Junior Doctors’ Orientation

Dr. Narendra Bendi MD, MHA

Deputy Medical Superintendent
Apollo Hospitals, Visakhapatnam
Contractual Obligations & Tenure

appointed by the Medical Superintendent

qualifications & interview

work as per job description issued to you

subjected to periodic evaluation of your performance

quality & improvement of patient care

2
 Credentialing
appointment based on credentialing info

keep a record of credential information

clinical & continuing medical education

shall comply with all credentialing requests made

inform any changes to the office of MS

qualification, registration status, address or contact info

3
 Administration
co-ordinate with MS for administrative purposes

attend an induction program before joining

follow the dress code (white coat or jacket)

inform when you are away & arrange for coverage

leave your contact address for any emergencies

attend medical audit meetings & peer review meetings

4
Code of Ethics Regulations 2002
Professional Conduct, Etiquette & Ethics

5
 Important Acts for Doctors
•
Drugs and Cosmetics Act, 1940
•
Pharmacy Act, 1948
•
Narcotic Drugs and Psychotropic substances Act, 1985
•
Medical Termination of Pregnancy Act, 1971
•
Transplantation of Human Organ Act, 1994
•
Mental Health Act, 1987
•
Environmental Protection Act, 1986
•
Pre–natal Sex Determination Test Act, 1994
•
Drugs and Magic Remedies (Objectionable Advertisement) Act, 1954
•
Persons with Disabilities (Equal Opportunities and Full Participation) Act, 1995
•
BioMedical Waste (Management and Handling) Rules, 1998

6
 Documentation
write your name, date & time clearly in block letters

Avoid Bed numbers

legitimate orders followed by legitimate signatures

Admission Note

History & Physical Examination (H&P) Sheet

IDTR (InterDisciplinary Team Rounds) Forms

Consent forms to be filled only by Doctors

Critical Values (Abnormal values / critical tests - indications)

7
 Critical Tests
tests or procedures that are conducted & reported
quickly

determine further course of action of treatment

rapid processing, performance & communication

even if results are within normal limits

list of critical tests is mentioned in the unit binder

8
 Doctors Notes
make atleast one entry during his/her duty

pain score - atleast once daily mentioned

date, time & signatures to be recorded

pain score > 4 - document intervention & review in 1 hour

9
 Documentation of Drug Orders
Right patient Indications

Right name STOP ORDERS

Right dose Inj. Tramadol

Right route SOS (si opus sit) / PRN (pro re nata) orders

Right frequency indication & repeats mentioned

Right indication change of dose

Right documentation sign with date & time

BLOCK LETTERS Medication Reconciliation each level

Drug Formulary

1
 Patient Family Education
important to educate & document that education

plane of care, treatment & services

basic health practices & safety

safe & effective use of medication / given to him

nutrition

safe & effective use of medical equipment

pain management - réhabilitation

Second opinion - patient right

11
In House Transfer (SBAR)

1
 Blood Transfusion
written & informed consent - before every transfusion

monitoring sheet - first hour (15mins), second hour

(30mins), then hourly

transfusion started & ended by a doctor only

1
 Restraint Order Sheet
monitoring every hour

order given by a doctor only

valid only for 24 hours

1
 Discharge Summary
reflect the high standards High end diagnostics & therapeutic
procedures
prepare it meticulously
significant findings & lab data
UHID # & IP #
any significant event & important drugs
date & time of admission & discharge
status at the time of discharge
diagnosis & comorbidities
discharge advice & medications
past hospitalisations & surgery
Follow up - date & time
Allergies
language of the patient
reason for admission
contact person in emergency
Avoid abbreviations
if transferred - reason for transfer

1
DAMA (Discharge Against Medical Advice)

reason for such a case is well documented

patient & relatives should be counselled

mandatory that a follow up is done - moral grounds

MRD - follow up is done for every DAMA case

relevant authorities are informed - if infectious or

psychiatry case goes on DAMA

1
 Surgical Care
surgical care plan names of surgeons & surgical
assistants
type of anesthesia
restraint details if applied
anesthetic technique
brief surgical report
monitoring values
Time of arrival & discharge from
response to complications Recovery
use of reversal agents condition on discharge - vitals,
post OP diagnosis ambulatory, surgical wound, pain,
blood sugar
surgical procedure, findings, and
specimens care after surgery

1
 Time Out
to be in all surgeries / procedures

both diagnostic & therapeutic

multiple surgeries - multiple time outs to be done

site marking - where laterality is involved

dental procedures - mark the site on radiograph

should be done only by surgeon

1
IN House Patient Transfer Policy
From wards / ER to ICU
duty doctor / ER doctor should accompany to ICU
hand over to ICU doctor informing him details
all medications / investigation reports to be accompanied
transfer summary / inhouse transfer form filled
From ICU / ER to wards
transfer summary should be complete
details of present condition & special care / instructions if any
transferring doctor has to call the ward duty doctor & inform him / her

1
IN House Patient Transfer Policy
From OTs to ICU / wards

patient to be accompanied by an anaesthetist

to meet duty doctor & hand over the details

accompanied by complete documented details

prior information to be obtained on availability on beds / equipment

In patient to OP Diagnostic Area

ticket to ride filled by nurses & return ticket when comes back to in patient

patient on Respiratory Support - accompanied by an anaesthetist during transport

2
 from ICU to ICU
patient in the respective specialty ICU - preferable

do not shift unstable patient

do not shift patient during night hour (after pm)

shift after informing consultant, ICU incharge & patient’s

attendant as well

ICU doctor will accompany while transfer and inform

2
 Inter Hospital Transfer
ensure stabilization is done prior to transfer

polytrauma cases - inform ERP to keep unit & personnel ready to

stabilize the case upon arrival

transportation arrangement through Ambulance Control Room with

qualified personnel & equipment

physician certification - expected benefits of transfer outweigh the

risks of transfer

whole transfer process is documented in patient’s record

2
 Blood Transfusion
check the identity with details written on compatibility certificate / case file
(note colour code)

Informed & written consent has to be taken before every transfusion

check the contents of the bag (colour change & expiry)

administer blood or components only with sets containing filters

keep the bag at room temperatures for 10 minutes prior to transfusion

not transfusing, return the blood bag to blood bank immediately

keep IV saline and drugs in readiness

no air inlet is required & check for air bubbles in the set

2
 Blood transfusion
first 15mins - 10 drops / minute

then the recommended rate as per physician order is used

a unit of blood is given over 4 hours in therapeutic cases

no drugs should be added to the blood unit

Glucose & RL not to be admin. - hemolyse the cells

monitor the patient closely & watch for reactions

2
Allergic related transfusion reaction

decrease the rate of transfusion

give antihistamine

record vital signs every 15minutes

inform physician

restart slowly after 30minutes

2
 Acute non-allergic reactions
stop transfusion immediately but keep IV line open

administer NS with a fresh IV set

record vitals every 15 minutes

send first void urine to Pathology (hemoglobinuria)

inform physician

send blood bag, saline sets intact to blood bank

send 5ml clotted bank sample and 2ml of EDTA blood sample with
transfusion reaction feedback form to the blood bank

2
 Policy for Restraints
Physical / Chemical Restraints
implemented only on written instructions from physician
reassessed after 24 hours for further continuation
care provider can take an action in emergency, but treating physician may
be intimated verbally
needs to be attended every hour & documented
vitals documented every fourth hourly or often
restraint implementation - adequately documented & authenticated

2
 Patient’s Rights
need for privacy shall be upheld
confidentiality
HIV or infectious aetiologies - primary consultants
adequately inform & educate patient / family
right to know identity & professional status of care giver
right to choose room / bed of his choice
protected from physical assaults & appropriate protection
informed consent
right to second opinion

2
 Emergency Alerts
codes usually announced over the hospital intercom, along with exact location

no longer exists, an “all clear” is made 3 times

Code Blue: Cardiac Arrest Call

Code Red: External Disaster Call

Code Brown: Internal Disaster Call (fire)

Code Pink: Baby Disaster Call

Code Grey: Security Threats / Workplace violence Call

Code Orange: MET Call

2
 Triage Colours
casualties who require immediate life saving
RED
interventions

casualties who do not require immediate life

YELLOW saving interventions and for who treatment can
be delayed

Individuals who need minimal or no medical

GREEN
care

BLACK Deceased

3
 Protocol for death & breaking bad news
involve family members early in resuscitation

continuously update the nearest relative on status

offer an area to sit (counseling room)

involve medical social worker early

break the bad news in counseling room

assistance with packing (nurses) & transport (ambulance)

ensure proper documentation of the resuscitation & death notes

MLC documentation in selective case before handing over to police

nurse in charge - mortuary protocol list before shifting to mortuary

any suspicion about the cause of death - ask for autopsy

discuss with the family about organ donation

3
 Protocol for brought dead patients
ER doctor confirms the death

Registration is done bedside

Death news is broken as per the protocol discussed

Documentation entered on the initial assessment sheet

in case of our hospital patient, the consultant notified

COD certificate can be issued ascertaining the case details

issue a brought dead certificate if there is no suspicion of unnatural death

in cases of any doubt - insist on PME / MLC registration

3
 Protocol for MLCs
Assess & treat the patient first

document the findings on the chart

all belongings including dress to be handed to security

hand over original to police & pink to security

yellow copy remains in the MLC book & green copy into patient’s folder

ensure appropriate documentation of patient particulars, injuries, treatment given

dying declaration from the magistrate if needed

collect body fluids & samples as necessary

in case of death of MLC patient - body handed over to the police for PME

3
 Insulin Policy
insulin order will be on - Diabetic chart, not on Drug chart
on drug chart write ‘please refer diabetic chart for insulin orders’
verbal orders can only be obtained by doctors
only the doctors will inform the blood sugar levels to consultants, on phone
nurse should administer insulin only after the written orders from the doctor
attention needs to be paid on type of insulin syringe used
concerned staff nurse should get insulin verified by shift-in-charge before
administration and both nurses have to document & sign the same
insulin needles not to be re-used & should not be recapped
every incidence of hypoglycemia - incident form is raised

3
 Insulin policy
insulin brought from outside should not be used

attendants’ insulin - not to be kept in patient care area

refrigerators

at the time of discharge - usage of insulin properly educated

attending periodic training on insulin is must

pharmacist on floor shall audit the fridge & document it in audit

form everyday

3
 Spill Management
Major Spill - >30ml of liquids or 30gms of solids

first cordon of area & call for Hazmat team (if hazardous material)

safety officer, security officer, assistant nursing superintendent, housekeeping

Minor Spill - <30ml of liquid or 30gms of quantity

locate the minor spill kit / neutralised

place the waste into black bag & label the spill (date, time, place, nature)

be sure to decontaminate the broom & dustpan after use

raise the incident form and send it to MS Office

3
Medication Management
medication errors are of four types:

Prescription error

Transcription error

Dispensing error

Administration error

3
 Prescription Errors
no route specified

as-needed order without an indication

drug is indicated but the dose is inappropriate

as-needed order without a time interval

dose change ordered without discontinuation of previous order

order is illegible (hand writing)

order is incomplete in specifying doses or frequency

self administration of medication - not allowed

medication brought from outside the organization - not allowed

3
 Narcotic policy
used in our hospital - morphine, pethidine, fentanyl

stored in double lock / two keys with different people

dosage administered & quantity remaining in the ampoule should be

mentioned

issued from pharmacy only with a manual prescription

specimen copy of Dr’s signature is available with pharmacy

left over narcotic - disposed off in the sink under running water & in front
of two witnesses

ampoules into black bag, labeled and sent to IP pharmacy

3
 Crash Cart
are available in all patient care areas

pharmacist checks all crash carts once / month

near expiry date medicines are replaced

before 3 months of expiry

cart shall be sealed

4
 After a Code Blue
crash cart seal opened

medication are used

nursing will inform pharmacy - within 15minutes

medications indented by pharmacist - within 30minutes

medications replaced by pharmacy

crash cart sealed by pharmacy within 1 hour of code blue

4
Policy on medication prescription
a licensed & registered medical practitioner shall prescribe

legible handwriting & signed by the physician

all medication prescribed to entered in drug / non drug chart

route, dosage, strength, time, frequency, route & indication

IM injections - site mentioned / vaccines - batch number in case sheet

discontinued - clearly indicated on the Drug / Non Drug order form

every entry - name, signature, date & time

medication instructions on discharge in layman’s language explained

4
 High alert medications
requiring special handling throughout the medication use process

verified by staff before dispensing

narcotics / conc. electrolytes (KCl, 3%NaCl, MgSO 4)

insulin / heparins / all chemotherapy drugs

look alike / sound alike drugs

sample drugs are not allowed in the hospital

mandatory to do medication reconciliation at time of admission &

discharge

4
 Adverse Drug Reaction
allergy or unexpected side effect

unintended response in doses appropriately prescribed

report it immediately to the prescribing doctor

complete the ADR report & send it to MS

ADRs are collected & analyzed by Drugs and Therapeutic

Committee

4
 Bio-medical waste categorisation
Category No 1 - Human Anatomical Waste

Category No 2 - Animal Waste

Category No 3 - Microbiological & Biotechnological Waste

Category No 4 - Waste Sharps

Category No 5 - Discarded Medicines & Cytotoxic Drug Waste

Category No 6 & 7 - Solid Waste

Category No 8 - Liquid Waste

Category No 9 - Incineration Ash Waste

Category No 10 - Chemical Waste

4
 Color Coding & Container type

Color coding Type of Container Type of Waste

Yellow Plastic Bag Human Tissues

Disinfected Container /
Red Plastics
Plastic Bag

Green Plastic Bag General Waste

Plastic Bag / puncture Sharps, needles,

White
proof container blades

4
 Pain Management Policy
pain assessed (within 30minutes in ER setting)

pain assessed (within 2 hours of admission in electives)

post invasive / patient complaining of pain - immediate

relatively assess pain during illness/recovery process

identify, document & monitor the level of pain

patient & family should be educated

4
 pain score >4
location of pain

intensity

character / radiating

duration
aggravating & relieving factors

response to pain intervention

check pain score after one hour of relief measure given & document

4
 FLACC Scale (0 to 5 years)
Categories Scoring
0 1 2
Occasional grimace or frown, Frequent to constant quivering
FACE No particular expression or smile
withdrawn, disinterested chin, clenched jaw

LEGS Normal postion or relaxed Uneasy, restless, tense Kicking or legs drawn up

Lying quietly, normal position Squirming, shifting back &

ACTIVITY moves easily forth, tense
Arched, rigid or jerking

Moans or whimpers; occasional Crying steadily, screams or

CRY No cry (awake or sleep)
complaint sobs, frequent complaints

reassured by occasional touching

difficulty to consosolne or
Consolability content, relaxed hugging or bing talked to
comfort
distractible

0-3 Mild / 4-6 Moderate / 7-10 Severe pain

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Visual Analogue Scale (> 5 years)

5
 Behavioral Pain Score
Item Description Score
Relaxed 1
Facial Expression Partially tightened (brow lowering) 2
Grimacing 3
No movement 1
Partially bent 2
Upper limbs
Fully bent with finger flexion 3
Permanently retracted 4
Toleration movement 1
Compliance with Coughing but tolerating ventilation for most of the same 2
venttilation Fighting ventilator 3
Unable to control ventilation 4

5
 Infection Control
Infection Control Nurses - surveillance activity
post operative wound infections or Surgical Site Infections
Urinary Tract Infections (UTI)
Ventilator Associated Pneumonia (VAP)
Catheter Related Blood Stream Infections (CLBSI)
Investigation of any outbreak of infections
Management of MRSA/MDR pathogens
Needle Stick Injury

5
 Hand Washing
When coming on duty
Before and after each patient contact
After removing personal protective equipment (gowns, gloves, booties, caps)
before preparing or serving food
before performing invasive procedures
when moving from contaminated body site to a clean body site
before and after eating food
after blowing & wiping the nose
after using toilet facilities
after contact with patient excretions, secretions or blood
On completions of duties

5
 Waterless Hand Antisepsis
when soap & water are not readily available
hands are not visibly dirty or contaminated with proteinaceous material
before donning sterile gloves when inserting invasive lines
before having direct patient contact
after contact with a patient’s intact skin
after contact with body fluids or excretions, mucous membranes, non intact
skin & wound dressings if hands are not visibly soiled
after touching inanimate objects (medical equipment)
after removing gloves

5
 Isolation / barrier nursing
Strict Isolation Category
Respiratory Isolation Category (Contact Isolation with Mask)
febrile neutropenia
AIDS & AIDS Related Complex (only rare cases)
Immediate post transplant
Burns
Open cases of Tuberculosis
Cases from epidemiological suspicion (plague, tularaemia)
Isolation of organisms like VRE

5
 Additional risk for high risk patients
Emergency patients: Risk of radiation exposure
Comatose patients: Risk of pressure ulcers
Patients on life support: BSI, VAP
Patients with communicable diseases: Risk of spread of infections in staff
Immune-suppressed patients: Risk of HAI
Dialysis: cross infections with other dialysis patients
Patients on restraints: risk of injury from physical restraints
Patient on chemotherapy: medication errors
Vulnerable patients: Risk of fall

5
 Quick Reminders
identify patients with two identifiers
document verbal information (Listen - Write - Read back)
document handovers in SABR format
site marking in wards & time out before incision
wash your hands
current summary for radiotherapy, chemotherapy, dialysis (30th day or 6th visit)
DNR not legal in India
Repeat IDTR daily in ICU & every 6th day in wards

5
 Quick Reminders
wear TLD badges in radiation exposed areas

BLS to be initiated immediately & ACLS in 5mins

all entries dated, timed and signed

drug orders always in BLOCK letters

check allergies, height & weight, BSA for chemo

report incidents & correct errors in the system / process

know the occupational hazards in your department

5
Thanks for listening
Questions????