER NURSE
 OPERATIONS TEAM
 HOUSEKEEPING

ORGANOGRAM:

MEDICAL DIRECTOR

ER HEAD

ER SENIOR ER INCHARGE ER CO-ORDINATOR

CONSULTANT NURSE

ER JUNIOR ER NURSES
CONSULTANT

REGISTRAR

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DEFINITION:

Triage: A process for sorting injured people into groups based on their need for or likely benefit from
immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields, and at disaster
sites when limited medical resources must be allocated.
➢Laceration: Lacerations, irregular tear-like wounds caused by some blunt trauma
➢Abrasion:-A wound consisting of superficial damage to the skin
➢Hypovolemic shock: Hypovolemic shock is an emergency condition in which severe blood and fluid
loss makes the heart unable to pump enough blood to the body
➢Anaphylactic shock: - A widespread and very serious allergic reaction. Symptoms include dizziness,
loss of consciousness, labored breathing, swelling of the wind pipe etc.
➢Status Asthmaticus: - Status asthmaticus is an acute exacerbation of asthma that does not respond to
standard treatments of bronchodilators and corticosteroids.
➢Epistaxis: Is the relatively common occurrence of hemorrhage from the nose, usually noticed when the
blood drains out through the nostrils.
➢Stab Wound: Are caused most obviously by knives, but are also caused by bayonets and swords, as
well as scissors
➢Stroke: A stroke is a medical emergency. Strokes happen when blood flow to your brain stops. Within
minutes, brain cells begin to die.
➢Glasgow Coma Score: Is a neurological scale which aims to give a reliable, objective way of
recording the conscious state of a person, for initial as well as subsequent assessment. A patient is
assessed against the criteria of the scale, and the resulting points give a patient score between 3
(indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or
revised scale).
➢ED Room: Receiving patients on emergency basis for evaluation and treatment
➢Cleaning: The removal of soil and reduction of microorganisms from a surface
➢Gestation: Gestation is the carrying of an embryo or fetus inside a female viviparous animal

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 PATIENT ENTRY

AMBULANCE ARRIVAL WALK IN

PRIORITY 1- PRIORITY 3 – OBSERVATION

RESUSCITATION AREA PRIORITY 2 – URGENT CARE BED/BEDSIDE CONSULTATION

TRIAGE AREA/BED-SIDE TRIAGE

ER NURSE SETS UP FOR INITIAL EXAMINATION

ER PHYSICIAN PERFOMS INITIAL EXAMINATION

INITIAL ASSESSMENT, TREATMENT AND STABILIZATION

RELEVANT INVESTIGATIONS ORDERED

ER PHYSICIAN CHECKS REPORTS

DETERMINES REQUIRED REFERRALS

DETERMINES TREATMENT PLAN FORMULATED

ADMISSION TO WARD ADMISSION TO ICU SHIFTED TO OT DISCHARGE/AMA /

REFFERAL OUT

PATIENT DISPOSITION

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 INITIAL ASSESSMENT & REASSESSMENT OF PATIENTS IN
EMERGENCY DEPARTMENT
Purpose:
To assure care provided to each patient is based on an assessment of the patient's relevant physical,
psychological, and social status needs.

Scope: Hospital Wide

Responsibility:
• ED Doctors

• ED Staff Nurse

• Dietician

Policy:
 Each patient upon admission to hospital shall be assessed by qualified individuals for appropriate
care or treatment needs / need for further assessment.
 The physical, psychological and social status of each patient shall be assessed. The scope and
content of assessment shall be defined by a multidisciplinary MRD Committee (Nursing
Admission Assessment, Initial Assessment, Nutritional Screening Guide, Physiotherapy
Assessment, etc).
 In Emergency department the scope and intensity of the assessment shall be determined by the
Triage criteria
 The patient shall be assessed and the findings shall be documented as appropriate to the patient’s
needs.
 A duly registered and credentialed doctor shall perform and document patient assessment.
 The nursing assessment shall be performed by a registered nurse and documented in the patient
record immediately.
 The nutritional assessment will be conducted by the dietitian/Nutritionist if the patients stay in
ED for observation.
 The initial assessment will include ascertaining the level of consciousness, checking the blood
pressure, pulse, temperature, SpO2, CBG in case of diabetes.
 The initial assessment will ascertain the condition of the patient whether stable or
unstable and appropriate measures will be taken.

Assessment criteria for Road Traffic Accident patient include:

 Presenting history:
 Past medical history:
 Allergies:
 Last meal:

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  O/E:
 Level of consciousness- , GCS, Pupils, Temp-,
BP- PRCVS/RS/ABD/CNS
 L/E:
 Investigations done:
 Provisional diagnosis:
 Treatment given:
 Course of action: outpatient/admission/transfer
out/references
 MLC initiated
 The initial assessment will result in document ED plan of care.

Time for Initial assessment is defined as follows:

Category Performed by Timeframe

Red Nurse initial assessment To be completed within 10
Doctor initial assessment min
To be completed within 15
min

Yellow Nurse initial assessment To be completed within 10

Doctor initial assessment min
To be completed within 15
min

Green Nurse initial assessment To be completed within 10

Doctor initial assessment min
To be completed within 15
min

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RE-ASSESSMENTOFPATIENT

Re-assessment of patients in the ED is done based on the MEWS score

Re-assessment in ED is done in the following way and it is documented:

RED
 Doctors-Every 30 mins
 Nurses-Every15minutes vitals to be checked and patient to be continuously monitored.
YELLOW
 Doctors-hourly
 Nurses-Every30 minutes vitals to be checked
GREEN:
 Doctors-2ndhourly
 Nurses-Every2ndhourlyvitalsto be checked

ALL TRAUMA CASES GCS TOBE MONITORED

Supporting document: ED observation chart, Triage sheet

REFERRAL OF PATIENTS TO OTHER DEPARTMENTS / SPECIALITIES

RATIONALE:

The Emergency Department(ED) provides life-saving and acute care services to

patients attending its premises.

In many situations, ED physicians may require assistance from other clinical

specialties with regard to opinion on the line of management, or referring the patient
for specialized services or admission. Response to these consultations should be timely
and on high-priority basis according to rules and regulations, as illustrated in this
policy and procedures guidelines (PPG).

Furthermore, this PPG identifies accountability concerning Requests for

Consultation by ED, and is part of the ongoing monitoring of performance of staff
members involved in providing services to our patients.

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SCOPE AND OBJECTIVES OF THE POLICY:

 This policy covers events occurring at, and initiated by, ED concerning
requests for consultation from other specialty services.
 This policy defines the mechanism whereby an ED staff initiates a consultation to a
specialty service.

 This policy defines the guidelines towards achieving timely response to

consultation requests by relevant departments and services.
 This policy identifies accountability of those involved in the consultation request process.
 This policy should facilitate patient disposition and management, and increase
efficiency of the ED.
 This policy would assure continuous quality improvement of services provided to our patient

DEFINITIONS AND EXPLANATIONS OF KEY TERMS:

 Consultation Request: The process by which an ED physician requests the professional

medical opinion of member of the on-call team of the specialty services, in order to
establish diagnosis and/or appropriate line of management of the clinical condition of
the patient.
 Consulting Service: The specialty service on-call for the ED on any given day.
The term is sometimes used as synonym to Specialty Service.
 First on-call: Refers to the individual physician listed on the days On-call list as
the initial person to be notified in case a need for consultation arises
 Second on-call: Refers to the individual physician listed on the days On-call
lists as this cond person to be notified in case a need for consultation arises.

CONSULTATION REQUEST PROCEDURES:

Non-Critical Patients:

 The request for consultation is the responsibility of any ED specialist who carries
out the primary patient evaluation and identifies the need for consultation from
relevant clinical specialty.

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  The ED resident shall secure approval by an ED specialist or ED consultant to
initiate consultation request. This approval can be verbal, written or by phone, and
should be documented, timed and signed by the ED physician on the patient ED
Observation chart.
 The ED physician shall call the first on-call physician on the requested
Consultation Services, and communicates to him/her the request for consultation.
This process should be dated, with the time of the call documented on the
Consultation Request Form and the patient's ED medical record.
 The time of arrival of the Consulting Physician shall be documented in the
Consultation Request Formby the Staff Nurse attending the patient at ED.
 Ideal time for response to consultation in non-critical patients should be around
15 minutes and should not exceed 30 minutes. However, in identified life-
threatening situations, the response time should be much shorter, and should
not exceed 15 minutes.
 The physician responding to the consultation request should provide advice
Regarding patient's disposition within two hours of the initial response to the
consultation. If, however, the physician responding to the consultation identifies
and documents that patient's condition would not require the care and
management by the Specialty Services requested by the ED, the patient would
remain under care of the ED Physician who may initiate a second consultation to
another Specialty Services if the situation warrants such request. If the referred
specialty feels that the patient warrants a totally different consultation, then, it is his/her
responsibility to contact the physician whom they would like to take over/refer.

 The respondent's scope of care and privileges are governed by those

approved by their respective department's rules and regulations.
 The physician responding to the consultation should inform his superiors /
consultant on a timely manner about all on-site consultations performed in
the ED.
 It is the responsibility of the ED nurse to document that the patient has
been seen, evaluated by the specialty services and all charts are signed prior
to admission to a unit or discharge from ED.

Request of Consultation for Critical Patients requiring Emergency Consultations:

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  The same procedures for requesting consultation for non-critical patients
should apply. However, the ED physician, at his discretion and provided
he/she documents all relevant and supporting data
May directly call the consultant on-call for the specialty service, bypassing calls to the first
and second on-call physicians.

Second Consultation Request:

Iftheinitialresponsetothefirstconsultationbytherespondingspecialtyservicesprovidesev
idence and/or document that the patient would not require their services /
management, the ED physician may initiate a second consultation request to another
service should he identify and document the need to such services.

Care of Patients during Consultation by Specialty Services at ED:

 Accountability for overall care of patient shall remain that of the ED
during and after consultation by Specialty Services as long as the
patient remains in the ED premises.
Accountability for professional and technical care of patient in ED shall become
that of the receiving Specialty once a transfer of care is documented and signed by
the responding Specialty Services. However, and despite this signed transfer of
care, the ED physicians are required to continue monitoring the patient as long as
he remains at the ED premises.

 At any time during the entire process of patient visit to ED, if the patient's
condition deteriorates and/or requires urgent emergency intervention, the
ED physician along with responding physicians from the specialty services
should strive to provide such needed care, as the patient remains under ED
care as long as he/she remains in the ED premises.

POLICY ON AMBULANCE

Purpose:

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To provide access to emergency patients

Abbreviations:
ACLS (Advanced cardiac life support)

BLS (Basic Life Support)

DEFINITION OF TERMS:

● Computer Aided Dispatch: software system

● Caller : is the person who calls the dispatch desk and asks for an ambulance

● Operator/Dispatcher: is the person who attends the call at the dispatch desk

● Location Tracking System: Software component which serves as a mapping system

● Driver/Pilot: is the person who drives the Ambulance

● EMT: Emergency Medical Technician

Applicable area:
Emergency and Responsibility lies with the HOD- Emergency, Manager- Emergency

Policy Statement:
Hospital has round the clock available ambulance service that is well equipped and manned with required
trained staff and hospital defines the benchmark for response time as well as standardize the protocols for
daily management.

Policy Details:
 The ambulance service / Emergency medical services is available in and around the hospital 24x7
and all the statutory requirements e.g. licensing, authorization and other norms (driver’s dress
code, training etc.) are as per state’s motor vehicle rule.
 Whenever a call is received, it is noted in the “Ambulance call-register mentioning: Date and
Time, Name, Address, Contact no, Informer message, Call received by, Time of Departure, time
of arrival, Accompanied by, Total approx. distance in Km , remarks and signature.
 The response time for emergency call for ambulance service is 3-5 min within which the
ambulance is made ready for call.
 The ambulance has a trained EMT / Paramedic along with the pilot.
 The medicines and the equipment in the ambulance are tallied using the checklist everyday by the
EMT
 The equipment is also checked for the working condition.

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  For proper communication, the ambulance driver is provided with a CUG phone.
 All the EMT’ s , Paramedics and the pilots are trained with BLS
 Sirens for the ambulance are regularly checked for its working order.
 For breakdown mechanism all complaints are recorded in an “Ambulance complaint register” and
the ambulance manager is informed immediately to take required action.
 The number of our Emergency medical services is *********
 Ambulance medication checklist

POLICY ON AMBULANCE DRIVER DUTIES

Purpose:
To attend Ambulance calls by the driver immediately. To keep ambulance ready to attend emergency
calls

Applicable area
This SOP is applicable to all Ambulance drivers.

Procedure:
 Driver has to be there on their allocated ambulance points regularly.
 Attendance is marked in the register available and counter checked by the ambulance manager
 To take over from the off duty driver (to take over the ambulance cug, to check ambulance,
oxygen supply, UPS, AC, Brakes, Diesel, Logbook)
 To complete work of ambulance i.e. washing, cleaning, empty and refill water in tank, vacuum
inside, change bed linen, check hand wash lotion, dustbin and other minor maintenances if its not
completed by the previous duty driver.
 Report to the Ambulance Manager immediately about deficit and coordinate with facility
manager
 Attend ambulance calls as and when it comes.
 Clean and keep ambulance ready for the next call and enter in the ambulance
 Continue duty if reliever is absent
 Sign out in the attendance register while leaving.

POLICY ON AMBULANCE EQUIPMENT CHECKLIST

Purpose:
To maintain all the medical equipment to the appropriate standards as prescribed by equipment
manufacturers, so as to ensure that all medical equipment to be used to provide the best health care
services to patient, staff and should be safe, efficient, effective, reliable and long lasting.

Abbreviations:
ED-Emergency Department

EMT-Emergency Medical Technician

Applicable Area

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Emergency department and Emergency Medical services department

Procedure:
The ambulance equipment to be checked every shift and checklist to be filled by EMT

The ambulance driver checks the working status of the ambulance twice a day and updates the register.

POLICY ON EMERGENCY MEDICAL TECHNICIAN DUTIES

Purpose:
To Receive and transfer the patients in the ambulance safely to the hospital

To stabilize the patient in the ambulance while transferring

Abbreviations:
ED-Emergency Department

EMT-Emergency Medical Department

Applicable Area:
Emergency Department and Emergency Medical Services Department

Procedure:
 The most important thing in the daily routine of an Emergency Medical Technician / Paramedic is
to maintain a proper grooming standard with a proper uniform.
 While entering to the duty, Check all the medicines and equipment stock check the oxygen level
in the cylinder, check the biomedical devices and check CUG.
 get a proper handing over from the previous shift EMT , the handing over includes the total
number of cases received in the previous shift, medicines and equipment used, oxygen level , and
any bending cases / works to be done.
 While receiving Calls in your CUG ,
 Make sure you introduce yourself first
 Know the details of the caller
 Ask the condition of patient / mode of injury, and number of patients expected on site
 Ask the crystal clear location of the incident with a proper land mark.
 Reassure the caller, that you have started and will reach the location in another few minutes.
 While reaching the site, wear your proper PPE to receive the patient.
 Make sure you apply the Cervical collar for the RTA patients with head injury while shifting in
the stretcher.
 Once you shifted the patient in the ambulance, get an IV access for the patient, in case of excess
blood loss, access a large bore iv cannula for the patient.
 Do Primary Survey for the patient and check all vitals.
 Give pre arrival instruction to ED CUG
 Monitor the patient while transferring and make sure you shift the patient safely.

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  Once you shifted the patient in ED, give a proper handing over to the ED staff and doctor.
 While shifting any sick patients to GH or MRI scans from POH, get the signature of the patient’s
attenders in a high risk consent form before transferring.
 Maintain Proper case sheets for the patients transferring to the hospital.

TRIAGE:
Introduction:

Triage, by definition, is the process by which a group of patients are sorted and prioritized according to
their need for care. The type of injury or illness, the severity of the presenting problem, and the facilities
available, govern this process.

Triage model is a comprehensive approach, based upon priorities of care, in order to provide the best care
for each individual patient that presents.

The following policy has been correlated to provide a clearer understanding of the aspects of this
approach and assess in the development of triage knowledge and skills.

Assigning Triage:

Triage assignment is based on the patient’s clinical parameters.

Other information that helps to quantitative severity (vital signs, PEFR, O2 saturation or symptoms, pain
scales, associated symptoms) and risk factors (age, gender, past history, co-morbidity)

TRIAGE CATEGORIES:

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GOALS OF TRIAGE:
 To rapidly identify patients with urgent, life threatening conditions.

 To determine the most appropriate treatment area for patients presenting to the ED.

 To decrease congestion in emergency treatment areas. To provide ongoing assessment of patients

 To provide information to patients and families regarding services, expected care and waiting
times.

 To contribute information that helps to define departmental acuity.

Rapid access to assessment by a health care provider increase patient satisfaction and enhance public
relations.
An efficient triage system should reduce client anxiety and increase satisfaction by reducing length of
stay and waiting times in the emergency department

Factors which influence triage design and operation include:

• Number of patient visit.

• Number of patients requiring rapid intervention

• Availability of health care providers in the ED

• Availability of specialty services

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• Environmental, legal and administrative issues

General Triage Guidelines:

 Greets client and family in a warm empathetic manner. Performs brief visual assessment.
Documents the assessment
 Triages and transports patient to treatment area when necessary

 Keeps patients/families aware of delays

 Reassesses waiting clients as necessary

Accurate assignment of triage levels is based on:

 Practical knowledge gained through experience and training.

 Correct identification of signs or symptoms.

 Use of guidelines and triage protocols.

 A triage level must be recorded on all patients, during all shifts.

 When the triage nurse has categorized more than 3 urgent patients, it is his/her responsibility to
prioritize these patients for the treatment nurse/emergency

The Triage Assessment:

 Chief complaint: patient's statement of the problem

 Validation and assessment of chief complaint

 Physical appearance: - color, skin, activities

 Degree of distress

 Complete Vital Signs

 Physical assessment

Triage is not a static process:

It is important to remember that triage is a dynamic process and patients may move up or down on the
urgency continuum while waiting for access to treatment areas, physician assessment, results of
investigation or response to treatment

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Triage Nurse Qualifications:

 Communication skills are crucial. Provider must interact with patient - family -visitors

 Must have tact, patience, understanding, and discretion

 Organizational skills -patient line-ups, inquiries, etc . (Constantly under patient scrutiny) Able to
perform in hectic situations.

 Can recognize who is sick. (Depends on experience, skill and expert clinical judgment

PEARL OF WISDOM: IF PATIENTS LOOK SICK AND YOU ARE NOT SURE,
TRIAGE THEM AS PRIORITY I OR 2

PROTOCOL TO BE FOLLOWED IN CARDIAC ARREST

Purpose:

Step wise approach for patient coming in with cardiac arrest

Scope:

cardiac arrest patients

Responsibility:

ED Doctor, ED Nurse

Definitons and Abbrevations:

ABG- Arterial Blood Gas

CPR- Cardio Pulmonary Arrest

S K+- Serum Potassium

J- Joules

VF/VT- Ventricular Fibrillation/Tachycardia

RBS- Random Blood Sugar

CPK- Creatinine Phosphokinase Enzyme

CAUSES:

5Hs:

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HYDROGEN ION CONCENTRATION (ACIDOSIS)

HYPER/HYPOKALEMIA

HYPOTHERMIA

HYPOVOLEMIA

HYPOXIA

5Ts:

TAMPONADE (CARDIAC)

TENSION PNEMOTHORAX

THROMBOSIS (PULMONARY AND CORONARY)

TOXINS (DRUG OVERDOSE)

THROMBOEMBOLISM (PULMONARY EMBOLISM)

Procedure:

Confirm diagnosis

 UNRESPONSIVE
 ABSENT CENTRAL PULSE
 NO SPONTANEOUS BREATHING
 CYNOSIS
 ASYSTOLE OR VENTRICULAR FIBRILLATION/TACHYCARDIA-ECG MONITOR

CARDIO-PULMONARY RESUSCITATION:

BASIC LIFE SUPPORT:

 To be initiated by the paramedical staff attending the patient even before the doctor on duty can
reach the patient.
 Shout for help or ask some other staff to initiate code blue(in case the arrest is detected in the
ward). don’t leave the bedside of the patient.
 Note the time
 Check central pulse, then check for breathing efforts.
 Start the cpr in 30:2 ratio.

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  Ask the other paramedical staff to attach the defibrillator.
 The concerned staff to continue cpr as elaborated.
 Secure large bore iv cannula and blood samples to be collected to rule out possible cause of
cardiac arrest

COMPONENTS OF BASIC LIFE SUPPORT:

Airway:

Head tilt (if no head or spinal injury) with the chin to be lifted and jaw thrust. open mouth of patinet.

Breathing:

Use ambu bag with mask and start the patient on artifical respiration @ 2 breaths for every 30 chest
compressionin case of 2 persons. this should be continued till the doctor reaches the patient and start
resustitation.

Chest compression:

CPR should not be interrupted except for intubation by appropriate endotracheal tube. for chest
compression to be adequate heel of the hand should be used with the elbows kept straight. centre over
the lower third of sternum. aim of the chest compression should be compressing the chest by atleast
5cm @100-120 compression per min.

Chain of Survial

24 | P a g e
25 | P a g e
 Patients who achieve ROSC Return of spontaneous circulation after cardiac arrest in any setting have
a complex combination of pathophysiologic processes described as post cardiac arrest syndrome,
which includes post arrest brain injury, post arrest myocardial dysfunction. Post cardiac arrest
syndrome plays a significant role in patient mortality.

Initial Stabilization phase:

Resuscitation is ongoing during the post-ROSC phase, and many of these activities can occur
concurrently. However, if prioritization is necessary, follow these steps:

26 | P a g e
 • Airway management: Waveform capnography or capnometry to confirm and monitor endotracheal
tube placement

• Manage respiratory parameters: Titrate Fio2 for Spo2 92%-98%; start at 10 breaths/min; titrate to
Paco2 of 35-45 mm Hg

• Manage hemodynamic parameters: Administer crystalloid and/or vasopressor or inotropes for goal
systolic blood pressure >90 mm Hg or mean arterial pressure >65 mm Hg

Continuous Management and Additional Emergent Activities:

These evaluations should be done concurrently so that decisions on targeted temperature management
(TTM) receive high priority as cardiac interventions.

• Emergent cardiac intervention: Early evaluation of 12-lead electrocardiogram (ECG); consider

hemodynamics for decision on cardiac intervention

• TTM: If patient is not following commands, start TTM as soon as possible; begin at 32-36°C for 24
hours by using a cooling device with feedback loop.

Other critical care management – Continuously monitor core temperature (esophageal, rectal,
bladder) – Maintain normoxia, normocapnia, euglycemia – Provide continuous or intermittent
electroencephalogram (EEG) monitoring – Provide lung-protective ventilation

27 | P a g e
28 | P a g e
CPR SHEET

To be attached

CPR GUIDELINES: CPR TEAM(Names):

-Start Compressions immediately: 100- -Leader:_________________________

120/min
-Recorder:_______________________
-Intubate and ventilate: 10 breaths/min
-drug prep & administration:
-Rotators Switch positions every 2mins,
Recorder gives signal ________________________________

- Evaluate ECG Tracing every 2 minutes -3 Rotators (compressions, airway/ventilation,

during rotator switch runner) :_________________________

29 | P a g e
HANDLING OF MLC CASES IN EMERGENCY DEPARTMENT

Purpose:

TO HANDLE MLC CASE

Scope:

EMERGENCY DEPARTMENT

Responsibility:

ER PHYSICIAN/ ER NURSE

POINTS TO BE NOTED:

 All MLC cases as listed below (but not limited to) should be registered as MLC.
 Issue of original wound certificate to police & patient is to be done by ER physician
 MLC register maintained in the ED should be completed by ER Physician.

CASES THAT FALL UNDER MLC:

 Road Traffic accidents including cases of head injury

 Poisoning, Chemical poisoning, Drug abuse, overdose, intoxication etc.
 All suspected cases of Homicide or attempted suicide
 Drowning/Hanging/Strangulation victims.
 Burns – fire, electrical burns, chemical burns, etc
 All patients brought dead
 Snake bite/victims of any animal ferocity
 Injury cases where foul play is suspected, if doctor thinks that the patient is an accused or victim
in a crime case
 Fall from height
 Non-Accidental Injuries
 Assault/gunshot/stab injuries
 Sexual assault

30 | P a g e
  Any other cases not falling under the above categories but has legal implications.
 Criminal abortions
 Postmortem

PROCEDURE FOR HANDLING MEDICOLEGAL CASES

MLC CASES

ER PHYSICIAN/ER NURSE

COLLECT HISTORY

EMERGENCY TREATMENT

DOCUMENT IN PATIENT
FILE & MLC RECORD

ER PHYSICIAN ON DUTY
WILL SEND THE POLICE
INTIMATION FORM
AFTER INITIAL
EVALUATION

ER PHYSICIAN WILL
INFORM THE
RESPECTIVE
CONSULTANT

IF ADMISSION IS REQUIRES
31 | P a gIFeDISCHARGE, FOLLOW ADMISSION
POLICE TO BE
PROTOCOL
INFORMED
 ER DISCHARGE
SUMMARY PROVIDED

 On Receipt of a suspected MLC case, the ER staff shall inform ER Physician

 The Physician will examine and assess the condition of the patient

 The Staff Nurse / ER Physician will give emergency first aid / take resuscitative measures to
stabilize the patient

 The Staff Nurse / ER Physician will take a detailed history of the accident / incident from the
patient / relatives / witnesses and document it.

 The ER physician will inform the respective Consultant who will visit the patient and decide on
any further management

 The respective Consultant will decide if the patient needs admission or can be treated on OPD
basis

 The Staff Nurse shall intimate the ER Nursing Supervisor about the MLC.

 The Staff Nurse should stamp “MEDICO LEGAL CASE (MLC)” on every document in the
patient’s file

 The ED physician will complete the police intimation form

 The pink copy of the police intimation form will be sent to the MRD department, the yellow copy
will be maintained in the ED & the white copy will be handed over to the police

 The Police PC number with signature is documented on the police intimation acknowledgement /
death register depending upon the situation.

 The ER physician will provide information to the Police, if asked

32 | P a g e
NOTIFICATION TO POLICE:

 Information should be given to Police in all cases labeled as ‘Medico legal’, including brought
dead

 A doctor can be charged under section 201-I.P.C for destruction of evidence if he fails to
discharge his duty to inform the police on time

 All intimations to the police department will be coordinated through the support services team.

Presentation and dispatch of material of evidential value for Police:

All clothing worn by injured and removed in hospital should be handed over to the security supervisor
who safe keep till Police comes and takes over for which acknowledgement to be taken. E.g. Gastric
lavage, bullets, pellets, weapons removed from the body of the patient, vomitus, blood, excretion, vaginal
swabs, pubic hair etc

Recording of dying declaration:

 In Medico legal cases when there is likelihood of death in the near future, call the magistrate.
Before recording the doctor should certify that the person is conscious and his mental status are
normal
 If no time to call magistrate, doctor himself can record in the presence of two witnesses
 If a person can write he can do it himself, otherwise the statement is taken down in the words of
the person without any alterations or video recording can also be done. Then it is read over to him
and his signature or thumb impression is taken. The doctor and the two witnesses should sign in
the statement. This declaration is then sent to a Magistrate in a sealed envelope with a covering
letter

When A Medico-legal Case Dies In Hospital:

 When death occurs- Note the time and date of death

 The ER physician shall declare the death to the relatives

 Inform police - 1st over telephone by ED Physician, then written information on the police
intimation form by ED physician/ treating doctor

 Police inquest – The police of the respective area of the accident will be conducting the inquest.

 The ER team should take immediate action to get Treatment summary from the treating doctor
wherever applicable

 In the case of poisoning the previously collected samples of blood, urine, aspiration fluid,
vomitus and faeces are handed over to police with acknowledgement

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  At the time of inquest, the following documents should be handed over to Police officials – Death
intimation

 When the dead body is released the police official is required to sign the register kept by the
security supervisor- with time, date and designation with PC number

Medico Legal Duties Of A Doctor In Case Of Poisoning:

 All cases of homicidal/Suicidal poisoning must be reported to Police

 Vomitus, Feces, stomach washings, contaminated food etc. are collected and dispatched for
chemical analysis to the forensic department of government hospitals depending on the police
jurisdiction.
 Detailed Records must be maintained.
 If the patient is conscious, but on the verge of death, record dying declaration ( in case where
magistrate is not immediately available)
 If death occurs, Police must be informed. DEATH CERTIFICATE SHOULD NOT BE
ISSUED

Maintenance of records (including diagnostics)- May be called up on for evidence in court.

Giving statements to police– as and when required

Supporting documents: MLC register, Police intimation forms

HANDLING OF BROUGHT DEAD CASES IN EMERGENCY DEPARTMENT

Purpose:

To formulate guidelines pertaining to the patient brought dead to the ED and related certifications.

Scope:

EMERGENCY DEPARTMENT

Responsibilty:

ED PHYSICIAN & ED NURSE

The ED Physician shall pronounce the death.

In ED, 12 lead ECG is performed and asystole recorded

The ED Physician will inform the patient relative/ bystander.

34 | P a g e
The ED Staff Nurse will tag the belongings with identification details.

The belongings will be handed over to the patient bystander appropriately and it should be

Documented.

Procedure:

The patient must be properly examined by the attending doctor to look for signs of life. Resuscitation if
needed should be attempted according to ACLS Guidelines and only then to be declared Brought Dead.

THE FOLLOWING ACTIONS ARE TO BE PERFORMED:

 Carotid pulse to be checked

 Chest observed for spontaneous breathing
 Pupils assessed for size and response to light
 Defibrillator connected and rhythm analyzed

IN CASE OF AMBULANCE CALL, NO DEATH WILL BE DECLARED IN THE AMBULANCE.

PATIENT WILL BE BROUGHT TO ER, ASSESSED BY THE ED PHYSICIAN AND PROTOCOL
FOLLOWED.

Documentation in the Death Register is a must in all cases Brought Dead to the hospital. To
facilitate this all brought dead cases must be registered at front office and UHID must be
created.

SCENARIO A:

WHEN THE DECEASED WAS UNDER THE TREATMENT OF A CONSULTANT OF SRM

HOSPITAL.

 Normally, a Brought Dead is always labeled as a Medico legal case and accordingly formalities
will have to be compiled with. However if the Brought Dead patient is under the treatment of a
Doctor and if the Doctor clinically is in a position to relate his or her Death to the underlying
medical condition of the patient, then the treating doctor representing the hospital may issue the
Death Certificate. These type of cases are not labeled as medico legal case.

 Patient who is under the care of a doctor who is attending to them regularly (within 14 days prior
to death) and knows that the cause of death is most likely by the disease under treatment or
complications- Form 4A vetted by the treating consultant can be given.

SCENARIO B:

35 | P a g e
WHEN THE DECEASED WAS NOT UNDER THE TREATMENT OF A CONSULTANT OF SRM
HOSPITAL.

 IF a patient under treatment of a doctor (not one of our institute) is brought dead to our ED by an
ambulance/ private vehicle and by the history of presenting complaints and available medical
records to the emergency doctors, it is found that the cause of death is likely to be related to his
existing illness and no foul play is suspected, then the following may be done:
 The body may be sent to the doctor who has attended to the patient in life, to certify the
death.
 The Brought Dead Certificate can be issued stating the date and time of death and after
discussion with the primary treating doctor FORM 4A can be considered to be given.
 In case of any resuscitative attempts in ED, COMPLETE documentation of the same &
Brought Dead Certificate to be issued. After discussion with the primary treating doctor
FORM 4A can be considered to be given.

 IF a patient not under treatment of a doctor of our hospital and does not have any history/medical
records of an illness that is likely to be the cause of death, Brought Dead Certificate can be issued
if no foul play suspected. If resuscitative attempts in ED, COMPLETE documentation of the
same & Brought Dead Certificate to be issued.
However FORM 4A WILL NOT BE ISSUED.

SCENARIO C:

BROUGHT DEAD PATIENTS FULFILLING THE CRITERIA FOR MLC

 MLC is compulsory for all patients brought to ed fulfilling the criteria for mlc
 In such cases following the declaration of death, the body cannot be handed over to the attenders.
MLC should be done and police should be intimated. Similarly, complete evidence in the form of
clothes and other materials must be taken in safe custody and to be handed over to police.
 The body is handed over to the police with relevant documentation or the body is shifted to GH
after informing the police.

MLC CRITERIA IS DESCRIBED BELOW:

 Cases of Burns, Trauma, where in surrounding circumstances and the context suggest
commission of criminal offence
 Electrocution
 Poisoning
 Road traffic accidents
 Natural calamities
 Child sexual abuse

36 | P a g e
  Sexual offence or rape
 Criminal abortions
 Death where cause is not known or appears to be unnatural
 Hanging
 Strangulation
 Drowning & suffocation
 Unnatural death of a woman within 7 years of her marriage
 Cases where the relatives allege crime commissioned by others
 When the attending doctor suspects some foul playor improper history or the suspicious
nature of the injuries suffered by the person.

HANDLING DEATH OF PATIENT IN EMERGENCY DEPARTMENT

Scope:

Emergency department

Responsibility:

ER physician, ER nurse

Policy:

Once death is confirmed the case should be treated as death on arrival, and necessary documentation
should be done.
ER physician should go into the detailed history of the patient and arrive at the probable cause of death.
Review previous clinical documents if brought along by attenders

ER physician / Specialty registrar should certify the cause of death in the Death Certificate after careful
and thorough examinations of the patient after discussing with the concerned consultant.
Death certificate is initiated if the death occurs within the hospital, unless there are grounds and evidence
to the contrary.
The cause of death should be well documented and a copy of the Death certificate should be filed along
with the medical documents of the deceased patient.
If any doubt it will be handled similar to a brought dead case

Note: A DOCTOR SHOULD NOT ISSUE THE DEATH CERTIFICATE IN THE FOLLOWING
CONDITIONS

 Persons brought dead to emergency department

 Persons dying in emergency department before reasonable diagnosis is made
 Persons dying after admission and before making diagnosis. In all cases of unnatural
deaths (accidents, suicides/homicides)

37 | P a g e
  Snake bites
 Death of a married woman in her husband’s house within 7 years after marriage

 Death of a patient should be handled carefully with concern without complacency

 Upon the death of a patient, all efforts must be made to assure for the proper care and disposition
of the body and every reasonable effort must be made to inform the next of kin.
In circumstances when there is no next of kin identified, attempts should be made to notify a
significant other or emergency contact if no one has been identified.
This shall be done by the Manager On Duty/ AO

 The ED nursing staff / Public relations team shall provide emotional support for next of kin
and/or significant other/emergency contact

 The AO shall coordinate for the release of the patient body and settlement of hospital dues.

 Acknowledgement for receipt of the body and the Death Certificate is obtained from Next of
Kin/Legal representative

 The ER staff shall ensure completion of all documentation during the process

 The security staff of the ED shall be present till the departure of the deceased and ensure
orderliness in handing over the body to the next of kin

SUPPORTING DOCUMENTS : ED register / Death register.

RECEIVING, REGISTRATION & BILLING OF PATIENT IN

EMERGENCY DEPARTMENT

Purpose:

To have a documented protocol for receiving, registration and billing of patient coming to ED.

Scope :

Emergency Department

Responsibility:

ER Physician, ER Nurse, Administrative officer, Admission Desk

38 | P a g e
Procedure:

Patient brought to ED by relative/ police/ public/ self

Receiving:

Patient brought to ED through ED entrance through ambulance or walk-in / other locations of the hospital

 Alert Mechanism: The security staff at the entrance alerts the ED staff through the call bell
provided
 ED nurse/DCF staff receive patients in stretcher, wheel chair or by walk
 Make the patient comfortable in the bed, observe general condition, check vital signs and record
 Triage protocol – initiated.
 Inform the ED doctor
 Record the patient details, time of arrival at ED/doctor response time
 Follow ED Physician’s instructions
 The administrative officer will collect the patient details, complete the registration process and
generate a Unique Registration number.

Registration & Billing:

 At the registration counter, patient is registered under Emergency Department

 Unique identification number is generated
 Medicines/ consumables used for the patient in ED will be charged to the patient.
 investigations and consultation charges will also be charged to the patient

Patient management in ED:

 All necessary investigations are carried out as advised by the ED physician / treating consultant
 All patient samples sent to the laboratory should be barcoded as per the hospital policy. In-case of
emergency samples, the emergency test requisition is to be selected before generating in the HIS
 Record all activities in the patient record in the ED observation chart & HIS
 The Staff Nurse will hand over in detail about the patient – treatment given, investigations done /
samples sent, if payments have been made, and the list of consumables / injections used, etc.,
 After the assessment by the ED physician, if patient is well, sent home with necessary treatment
& ED summary
 If patient is critically ill or revived after CPR, follow admission procedure to ICU
 If patient needs admission, the Administrative Officer will assist the patient attender with the
admission procedures

Observation of patients in emergency department:

 The ED physician and the respective consultant determines which patient need to be observed for
what period of time prior to discharge from ED.

 The initial assessment of the patient’s condition is done on arrival and the frequency of the
reassessment will be based on the patient’s acuity and procedure/ medication protocol

39 | P a g e
  The holding time (time from arrival of patient till a disposition decision is made) in case of
standard cases is maximum of 4 hrs& boarding time (time from disposition decision is made till
the time the same is executed) is 2 hrs which is a total of 6 hrs for the patient in ED depending on
patient’s need / availability of beds.

ADMISSION PROCESS FROM EMERGENCY DEPARTMENT:

 If patient requires admission, the admission desk is informed about the same
 The administrative Officer will complete the financial counseling
 Admission desk will check the status of beds in wards/ICU
 If the patient is undergoing any Emergency surgery; follow the procedure for shifting patient for
surgery from ED.
 Update all records
 Admission consent is obtained by the admission desk prior to shifting the patient.
 Shift the patient to respective ward/ ICU following the hospital admission procedure
 Inform the concerned consultant and carry out his orders
 Patient who do not match the organizational resources, can be transferred to another facility with
permission of patient and relatives and after informing the respective hospital / doctor
 If patient is not willing for investigation, admission and further management patient can be
discharged against medical advice & these will be labeled as LAMA (Leaving Against Medical
Advice)
 In case of death do all the formalities that are required, refer work instruction for handling death
in ED , in case of brought dead follow work instruction for handling brought dead

PATIENTS WITH SURGICAL EMERGENCY:

 In case of patients in ED requiring surgical procedure the ED Nurse informs the OT Nurse-In
Charge/ OT Nurse regarding the same
 The ED Staff Nurse informs the OT Nurse about the details of the procedure, time and the name
of the Surgeon who will be doing the surgery
 The ED staff prepares the patient for the surgery and sends the patient directly to the Operation
Theatre after ensuring completion of the necessary checklists and consents ( i.e. pre op
checklist, anaesthesia consent, surgery consent, high risk procedure consents as applicable)
 The ED Staff Nurse will complete the pre-operative preparation (Physical preparation

 Informed consent of to be obtained from patient or legal guardian.

Note: Consents have to be explained and obtained by the person performing the procedure/
Surgeon. The Surgeon will explain the purpose of the procedure, method, risks, alternatives &
complications. In case the surgical procedure may result in sterility, it should be explained to
both husband and wife and consent taken

 The consent should be signed by the patient himself. If the patient is unable to give consent, the
legal guardian / attender can provide the consent

40 | P a g e
  The ED Nurse / Team leader informs the Admission desk for admission of the patient
postoperatively & the patient relatives are directed to the admission desk for further requirements

CRITERIA FOR ADMISSION TO ICU FROM EMERGENCY

DEPARTMENT

Purpose:

To define the criteria for admission to ICU

Scope:

EMERGENCY DEPARTMENT

Responsibility:

ED physician , Nurse in-charge & ICU in charge

Procedure:

 The Staff Nurse shall monitor vitals and initiate the resuscitative measures, to stabilize the patient
 Any inter-department transfer of patients from ED, should be in coordination with the respective
area
 The ED nurse will coordinate with the admission desk to confirm availability of vacant beds in
the ICU.
 The ED physician will notify the relatives of the need to admit the patient to the ICU. Patient
relatives will be directed to the Admission desk for admission process.
 The admission process will further be coordinated by the admission desk
 The ED physician will inform the Intensivist on duty about the details of transfer.
 After completion of the admission procedures, the patient will be transferred to the respective
ICU. The Staff Nurse will ensure that the patient is on life support system, if required.
 Prior to shifting of patient from ED to ICU, the necessary documents should be arranged. The
inter-departmental transfer form should be completed by the ED Doctor & shifting nurse
 Patient must be escorted by the ED nurse and ED Doctor/ ICU specialist (depending upon the
criticality of the patient )
 The ED Nurse/ ED resident will hand over the patient to the Intensivist / Staff Nurse in the
respective ICU with complete detail regarding the patient’s condition from arrival, observation,
assessment, attending Consultant, treatment, procedures and investigations prescribed and
completed, etc

 The receiving nurse at the ICU will acknowledge the transfer form through HIS. The patient
handover tool to be completed and acknowledged by the ED nurse and respective ICU nurse
 All available healthcare records must accompany the patient during transfer.
 Staff at the ED, should ensure, that patients’ shifted in wheelchairs should have safety seat belts
put on, and, stretchers should have side rails kept.

41 | P a g e
ADMISSION CRITERIA:

 Patient can be admitted to the ICU for any of the following criteria :

 VITAL SIGNS:
 Pulse <40 or >150 beats / minutes
 Systolic arterial pressure <80mm Hg or 20mmHg below patient’s usual pressures
 Mean arterial pressure <60mm Hg
 Diastolic arterial pressure >120mmHg
 Respiratory rate >35 breaths / minutes
 Hypo/Hyperthermia

 LAB VALUES:
 Serum Sodium < 120 --- >155
 Serum Potassium < 2 --- >6
 PaO2 < 60 on room air (Except Chronic Hypoxemia)
 PH < 7.30
 Serum glucose > 500
 Serum Calcium >15
 Severe Anemia/Acute Drop in hemoglobin – Hb<8

 RADIOLOGY IMAGING: CXR/USG/CT / MRI:

 Cerebral Hemorrhage, Ischemic Stroke
 Ruptured Viscera, Solid Organ Injury, Free fluid in abdomen
 Pulmonary oedema/ Consolidation/ Pleural Effusion
 Rib Fractures/Pneumothorax/ Hemothorax/Lung Contusions
 ARDS

 PHYSICAL FINDIGS:
 Any type of Brady or Tachyarrhythmia and unstable rhythms
 GCS < 10-11
 Unequal pupils in an unconscious patient
 Acute confusional state / Altered Mental Status
 Anuria/Oliguria
 Airway obstruction
 Seizure
 Cyanosis

 Acute Neuromuscular weakness

 Meningeal signs
 Patient Requiring Drug Infusion (Vasopressors, Antiarrhythmic, 3%Nacl)

 Polytrauma patients with hemodynamic instability

 Requirement of mechanical ventilation

42 | P a g e
  Evidence of coagulopathy and sepsis
 Acid- base imbalance
 Fluid imbalance (gross hypovolemia
 Severe anaemia, requiring blood transfusion
 Abnormally high PT /INR
 Patients with Acute Coronary Syndromes.
 Patients requiring temporary pacing.
 Multi-system organ failure
 Respiratory failure/dysfunction
 Acute/chronic renal failure
 Drug overdose
 Gastrointestinal hemorrhage
 Diabetic ketoacidosis
 Hypertensive crisis
 Severe Congestive Heart Failure / Cardiomyopathy
 Traumatic Brain Injury
 Cranial Vault fractures/ Facial Bone Fractures with impending airway compromise
 Spine Dislocation/ Fractures with instability
 Acute Stroke with Altered Mental Status
 Neuromuscular Disorders with Deteriorating Neurologic/ Pulmonary Function
 Epilepsy Refractory to Therapy requiring Sedation/ Ventilation/ Surgery
 Close monitoring of respiratory status
 Patients who require Advanced haemodynamic monitoring

 IN ADDITION TO THE ABOVE CRITERIA, THE RESPECTIVE CONSULTANTS

CAN USE HIS/HER DISCRETION TO ADMIT HIS/HER PATIENT TO THE ICU

ADMISSION OF UNKNOWN PATIENT IN EMERGENCY DEPARTMENT

Purpose:

To provide emergency care to the Unknown patients

Scope:

Emergency department

Responsibility:

ED Physician, ED Nurse, Administrative officer, Security In charge

Procedure:

 Reception must register the patient as per the tagging

43 | P a g e
  If Unknown patient, the Manager on duty/Administrative officer is intimated and patient is
registered as Unknown: 1…2…3…and so on.
 Arrange a photograph to be taken
 Inform the Nursing Supervisor & the ED physician immediately
 Patient information to be collected by ED physician from the person who accompanied the
patient
 ED staff should handover the patient belongings to the Security Supervisor and obtain signature
with MOD/Administrative Officer as witness
 Immediate management of the patient as necessary. Follow the instructions of the ED physician.
 Continue with admission formalities (Refer to admission procedure).
 The Manager on duty/Administrative Officer shall try to contact the relatives as early as possible.
 If patient still remains unknown inform to Emergency Department HOD, COO / CMS and the
Police. The patient may be shifted with staff to nearby Government Hospital after intimation to
the Police
 Generate the bill (Inform the Billing In charge)
 The summary of treatment in ED and patient belongings should be handed over to the police. The
same should be documented in the ED

PROCEDURE FOR ORDERING / REPORTING OF DIAGNOSTIC

INVESTIGATIONS

Scope:

EMERGENCY DEPARTMENT

Responsibility:

ED Physician, ED Nurse

Procedure:

 REQUISITION FOR LABORATORY INVESTIGATIONS

 The ED Physician shall write the order for emergency investigations. Medical notes will be
completed by the ED Physician /Treating doctor / Staff Nurse

 The Staff Nurse will draw the samples and barcode them as per the ED Doctor’s orders. The
requisitions from ED is tagged as “Emergency”
 All samples will be collected by the laboratory technician from the ED
 The nurse will check with the laboratory technician regarding the time the report is expected
to be ready.
 The Staff Nurse will ensure that a printed report is retrieved from Laboratory later
 The staff nurse will report the findings to the ED Physician immediately
 The ED Physician will inform to the treating Consultant

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  REQUISITION FOR RADIOLOGICAL INVESTIGATIONS :

 The ED Physician / Treating consultant will enter the prescribed investigation in the
Radiology Request form
 The ED Staff Nurse will inform the Radiology Department about the investigation
 In case of portable X-rays, the same is to be conducted bedside in ED only. The technician to
be informed about the same.
 Patients transferred to Radiology department for any other radiological investigations shall be
transferred on bed / wheelchair
 After the investigation, the patient shall be brought back to the ED until the treating
consultant determines the transfer to the Ward / ICUs.

SAFETY OF PATIENTS AND HEALTHCARE WORKERS DURING TRANSFERS:

 PATIENT SAFETY DURING TRANSPORTATION

 Treat any treatable underlying medical condition which increases risk of fall.
 Do not leave at risk patients unattended in diagnostic or treatment areas. If patient is left
unattended for brief periods make sure side rails are up.
 During movement of patients on trolleys make sure the safety belts are used properly and
apply safety as appropriate
 Place assistive devices such as canes or walkers within easy reach of the patient
 Ensure side rails are applied while shifting patients on stretchers
 Ensure seat belts are applied while movement of patients on wheelchairs
 Based on the criticality of Patient, ED Physician decides on team to accompany the patients
 On Arriving to the site, quick clinical examination is done and vitals are recorded by the
Doctor / Nurse

 SAFETY OF HEALTHCARE WORKERS IN AMBULANCE

 Immunization of ambulance staff against Hepatitis B is mandatory

 Appropriate personal protective equipment is available in the ambulance (mask, gown, glove,
cap, goggles / face shield

 Medical personnel and others who come in contact with the patient should follow proper
hand hygiene and barrier precautions when an infection is suspected
 For transporting a patient with known infection, appropriate precautions should be taken by
the healthcare workers (For e.g. respiratory precaution of T.B).
 Any spills of blood or body fluids is managed as per hospital protocol
 After an ambulance transfer - After shifting the patient out of the ambulance, all the
equipments and the interior of the ambulance should be disinfected

TRANSFER-IN OF STABLE AND UNSTABLE PATIENTS TO THE

ORGANIZATION

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Purpose:

To provide mechanism for safe transfer-in of stable/unstable patient from another facility

Scope:

Emergency department

Responsibility:

Treating consultant, ICU consultant, ED physician

Procedure:

 It is the policy of to accept the transfer of stable, unstable patients when space, facilities, and
personnel are available. Every effort shall be made to accept patients when the sending facility
does not have the space, facilities or personnel to provide safe and appropriate care
 Acceptance of stable, unstable patients for transfer-in to is made contingent upon verification of
available resources at
 Transfer-in of patients include planned and unplanned transfers
 In case of planned transfers, requests from other health care providers for transfer of patients for
advanced care, is informed to Emergency contact number
 The ED Doctor/ ED Nurse In-Charge / Manager on duty shall check the availability of beds/
facilities at and coordinate with the transferring hospital for further management
 The referring hospital request must stabilize any emergency medical condition of the patient prior
to transfer
 When the transferring facility is requesting for the transfer of an UNSTABLE patient, the
following conditions must be met:

 ICU doctor from the referring facility will discuss the patient condition with the ED
Doctor/ICU doctor at prior to transfer after which the transfer will be initiated after
confirming the availability of beds/ ventilators/Facilities at
 High Risk Consent should be taken from the patient’s family by the transferring hospital
 Stabilize the patient in order to minimize any risks of the individual during transfer
 Consider our capacity and capability to treat the transferred patient
 Delivery of all appropriate medical records from the transferring facility
 Transfer shall be made with qualified personnel and required medical equipments

 During planned transfers, ambulance arrangements shall be made by if requested by the transferring
hospital.
 All planned transfers, shall be received at the hospital ED. The ED consultant shall evaluate the
patient in coordination with the consultant from the concerned specialty
 The Stable, non-emergent transfers shall be admitted to hospital wards after evaluation by the
concerned specialty consultant.
 Unstable patients will be transferred from ED to the intensive care units as per the treating
consultant’s orders. The patient should be accompanied by a nurse and ED doctor while transfer to

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 ICU. Situations wherein the ED Physician is busy in the department, a doctor can be called in from
ICU to accompany the patient
 During Unplanned transfer-ins, the similar protocol shall be followed. All such cases will be received
by the ED, evaluated and stabilized. The patient will be registered under the concerned specialty as
per the evaluation of the ED team

TRANSFER OUT OF STABLE AND UNSTABLE PATIENT WHO DOES

NOT MATCH THE ORGANIZATIONAL RESOURCES:

INTRODUCTION :

An “appropriate transfer” is defined as one in which the receiving facility has available resources and
agrees to accept the transfer and provide necessary treatment, and the transferring facility provides the
receiving hospital with a complete copy of the patient’s records and other information (such as discharge
summary, copies of X-rays, etc.), and the transfer is effected through qualified personnel and
transportation equipment, including use of necessary and medically appropriate life support measures
during the transfer

Purpose:

To provide mechanism for safe transfer-out of stable/unstable patient to another facility

Scope:

Emergency department

Responsibility:

ED Physician/ Treating Doctor

Definitions:

 MEDICALLY UNSTABLE CONDITION- The term “medically unstable condition” means -

medical condition manifesting itself by acute symptoms of sufficient severity (including severe
pain) such that the absence of immediate medical attention could reasonably be expected to result
in placing the health of the individual (or, with respect to a pregnant women, the health of the
woman or her unborn child) in serious jeopardy, serious impairment of bodily functions , serious
dysfunction of any bodily organ or part
 Stabilized - The term “stabilized” means with respect to a medically unstable condition that no
material deterioration of the condition is likely, within reasonable medical probability, to result
from or occur during the transfer of the individual from a facility

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PROCEDURE FOR TRANSFER OF PATIENTS:

 Scenarios for transfer from to another facility are as follows:

 Burn cases more than 10%

 Psychiatric conditions which needs further evaluation and admission
 Transfer to another facility as per patients request
 Transfer only for diagnostic requirements

 PATIENT BROUGHT TO ED:

If a patient brought to ED requires services which not available at , the transfer shall be initiated
with a recommendation to contact the nearest facility with the necessary capabilities. The ED
physician conducts the initial evaluation and stabilization of the patient prior to the transfer.
Stabilization prior to transfer shall include securing the airway (if needed), intravenous access,
appropriate fluid replacement and pain control.
 Patients and their relatives should be well informed in the decision for transfer and their consent
should be taken where appropriate. The treating consultant / ED physician should discuss the
risks and benefits of the transfer ( stable/ unstable) with the patient relatives / patient
 Transfer procedures should be completed within 30 mins for unstable patients and within 60
minutes for stable patients
 The responsibility for the transfer primarily lies on the physician at the referring hospital until the
patient is taken over by the medical personnel at the receiving hospital
 The receiving hospital shall be asked to send their ambulance along with staff for transfer of
patient from . In-case of non-availability of ambulance with the receiving hospital, the ED staff/
MOD shall arrange for the Parvathy ambulance or other ambulance facilities for transfer of
patient
 All doctors and nurses undertaking the transfer should be properly trained, qualified and certified.

 Unstable patient: The receiving hospital shall be asked to send their ambulance along with staff
for transfer of patient from
 Monitoring of unstable patients during transport: The minimum standards for monitoring
during the transport of critically ill-patients / unstable patients include continuous pulse
Oximetry, electrocardiography, non-invasive blood pressure and respiratory rate. In addition,
based on the patient's clinical status, additional monitoring such as capnography and invasive
monitoring for arterial, central venous or intracranial pressure may be needed. Documentation
should be completed on the Intra ambulance monitoring form.
 Transfer Summary: Patients being transferred from shall be accompanied by a transfer
summary that shall include the following details: Referring physician's name, designation, contact
details; date and time at which decision to transfer was taken and reasons for transfer. Patient's
clinical status and vital parameters before, during and after transfer should be documented, so
also the medical management during the transport. Copy of patient's medical records and results
of investigations should be given to the receiving hospital
 Upon reaching the facility, all the patient documents are handed over to the respective
consultant / doctor at the facility and signature is obtained

PATIENT TRANSFER FOR DIAGNOSTIC SERVICES ONLY:

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  Patient transfer to another facility for diagnostic services are coordinated by the ED staff.
 The ED Staff/ MOD checks for availability of services and books an appointment for the patient
 Hospital ambulance is arranged for transport of the patient
 Patients and their relatives should be well informed in the decision for transfer and their consent
should be taken where appropriate. The treating consultant should discuss the risks and benefits
of the transfer ( stable/ unstable
 The allocated nurse / ED nurse checks the patient’s vitals and documents the same in the patient
file prior to the transfer
 Complete patient record along with the transfer summary is documented by the treating
consultant stating the need for transfer
 In case of transfer of unstable patient, the patient should be accompanied by a doctor/ BLS
trained nurse & patient care service team member. If the patient is stable, nurse and patient care
service team member shall accompany the patient.
 Upon reaching the facility, all necessary requirements are coordinated by the patient care service
team member
 The patient is brought back to after all necessary investigations
 Patient is shifted back to the ICU/ Wards
 The ED staff nurse shall check and document of patient vitals immediately after shift out from the
ambulance

PROCEDURE FOR DISCHARGE OF PATIENT FROM EMERGENCY

DEPARTMENT
Purpose:
To ensure safe and timely discharge of patients from ED
Scope:
Emergency department

Responsibility:
ED physician/Patient care service team

Procedure:

 Discharge procedures shall be followed to ensure patients are discharged

effectively and efficiently, allowing for optimal utilization of available
resources.

 Discharge Process is discussed with patient and family and planned accordingly.

 An authorized hospital discharge shall only be made by an authorized, written

order. However, a patient may discharge himself/herself against medical
advice. In such instances , DAMA/ LAMA consent should be obtained.

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  The treating Consultant shall document discharge instructions in the discharge
order at the time of anticipated discharge. Discharge Summary shall be
prepared and the Consultant signs the discharge summary, the patient shall be
provided a copy.

 The Inpatient service manager/ team shall be the responsible person to ensure
compliance with this policy.

 The nurse shall be responsible for completing the discharge checklist and
explaining the discharge summary to the patient. Patient/family understanding
shall be documented on the discharge register by obtaining the patient/family
signature.

The discharge summary shall contain:

 The reason for admission ,diagnosis

 Allergies
 Significant findings
 Any diagnosis
 Procedures performed
 Any medications administered
 Condition at discharge
 Discharge medications and follow-up instructions
 Investigation results

In case of death the discharge summary shall include cause of death. But in case of an MLC cause should
be mentioned as “Postmortem Report Awaited”

Discharge criteria:
 Discharge of the patient from ED will depend upon the condition of the patient.
 ED physician/treating consultant shall determine on the discharge of the patient.
 ED nurse shall assess and record the patient status
 Patient Vitals should be normal

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  GCS- normal
 To comply with the discharge criteria re-assessment reports of the patient shall be
verified.
Discharge of MLC Patient:

The ED physician informs the police about the discharge of the patient.

Patient under Observation

 Patients who come to the ED and are advised observation of their condition for a few
hours.
 Patients may be kept in the ED incase of non-availability of beds in the Wards/ICU.
 The Staff Nurse will direct the patient/relatives to the billing department to
make the payment.
 The ED physician shall explain the treatment/medicines/investigations to be done, follow
up/OPD consultation ,etc. to the patient/relatives
 Signature of the patient/relative will be obtained on the master register
 Discharge
 Summary will be filled by the ED physician.

Supporting documents:

HIS, ED Discharge summary, ED observation and re-assessment

LEAVING AGAINST MEDICAL ADVICE FROM EMERGENCY

DEPARTMENT

Scope:
Emergency department

Responsibility:
ED physician/Specialty consultant/ED staff and Patient care service team
Procedure: supporting documents: LAMA, Discharge Summary

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OBTAINING BLOOD FOR TRANSFUSION

Scope:
Emergency department

Responsibility:
ED Physician / Blood bank technician

Procedure:

 The ED Physician / treating doctor will send the requisition form.

 The ED Staff Nurse will collect the sample for grouping and cross matching.

 The ED Physician / Staff Nurse will explain to the relatives and send them to the Blood Bank for
further instructions.

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  If the blood is not available, the technician will inform the ED Physician and simultaneously try
to arrange for the blood from other blood banks

 In-case of emergency surgeries / requirements and non-availability of blood / blood products in

the blood bank, the same will be arranged after discussion with the surgeons of other elective
procedures. The blood / blood products for the elective procedure will then later be arranged from
outside.

 On arrival of the blood, the ED Physician / Staff Nurse will check the blood for blood group,
whether cross matching has been done, Rh compatibility, expiry date, etc.

 Turnaround time for Issue of blood and blood products to ED should be within 30 min.

PROCEDURE TO OBTAIN MEDICATIONS NOT LISTED IN THE HOSPITAL

DRUG FORMULARY

Requisition for drug not listed in

Formulary

Routine Emergency

The treating consultant/physician

Inform Pharmacy manager
has to fill up the New
DrugRequisitionform

Pharmacy manager shall obtain Pharmacy manager shall obtain

approval from COO/ Manager oral approval from COO
purchase department

If approved If not approved

Pharmacy department shall Inform the consultant / physician

arranged for local purchase of the and suggest alternative available in
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drug the hospital as per the formulary
STORAGE & LABELLING OF MEDICATION:
Purpose:

To guide drug storage and control

Scope:

Emergency department

Policy:

Storage:

 Medications shall be stored as per manufacturer’s recommendations.

Appropriate temperature is below 25 °.Medications that needs to be stored
between 2 to 8 degree should be stored in the designated medication storage
refrigerators.
 Medication refrigerators shall be used only for storage of medications and nothing else.
 A temperature log must be maintained for each medication refrigerator used
for storage of medication. The documentation must indicate that the
temperature is monitored on a daily basis during each shift. In case of any
complaints regarding the temperature of the refrigerators the maintenance
department should be contacted immediately.
 Room temperature of all medication storage areas to be monitored daily.

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  All medications to be maintained under constant surveillance by
appropriate personnel. Narcotic drugs and psychotropic substances to be
stored in double locked cup board to prevent loss/theft/misuse.
 Medications that are easy to confuse (sound alike and look alike drugs or
reagents or chemicals that may be mistaken for medications)shall be segregated.
 High alert drugs are stored with red label
 All medication storage areas shall be periodically inspected with the respective checklist
according to policy to ensure medications are stored properly.
 Medications shall not be stored under any sink.
 Medications shall not be stored on the floor or next to ceiling.
 Medications shall be stored in an orderly & uniform manner in medication
cupboards and in carts of sufficient size to prevent crowding in separate
compartments.

 Medications bearing an expiration date will not be dispensed or distributed

beyond the expiration date. All near to expiry medications shall be removed
from the designated area and returned to the pharmacy as per the policy. Refer
to Expiry of medication policy
 In case of delay in return the same should be removed from their area and placed in a
separate box labeled “near to expiry drugs” and kept in the department cupboard.
 Expired, discolored, damaged, or inappropriately labeled controlled substances
from Inpatient care areas shall be returned to the Pharmacy for proper credit
and/or disposal along with incident reports.
 Limiting use of multi dose containers for single patient use unless reason ably justified.
 Medication used for patients & stored in the fridge should be labeled with
patient name/UHID and date of opening in all the patient care areas.
 The organization has developed a proper mechanism to prevent pilferage,
loss, and theft of medicines by way of proper inventory control.
 Emergency drugs / Crash cart drug storage: The crash carts with the
emergency drugs maintained in the department will be under the responsibility
of ED Nurse supervisor. The crash cart to be maintained locked at all time.
Monthly check and Replenishment of items in the crash carts are under the
responsibility of the ED Nurse supervisor in coordination with the hospital RRT
team.

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  Inspection of drug storage facilities: Regular inspections / audits to monitor
the compliance to drug storage throughout the hospital shall be conducted by the
clinical pharmacists & quality department.

POLICY FOR STORAGE, PRESCRIPTION AND ISSUE OF NARCOTICS

Purpose:

To provide guidelines governing a proper control of storage, dispensing, handling, prescription,

administration and balance disposal of Narcotic Medications in in consonance with Narcotic Drugs and
Psychotropic Substances Act of the Country as instituted and modified by the Government of India and
State of Tamil Nadu.

Scope:

Central pharmacy and other pharmacy areas as well as all patient care units of

Roles & Responsibility:

Senior Consultants, Senior Specialists, Specialist, Resident doctors, Pharmacist, Nurses &Technicians.

Storage of narcotics:
List of Narcotics used at :

 Inj.Fentanyl Citrate
 Inj.Morphine
 Inj.Pethidine

 Narcotic drugs and psychotropic substances shall be used as per Narcotic drugs and psychotropic
substances Act.
 The Pharmacy Manager is the responsible person for receiving, storing, dispensing narcotic drugs
to authorized patient care areas with appropriate documentation and over viewing the entire
process of safe storage and use of Narcotic drugs in the hospital.

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  Narcotics shall be stored only in specified patient care areas which are approved by medical
director based on the treatment requirement of the patient category admitted in the units.
 The Narcotics shall be stored under double lock and key to ensure its rational usage throughout
the hospital. In patient care areas, the same shall be locked and one key is maintained with the
Nurse Officer and the next key with the senior staff nurse on duty.
 In pharmacy, the Narcotics shall be stored under double lock and one key is maintained by the
senior pharmacist on duty and one with the Nurse supervisor for the hospital. Handover of the
key is recorded in the register maintained in pharmacy.
 Other than narcotic drugs, no items are permitted to be stored in the narcotic drug cupboard.

Prescription & issue of narcotic drugs

 Narcotic and psychotropic medicines shall be issued only according to a registered medical
practitioner’s prescription.

 There shall be only two staff members (registered nurses / anesthesia technologist / medical
practitioner) involved in the issue, preparation, administration of a prescribed drug and disposal
of wastage ,if any, for any single patient, in the area where floor stock is available
 Narcotics shall be prescribed in the approved Prescription format only.
 Rational prescription policy shall be adhered to in prescribing Narcotics.
 Injections of morphine and fentanyl or Transdermal patches of Fentanyl can be prescribed by all
doctors in Anesthesiology, Critical Care and Emergency Medicine departments and those who are
privileged for providing IV Sedation for procedures. The prescribing doctor will take the
responsibility of its safe use, administration, monitoring and management of the side effects if
any. Prescriptions by other Doctors require counter signature by a privileged doctor.
 Only authorized personnel shall handle these drugs in accordance with policy. Telephonic orders
for Narcotics is not acceptable
 Issues shall be under perpetual declining inventory and against prescription from the medical
practitioner. The prescribing practitioner shall be responsible in case the prescription does not
conform to statutory regulations. Nursing station shall ensure the entry of batch number in the
prescription form while administering
 After preparation and administration of the drugs the empty ampoules shall be returned to the
indenting/dispensing location.
 The Nurse should withdraw the solution from the ampoule near the medication preparation area
in the unit and return the empty ampoule immediately to the narcotic cupboard to avoid
misplacement of the empty ampoules.
 The left over narcotic drug shall be discarded after the administration of the drug in the presence
a staff who can be a registered medical practitioner or a registered nurse or a privileged staff and
the amount discarded is documented in the register with the signature of both staff. The narcotic
syringe should be flushed with water and discarded appropriately.
 For continuous infusions the drug should be diluted as prescribed and label the syringe with the
name of the patient, UHID, name of the medication, quantity per ml, date and time of preparation,
signature of the person prepared.
 Narcotic usage entry should be done in narcotic register without fail, and to be countersigned by a
witness. All entries on the Narcotic administration record must be in blue or black ink only and
stock update by the pharmacist in red ink which will be counter signed by receiving nurse.
Documentation in the narcotic register shall be done with utmost care. If any spelling mistake or

57 | P a g e
 wrong dose entry in the narcotic prescription or register should be corrected with a new entry
after striking off the incorrect entry which should be countersigned.
 Daily Narcotic stock audit: Narcotic drug stock check should be done during the shift handover.
At the beginning of the shift, in-coming assigned staff and the out-going staff should ensure the
stock balance, empty ampoules and the ampoules used in the prescriptions are matching.
 Discrepancies/errors identified on the Narcotic register or prescription or stock at the time of
count or at any time, shall be notified to the team leader/ nursing officer/Nurse Manager and
resolved by the entire staff. No staff from the unit will leave the unit, until the narcotic count is
reconciled
 Any unresolved discrepancy (drug, quantity and reason for the discrepancy) should be escalated
immediately to pharmacy manager, CNO and quality department through incident reporting and a
proper RCA should be done if indicated.
 The Clinical pharmacists team or along with Nurse Manager will conduct periodic inspections
regarding safe storage and appropriate record keeping of narcotics in the patient care area where

narcotics are stocked. Audits shall also be conducted by the Quality team on monthly basis to
assess the storage, prescription practices
 If an ampoule is broken accidentally, secure the broken ampoule/pieces safely and inform the
Nursing officer on shift, Pharmacy manager and CNO. Nursing officer on shift or pharmacy
manager will verify it on the site. An incident report should be raised by the staff nurse involved
or the nurse who witnessed the incident and forward the incident report to Quality department
 Quality department shall ensure that a proper RCA being done and appropriate preventive action
has been taken. Replacement shall be obtained as approved by medical director

Narcotic Drug Request from Pharmacy

 The indent for new stock or stock enhancement of narcotics shall be raised on
Narcotic request form after getting approval from CMS. The Pharmacy main store
shall release the narcotics medications as per the approval and indent
 For Further Refill of the Narcotic Medications : The Pharmacy main store shall release
the Narcotics, when the used ampoules, (empty ampoules) along with matching
number of white copies of triplicate prescriptions and a request for refill of the stock.
Refill request form can be filled by the senior nurse of the unit which is counter signed
by nurse manager.
 Details of Narcotic request form and the issue number to be entered in the Narcotic
register in the Pharmacy and daily account of essential Narcotic drugs to be maintained
as per the NDPS Act. The white copy of Narcotic drug request form shall be kept in
the main pharmacy.
 Narcotic drugs from the central pharmacy shall be collected by the assigned nurse/
assigned staff.
 The pharmacist will check the prescription order carefully and make sure that all

58 | P a g e
 the information is complete, as well as the consumed amount in the document is
correct and there maintaining balance is properly used or discarded, documented
and signed.
 The pharmacist who issues the drug should also verify the prescription with the entry in the
register and update the stock with the issue quantity with the stock balance which can be
countersigned by the receiving nurse.
 The nurse shall bring the Narcotic drug to the unit and keep in the narcotic cupboard in the
presence of the senior nurse/assigned narcotic nurse in the unit after verifying the stock balance in
the register and in hand

POLICY ON USE OF MEDICATIONS NEARING EXPIRED OR

OUTDATED
Purpose:

 To lay down a policy for Identification and disposal of near expiry, slow /nonmoving, damaged
and banned Items.
Scope:

 All patient care areas

Procedure for Identification & Returns of Expiry Items:

 Every effort should be taken by the user departments to identify the non-moving & near expiry
items on a monthly basis.
 Pharmacy Return Slip shall be prepared for the items & the same should be sent to the Pharmacy
where they will be verified and taken in to the stock ledger.
 The goods will be moved to a near marked area in pharmacy return bay
 Medicines should be removed from their assigned areas 90days prior to the actual expiry date.

Procedure for Pharmacy Returns of damaged goods:

 Materials found damaged at the time of receipt by User Department stores, will return
immediately to hospital pharmacy with Return Slip referring the Issue number / Transfer number.
 In case the damaged items are found in stock at a later date either by the User Department, the
same will be returned back to the hospital pharmacy with a “Stores Return” clearly indicating the
reason for damage.
 In all the above, users stock return slip shall be a signed by the Departmental Heads clearly
stating the reason
 Pharmacy Return will be acknowledged by the Pharmacy department on receipt of the Materials.
 Pharmacy in c///harge after verification of material will move the same to the supplier return area.
 The damaged material shall be intimated to the supplier, obtain date & return to the supplier

59 | P a g e
 along with gate pass either on replacement basis or obtain credit note, toward the value. Any
dispute arises between the vendor & unit the same shall be refer to purchase department for
necessary advice and action.
 Incident report to be raised by the user departments in case of receipt of damaged / expired
medication from pharmacy.

BREAKING OF BAD NEWS IN EMERGENCY DEPARTMENT

Principles of Breaking Bad News to Patients

Patients have a right to

 Accurate and true information

 Receive or not receive bad news
 Decide how much information they want or do not want
 Decide who should be present during the consultation ,i.e .Family members
including children and/or significant others
 Decide who should be informed about their diagnosis and what information
that person(s)should receive

Patients and circumstances differ

The impact of bad news is influenced by the difference between the patient’s
expectations, including his or her ambitions and plans, and the medical reality of the
situation. When breaking bad news to patients and/or their family and significant
others, their capacity to understand the information being offered should be considered.
While the legal age of consent for medical treatment is 18, in general, when dealing
with people under 18, their parents or guardians should be involved.

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 We should also respect denial of bad news, which is a natural response.
Communication happens through time, not only in one place and location. Consider
communication as a process, and plan for follow-up.

Different types of communication are appropriate in different situations, such as

communications between patient/family and professional; between patient and family;
and between professionals

PROCESS FOR BREAKING BAD NEWS

Elicit Person’s
Understanding

Does person know or

suspect the truth?

‘Fire Warning Explore Level of

Shot’ Knowledge

Break news at person’s pace Confirm news at person’s

in manageable chunks pace

Acknowledge immediate
reactions

Allow person time for initial shock

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 Deal with emotional reactions and questions

Offer support as appropriate

How should we give the bad news?

Identify correct patient and family

It is vital that the team first identify the correct patient, and where appropriate the correct family members
and/or significant others, who have permission to be informed. The person breaking the bad news is
responsible for ensuring that all information available is accurate and relates to the correct patient. All
shared information must be documented in the named patient’s record.

Who should break bad news?

The bad news will be imparted only by the lead consultant or senior member from the treating team, who
is known to the patient or in whom the patient has trust.

The task of breaking bad news should not be given to junior staff. It is recommended that one other
member of the multidisciplinary team, such as a nurse should be present (or at least available) when bad
news is being broken and during ongoing consultations.

Who else should be informed?

If members of the multidisciplinary team actively involved in the immediate direct care of the patient are
absent during the breaking of bad news, the absent members of the multidisciplinary team should be
informed as soon as possible. Such discussions should be documented in the patient’s clinical notes and
should include the key phrases that were used. With the patient’s consent the general practitioner, and
other medical advisers, should be promptly informed about what the patient has been told and how he/she
has responded to the information.

Where should we give the bad news?

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The location for telling bad news is important. Every effort should be made to ensure privacy and
confidentiality and to help the patient feel comfortable. If the patient is bed-bound it may be necessary to
transfer the patient in his/her bed to a suitably private room. If possible, but only with the patient’s
permission, try to ensure that the patient has the support of a key relative or friend of their choosing while
the bad news is being broken. It is ideal to have a private room, with comfortable chairs at an even height,
and with no objects or furniture, such as a desk, between the people giving the information and the patient
and/or others in receipt of the bad news.

Mobile phones can be disruptive. It is best to leave them with a colleague or ensure the volume is turned
down. Apologize if it is vital to bring a pager/mobile phone into the meeting. A ‘Meeting in Progress’ or
‘Do not Disturb’ notice on the door is also helpful as it can help to avoid unnecessary and distressing
interruptions.

The discussion might need to be conducted by the patient’s bedside. Check with the patient that this is
agreeable. If so, the curtains should be drawn. The person relaying the bad news should also try to sit near
the patient, at eye level, rather than standing at the end of the bed.

When to tell bad news?

As early as possible in the diagnostic process the multidisciplinary team should begin to prepare the
patient for the possibility of bad news. It should be a goal of good practice that patients are informed of
significant information as soon as it is confirmed, provided they are in a fit state to receive the
information and have access to support should they wish. Be mindful that some patients prefer to receive
bad news by themselves and their wishes must also be respected.

In many cases, the need to break bad news can be anticipated, for example, during the post-surgery ward
round or following the arrival of histology reports. It is vital that sufficient time be set apart for
communicating bad news and that it be planned into work schedules.

What should a patient be told?

The definitive answer is the truth, and nothing but the truth. The doctor’s primary responsibility is to the
individual patient. Responsibility to relatives and/or significant to there is important but secondary.
However, always ask the patient how much information they already have about their condition and how
much they want to know.

Knowing how much information the patient wants to receive will guide you in informing them without
overloading them with information. It also gives the patient a sense of some control over the process.

Remember, it can be difficult to take in information while bad news is being broken. It is always worth
asking the patient if he or she would prefer to be fully informed or if they would rather that you talk with
a family member or friend about their medical situation. It is important to obtain the patient’s permission
to discuss his or her care with family members or friends.

Take your lead from the patient. Listening to their concerns conveys respect and acknowledging that the
news is difficult for them is also helpful.

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To ensure that the patient understands any implications, give accurate and reliable information. The
information given should reflect the needs of the patient at that time, for example, if consenting to a
procedure or treatment, or requesting more information on an illness or prognosis. It is often difficult for
people to take in all the information during one meeting. It may be necessary to arrange a follow-up
meeting to allow the patient to come to terms with the news and to ask any additional questions they
might need answered.

The patient, not the family, should be the first person to be informed of the news, except in the case of a
minor. Patients with an intellectual disability or cognitive impairment, or who are minors, have a right to
information regarding their health. This should be approached with special preparation and sensitivity and
should involve people who can support the individual, like family members, significant others, or care
workers who know the person well.

Varying responses to bad news

DENIAL SHOCK

ANGER GUILT

BLAME AGITATION

HELPLESSNESS SENSE OF UNREALITY

MISINTERPRETING INFORMATION REGRET/ ANXIETY

Cultural and language difficulties:

If there are language difficulties, a trained and independent (non-family) interpreter should be used.
Never use young children, even if they are the only ones available with the language skills. If using an
interpreter, face-to face rather than telephone conversations are preferred. Be aware that the culture, race,
religious beliefs and social backgrounds of the patient ,families and/or significant others may affect how
he/she deals with the information received. If you are unsure about particular cultural implications,
always ask for more information- never make assumptions.

Supporting the patient & family following bad news

It is important to ensure that any concerns raised are addressed. Written information should be given on
useful contacts and numbers. Don’t be afraid to say, “I don’t know.” Be empathic and also aware that
casual remarks can be misunderstood. The patient, family and significant others also need private time.
They should also be reassured that they are not expected to remember or understand all the information.

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They should be encouraged to check what they have remembered or understood with members of the care
team. If appropriate, follow-up meetings should be offered.

Self-Care
Breaking bad news can take a toll on the person delivering it to the patient. Be aware of your own feelings
and those of others involved. Peer group and other staff support may be valuable. This is especially
important if you have recently experience dabereavement.

When Sudden Death Occurs

Each case of sudden death is unique and the needs of the family and/or significant others must be
assessed on an individual basis. However, the following guidelines (which are similar to the general
guidelines on breaking bad news), may be helpful in cases involving sudden death. The short period
before the breaking of bad news - the journey to the hospital, during resuscitation or when beings own
into a family room-may produce arrange of emotions such as fear, hope ,anger ,and sorrow.

The most experienced member of staff available should be allocated to the family and/or significant
others. Where appropriate, other members of the multidisciplinary team should be involved in the
process. Involve pastoral care as soon as possible and in accordance with the family’s/significant others’
wishes. Social workers are a useful resource when supporting families and children in sudden death.

When possible the team should prepare the family/significant others for the possibility of bad news as
early as possible on the telephone or during the resuscitation process. You could say, for example, “The
news is not good …….” Inform the family/significant others as soon as death is confirmed. It is important
to say what you mean, to use the word ‘dead ’and ‘died’ rather than he has ‘gone ’or ‘passed away. ’The
deceased should be referred to by name.

Find out what the family/significant others know - fill in the details. Give accurate and reliable
information so that the family/significant others understand what has occurred. If requested, inform the
family and/or significant others of the people who were present at the time of death.

When a doctor has broken the bad news it is preferable that he/she hand the family into the care of a nurse
who can stay with them and answer any questions that might arise, rather than leave the family standing
alone on a corridor not knowing what to do. If a nurse was present when the person died, the family may
wish to speak with him or her, again to aid understanding and acceptance.

It is important that staff members have access to support following involvement with be reaved
family/significant others.

Viewing the body

 Provide a private, dignified environment for viewing the body.

 Viewing the body will help to confirm the death for the family/significant others.
 It provides an opportunity for positive identification.

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  If there are disfiguring injuries, give informed choice prior to viewing.

 Advise the family that ,if there is a post-mortem, intubation tubes and intravenous lines must be
left in.
 In consultation with the family consider the needs of the children.
 During the viewing invite the relative or significant others to touch and hold the deceased as
appropriate.

Attend to formalities
There are many formalities surrounding the death of a patient. You should document details of next-of
kin, information given, plans, interventions and, if necessary ,reactions to bad news and/or changes in
prognosis or outcomes.

The possibility of organ donation should be discussed and documented.

INFECTION CONTROL GUIDELINES IN EMERGENCY DEPARTMENT

1. All Emergency physicians & ED staffs will undergo mandatory training on

infection control practices
2. All Emergency physicians and staffs will follow the infection control procedures
as laid down by the Hospital Infection control Committee.
3. All Needle prick injuries will be reported through incident report to the Infection control
nurse.
4. Screening for MRSA will be done in the ED for all patients who are
transferred in from other hospital with History of 48hrs and above stay in that
hospital .screening will also be done for bed ridden patients.
5. Swabs will be taken from the nose, axilla, groin, bedsores (if present) of patients
fulfilling those criteria and sent to lab and will be informed to the Respective
unit nurse on handing over the patient.
6. Since ED is one of the high risk areas standard precautions will be taken by the staff at all
times.
7. Equipment cleaning and sterilization will be supervised by the nurse in-charge.
8. Swabs will be taken from the different areas and will be screened for nosocomial pathogens.

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Infection Prevention Measures In the Emergency Room
Implementation of Standard Precautions

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Use of PPE recommendations–

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Implement Transmission Based Precautions–

Eg. Contact Precautions

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The ER staff shall be trained on initiating isolation precautions based on the clinical
syndrome.

 Conduct a yearly risk assessment at ER for possible exposure to blood /body fluids
and airborne infections including TB.
 Ensure basic engineering control components are in place.
 Ensure good environmental &equipment disinfection practices are followed in the ER.This
includes the ambulance facility. Ambulance will be maintained as a “clean” area.

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  Training in locally prevalent infectious diseases shall be provided to ER staff annually.
 Appropriate training in management of infectious exposures including availability
of post exposure prophylaxis shall be ensured

QUALITY ASSURANCE IN EMERGENCY DEPARTMENT

Quality assurance (QA) is an increasingly important element in the administrative management of the ED.
The need to critically self-evaluate physician performance, allocate scarce resources, and conduct careful
risk management requires a methodology well met by a comprehensive QA plan.

Quality Plan

Monitoring
Sl. Record
No. What When How Who

Training on Emergency
As per Training Internal Training
1. BLS/ACLS/PAL Physician/
Schedule /External Attendance
S/ITLS Nurses /L&D
Trainer
Dept.

Departmental Emergency Training

2. teaching Every week Seminars Physician Attendance
/ED Nurses

ED staffs /
Emergency Every Mock drill
Quality team &
3. Preparedness 6months Mock Drills reports are
other supporting
maintained.
departments
Training an
Departmental internal Infectious disease Internal audits
4. Infection control Every month infection control dept and training
surveillances records

71 | P a g e
Quality Indicators Monitored in ED:

Quality Indicators Monitored Frequency of

monitoring
ER Efficiency Indicators
1 Average time taken from arrival at Emergency unit to triage initiation Monthly
2 Average time taken for initial assessment by physician(hours: minutes) Monthly
Time taken for assessment of ER cases
3 Percentage of 'Green'/ Non urgent category patients seen with in 60Minutes Monthly
(or as per the hospital policy)
4 Percentage of 'Yellow'/urgent category patients seen within 30minutes (or Monthly
as per the hospital policy)
5 Percentage of 'Red'/immediate category patients seen with in 5minutes (or Monthly
as per the hospital policy)
Holding & Boarding Time
6 Compliance to holding time of the patient in ER Monthly
7 Compliance to boarding time of the patient in ER Monthly
8 Percentage of Return to the Emergency Department within 72 hours with Monthly
Similar presenting complaints
9 CPR survival rate Monthly
10 Average door to needle time for intravenous rt-PA in ER patients with Monthly
acute ischemic stroke(hours: minutes)
Transfer Out Summary Documentation
11 Percentage of Transfer out cases Monthly
12 Compliance to ER Transfer out summaries given to patient Monthly
13 Completeness of the ER transfer out summaries Monthly
Discharge Summary Documentation
14 Percentage of ER discharges Monthly

15 Compliance to ER discharge summaries Monthly

16 Completeness of the ER discharge summaries Monthly

Managerial indicator

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 17 Total ER visits (excluding OPD) Monthly

18 Percentage of LAMA cases Monthly

19 Percentage compliance to LAMA consents taken Monthly

20 Completeness of the LAMA consents Monthly

21 Percentage of MLC patients Monthly

22 Percentage of patients brought dead Monthly

23 Percentage of patients declared dead Monthly

AMBULANCE

24 Average ambulance response time(hours: minutes) Monthly

25 Average time taken by ambulance to bring the patient to ER(hours: minutes) Monthly

26 Percentage compliance to intra transfer monitoring Monthly

27 Percentage of ER patient satisfaction Monthly

28 Percentage Ambulance patient satisfaction Monthly

OCCUPATIONAL HEALTH AND SAFETY IN EMERGENCY DEPARTMENT

Hazards for Staffs/Patients in Emergency department:

 Emergency Department (ED) workers are at particular risk for exposure to blood and blood-borne
pathogens because of the immediate, life-threatening nature of emergency treatment
 Because of the emergency atmosphere, (i.e., high traffic and compact treatment spaces) slips
/trips/falls may be a specific concern for ED areas.
 Injury may occur to employees from improper training or use of equipment (e.g., defibrillators).
Electric shock may also occur as a result of lack of maintenance or misuse of equipment and/or
its controls. Oxygen-enriched atmospheres and water may contribute to hazardous conditions
 Workplace violence is an issue in EDs because of the crowded and emotional situations that can

occur with emergencies. In addition, ED patients could be involved with crimes, weapons, or
violence from other people that could put the ED employee at an increased risk of work place
violence.
 Exposure to Tuberculosis and other infectious agents from patients in waiting room and treatment
areas. Staff may be treating an emergency and be unaware of other pre-existing infectious

73 | P a g e
 conditions
 Exposure of ED staff and other hospitals workers to patients exposed to biological agents,
chemical agents, and mass causalities as a result of terrorist attacks or events.

DISASTER MANAGEMENT IN EMERGENCY DEPARTMENT:

 A MASS CASUALTY INCIDENT describes an incident in which the Emergency Department
resources, such as personnel and equipment, are overwhelmed by the number and severity of
casualties.
 Disasters, whether natural or manmade, usually occur without much warning.
 Even if the probability of occurrence of such disasters may be considered as low, the necessity of
being prepared for the worst has to be accorded topmost priority.
 Advance planning, therefore, has to be done and all the planned activities adequately rehearsed so
that if the need arises, all concerned are prepared to take immediate action
 Normally, the Emergency Department will be the first to know of an external or internal disaster. It is
also the initial site of the hospital were patients will be triaged and treated

Purpose:

 To attend promptly and effectively to all individuals requiring medical attention

 To protect patients, visitors and staff from injury
 To protect property, facility and equipment
 To outline the emergency department responsibilities
 To prepare the emergency department staff and resources available within for optimal
response in a disaster situation

Scope:

EMERGENCY DEPARTMENT will triage all patients as per the severity of their condition
and provide resuscitative care, definitive treatment and appropriate transport. The hospital
departments and senior staff will provide the necessary resources, support and coordination to the
ER response in order to ensure medical care to a large number of patients

PROCEDURE:

Disaster response flow

First information about disaster received at Emergency department

Emergency Physician on duty will inform HOD – EM or Hospital command control and take Authorization to declare CODE BROWN

“CODE BROWN” announcement will be made 3 times and repeat again after 2 minutes

Hospital telephone operator will inform the key personnel in the predefined disaster call list

74 | P a g e
Triaging will be performed by the triage team as per the triage algorithm and the patients moved to appropriate patient
If no
If more victims
possible, these Patients
arrive,
procedures
Hospital willBROWN
thecommand
CODE
must
Paging be
betreated
willby
followed
control
announcement the
COORDINATOR
Back
before
overseerespective
to will
normal
the
shouldand take
victims
beassist
“CODEteams
enter
all asresponding
authorization
work flow
the
areas
BROWN per standard
ALLfrom
triaging hospital
area
CLEAR” ED
3ortimes
during thepolicy
command control
emergency
CODE BROWN for code BROWN
department
care areas
 The emergency nurse in charge will call all members of the emergency department starting from the
emergency physicians, followed by emergency nurses and the paramedics.

The HOD – EM or senior emergency physician on duty will assume the role of CODE BROWN
COORDINATOR. He will make arrangements to receive the disaster victims by clearing the emergency
areas and allocating areas/ responsibilities to the staff.

Patients will be received in the triage area, (incase of chemical contamination, follow DECON PROCEDURE)
(in case of radio-active exposure, follow RADIATION ADDENUM). (In case of infectious agents, follow
EPIDEMIC THREAT RESPONSE PLAN.)

HOSPITAL DISASTER RESPONSE TEAM:

 MEDICAL DIRECTOR
 COO & CENTRE HEAD
 HEAD OF EMERGENCY DEPT & ER PHYSICIAN ON DUTY
 TRANSPORT MANAGER
 NURSING DIRECTOR
 OPERATIONS TEAM
 PHARMACY INCHARGE
 HOUSEKEEPING INCHARGE
 SECURITY INCHARGE

CLASSIFICATION OF DISASTERS:

• INTERNAL DISASTER: FIRE, EXPLOSION, HAZARDOUS MATERIAL SPILL OR

RELEASE

• MINOR EXTERNAL DISASTER: INCIDENTS INVOLVING SMALL NUMBER OF

CASUALTIES. LESS THAN 10 PATIENTS

• MAJOR EXTERNAL DISASTER: INCIDENTS INVOLVING LARGE NUMBER OF

CASUALTIES, MORE THAN 10 PATIENTS

DISASTER SCENE TO HOSPITAL COMMUNICATION: Using the METHANE message format

M- MAJOR INCIDENT

E- EXACT LOCATION

T- TYPE OF INCIDENT

H- HAZARD PRESENT OR SUSPECTED

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A- ACCESS: ROUTES THAT ARE SAFE TO USE
N- NUMBER, TYPE, SEVERITY OF CASUALTIES

E- EMERGENCY SERVICES PRESENT & REQUIRED

HOSPITAL’S ROLE DURING DISASTER:

 Dispatch of Ambulances and EMTs to the scene

 Dispatch of Emergency Physicians to the scene if required
 Triage & prioritization of victims at the scene
 Transportation of victims to the hospital
 Triage of victims at the ED
 Emergency care of patients based on their priority and condition
 Stabilization, appropriate speciality referral and surgical interventions
 Supply manpower, equipment, drugs and consumables during disaster response
 Overall supervision and coordination of the disaster response
 Medico legal formalities whenever applicable

ACTIVATION CRITERIA:

AT SRM HOSPITAL, THE HOSPITAL DISASTER RESPONSE PLAN OR CODE BROWN IS

ACTIVATED IF THE NUMBER OF VICTIMS IS MORE THAN 10 ARRIVING FROM A SAME
INCIDENT.

SPECIALITIES TO BE INFORMED:

• ORTHOPEDICS

• PLASTIC SURGERY

• NEUROSURGERY

• GENERAL SURGERY

• VASULAR SURGERY

• CARDIAC SURGERY

• GYNAECOLOGY

TRIAGE & IDENTIFICATION OF CASUALTIES:

RED PRIORITY 1 – Patient battling for life in need

RESUSCITATIVE/EMERGENT of resuscitation/ severe
hemodynamic compromise/
Shock/ Traumatic amputation
of an extremity.

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 Seriously injured patient who
needs rapid medical
intervention/ penetrating
chest, head or abdominal
injury/ neurovascular
compromise of an extremity

YELLOW PRIORITY 3 - URGENT Patient with stable vitals but

the presenting problem
suggests further evaluation

GREEN PRIORITY 4 - LESS Stable patient with lesser pain

URGENT/NON URGENT scale/ laceration/ puncture
wound requiring sutures/
isolated upper extremity
injury.

Minor contusions, abrasions,

lacerations not requiring
closure, non urgent with
minor complaint

BLACK DECEASED NO REGISTERED

BREATHING AFTER
CLEARING OF AIRWAY

ALLOCATED AREAS ACCORDING TO TRAIGE CATEGORY:

• RED- EMERGENCY DEPARTMENT, 3 BEDS

• YELLOW- EMERGENCY DEPARTMENT, 5 BEDS

• GREEN- OPD AREA

• BLACK- REVIEW OPD

• ATTENDER WAITING AREA- RECEPTION AREA

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ROLE & RESPONSIBILTIES OF ER PHYSICIAN:

• Takes the charge of the incident and assign roles

• Head of Emergency department must be informed

• Update
ER NURSE MANAGE THE TRIAGING OF
PATIENTS highest
authority of
the ER/ICU NURSE MANAGE THE RED ZONE hospital
WARD NURSE/ ER NURSE MANAGE THE YELLOW about
ZONE magnitude
of incident on
OPD NURSE MANAGE THE GREEN ZONE
time to
time basis (Chairman/Executive Director/Managing Director/ Director, in Descending Order)

• Emergency physician on duty (team leader) will be in charge until the Head of Emergency
Department arrives.

• Ensure the presence of each team member

• Emergency physician on duty (team leader), and the nurse team leader will be responsible for
establishing the triage area, and then starting the triage process with other staff.

• Ensure documentation

• Announce stand down

• STAND DOWN: CRITERIA

 All victims of events are sorted in terms of care they need
 No more active threats of the same disaster and all required resources are established for
all affected victims

• Ensures disposition of patients which helps the department readiness for further emergencies

Existing patients in the emergency department:

• The Emergency Physician-Team Leader will

 Speed admission process of patients waiting for admission

 Complete pending discharged patients

 Clear acute area/ trauma room

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  Transfer patients to other designated OPD area as needed

ROLE OF NURSING DIRECTOR:

• Identifying Nursing Needs

• Mobilize Nursing Staff to Triage and treatment area as needed

• Periodic review of arrangements

allocation of nursing staffs during disaster shall be:

ROLE OF PHARMACY INCHARGE:

• Report to the ER Physician-Team leader

• Update to team leader regarding stock of medication available

• Have list of suppliers who can provide emergency supplies quickly

• Coordinate with the ED team and arrange necessary supplies of medications and consumables as
required

• OP and IP Pharmacy should remain open and have a runner to deliver required medications to
respective areas

ROLE OF TRANSPORT MANAGER:

• To ensure appropriate Communication between Ambulance staff and ER

• To ensure Pre Arrival Intimation is given to ER

• To have his team on standby for transportation purpose

• To Mobilize EMTs to ER if and when required

ROLE OF OPERATIONS TEAM:

• To ensure Patient Registration & Billing

• Unique registration number is generated

• To coordinate with the nursing staff and keep track of medicines, consumables, investigations and
consultation charges for the patient

• To intimate the Police and coordinate accordingly

• To coordinate with COO and get necessary equipment & personnel available

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ROLE OF SECURITY INCHARGE:

SECURITY OFFICERS ARE TASKED WITH

• securing the premises and personnel by staying on patrol

• monitoring surveillance

• performing inspections

• guarding entry points and verifying visitors

ROLE OF HOUSE KEEPING INCHARGE:

• Keeping facilities and common areas clean and maintained.

• Cleaning up spills with appropriate equipment

• Collecting and disposing of trash

• Assisting patients & attenders when necessary.

• Cleaning and stocking restrooms

DEBRIEFING:

• Debriefing should be done by the MEDICAL DIRECTOR, COO & ER HEAD after stand down

• All team leaders have to be there with feedbacks from their team

• Points for improvement must include

• Deficiency while managing the disaster

• Assess hazards, look for vulnerable areas and work towards reducing risk

• Provide the psychological support to the team members if they are affected by the impact of
disaster.

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PATIENT RECORD & ED RECORD COMPLETION:
Purpose:

To maintain index of records maintained within the ED

Responsibility:

ED physician/ED staff nurses

Policy:

 The Emergency Department records to be completed in a timely manner, immediately up on

patient encounter.
 The ED nurse should ensure the completion of records before transferring the patients to the acute
care units or any other unit
 The ED physician documents the details of assessment and condition along with the treatment
plan in the patient chart.
 The Nurse treating the patient shall document the details of nursing interventions in the nurse’s
note.
 Hand over notes are maintained during change of shifts.
 A brief note is documented in the Emergency Register before the discharge of the patient
 All the patient medical records are sent to the Medical Records department after the patient is
discharged from ED.

List of Register maintained in the Emergency department:

Registers Control Number

NOMINAL

AMA REGISTER

MEDICINE REGISTER

GENERAL INVENTORY

CBG REGISTER

NARCOTIC REGISTER

INDENT NOTE REGISTER

MEDICINE COMSUMING AND REPLACING

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 Forms/Formats ControlNumber
ER MOVEMENT REGISTER
DEATH REGISTER
ER IP NOMINAL REGISTER
ER USG SHIFTING REGISTER
REGISTER
CULTURE NOTE REGISTER
MRI Scan note REGISTER
ER ASSIGNMENT
Store indent register
DUTYMLC ROSTER
note REGISTER
Defibrillator register
INJECTION NOTE
O2 and suction checklist
Ambulance request REGISTER
HANDOVER form
Defibrillator checklist
MRD
CPR REGISTER
sheet
Sedation procedure consent
ON JOB TRAINING REGISTER
Radiology consent form
Surgical procedure consent form
FOGGING REGISTER
Invasive procedure consent form
High risk consent
ER INTUBATION form /72 HRS RETURN
REGISTER
DIL consent form
REGISTER
HIV consent form
COMMUNICATION
ED High Alert medications REGISTER
Medication Trolley checklist
Refrigerator checklist
Consent for Anaesthesia
DAMA/LAMA Consent

Consent for HIV

Consent for procedure performed outside

OT

Informed consent for High risk procedures

Consent for Admission

Informed consent for Blood &blood

product, Transfusion

Procedure Trolley

Narcotic checklist

Equipment functioning checklist

Crashcart checklist (Adult)

Crashcart checklist (Daily checklist)

CSSD register

Adverse drug reaction form

Incident reporting
82 | P a g e Pre-operative checklist
MANAGEMENT OF TRAUMA RELATED EMERGENCIES
Purpose:

A step wise approach for the assessment of trauma patients

Scope:

Trauma patients

Responsibility:

EMO

Procedure:

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MANAGEMENT OF DIABETIC KETOACIDOSIS/KETOSIS
Purpose:

To manage a case of diabetic keto acidosis.

Scope:

All diabetic patients admitted with keto acidosis.

Responsibility:

Emo.

Definitions and abbreviations:

Diabetic keto acidosis more commonly occurs in type 1 dm but may be a mode of presentation in a
patient with type 2 dm especially in patients with mi,infection and post op, non compliance or due to the
use of wrong dose of insulin.

 Rbs random blood sugar.

 Abg arterial blood gas
 Cbc complete blood count’
 Cpk creatinine phosphokinase.
 Honk hyperosmolar non ketotic
 Lmwh low molecular weight heparin.

Procedure:

Components:

 Hyper glycaemia
 Ketosis
 Acidosis(ph<7.3 usually)
 Dehydration

Signs and symptoms:

 Polyuria
 Polydipsia
 Lethargy
 Anorexia
 Hyper ventillation
 Ketotic breath
 Dehydration

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  Vomiting
 Abdominal pain
 Coma.

Management guidelines (emergency):

 As soon as patient with unexplained coma comes to the emergency physician should take a detailed
history regarding history of fall or trauma to the head,history suggestive of infection, history of
patient being diabetic, consumption of poisons or other intoxicants or any medication in excess etc.

 If grbs values>250mg/dl, arterial ph<7.3, bicarbonate level <18meq/i and anion gap more
than 10-12.
 Collect blood for basic metabolic panel and initiate iv fluid resuscitation.
 The nursing staff should secure large bore iv access immediately and send the blood for the
following investigations urgently;

 Blood gas analysis

 Complete blood counts
 Rbs or check glucose levels stat
 Bun/s.creatinine
 Urine for sugars and ketones by keto-diastix
 Urine for routine and microscopy
 S. Electrolytes
 S. Osmalality and urine osmolality
 If grbs >250mg/dl then ask for s. Ketones
 Serum amylase
 Blood culture
 Ecg
 X-ray chest
 Cpk,cpk-mb,trop-t if ecg changes s/o mi or unstable angina.

 Infuse 1 litre of crystalloid preferably 0.9% normal saline over 1 hour in severe shock.
 After initial bolus of 1 liter normal saline. Patient is to be reassessed and to be started on 0.45%
saline or 0.9% saline @200ml/hr depends on the corrected sodium levels.
 Insulin therapy to be initiated after initial fluid challenge.
 Ensure potasssium levels are >3.3meq/i before initiation of insulin therapy(supplement potassium
intravenously if necessary).
 A continuos infusion of regular insulin @ 0.1 u/kg/hr is started and tapered accordingly.
 Foleys catheter to be inserted to measure the urinary output every hourly.
 Intubate the patient if nessessary.
 Nasogastric tube to be inserted and to be aspirated if patient has been intubated.
 Transfer the patient to the icu.

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 Management guidelines (icu):

 Relevant and detailed history to be obtained by the attending physician in the icu.
 The attending nursing staff should attach the monitors to the patient and be
prepared with a emergency cart and ventilator on standby.
 As soon as the patient is brought into the icu, grbs and urine must be checked for
glucose level and presence of ketones making a note of the same in the chart for
monitoring patients with dka.
 The investigations from the emergency to be traced immediately.
 Take the consent from the relatives for insertion of central line in order to
invasively monitor blood pressure and give multiple medications as well as to
draw blood samples.

 Dehydration to be corrected as follows:

 Initial fluid bolus given as followed.

 1 liter of 0.9% ns over a period of 60 minutes, followed by 0.9%ns or 0.45% ns @200ml/hr
followed by which blood glucose should be rechecked, when glucose is <200mg/dl change iv
fluids to 5%dextrose containing 0.45%nacl @ 150 to 200ml/hr based on the patients fluid
status and that the target glucose remains (150-200mg/dl).
 The same glucometer to be used every time to minimize the error in measuring grbs.
 Calculate the corrected na+ by the following formula = na++2.4(glucose-120)/120)
 Dns should be used as soon as the grbs comes down to <250mg%.
 Correction of serum k+ to be done with the help of short drips. Less k+ correction is required
in case of renal failure or if there is oliguria. K+ to be corrected according to the formula.
 Investigations should be done as follows:

investigation hourly

hgt 1 hourly till patient is on a hri drip later 2 hourly for 1 day followed by 4
hourly for 1 day and before discharge from icu bbf,bl,bd.

Urine for sugars and 1 hourly till ketones negative, later once in 12 hours and later everyday.
ketones

Serum potassium 4 hourly till patient on hri drip followed by 8 hours till patient in icu.

Abg 4 hourly till patient out of acidosis later every 12 hourly.

Hco3- 4 hourly till acidosis persists later 12 hourly.

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  The patient should be monitored hourly as described above and should change the dose of hri
as per the sliding scale of insulin.
 Also the k+ to be corrected in consultation with the attending physician on duty.
 The staff should monitor the following and maintain a chart as shown below.
 The patient should be evaluated for underlying infection that could have triggered dka.
 Soda bicarbonate should not be initiated till the ph is <7.1. Give 1mg/kg only once over 1
hour. Repeat after 1 hour.
 Lmwh to be administrated after checking patients coagulation profile.

 Criteria for resolution of DKA:

 Glucose <200mg/dl along with
 Serum bicarbonate >15.
 Ph>7.3
 Anion gap <12
 Iv fluids to be stopped.
 Switch to subcutaneous insulin when the patient can take orally and after resolution of
dka and iv insulin to be stopped 2hrs after the subcutaneous dose.

Chart for monitoring patient in DKA

Time

Investigatons

Grbs

serum potassium

Abg

hco3-

urine sugars

urine ketones

Chart for correction of k+ (in consultation with physician on duty)

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MANAGEMENT OF SEPTIC SHOCK
Purpose:

Resuscitation and treatment of patients in septic shock.

Scope:

All patients with sepsis and septic shock.

Responsibility:

Emergency physician.

Definition and abbreviations:

Sepsis- a systemic inflammatory response syndrome (sirs) due to a suspected or confirmed infection with
2 or more of the following criteria:

 Temperature below 36°c or above 38°c

 Heart rate greater than 90/minute
 Respiratory rate above 20/minute, or arterial partial pressure of carbon dioxide less than 32 mm
hg
 White blood cell count less than 4 × 109/l or greater than 12 × 109/l, or more than 10% bands.
Severe sepsis was defined as the progression of sepsis to organ dysfunction, tissue hypoperfusion, or
hypotension. Septic shock was described as hypotension and organ dysfunction that persisted despite
volume resuscitation, necessitating vasoactive medication, and with 2 or more of the sirs criteria listed
above.

Tools for identifying high risk: sofa and qsofa: Sofa is an objective scoring system to determine
major organ dysfunction, based on oxygen levels (partial pressure of oxygen and fraction of inspired
oxygen), platelet count, glasgow coma scale score, bilirubin level, creatinine level (or urine output), and
mean arterial pressure (or whether vasoactive agents are required). It is routinely used in clinical and
research practice to track individual and aggregate organ failure in critically ill patients.

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ACUTE CORONARY SYNDROME

Refers to a group of diseases in which blood flow to heart is decreased or compromised.

It encompasses:

1. ST ELEVATION ACS (STE-ACS)

2. NON ST ELEVATION ACS (NSTE-ACS)
A] NSTEMI

B] UNSTABLE ANGINA

Objectives:

 Identify risk factors for ACS

 Identify how a patient with ACS might present and how the evaluation should be
 Describe the treatment of ACS
 Describe the importance of well coordinated inter professional teamwork

Risk factors:

 Smoking
 Hypertension
 Diabetes mellitus
 Hyper lipidemia
 Physical inactivity
 Obesity
 Family history of early mi (<55 years of age)

Pathophysiology:

Underlying patho physiology is decreased blood flow to part of heart musculature which is usually
secondary to plaque rupture and formation of thrombus. Sometimes it can be secondary to vasospasm
with or without underlying atherosclerosis.

Symptoms:

Classic symptom- substernal chest pain, crushing or pressure-like feeling radiating to jaw and/or left arm,

Can also present with breathing difficulty, light headedness, isolated jaw pain or left arm pain, nausea,
epigastric pain, diaphoresis.

Female gender, patients with Diabetes and older age can be associated with vague symptoms.

A high degree of suspicion is warranted.

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THROMBOLYTIC REGIMENS FOR STE-ACS/STEMI:

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 THROMBOLYTIC AGENT CO-THERAPY

1 INJ STREPTOKINASE 1.5 million units in 100ml NS over LMWH after 6-8hours
30-60minutes

0R

2 INJ RETEPLASE 10units + 10 units iv bolus given LMWH 20 minutes prior to

30minutes apart initiating therapy

OR

3 INJ TENECTEPLASE- single IV bolus LMWH 20 minutes prior to

initiating therapy

WEIGHT DOSE

<60kg 30mg

60-69kg 35mg

70-79kg 40mg

80-89kg 45mg

>90kg 50mg

PHARMACOINVASIVE PCI:

Is an alternative when primary PCI cannot be achieved within 120 minutes of first medical contact

INVOLVES FIBRINOLYSIS FOLLOWED BY TRANSFER TO A PCI CAPABLE CENTRE WITHIN

24 HOURS OF FIBRINOLYSIS.

DIAGNOSIS OF STE-ACS/STEMI

NO CONTRAINDICATIONS FOR THROMBOLYSIS

THROMBOLYSIS

PERCUTANEOUS CARDIAC INTERVENTION

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NON ST ELEVATION ACS (NSTE-ACS):

DIAGNOSTIC CRITERIA:

 All ACS without significant ST elevation are classified as NSTE-ACS

 There can be ST segment depressions and/or T wave inversions
 A minority of patients with NSTE-ACS display normal ECG

 NSTEMI:
DIAGNOSTIC CRITERIA WITH ELEVATED TROPONIN

 UNSTABLE ANGINA:
DIAGNOSTIC CRITERIA WITH NORMAL TROPONIN

PATHOPHYSIOLOGY:

partial occlusion causing subendocardial ischemia

TREATMENT:

 LOADING MEDICTIONS: As aforementioned

 SUPPORTIVE MEDICATIONS/THERAPY: As aforementioned
 INDICATIONS FOR PRIMARY PCI IN NSTE-ACS

 Refractory Angina/ Recurrent Angina

 Symptoms of heart failure
 New or worsening MR
 Hemodynamic instability
 Cardiac Arrest/ sustained VT or VF
 A worsening Troponin levels should trigger an early invasive therapy

MANAGEMENT OF BRADYCARDIA/BRADYARRHYTHMIA:

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Purpose: To define management of patients having symptomatic bradycardia

Scope: EMERGENCY DEPARTMENT

Responsibility: ED Physician, ED Nurse, Cardiologist

Procedure:

 DEFINITION: Bradycardia is generally defined as any rhythm disorder with a heart rate less than
60/min but for assessment and management of a patient with symptomatic bradycardia, it is
typically defined as having a heart rate less than 50/min

 RHYTHMS FOR BRADYCARDIA:

 Sinus bradycardia
 First-degree AV block
 Mobitz type I AV block
 Mobitz type II second-degree AV block
 Third-degree AV block

 SIGNS AND SYMPTOMS:

Unstable bradycardia leads to serious signs and symptoms that include

 Hypotension
 Acutely altered mental status
 Signs of shock
 Ischemic chest discomfort
 Acute heart failure

 DRUGS FOR BRADYCARDIA:

 Atropine
 Dopamine (infusion)
 Epinephrine (infusion)
 If atropine is ineffective, provide transcutaneous pacing and/or dopamine 5 to 20 mcg/kg per minute
infusion (chronotropic or heart rate dose) or epinephrine 2 to 10 mcg/min infusion

BRADYCARDIA ALGORITHM:

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MANAGEMENT OF TACHYCARDIA/TACHYARRHYTHMIA:
Purpose: To define management of patients having tachyarrhythmia

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Scope: EMERGENCY DEPARTMENT

Responsibility: ED Physician, ED Nurse, Cardiologist

Procedure:

 Definition:
 Tachycardia: defined as an arrhythmia with a heart rate typically 100/min or greater
 Symptomatic tachycardia: signs and symptoms due to the rapid heart rate
 The rate takes on clinical significance at its extremes and is more likely attributable to an
arrhythmia if the heart rate is 150/min or greater
 It is unlikely that symptoms of instability are caused primarily by the tachycardia when the
heart rate is less than 150/min unless the patient has impaired ventricular function.

 Rhythms for unstable tachycardia:

• Sinus tachycardia

• Atrial fibrillation

• Atrial flutter

• Supraventricular tachycardia (SVT)

• Monomorphic VT

• Polymorphic VT

• Wide-complex tachycardia of uncertain type

 Signs and symptoms:

Unstable tachycardia leads to serious signs and symptoms that include

• Hypotension

• Acutely altered mental status

• Signs of shock

• Ischemic chest discomfort

• Acute heart failure

 Rapid recognition:
The 2 keys to managing unstable tachycardia are rapidly recognizing that

1. The patient is significantly symptomatic or even unstable

2. The signs and symptoms are caused by the tachycardia

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 Quickly determine whether the tachycardia is producing hemodynamic instability and the serious
signs and symptoms or the serious signs and symptoms (eg, the pain and distress of an AMI) are the
cause of the tachycardia.

 Indications for cardioversion:

Rapidly identifying symptomatic tachycardia will help you determine whether to prepare for immediate
cardioversion:

• At heart rates typically 150/min or greater, symptoms are often present and cardioversion is often
required in unstable patients.

• If the patient is seriously ill or has underlying cardiovascular disease, symptoms may be present at
lower rates.

TACHYCARDIA ALGORITHM

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MANAGEMENT OF STROKE IN EMERGENCY DEPARTMENT
Purpose:

Early recognition and treatment of patients presenting with stroke to minimize brain injury and maximize
the patient’s recovery.

Scope:

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EMERGENCY DEPARTMENT

Responsibility:

ED Physician, ED Nurse, Neurophysician

Definition:

It refers to an acute neurologic impairment that follows interruption in blood supply to a specific area of
the brain.

The major types of Stroke are

1. ISCHEMIC STROKE: accounts for 87% of all strokes and is usually caused by an occlusion of
an artery to a region of the brain
2. HEMORRHAGIC STROKE: accounts for 13% of all strokes and occurs when a blood vessel in
the brain suddenly ruptures into the surrounding tissue. Fibrinolytic therapy is contraindicated in
this type of stroke. Avoid anticoagulants.

Signs & symptoms:

 Sudden weakness or numbness of the face, arm, or leg, especially on one side of the body
 Trouble speaking or understanding
 Sudden trouble seeing in one or both eyes
 Sudden trouble walking
 Dizziness or loss of balance or coordination
 Sudden severe headache with no known cause
 Sudden confusion

Procedure:

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  THE 8 D’S OF STROKE CARE:
The 8 D’s of Stroke Care highlight the major steps in diagnosis and treatment of stroke and key points at
which delays can occur:

 Detection: rapid recognition of stroke signs and symptoms

 Dispatch: early activation and dispatch of EMS
 Delivery: rapid EMS stroke identification, management, triage, transport, and pre hospital
notification
 Door: emergent ED/imaging suite triage and immediate assessment by the stroke team
 Data: rapid clinical evaluation, laboratory testing, and brain imaging
 Decision: establishing stroke diagnosis and determining optimal therapy selection
 Drug/Device: administration of fibrinolytic and/or EVT if eligible
 Disposition: rapid admission to the critical care unit, or emergent inter facility transfer for EVT
 Immediate general and neurologic assessment by the emergency physician within 10 minutes
after arrival to ED
 assess ABCs and give oxygen if needed; obtain IV access and perform laboratory assessments;
check glucose and treat if indicated; review patient history, medications, and procedures;
establish time of symptom onset or last known normal; perform physical exam and neurologic
examination
 Prepare for emergent CT Scan of Brain, should be performed within 20 minutes of arrival to ED
 Immediate interpretation of the CT Scan
 Initiation of fibrinolytic therapy in appropriate patients (those without contraindications) within
45 minutes after hospital arrival
 CRITICAL TIME PERIODS:
 Patients with acute ischemic stroke have a time-dependent benefit for reperfusion therapy.
Critical time periods from hospital arrival are summarized here and represent maximum times:
 Immediate general assessment: within 10 minutes
 Immediate neurologic assessment: within 20 minutes
 Acquisition of CT Scan of the head: within 20 minutes
 Interpretation of the CT/MRI scan: within 30 minutes
 Administration of fibrinolytic therapy, timed from ED arrival : within 60 minutes
 Administration of fibrinolytic therapy, timed from onset of symptoms: within 3 hours, or 4.5
hours in selected patients
 Administration of EVT, timed from onset of symptoms: up to 24 hours for patients with large
vessel occlusion (LVO): 0 to 6 hours requires eligible NCCT scan; 6 to 24 hours requires
eligible penumbral imaging
 Interfacility transfers for EVT (door-in-door-out): 1 hour

Stroke algoritham:

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PROTOCOL AND MANAGEMENT OF COPD

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Scope:

All patients presenting with acute exacerbation of copd.

Responsibility:

Pulmonologist/emergency physician.

Definitions and abbrevations:

Copd - chronic obstructive pulmonary disease

Abg – arterial blood gas

Cxr – chest xray

Pft – pulmonary function test

Ecg – electrocardiogram

Procedure:

No conclusive staging system for acute exacerbation of copd available.

The cardinal symptoms for diagnosing acute exacerbation are.

 Worsening of dyspnea
 Increase in sputum purulence
 Increase in sputum volume

Criteria for admission:

 Respiratory distress and use of accessory muscles of respiration.

 Worsening respiratory acidosis on abg.
 Altered sensorium.
 Severe hypoxia with type 2 respiratory failure.
 Asssociated cardiac, hepatic, renal dysfunction leading to dyselectrolemia and increased
morbidity.
 Asssociated severe respiratory infection.
 Patient in requirement of nippv and mechanical ventilation.
 Haemodynamically unstable patients.
Therapeutic intervention

MECHANICAL VENTILLATION IF NIPPV TRIAL FAILS:CRITERIA FOR MECHANICAL

VENTILLATION:

 RESPIRATORY
OXYGEN THROUGHACIDOSISMASK
<7.25– MAINTAIN PaO2>60 OR SAT>=90%
 SEVERE HYPOXEMIA PaO2 <50
 ALTERED SENSORIUM
A SHORT
A SHORT COURSE
COURSE OFOFANTIBIOTICS
ANTIBIOTICS – EFFECTIVE
– EFFECTIVE
AGAINST
AGAINST
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ADDITION gHEMODYNAMIC
eOF OF
SYSTEMIC INSTABILITY
NIPPV ISCORTICOSTEROIDS
USED IN PATIENTS–WITH
40-60SEVERE
mg Q6HHYPOXIA
– INITIALLY
WITHPARENT
TYPE II
INFLUENZA/ATYPICAL/BACTERIA/PSEUDOMONAS/RESISTANT
INFLUENZA/ATYPICAL/BACTERIA/PSEUDOMONAS/RESISTANT GRAM
GRAM NEGATIVE
NEGATIVE
RALLYCONVERTED
TACHYPNOEA:
RESPIRATORY RR>35/MIN
TOFAILURE
ORAL PATIENT IS STABILIZEDOF
FOR IMPROVEMENT X 2HYPOXIA.
WEEKS
ORGANISM
ORGANISM IS IS
REQUIRED
REQUIRED X 7-10
X 7-10
DAYS.
DAYS.
MANAGEMENT OF ACUTE INGESTION OF POISON
Purpose:

For treatment of acute poisoning.

Scope:

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Patient with ingestion of poison.

Responsibility:

Emergency physician.

Definitions and abbrevations:

Abg- arterial blood gas, opc- organo phosphorous compound.

Procedure:

All patients presenting with the alleged history of acute poisoining to be considered as “high risk”
patients and universal safety precautions to be followed strictly by all the staff concerned in order to
prevent any unintended exposure to blood as well as other secretions of the patient.

 Remove the patient’s clothing and change them to prevent absorption of certain poisons such as
opc’s.
 Abc’s to be assessed and to take the relevant steps as required to prevent aspiration and to protect
the airway.
 A relavant history as to the name, nature of poison, and the amount consumed to be obtained
from the patient and confirmed from the relative in case of concious patient. If the patient is
unconcious then the relevant details to be obtained from the relatives of the patient.
 It’s the duty of the emergency physician on call or nurse incharge to inform regarding the arrival
of the patient to the concerned police station, for medico legal registration.
 If the patient is concious then take the patient’s consent for insertion of a nasogastric tube. If the
patient is comatose then the patient’s relatives consent to be obtained.
 Never induce emesis.
 A nasogastric tube is contraindicated in case of acute poisoning with acids, alkalis, petroleum and
hydrocarbons.
 After a nasogastric tube is inserted in position and to be confirmed by ausculation or cxr.
 The first aspirate is aspirated and sent to the lab for chemical analysis.
 Naso-gastric wash is to be given if patient presented less than 1 hour from the time of ingestion.
The naso-gastric lavage to continue till the returning fluid id either clear or it doesnot not contain
any remnants. In case of acute overdose with paracetamol a single lavage may suffice but in case
of barbiturates and opc’s multiple lavages at an interval of 4 hours are necessary.
 The amount of fluid siphoned in via the naso-gastric tube should be less than or equal to the fluid
siphoned out.
 After the lavage a solution of activated charcoal (50g in 200cc tepid water) is adminstrated in the
stomach for the patient with tablet overdose. In patient with paracetamol overdose a single dose
of activated charcoal would suffice but in case of overdose by benzodiazepines it has to be given
very 4 hourly.
 Specific antidote treatment is then insitituted.
 The following investigations are to be done.
 Cbc
 Serum creatinine/bun

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  S. Electrolytes
 Prothrombin time with liver function tests.
 Activated ptt.
 Blood for cholinesterase level.
 Abg
 Ecg
 X-ray chest
 Blood for digoxin levels, paracetamol level if indicated.
 Random blood sugars.
 Chemical analysis in case of ingestion poison.
 Upt (female patient)
 Covid 19 rtpcr/abott

 Patient to be then admitted in medical icu as per protocol or to be transferred to ward according to
patients hemodynamic stability.

MANAGEMENT OF PULMONARY EMOBILSM

Purpose:

Protocol for management of pulmonary embolism.

Scope:

All patient with pulmonary embolism.

Responsibility:

Emergency physcian/ cardiologist.

Definition:

Pulmonary embolism (pe) occurs when there is a disruption to the flow of blood in the pulmonary artery
or its branches by a thrombus that originated somewhere else. In deep vein thrombosis (dvt), a thrombus
develops within the deep veins, most commonly in the lower extremities. Pe usually occurs when a part of
this thrombus breaks off and enters the pulmonary circulation.

Etiology:

Genetic risk factors:

 Thrombophilia factor v leiden mutation,

 Prothrombin gene mutation
 Protein c defpiciency

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  Protein s deficiency
 Hyper homocysteinemia.

Acquired risk factors:

 Immobilization for prolonged periods (bed rest greater than three days
 Anyone traveling greater than 4 hours, whether by air, car, bus, or train)
 Recent orthopedic surgery
 Malignancy
 Indwelling venous catheter
 Obesity
 Pregnancy
 Cigarette smoking

Other predisposing factors for vte include:

 Fracture of lower limb

 Hospitalization for heart failure or atrial fibrillation/flutter within the previous three months
 Hip or knee replacement
 Major trauma
 History of previous venous thromboembolism
 Central venous lines
 Chemotherapy
 Congestive heart failure or respiratory failure
 Oral contraceptive pill use

Types of pulmonary embolism:

 Hemodynamically unstable pe which results in hypotension (as defined by systolic blood

pressure(sbp) less than 90 mmhg or a drop in sbp of 40 mm hg or more from baseline).

 Hemodynamically stable pe is a spectrum ranging from small, mildly symptomatic or

asymptomatic pe (low-risk pe or small pe) to pes, which cause mild hypotension that stabilizes in
response to fluid therapy, or those who present with right ventricle dysfunction.

Pathophysiology:

Pulmonary embolism occurs when clots break off and embolize into the pulmonary circulation.

Large emboli tend to obstruct the main pulmonary artery, causing saddle embolus with deleterious
cardiovascular consequences. In contrast, smaller sized emboli block the peripheral arteries and can lead
to pulmonary infarction, manifested by intra-alveolar hemorrhage.

Pe leads to impaired gas exchange.

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Signs:

• Tachypnea

• Tachycardia

• Calf swelling

• Tenderness

• Erythema

• Palpable cords

• Pedal edema

• Rales

• Decreased breath sounds,

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• Signs of pulmonary hypertension such as elevated neck veins,

• Loud p2 component of second heart sound, a right-sided gallop, and a right ventricular
parasternal lift might be present on examination.

INVESTIGATIONS:

 Arterial blood gas (abg) analysis

 Brain natriuretic peptide (bnp)
 D- dimer
 Troponin
 Electrocardiography (ecg)
 Chest radiograph (cxr)
 Computed tomographic pulmonary angiography (ctpa)
 Pulmonary angiography
 Echocardiography
 Compression ultrasonography (us)

TREATMENT / MANAGEMENT:

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HEMODYNAMICALLY STABLE PATIENTS:

 Patients with a high clinical suspicion for pe, anticoagulation is started even before diagnostic
imaging is obtained.

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  Patients with a low clinical suspicion for pe, if diagnostic imaging can be performed within 24
hours, then wait for imaging to establish a definitive diagnosis before starting treatment with
anticoagulation.
 Patients with an intermediate clinical suspicion for pe, if diagnostic imaging can be performed
within 4 hours, then wait for imaging to establish a definitive diagnosis before starting treatment
with anticoagulation.
 Patients in whom anticoagulation is contraindicated, ivc filter placement should be considered
once the diagnosis of pe is confirmed.

HEMODYNAMICALLY UNSTABLE PATIENTS:

 Patients with a high clinical suspicion for pe who are hemodynamically unstable, emergent ctpa,
portable perfusion scanning, or bedside transthoracic echocardiography should be performed
whenever possible.
 Primary reperfusion treatment, usually, thrombolysis, is the treatment of choice for patients with
hemodynamically unstable acute pe.
 Surgical pulmonary embolectomy or percutaneous catheter-directed therapy are
alternativereperfusion options in patients with contraindications to thrombolysis.
Reperfusion strategies

 Thrombolysis
 Catheter-directed treatment
 Surgical embolectomy
 Vena cava filters

MANAGEMENT OF ANAPHYLAXIS:
Purpose:

To define early recognition and treatment of anaphylaxis

Scope:

EMERGENCY DEPARTMENT

Responsibility:

ED Doctor, ED Nurse

Procedure:

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MANAGEMENT OF SEIZURES/STATUS EPILEPTICUS

Purpose:
Protocol of management of status epilepticus.

Scope:

All patient with status epilepticus.

Responsibilitity:

Emergency physician

Definition:

Status epilepticus was defined as a seizure with a duration equal to or greater than 30 minutes or a series
of seizures in which the patient does not regain normal mental status between seizures.

Status epilepticus may be convulsive, non-convulsive, focal motor, myoclonic, and any can become
refractory.

 Convulsive status epilepticus consists of generalized tonic-clonic movements and mental status
impairment.
 non-convulsive status epilepticus is defined as seizure activity identified on an
electroencephalogram (eeg) with no accompanying tonic-clonic movements.
 Focal motor status epilepticus involves the refractory motor activity of a limb or a group of
muscles on one side of the body with or without loss of consciousness is myoclonic status
epilepticus.
 Refractory status epilepticus refers to continuing seizures (convulsive or non-convulsive) despite
appropriate antiepileptic drugs.

Etiology:

 Central nervous system (cns) infections (meningitis, encephalitis, and intracranial abscess)
 Metabolic abnormalities (hypoglycemia, hyponatremia, hypocalcemia, hepatic encephalopathy,
and inborn errors of metabolism in children)
 Cerebrovascular accidents
 Head trauma (with or without intracranial bleed)
 Drug toxicity
 Drug withdrawal syndromes (e.g., alcohol, benzodiazepines, and barbiturates)
 Hypoxia
 Hypertensive emergency
 Autoimmune disorders

Pathophysiology:

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A seizure is a paroxysmal electrical discharge of neurons in the brain resulting in a change of function or
behavior. It is important to understand that a seizure is a cns event and may present as convulsive or non-
convulsive.

History:

Status epilepticus is defined as a seizure with 5 minutes or more of continuous clinical and/or
electrographic seizure activity or recurrent seizure activity without recovery between seizures. The
findings of convulsive status epilepticus include generalized tonic-clonic movements of the extremities
and impaired mental status.

Investigation:

 Computed tomography (ct) scan of brain

 Magnetic resonance imaging (mri) of the brain
 Blood glucose level
 Serum electrolytes (sodium, potassium, calcium, and magnesium),
 Bun
 Creatinine
 Serum bicarbonate
 A complete blood count
 Lumbar puncture with cerebrospinal fluid (csf) evaluation
 Eeg

Treatment / management:

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