Guidelines for Accident and

Emergency Department of District

Hospital

Quality Assurance Division

Haryana State Health Resource Centre,
Government of Haryana
 CONTENTS

TOPIC PAGE NO.

i. Abbreviations........................................................................................................................................5

1.0 INTRODUCTION.......................................................................................................................................7

1.11 CURRENT SCENARIO..............................................................................................................................7

1.12 STATISTICS...............................................................................................................................................7

1.13 LEGAL MANDATES................................................................................................................................8

1.14 NEED FOR STANDARDISATION OF ACCIDENT AND EMERGENCY SERVICES......................8

1.15 PROBLEMS IN ACCIDENT and EMERGENCY CARE DELIVERY IN INDIA AT THE

HEALTHCARE
FACILITY............................................................................................................................................................8

2.0 PURPOSE OF THE GUIDELINES............................................................................................................................8

3.0 OBJECTIVE OF THE GUIDELINES............................................................................................................................8

Chapter -1 SCOPE OF SERVICES FORACCIDENT AND EMERGENCY DEPARTMENT FOR 200

BEDDED DISTRICT HOSPITAL.............................................................................................................11

1.0 INTRODUCTION........................................................................................................................................................11.

1.2 GOALS...........................................................................................................................................................11.

TABLE 1- SCOPE OF SERVICES FOR A&ED.............................................................................................12..

Chapter-2 DESIGNING FOR ACCIDENT AND EMERGENCY DEPARTMENT (A & ED)...........18

1.0 INTRODUCTION............................................................................................................................................................18
2.0 GUIDELINES ON EMERGENCY DEPARTMENT DESIGN18
3.0 MAJOR SPACE DETERMINANTS: ESSENTIAL COMPONENTS FOR NEW
INFRASTRUCTURE.18

Chapter -3 MANPOWER REQUIREMENT FOR ACCIDENT AND EMERGENCY DEPARTMENT

1.0 INTRODUCTION.................................................................................................................................................................35

1.2 NEED FOR OPTIMUM MANPOWER............................................................................................................................35

1.3 (a) PRINCIPLES OF APPROACHES TO PLANNING NURSE STAFFING ...............................................................35

2
1.3 (b) APPROACHES TO PLANNING OF WORKFORCE ..............................................................................................36
1.4 CHALLENGES IN DECIDING STAFFING LEVELS FOR A&ED...............................................................................37.

1.5RECOMMENDED A&ED STAFF MIX......................................................................................................................................37

Chapter: 4 STANDARD CONCEPTS RELATED TO ACCIDENT AND EMERGENCY

DEPARTMENT AND QUALITY INDICATORS FOR A&ED OF
HOSPITAL.......................................................................41

1.0 STANDARD CONCEPTS RELATED TO ACCIDENT AND EMERGENCY

DEPARTMENT........................................41
CONCEPT 1.
TRIAGE.........................................................................................................................................................................41
1.1GOALS OF
TRIAGE.............................................................................................................................................................41
CONCEPT 2. REVERSE TRIAGE.......................................................................................................................................41

CONCEPT 3. GOLDEN HOUR............................................................................................................................................42

2.0 QUALITY INDICATORS FOR A&ED OF

HOSPITAL.............................................................................................................43
2.1 CLINICAL QUALITY INDICATORS ................................................................................................................44
2.2 DESCRIPTION OF CLINICAL QUALITY INDICATORS.............................................................................44

Chapter- 5 STANDARD PROTOCOLS FOR EMERGENCY DEPARTMENT..............................................48..

1. RECEIVING OF THE PATIENT ...........................................................................................................48

2. REGISTRATION OF THE PATIENT........................................................................................................49
3. IDENTIFICATION OF THE PATIENT .......................................................................................................50
4. INITIAL ASSESSMENT OF PATIENT.........................................................................................................51
5. REASSESSMENT OF PATIENT..................................................................................................................52
6. SHIFTING/ TRANSFER OF PATIENT WITHIN HOSPITAL..............................................................52
7. REFERRAL OF PATIENTS.............................................................................................................................53
8. DISCHARGE OF THE PATIENT....................................................................................................................54
9. PATIENT CARE PROTOCOLS.......................................................................................................................55

Chapter-6 DISASTER MANAGEMENT ............................................................................................................................59

1.0 DEFINITION...................................................................................................... ...........................................................................59.

1.1 AIM AND OBJECTIVES.............................................................................................................................................59.

1.2 TYPES OF DISASTERS.....................................................................................................................................59

2.0 ESSENTIALS OF DISASTER MANAGEMENT PLAN........................................................................................................59

3
3.0 GENERAL CONSIDERATIONS......................................................................................................................................59.
3.1 LINES OF AUTHORITY...........................................................................................................................................59

3.2 DISASTER MANAGEMENT COMMITTEE.....................................................................................................................59

3.3 DISASTER MANAGEMENT PLAN..................................................................................................................................60

Chapter-7 INFECTION CONTROL PRACTICES FOR EMERGENCY DEPARTMENT.........................68

1.0 STATISTICS OF HOSPITAL ACQUIRED INFECTIONS ..............................................................................................68

1.1 IMPORTANCE OF HAI IN EMERGENCY ROOM...............................................................................................................68

1.2 COMPONENTS OF INFECTION CONTROL...................................................................................................................68

1.3 PROCESS CONTROL FOR HAI..........................................................................................................................................69

2.0 TRAINING REQUIREMENTS OF EMERGENCY STAFF FOR INFECTION CONTROL........................................70

3.0. RISK ASSOCIATED WITH INFECTIONS IN EMERGENCY DEPARTMENT............................................................70

Chapter-8 MANAGEMENT OF MEDICATION

1.0 INTRODUCTION ...................................................................................................................................................................80.

2.0 PROCESS CONTROL FOR MANAGEMENT OF MEDICATION....................................................................................80.

BIBLIOGRAPHY........................................................................................................................................................................90.

ANNEXURES........................................................................................................................................................................................92

4
ABBREVIATIONS

A&ED Accident and Emergency Department

AIDS Acquired Immune Deficiency Syndrome
APIC Association for Professionals in Infection Control
BID Brought In Dead
BPL Below Poverty Line
CCTV Closed Circuit Television
CPR Cardio-Pulmonary Resuscitation
CSSD Central Sterile Supply Department
EMT Emergency Medical Technician
HAI Hospital Acquired Infection
HBV Hepatitis B Virus
HCV Hepatitis C Virus
HR Human Resource
HVAC Heating Ventilation and Air Conditioning
ICU Intensive Care Unit
IPD In-Patient Department
LAMA Leaving against Medical Advice
LASA Look Alike Sound Alike
MLC Medico legal Case
NACO National AIDS Control Organisation
OPD Out-Patient Department
OT Operation theatre
PEP Post Exposure Prophylaxis
POP Plaster of Paris
PPE Personal Protective Equipment
WHO World Health Organization

5
 GUIDELINES ON
ACCIDENT & EMERGENCY DEPARTMENT

6
1.0 INTRODUCTION
Accident and Emergency services is a vital component of hospital services because injury is
always unexpected and unplanned and if not treated urgently can result in damage, deformity
and death.
The patients entering an emergency department can be saved only if they arrive at the right time,
at the right place, receives the right treatment and right resources.

The aspect of speed, accuracy and sympathy are important in the emergency department.
The major functions of an emergency department involve:
1) To treat unexpected patients with life threatening and routine conditions.
2) To provide services at all 365 days in a year.
3) To provide immediate, appropriate and life saving care.
4) To provide services in efficient and effective manner.
5) To be sensitive to emotional needs of the patients and their relatives
6) To liaise with courts and police in emergency.
7) To be ready for disaster and mass casualty.

The Emergency Medical System is an area which needs to

1.1 EMERGENCY MEDICAL SYSTEM be given special focus. Emergency Medical services suffer
from inadequate delivery of quality services due to lack of
organised pre-hospital care, emergency preparedness
and the high volume of patients in district hospitals

1.1.1 CURRENT SCENARIO

Health care services in India follow a three tiered approach providing primary, secondary and
tertiary level of care. Wherein the Primary Health Centres/ Community Health Centres serve as the front
line of emergency medical care providing first aid, district hospitals provide the secondary level of
healthcare services whereas medical colleges provide tertiary level care. However, functionally the
emergency services are not planned and organised around this tiered approach. The patient are not
categorised or referred according to level of care required.

1.1.2 STATISTICS

Emergency services is a broad term as such in clued trauma and non-trauma emergencies like poisoning,
burns, acute Myocardial Infarction etc. There are no state and National level statistics available on
incidence of emergency conditions. For trauma emergencies the National Health Profile of India 2009 lists
injury as the 3rd leading cause of death in India. Recent calculations by the Planning Commission of India
estimate the total societal cost of injury in India to be approx. 3% of Indias GDP. 1 Planning and
standardisation of emergency services is a vital step in order to decrease these cost implications.

1
Report of the Working Group on Emergency Care in India,
Ministry of Road Transport and highways, Government of India Pg 1

7
1.1.3 LEGAL MANDATES

With increase in awareness and expectations the law has mandated that immediate care should be
provided to a patient in emergency. It is now mandatory to provide treatment to patients entering
emergency departments (Supreme Court of India; Parmanand Katara vs. Union of India AIR1989SC
2039). Failure to comply is considered as an act of negligence.2 At the present level of care and with the
high volumes of patients entering government hospitals the proportionality of cases of medical
negligence could be astounding.

1.1.4 NEED FOR STANDARDISATION OF ACCIDENT AND EMERGENCY SERVICES3

Standardisation of Accident and Emergency Departments (A&ED) of district hospitals is need of the hour.

Some important areas which need to be addressed on priority basis are:

Infrastructural requirements of Accident and Emergency Department include

proper Design, layout, Signage, Access and Linkages with other departments like
ICU, OT, Diagnostics, Blood Banks & Support Services etc.
Provision of proper and adequate manpower and training requirements
Provision of equipment and Drugs related to Accident and Emergency Department.
Standard Protocols for Emergency.

1.1.5 PROBLEMS IN ACCIDENT and EMERGENCY CARE DELIVERY IN INDIA AT

THE HEALTHCARE FACILITY
1) There is a mismatch between the healthcare facility capacity vis a vis the catchment area
resulting in overcrowding at the limited number of available facilities.
2) Infrastructure at the existing healthcare facilities is deficient due to lack of funds or poor
planning.
3) Inadequately equipped healthcare facilities due to lack of National Standards and Guidelines
regarding the same.
4) Sub-optimal quality care at the existing health facilities due to inadequately skilled manpower.
5) Lack of Standard Operating Procedures regarding the handling of a patient on its arrival at the
healthcare facility.
6) Lack of accountability and monitoring mechanisms to ensure timely and optimal care.

2
Parmanand Katara vs. Union of India (Supreme Court, 1989).
3
Report of the Working Group on Emergency Care in India, Ministry of Road Transport and highways,
Government of India

8
 2.1 The purpose of these guidelines is to provide
2.0 PURPOSE OF THE support and guidance to management, hospital staff and
GUIDELINES
policymakers to establish health facilities providing
quality services in Accident and Emergency Department.

2.2 To assist in providing standardised, comprehensive

and optimum level of health care services in Accident and
Emergency Departments to the people in the district at an
acceptable level of quality and being responsive and
sensitive to the needs of people.

Various aspects covered in the guidelines are:

9
 Chapter -1

SCOPE OF SERVICES FOR

ACCIDENT AND EMERGENCY DEPARTMENT
FOR 200 BEDDED AND ABOVE DISTRICT HOSPITAL

10
 Chapter -1

SCOPE OF SERVICES FOR

ACCIDENT AND EMERGENCY
DEPARTMENT FOR 200 BEDDED AND
Defining the Scope of
ABOVE DISTRICT HOSPITAL Services for district hospital
would enable the right
1.0 INTRODUCTION
category of patients to enter
A & E Department would provide a comprehensive the right facility.
emergency service to all patients presenting to the department on
24*7 bases.

The department would accept all patients of all age groups (Adult
as well as paediatric) and they would receive emergency care and
referral as necessary.

1.2 GOALS

1) To provide priority care for individuals who require

immediate medical attention as per triage guidelines.
2) To provide rapid resuscitation, stabilisation and referral of
critically ill patients.
3) To provide necessary definitive medical care to stabilise 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.

11
Table1. SCOPE OF SERVICES FOR ACCIDENT AND EMERGENCY DEPARTMENT IN A
DISTRICT LEVEL HOSPITAL

(It is an indicative list and may not be exhaustive)

SNO. NAME OF ILLNESS

1 CARDIOVASCULAR SYSTEM

a) Chest Pain (Ischemic Heart Disease)

b) Acute Myocardial Infarction

c) Accelerated Hypertension

d) Congestive Cardiac Failure

e) Arrhythmias

2 GASTROINTESTINAL TRACT

a) Acute Cholecystitis

b) Acute Gastroenteritis with/without dehydration

c) Dysentery

d) Vomiting

e) Pain Abdomen

f) Ascitis

g) Haematamesis

h) Cirrhosis

i) Alcoholic Liver Disease (ALD)

3 DIABETIC COMPLICATIONS

a) Hypoglycaemia

b) Ketoacidosis

c) Diabetic Coma

d) Hyperglycaemia

4 Shock

5 Pyrexia of Unknown origin

6 Anaphylactic Reactions

12
7 Septicaemia

8 Snake Bite

9 Animal Bites

10 Insect Bites

11 Heat Stroke

12 VECTOR BORNE DISEASES :

a) Dengue

b) Chikungunia

c) Malaria

d) Swine Flu

e) Japanese Encephalitis

13 RESPIRATORY SYSTEM (CHEST & TB)

a) Bronchial Asthma

b) Pleural Effusion

c) Pneumonitis

d) Allergic Bronchitis

e) Chronic Obstructive Pulmonary Disorder (COPD)

f) Acute Respiratory Infections

g) Respiratory Failure

h) Haemoptysis

i) Acute Respiratory Distress Syndrome (ARDS)

14 NEUROLOGY

a) Cerebro-Vascular Accident (CVA)

b) Transient Ischemic Attack (TIA)

c) Vertigo

d) Headache

e) Spinal Injury

f) Encephalitis

g) Epilepsy

13
 h) Meningitis

i) Febrile convulsions

15 HAEMATOLOGY

a) Severe Anaemia

b) Bleeding Disorder like Haemophilia, Thallasemia

16 COMMUNICABLE DISEASES

a) Cholera

b) Measles

c) Mumps

d) Chicken Pox

e) Diphtheria

f) Rabies

17 PSYCHIATRY

a) Anxiety disorders

b) Alcohol and Drug Abuse

c) Stress disorder

d) Depression

e) Acute Psychiatric Illness

18 NEPHROLOGY

a) Urinary Tract Infection (UTI)

b) Nephrotic Syndrome

c) Acute Nephritis

d) Diabetic Nephropathy

e) Hypertensive Nephropathy

f) Nephrolithiasis

g) Acute Renal Failure/Chronic Renal Failure

19 GENERAL SURGERY

a) Intestinal Obstruction

b) Burns

14
 c) Cellulitis

d) Acute Abdomen

e) Acute Appendicitis

f) Acute Cholecystitis

g) Perforation

h) Assault Injuries

i) Haemorrhoids

j) Acute Urinary Obstruction

k) Liver Abscess

l) Benign/ Malignant Tumors- (Investigate and Decide further)

m) Road Traffic Accident

n) Head Injury (Not requiring Surgery)

o) BPH with Urinary Retention

20 OPTHALMOLOGY

a) Foreign Body

b) Injuries

21 EAR, NOSE, THROAT

A EAR

a) Infections

b) ASOM/SOM/CSOM

c) Mastoiditis

d) Foreign Body in Ear

B NOSE

a) Epistaxis

b) Foreign body

C THROAT

a) Tonsillitis/ Laryngitis

15
 b) Quinsy

c) Malignant Larynx

d) Foreign Body Oesophagus

e) Foreign Body Bronchus

f) Malignancy of Larynx

22 ORTHOPEDICS

a) Osteomyelitis

b) Road Traffic Accident / Polytrauma

c) Fractures

d) Acute Gout

23 DENTAL SURGERY

a) Injuries -Trauma

b) Toothache

24 MLC CASES

a) Assault

b) Poisoning

c) Intoxication

d) Burns

e) Drowning

f) Suicidal Attempts

g) Vehicular/ Factory/ Unnatural Accident

h) Sexual Assault

i) Criminal Abortion

j) Unconscious patient

k) Cases referred from field as Medico-Legal

l) Brought Dead

m) Post Mortem

n) Any person brought by police for Medical Examination

o) Any other case not falling under the above categories but has legal
implications

16
 Chapter -2

DESIGNING FOR ACCIDENT AND EMERGENCY

DEPARTMENT
(A & ED)

17
 Chapter-2

DESIGNING FOR ACCIDENT AND

EMERGENCY DEPARTMENT (A & ED) A wrongly planned
emergency department
can ruin a hospitals
activities. A hospital
2.0 INTRODUCTION
must be adequately
Emergency Department is a place where within no time every equipped to handle
facility in a hospital is required. Here the care givers have to always emergencies like
be on toes to save a life. accidents, involving
mass causalities,
Activities in an A&ED can be broadly classified in two major parts.
internal and external
disaster
First is related to clinical procedures being done and other to
manage the patients' attendants, friends and relatives in grief. For
the former, proximity of the diagnostics, ICU and operation theatres
is essential and it is important that the route of travel to these
facilities should not criss-cross other circulation pattern of a
hospital. However for the later, managing emotions of the crowd
becomes extremely difficult the emergency personnel are
specifically trained.

The scope of services being provided by an Emergency Department

is a major determinant of the level of staffing, resources and
physical design required.
Key considerations for planning A&ED include safety and security,
provision of amenities, access, patient expectations, and evolving
good practices.

2.1 GUIDELINES ON EMERGENCY DEPARTMENT

DESIGN
Sizing and allocation of space in an emergency is expressed in
relation to the various departmental activities. In general number of
attendances, types of attendances their severity and the desired
performance level like waiting times etc. determine the amount and
type of space required.

18
The emergency department is a core clinical unit of a hospital. Its function is to receive patients, conduct
effective triage, stabilize and provide emergency management to patients who present with a wide
variety of critical, urgent and semi urgent conditions. The emergency department also provides for
proper reception and management of patients who are victims of a disaster as part of its role in the
disaster plan of that region. In addition to standard treatment areas, some additional specifically designed
areas may be required to fulfill special roles, such as:
Management of patients following sexual assault
Management of infectious patients

And facilities for carrying out essential functions such as:

Administration
Staff amenities
Storage areas

Information which would assist in the planning of an emergency department include

Annual census and trends
Average daily census with peak patient volumes
Triage categories of patient presentations
Admission/transfer rate, including the number of cases requiring monitoring
Average length of stay
Turnaround times for radiology and laboratory

2.2 MAJOR SPACE DETERMINANTS: ESSENTIAL COMPONENTS FOR

NEW INFRASTRUCTURE
2.2 A. FUNCTIONAL RELATIONSHIPS:
An emergency department is comprised of the following functional areas:

Entrance/Reception/Triage area
Resuscitation area
Acute Treatment area
Consultation area
Workstations of Staff
Amenities

19
Fig. FUNCTIONAL RELATIONSHIP OF AREAS IN THE EMERGENCY DEPARTMENT

AMBULANCE
BAY

AMBULANCE
TRIAGE RESUSCITATION OBSERVATION SUPPORT

CIRCULATION OPERATING
From UNIT/
CLERICAL
Main TRIAGE INTENSIVE
Entry
RECEPTION
STAFF ACUTE CARE/
CAR SUPPORT IMAGING/
STATION OBSERVATION
PARK
WAITING INPATIENT
WORK BAY UNITS/
MORTUARY

OPTIONAL INTEGRATION
OBSERVATION SUPPORT
X-RAY

The main aggregation of clinical staff over 24 hours will be at the staff station in the Acute
Treatment/Resuscitation area.
Therefore it should be the focus around which the other clinical are as are grouped.
The Entrance/Reception/Triage area is the area in which an emergency patient initially
presents.
The Administration area should be accessible to the clinical areas but should not impair
the clinical function of the department.
The support areas are best arranged around the periphery of the department.

20
 Accessibility of various functional spaces in an Accident and Emergency Department

Direct Access Ready Access Access

Ambulance Intensive Care Unit Inpatient Wards

Medical Imaging Operating Rooms Pharmacy

Observation Ward/ Area Laboratory Outpatients

Blood bank Mortuary

Pathology/Transfusion Services Medical records

2.2B DESIGN CONSIDERATIONS

Essential Remarks
Components for
creating new
infrastructure
2.2.1 General A &ED design should allow rapid access to every space with a minimum
Considerations of cross traffic.
There should be close proximity between the Resuscitation area, Acute
Treatment areas for non-ambulant patients and treatment areas for
ambulant patients, as staff may require to rush from one place to
another.
Visitor and patient access to all areas should not traverse through
clinical areas.
Due consideration should be given to protection of privacy, whilst
recognizing the need for observation of patients by staff.
Radiological, imaging, laboratory and other diagnostic services as per
scope of hospital must be available within a reasonable period of time
for individuals who require these services.
Appropriate signs consistent with the applicable regulations and laws
should indicate the direction of the A&ED from major thoroughfares
along with broad outline of services available.
Adequate provisions for the safety of the A&ED staff, patients, and
visitors must be designed and implemented.

2.2.2 Access and Car The emergency department should be clearly identified from all
Parking - entrances.
The emergency department should be located on the ground floor for
ease of access.
It should be close to public transport.
Adequate bilingual signage should be available to ensure ease of way
finding.
Illuminated signage is required for some signs to ensure visibility at
night. The use of graphic and character display (Eg. a white cross on a
red background with the word EMERGENCY is recommended.
Car parking should be close to the entrance, well lit and available
exclusively for patients, their relatives and staff.
Undercover parking should be available for appropriate number of
ambulances. This will be determined by case load.

2.2.3 Fire Safety Constructed in compliance with fire regulations

21
2.2.4 Bed Spacing In the Acute Treatment area there should be at least 7.8 feet (2.4
meters) of clear floor space between beds. The minimum length
should be 10 feet (3 meters).

2.2.5 Lighting It is essential that a high standard focused examination light is

available in all treatment areas.
Each examination light should have a power output of 30,000 lux,
illuminate a field size of at least 150mm and be of robust construction.
Clinical care areas should have exposure to daylight wherever possible
to minimize patient and staff disorientation.

2.2.6 Sound Control Designed so as to minimize the transmission of sound between

adjacent treatment areas

2.2.7 Service Panels Service panels should be minimally equipped as follows:

Centralized oxygen outlet
Centralized suction outlet
Sockets

2.2.8 Physiological Each Acute Treatment area bed should have access to a physiological monitor
Monitors which should include a minimum of:
ECG
Non Invasive Blood Pressure (NIBP)
Temperature
SpO2

2.2.9 Cabling Adequate cabling should be provided to ensure availability of sockets to

all clinical and nonclinical areas.
Provision should also be made for cabling of telephone, patient call,
emergency call, and computers to areas where these are necessary.

2.2.10 Medical Gases Medical gases should be internally piped, to all patient care areas.

2.2.11 Doors All doors through which patients may pass must be of sufficient size to
accommodate a full hospital bed.

2.2.12 Corridors
In general, the total corridor area within the department should be
minimized to optimize the use of space.
Where corridors are necessary, they should be of adequate width to
allow the cross passage of two hospital beds or a hospital bed and linen
trolley without difficulty.
There should be adequate space for trolleys to enter or exit any of the
consulting rooms, and to be turned around.
Standard corridors should not be used for storage of equipment, linen,
waste or patients.

2.2.13 Air The emergency department should have a HVAC system capable of
Conditioning rapid change from recirculation to fresh air flow.
Special purpose rooms like Infectious Disease Isolation Room may have
special flow and filtering requirements.

22
2.2.14 Information/ Emergency departments are high volume users of telecommunications
Communications and information technology. Telephones should be available at all staff
Support stations and all consultation areas.
An intercom and public address system that can reach all areas of the
emergency department should be available.
Public telephones should be available in the waiting area.
Direct communication should be available between the ambulance
service and the emergency department.

All patient care areas including toilets and bathrooms require

2.2.15 Patient Call individual patient call bell facilities.
Facilities Emergency department bed spaces should have call buttons that can be
easily reached by a patient on the emergency department trolley.

2.2.16 Hand Adequate hand washing facilities should be available.

Washing Facilities Basins for hand washing should be available within treatment area.
There should be basins at a ratio of 1:8 in observation area and at the
ratio of 1:1 for every Procedure/ Consulting
room/Triage/Isolation area.
Taps in clinical areas should be operated hands free.
Sufficient quantities of PPE should be present to assist staff compliance
with standard precautions.

2.2.17 Emergency Emergency power must be available to all lights in the Resuscitation
Power and Acute Treatment/Observation areas of the department.
Emergency lighting should be available in all other areas.
All computer terminals should have access to emergency power.
In the event of a total power failure, sufficient space and power points
should be available to enable a backup system.

2.2.18 Wall Finish
Hospital beds, ambulance trolleys, and wheelchairs may cause damage
to walls, so all wall surfaces in areas which may come into contact with
mobile equipment should be reinforced.
Bed stops should be fitted to the floor to stop the bed head from coming
into contact with and damaging fittings, monitors, etc.

2.2.19 Floor The floor covering in all patient care areas and corridors should have the
Covering following characteristics
Non slip surface
Impermeable to water, body fluids
Durable
Easy to clean

2.2.20 Wall Clocks A wall clock should be visible in all clinical areas and waiting areas.
Time clocks are desirable in the resuscitation, procedure and plaster
rooms.
Times displayed in all areas and on computers must be synchronized.

23
2.3. DESCRIPTION OF PATIENT FLOWS

The following diagram outlines the various pathways that a patient may follow when he enters
the emergency department:

The way to recovery:

AMBULANT AMBULANCE

Consultation Acute &

Area TRIAGE Sub-acute
Assessment

Specialities RESUSCITATION &

Women & TRAUMA IMAGING
Child Health SERVICES

Short Stay
Unit
Inpatient Wards

HOME

2.3.1 Entrance The entrance to the Emergency Unit must be well-marked, illuminated,
Area and covered.
It shall provide direct access from public roads for ambulance and
vehicle traffic, with the entrance and driveway clearly marked.
A ramp shall be provided for pedestrian and wheelchair access.
The entrance to the Emergency Unit shall be paved to allow discharge
of patients from cars and ambulances.
Temporary parking should be provided close to the entrance.

2.3.2 Reception The Reception Area is required to accommodate:

Reception of patients and visitors
Registration of patients
Handling patient enquiries

There is a close operational relationship between Triage and reception.

Administrative staff at the reception counter may receive patients
arriving for treatment and direct them to the Triage area.
After assessment at the Triage area, patients or relatives will generally be
directed back to the Reception where staff would register the patient.
However in critical category patients the process of registration may be
completed after administering treatment.
When the decision to admit has been made, admission details are filled at
reception.

24
2.3.3 Triage There may be need for triage when a school bus accident or a large pile-
up of cars on a highway results in too many injured people for too few
ambulances or EMTs.
The first interaction with the patient happens at the Triage.
The term "Triage" refers to a sorting of injured or sick people according to
their need for emergency medical attention.
It is used to determine priority for who gets care first.
Triage may be performed by anyone from emergency medical technicians
(EMTs) to emergency room gatekeepers.
The most common triaging system is the 4 level systems:

Priority I (Immediate) - Patients have life threatening injuries or patients who

can survive need immediate treatment. Examples: Airway compromise, tension
pneumothorax, shock, cardiac arrest, seizures, etc.

Priority II (Delayed) - Patients require definitive treatment but no immediate

threat to life exists. Patients may remain stable for 10 to 20 mins. Examples: Limb
injuries, lacerations with haemorrhage (controlled), high fever, altered sensorium,
severe pain etc.

Priority III (Minimal) - Patients have minimal injuries or minor conditions and
are ambulatory. Examples: Sore throat, abrasions and superficial lacerations,
chronic self limiting disorders, etc.

Priority IV (Expectant / Dead) - Victims are dead or have lethal injuries and will
die despite treatment. Examples: Devastating head and chest injuries, 3rd degree
burns over most of the body, destruction of vital organs, etc.

2.3.4 Treatment After triage patients may be directed to:

Area a. Resuscitation area
b. Acute Treatment/ Observation area
c. Consultation area
d. Waiting area
In areas a-c, consultation/examination/investigations/treatment will be
performed either in sequence or concurrently, depending on the severity
of the patient's condition.
Support services and, in certain cases, specialized areas, Eg. Plaster room,
minor OT may be utilized.
After assessment and treatment, patients are admitted, transferred,
referred or discharged.

2.3.5 Patient and Patient and visitor exit routes out of the emergency department should be
Visitor Exit Routes clearly sign posted from within the emergency department.

2.4. Space and general requirements

2.4.1Total Area Area

required for A&ED
The total internal area of the emergency department, should
be at least 50m2 (540 ft2) /1000yearly attendances or
145m2(1560 ft2)/1000) yearly admissions, whichever size
is greater.
The minimum size of a functional emergency department that

25
 can incorporate all of the major areas is 700m2 (7530 ft2).

2.4.2Reception/Triage It is the area where patient initially presents.

Area Area
The combined area of the reception/triage/clerical area should be at
least 1.8m2 (20 ft2) /1000 yearly attendances

General Requirements
The department should be accessed preferably by two
separate entrances; one for ambulance patients and the other
for walk-in patients.
It is recommended that each entrance area contains a
separate foyer.
Both entrances should direct the patient flow towards the
Reception/Triage area.
The Reception/Triage area should have clear vision to both
the waiting room and the ambulance entrance.
The reception/triage area should be designed to cater for the
easy access of wheelchair bound or otherwise disabled
patients.
The area should be designed with due consideration for the
safety of staff.
Access to treatment areas from reception/ triage should be
restricted by the use of security doors.
There should be direct communication between the
Reception/Triage area and the Nursing Station in the Acute
Treatment/Observation area.

Equipment
The Reception/Clerical office should have access to the following
equipment Computer terminals
Telephones
Photocopier
Computer printers
Storage space for stationery and medical records
Switches/ Sockets

The Triage area should have access to the following equipment:

Sphygmomanometer (BP Apparatus)

Facility for hand washing
PPEs
Examination light
Storage space for bandages, stationery etc.

2.4.3Resuscitation This room is used for the resuscitation and treatment of

Room/ Bay critically ill or injured patients.

Area
Resuscitation area may be further divided into separate bays

26
 Minimum size for a single bed resuscitation room is 35m2
(376 sq ft) or 25m2 (270 sq ft) for each bed space if in a
multi bedded room (not including storage area).
Ideally the number of resuscitation areas should be no less
than 1/15,000 yearly attendances or 1/5,000 yearly
admissions and at least 1/2 of the total number of these areas
should have BP, Pulse, RR monitoring ,but there should be at
least one dedicated single bedded resuscitation room in A&ED
of each district hospital.

General Requirements
The Resuscitation area should be easily accessible from the
ambulance entrance and separate from patient circulation
areas.
It must be easily accessible from the staff station in the Acute
Treatment/Observation area.
The Resuscitation area should have a full range of vitals
monitoring and resuscitation equipment.
The Resuscitation area should preferably have solid partitions
between it and other areas.
Sufficient area should be there to fit a specialized resuscitation
bed.
Space to ensure 360 access to all parts of the patient for
procedures.
Space for equipment, monitors, storage and disposal facilities.
Circulation space to allow movement of staff and equipment.
Appropriate lighting, equipment to hang IV fluids etc.
Maximum possible visual and auditory privacy for the
occupants of the room and other patients and relatives.

Equipment

Each Resuscitation bed space should be equipped with:

Wall mounted BP apparatus
Fully equipped crash cart
Defibrillator/ AEDs
Sockets
Vitals monitor with facility for ECG, NIBP, SpO2 ,
temperature
An operating room light
IV stand
Wall clock
Infusion pumps
Drugs cupboard

The following should be immediately accessible:

Intravenous access trolleys
Urinary catheterization tray
Airway management tray (including surgical airway
equipment)
Pediatric resuscitation equipment

27
 Acute treatment area is an area for management of patients
2.4.4 Acute Treatment with serious or potentially serious illness.
Area
Area
Each treatment area must be at least 12 m2 (130 ft2) in area.
Areas such as procedure and plaster rooms are not considered
as treatment areas nor are observation unit beds for admitted
patients.
Minimum recommended space between centers of two
adjoining beds is 2.4 meters. (8 ft).

General Requirements
It is divided into number of small units and each unit
treatment area has the following requirements:
Area to fit a standard mobile bed.
Storage space for essential equipment, E.g. Oxygen masks.
Space for equipment, monitors, storage and disposal facilities.
Appropriate lighting, equipment to hang IV fluids etc.
Circulation space to allow movement of staff and equipment
around the work area.
If possible there should be a separate paediatric area/beds for
the treatment of children.
All of these beds must be situated to enable direct observation
from the Nursing Station.
If possible a separate dedicated area/ room should be present
for examination of MLC cases.

3.3.5 Consultation Consultation areas are provided for the examination and
Area treatment of walk-in patients who are not experiencing a major or
serious illness requiring resuscitation or close monitoring.
Area
Minimum 12 m2 (130 ft2) in area.
General Requirements
Each area should be of sufficient size to house:
Examination couch/trolley
Desk and chairs
Patient stool
Computer outlet and terminal

3.3.6 Plaster Room The Plaster room allows for the application of Plaster of Paris
(POP) and other splints for the closed reduction under sedative or
regional anaesthesia, of displaced fractures or dislocations.

Area
It must be at least 20 m2 (215 ft2) in size, excluding crutch or
splint storage areas.
General Requirements
It should be easily accessible from A&ED.
There can be two separate entrances one for A&ED patients
and other for OPD and IPD patients.
Location should be such that routine patient flows to this
room does not pass through main A&ED area.

28
 Equipment
The following equipment are required:
Storage for plaster bandages
X-Ray viewing panel
Monitoring equipment (NIBP, SpO2, ECG) including access
to resuscitation equipment
Nitrous oxide delivery system or storage space for a
portable nitrous oxide delivery system
Plaster trolley
Sink and drain with a plaster trap
Work bench

3.3.7 Procedure Room The Procedure room is required for the performance of
procedures such as lumbar puncture, chest tube insertion, plural
tap, ascitic tap, bladder catheterization, suturing, dressing etc.

Area
It must be at least 20 m2 (215 ft2) in size.

General Requirements
It should be directly accessible from A&ED.
It should have Area to fit a standard mobile patient trolley.
Storage space for essential equipment and dressing material
Eg. Oxygen masks, Ryles tube, PPE etc.
Space for dressing trolleys.
Space for disposal facilities.

Equipment
Minimal equipment include:
Operating theatre light suspended from the ceiling
X-Ray viewing box
Monitoring equipment: NIBP, SpO2, ECG with access to
resuscitation equipment.

3.3.8 Nursing Station The Staff Station in the Acute Treatment area will be the major
staff area within the department.
Area
The staff station(s) must be at least 10m2 (108 ft2) in size or
1m2 (10 ft2) /1000 yearly attendances, whichever is larger.

General Requirements
The station should provide an uninterrupted view of patients
and the floor may be raised to achieve this aim.
It should be centrally located and constructed in such a
fashion to ensure that confidential information can be
conveyed without breach of privacy.
An enclosed area is recommended for this reason and also to
provide security of staff, information and privacy.

Equipment
The following equipment and fittings should be accessible:

29
 Intercom
Direct line telephone for incoming Ambulance/Police use
only
Computer terminal
Medicine cupboards
Emergency and patient call display
Alarm
Valuables storage space
Storage for stationery
Writing and work benches

3.3.9 Emergency Ward/

This facility may be provided either within or adjacent to the
Short Stay Unit
Emergency Unit for the prolonged observation and ongoing
treatment of patients who are planned for subsequent discharge
(directly from the A&ED).
Area
The types of patients planned to be admitted to this Unit
will determine the number and type of beds provided, and
the design of associated monitoring and equipment;
however 8 beds is considered to be the minimum
functional size.
The configuration of the short stay unit should be a
minimum of 1 bed per 4000 attendances per year.

General Requirement
Patients may be kept in this Unit for diagnosis, treatment,
investigation or for medical stabilization.
The length of stay in the Unit is generally between 4 and 24
hours, although some patients may require longer stays.
The Unit may also be situated separately to the Emergency
Unit, although functionally linked. According to the service
plan, dedicated beds for short stay are separately
designated and staffed.
The number of beds required will be influenced by the
function and type of patient in the unit.
Some of the beds should be capable of physiological
monitoring similar to an acute treatment area.
There should be a separate nursing station of an
appropriate size.
Hospital beds and not trolleys must be provided.

30
3.3.10 Waiting Room This area is meant for patients attendants. In case of excessive
rush patients belonging to triage category 3 can be made to wait in
this area.
Area
The waiting area must be of a total size of at least 5.0m2 (54
sq ft) /1000 yearly attendances that includes seating,
telephones, display for literature, public toilets and circulation
space.
The waiting room should include one seat per 1000 yearly
attendances.
General Requirements
The area should be open and easily observed from the Triage
and Reception areas.
Seating should be comfortable and adequate space should be
allowed for wheelchairs and patients being assisted.
Natural lighting should be maximized.
There must be access to:
Triage and Reception areas
Toilets
Public Telephones
Health literature

The waiting area should provide sufficient space, TV, Small

Canteen for waiting patients as well as relatives.

The area should be continuously monitored by electronic

surveillance to safeguard security and patient well being.
3.3.11 Security Room General Requirement
The location of an office for security personnel near the
entrance should be considered.
This room should be so positioned as to enable direct
visualization of the waiting room, triage and reception areas
with immediate access to these areas being essential.
Remote monitoring of other areas in the department by CCTV
should also occur from this area.

3.3.12 CLINICAL
SUPPORT AREAS 1 Clean Utility
This should be of sufficient size for the storage of clean and sterile
supplies.

2 Dirty Utility/Disposal Room

Access should be available from all clinical areas.
There should be sufficient space to house the following:
Stainless steel bench with sink and drainer
Storage space for soiled linen

3 Equipment/Store Room
This is used for the storage of equipment (Eg. IV stands) and
disposable medical supplies for the department. There should be
sufficient space to store. The total area of dedicated store rooms
must be at least 2.2m2 (24 sq ft) /1000 yearly attendances.

31
 This does not include storage space within treatment areas. As a
general principle, emergency departments should have sufficient
storage space to carry one weeks supply of disposable medical
supplies and intravenous fluids. Local logistic issues and risk
management considerations may dictate larger storage capacity.

4 Pharmacy Sub Store

Used for the storage of medications used by the department.
Entry should be secure with a self-closing door. The area should
be accessible to all clinical areas and have sufficient space to
accommodate storage racks, and a refrigerator for storage of heat
sensitive medicines.

5 Disaster Equipment Store

This should be located near the Ambulance Entrance and should
be of a size consistent with the role of the A &ED in a major
incident or disaster.

6 Janitors Room
It should have a basin, water facility for washing and
adequate space for keeping mops, broom and reagents.
The flooring should be non slippery and stain resistant.
7 Patient toilets
In an Emergency Unit the following Patient Toilet facilities will be
required, (separate Male and Female):
Up to eight treatment beds- 2 patient toilets, one each for
male/ female.
Between nine to twenty treatment beds-4 patient toilets,
two each for male/ female.
Between 21 to 40 treatment beds-6 patient toilets, 3 each
for male/ female.
At least two of the above toilets to be assessable for
wheelchair, one each for male /female

3.3.13 STAFF
FACILITIES 1. Staff Room
At least two rooms should be provided within the
department one for doctors and other for staff nurses to
enable staff to distress during rest periods.
There should be appropriate table and seating
arrangements.
It should be located away from patient care areas and
have access to natural lighting and appropriate floor and
wall coverings.
The staff room should be based upon the number of staff
working at any one time and their anticipated needs, and
as an initial guide, this should be at least 0.8m2 (9 sq ft)
/1000 yearly attendances, which can be adjusted
depending on staff numbers.
Staff should have access to independent toilets. Staff
lockers should be available.

32
 Appropriate security and restricted access to this area
should be available.

3.3.14 SECURITY The emergency department receives a large number of

patients and their attendants, many of whom may be
distressed, intoxicated or involved in violence.
The hospital has a duty of care to provide for the safety and
security of employees, patients and visitors.
Policies, structures and training should be in place to
minimize injury, psychological trauma and damage or loss of
property.
The precise details of security features should be designed in
conjunction with a security risk assessment for the specific
site.
The following specific security issues should be considered:

1 Ambulance Access Control

Ambulatory and Ambulance entrances should be separate. Access
from the waiting areas to the treatment areas should be
controlled. There should be restricted access from the remainder
of the hospital into the A &ED.

2 Security Personnel
Uniformed security personnel may be required at very short
notice to assist with a safety or security issue. Their base should
be positioned either within or immediately adjacent to the A&ED,
with rapid communication links.

3 Electronic Surveillance
Relatively secluded or isolated areas should be monitored
electronically (for example, by closed circuit TV), with monitors
in easily visible and continuously staffed areas.

33
 Chapter -3
MANPOWER REQUIREMENTS FOR ACCIDENT AND
EMERGENCY DEPARTMENT

34
 Chapter -3

MANPOWER REQUIREMENT FOR ACCIDENT AND EMERGENCY

DEPARTMENT
1.0 INTRODUCTION

1.1 CURRENT SCENARIO

There is a wide range of services that could be offered in an A&ED department ranging from urgent care
to severe trauma care. It has been noted that in recent times there has been a change in the patients who
are presenting to emergency departments, the conditions they are presenting for, and the public
expectations of the services. Almost 25 percent or more of these patients could be treated in OPD setting,
whereas major trauma usually represents less than one percent of all A&ED patients.

1.2 NEED FOR OPTIMUM Emergency departments need to be properly staffed in

MANPOWER order to assure patient, nursing staff and medical staff
satisfaction.

Short staffing compromises care both directly and indirectly.

Recurrent short staffing results in increased staff stress and reduced staff wellbeing, leading to
higher sickness absence, and more staff leaving.
All of this impacts on the cost and quality of care provision. Higher patient to staff ratios are
associated with a number of adverse outcomes in hospitals for both patients and staff.
For each additional patient assigned to a nurse, there is a 7% increase in the likelihood of patient
death within 30 days of admission, and a 7% increase in the odds of failure-to-rescue.
Each additional patient is also associated with a 23% increase in the odds of nurse burnout and a
15% increase in the odds of nurse dissatisfaction with their job.

1.3 (a) PRINCIPLES OF A range of methods exists that enables staffing to be

APPROACHES TO PLANNING planned.
NURSE STAFFING

The principles to planning staffing rely on quantifying the volume of nursing care to be
provided on the basis of :
The size of population,
Mix of patients, and
Type of service - and
Relating it to the activities undertaken by different members of the team.
Good quality data (HR, quality and outcomes) is therefore the cornerstone of effective
staff planning and review.
Staffing decisions cannot be made effectively without having good quality data on the
following parameters

35
 Factors that
impinge on daily Evidence of the
Patient mix Current staffing
staffing levels effectiveness of
(acuity/dependency) (sanctioned/vacant
(absence, staffing - quality
and service demands posts)
vacancies, patient outcomes
turnover)

1.3 (b) APPROACHES TO There are two broad types of approach to workforce
PLANNING OF WORKFORCE planning: top-down and bottom-up. While they can be
used in isolation of one another, they are best considered
as complementary approaches.

TOP-DOWN PLANNING BOTTOM-UP METHODS

It involves the use of existing It is based on identifying and

health care data to calculate quantifying the factors which
staffing levels based on a formula. influence a nurses workload.

These methods are generally based on

For example taking into account how
inter-hospital comparison
unwell patients are (or their acuity)
(benchmarking) and population need.

Staffing ratios are an example of a top- Their level of dependence on nursing

down methodology, for example using
the number of occupied beds as a
measurement of service capacity, and
then relating this to the number nurses
per bed.
interventions and the work
associated with likely activity in
order to calculate staffing levels.
(for example, number of patients
going to operation theatre)

The two key factors considered in this approach are

Patient dependency/acuity and

Nursing workload.

Top-down methods are more remote and used by workforce planners in health care management,
whereas bottom-up methods are frequently associated with planning at local or ward level.

36
1.4 CHALLENGES IN It is necessary to provide staff to cover a workload higher
DECIDING STAFFING LEVELS than the average number of visits keeping in view the
critical nature of patients coming to A&ED.
FOR A&ED

It is necessary to provide staff to cover a workload higher than the average number of visits
keeping in view the critical nature of patients coming to A&ED. This results in some standby or
idle time of the staff. Despite this idle time, staff cannot be reassigned to other areas and pulled
back when patients arrive. Matching the peak patient volumes to peak staffing pattern is a
challenging task.
Volume varies significantly from day to day and also during the 24 hours. Often the highest
volumes occur during odd hours and on weekends and holidays when alternative sources of care
are closed, Eg., doctors offices and clinics. While the total number of visit may be higher on
weekends, the number of admitted patients does not go up at the same rate, and may not
increase because the acuity is lower on weekends.
The distribution of patients by shift is somewhat dependent on where the hospital is located. An
inner city hospital may have more patients admitted on the night shift as compared to a
suburban hospital.
Type of patients coming to A&ED department varies depending upon location of hospital in the
city as well as the region of state in which hospital is located. For Eg. hospitals close to national
highways may have more accident cases. Hospitals closer to medical colleges may be catering to
lesser number of patients and less acute cases.
Other significant factors impacting the staffing standard are the percentage of patients admitted
rather than treated and released, and whether or not the ED staff is responsible for selected
activities. The admitted percentage can range from less than 10% to almost 25% of all patients.

1.5 RECOMMENDED A&ED MANPOWER REQUIREMENT FOR ACCIDENT, EMERGENCY

STAFF MIX AND TRAUMA DEPARTMENT

SNO STAFF CATEGORY IN A & ED REMARKS

1 Supervisory personnel like A dedicated person should be assigned as in-

Resident Medical Officer or charge of emergency department.
Emergency In charge-

2 Medical Officers For Emergency OPD and Emergency wards

If a Medical Officer is able to provide
consultation to one patient in 15 min.
So in a 6 hour shift =
1MO is able to provide consultation to 4
patients in 1 hour.
1 MO is able to provide consultation to 24
patients in 6 hours.
In 3 shifts during 24 hours @ of approx 25

37
 patients/ shift, total patients seen = 75
approx

So for a workload of
< 75 patients/ 24 hrs = 1 MO / shift ( Total
3 MO during 24 hours)
75-200 patients/24 hrs = 2 MOs/ shift (
Total 6 MO during 24 hours)
200 patients/24hrs = 3 MOs/ shift ( Total 9
MO during 24 hours)
All the specialists to be available on call round
the clock as per pre defined roster.
It is assumed that morning and evening shift is
of 6 hours and night shift is of 12 hours.

3 For Emergency OPD-

Staff Nurses When registration staff is separate from
clinical staff
So for
< 75 patients/24 hrs = 1 SN / shift( Total 3
SN during 24 hours)
For every additional attendance of 35
patients add one more staff nurse in 24
hours.
For Emergency ward-
1:6 per shift + 15% leave reserve.

4 Emergency Medical Technicians One EMT/ ambulance/shift.

When they are not accompanying ambulance
they can assist nursing staff or staff posted in
minor OT.
Duration and number of shifts may vary
depending upon workload.

5 Other Support Staff:

a) Staff for Minor OT- For a workload of

< 50 patients/24 hrs = 1 OTA and or
dresser/ shift (Total 3OTA/Dresser during
24 hours) for dressings, splint application and
suturing of minor injuries.
50-100 patients/24hrs = 2 OTA and or
dresser/ shift during morning shift and 1
OTA and or dresser during evening and
night shift.
>100 patients/24hrs = 2 OTA and or
dresser/ shift during morning and evening
shift and 1 OTA and or dresser during

38
 night shift.
b) Registration Clerk- A dedicated person to be present for
registration of patients in all shifts.

c) Data Entry Operator- A dedicated person to be present for

computerised medico legal record entry in all
shifts.

d) Lab technician- For Emergency Sample Collection Centre:

< 100 samples/24hrs = 1 LT/ shift (Total 3LT
during 24 hours).
100-200 samples/24hrs = 2 LT/ shift
(Total 6LT during 24 hours).

e) Security staff- For a workload of

< 150 patients/24hrs= 1 Security Staff/ shift
(Total 3 security staff during 24 hours).
>150 patients/24hrs = 2 Security Staff/shift
(Total 6 security staff during 24 hours).

f) Group D staff- For a workload of

< 150 patients/24hrs= 1 Group D staff/ shift
(Total 3 Group D staff during 24 hours).
>150 patients/24hrs = 2 Group D staff/shift
(Total 6 Group D staff during 24 hours).

g) Housekeeping staff- For a workload of

< 150 patients/24hrs= 1 Housekeeping staff
/ shift (Total 3 Housekeeping staff during 24
hours).
>150 patients/24hrs = 2 Housekeeping
staff/shift (Total 6 staff during 24 hours).

39
 Chapter-4

STANDARD CONCEPTS RELATED TO ACCIDENT

AND EMERGENCY DEPARTMENT
AND
QUALITY INDICATORS FOR A&ED OF HOSPITAL

40
 Chapter: 4

STANDARD CONCEPTS RELATED TO ACCIDENT AND

EMERGENCY DEPARTMENT
AND
QUALITY INDICATORS FOR A&ED OF HOSPITAL

1.0 STANDARD CONCEPTS RELATED TO ACCIDENT AND EMERGENCY

DEPARTMENT

CONCEPT 1. GOLDEN HOUR The rst hour after injury largely determines a critically-
injured persons chances for survival, it is also known as
the Golden Time.

It is the time period which can range from a few minutes to a few hours, i.e. not necessarily one
hour, but the amount of time which follows a traumatic injury sustained; during which there is
highest likelihood that prompt medical treatment will prevent death.

During this time period, the possibility of saving ones life is the highest through emergency
medical treatment. Special trauma centres and many other emergency medical services are
designed just because of this reason and to make sure that the injured person is properly treated
in the case.
Death following Trauma generally occurs due to a shock. Major causes include internal bleeding
leading to haemorrhage shock. It is crucial to provide proper and instant medical help to
someone in dire need of it. If the injury can be treated on time, the blood flow controlled and
blood pressure restored in that course of time, a life can be saved.
In case of heart and chest injuries, the patient can get a stroke easily and during that time the
theory behind Golden Hour comes into real-time practice.
Since the patient is in a state of shock, a well trained medical practitioner can provide the help
they need and that can be vital in saving their life.

It is a process of setting priorities for treatments for a

CONCEPT 2. TRIAGE patient or a group of A&E patients. The sorting of patients
into priority categories is performed by an experienced
staff.

1.1GOALS OF TRIAGE

a. Rapidly identify patients with urgent, life-threatening conditions

b. To allocate the patient to the most appropriate assessment and treatment area
Assess/determine severity and acuity of the presenting problem
c. To ensure that patients are treated in the order of their clinical urgency
d. To ensure that treatment is appropriate and timely.

41
 e. Re-evaluate patients awaiting treatment

All patients presenting to an Emergency Department should be triaged on arrival by a specifically

trained and experienced person, which may be Staff Nurse or Medical Officer on duty.
The triage assessment and Triage Scale code allocated must be recorded.
The staff should ensure continuous reassessment of patients who remain waiting, and, if the
clinical features change, re-triage the patient accordingly.

Category 1 Category 2 Category 3 Category4

Emergency (Red) Urgent (Yellow) Minimal (Green) Expectant (Black)

Patient whos ABCs are These are Walking Patients who can safely Patients who are expected
compromised Wounded. Those whose wait to be seen by to die despite treatment /
condition needs physician as time very poor prognosis or are
already dead on arrival
investigation and permits
treatment

Patients with life or Patients with serious Patients who have Victims who are dead or
limb threatening conditions who need conditions which are have lethal injuries and
conditions who may immediate treatment not life threatening and will die despite treatment.
die without immediate quickly to avoid any can wait for same time Examples: Devastating
treatment further problems. like patients with minor head and chest injuries,
/resuscitation. (Treated in treatment injury ,cuts etc. 3rd degree burns over
(Treated in area and kept under most of the body,
resuscitation room.) observation in destruction of vital organs,
observation area/ etc.
room.)
Patients in Red Patients in Yellow Patients in Green Patients in Black Category
Category should be Category should be sent Category should be sent should be sent to Morgue
sent to the to Observation Area to Consultation Area once declared dead
Resuscitation Area

CONCEPT 3.REVERSE TRIAGE This concept is used to provide extra patient beds during
public health emergency.

Sometimes the less wounded are treated in preference to the more severely wounded. This may
arise in a situation such as disaster situations where medical resources are limited in order to
conserve resources for those likely to survive but requiring advanced medical care.
This method evaluates inpatients to see which ones can be safely discharged to free up beds for
other patients in more immediate need of medical care.
Patients who have only a slight chance of experiencing an adverse event within four days of
leaving the hospital may be discharged to free bed space. A&ED staff can provide a daily initial
reverse triage score for patients being admitted, even if a disaster is not imminent.

42
 2.0 QUALITY INDICATORS FOR A&ED OF HOSPITAL

2.1 CLINICAL QUALITY INDICATORS

The A&E clinical quality indicators are required to:

Measure performance in terms of patient safety and clinical effectiveness.
Encourage continuous improvement with better information leading to better clinical
outcomes and patient experience.
Provide information that is easier to understand for patients.

2.2 DESCIPTION OF CLINICAL QUALITY INDICATORS

2.2.1 PERFORMANCE INDICATORS

Total monthly attendance : Total monthly

Total number of patients
attending emergency
department in a month.
Disease wise classification
admissions:Total number of
of patients as per scope of
patients admitted through
services document.
emergency in a month.

Number of patients Number of patients

Referred in from periphery Referred out to other Number of successful CPR
with details of referring hospital with details of out of total CPR done in a
institute along with reason for referring institute along with month.
referral. reason for referral.

2.2.2 PATIENT SAFETY INDICATORS

Time to Initial Assessment Time to Treatment

Time to initial assessment

This indicator only applies to patients who arrive by ambulance.
It measures the length of time from arrival in the department to when an initial
clinical assessment is completed.
The aim is to achieve less than 15 minutes as this minimises clinical risk by detecting
those patients who need emergency intervention.

43
 Time to treatment
This indicator applies to all patients coming to emergency. It shows the time taken
from arrival to seeing a doctor and nurse who will start the treatment for the
patients condition.

2.2.3 PATIENT QUALITY INDICATORS

Total time spent in

Unplanned re- Patient satisfaction
emergency Time to shifting
attendance rate surveys
department

Total time spent in emergency department

This indicator shows how long patients are spending in Emergency Department from the
time they arrive until when they are either discharged, or admitted to the hospital including
admission to emergency ward.

Time to shifting

This indicator shows the number of patients shifted to respective wards within 8 hours of
admission out of total admissions.

Unplanned re-attendance rate

This indicator includes patients who return to A&ED within seven days of the original
attendance and are classified as an unplanned re-attendance if they have not been
specifically asked to re-attend.

Patient satisfaction surveys

Patient satisfaction surveys should be conducted regularly on sampling basis to assess

service quality.

2.2.4 INCIDENT REPORTING:

Needle Stick Injuries

Needle stick injury is a penetrating stab wound from a needle (or other sharp object)
that may result in exposure to blood or other body fluids.

All incidences of needle stick injuries should be assessed on a case-to-case basis.

Data from injury reporting should be compiled and assessed to identify where, how,
with what devices, and when injuries are occurring and the groups of health care
workers being injured.

44
 Medication Errors

A medication error is any preventable event that may cause or lead to inappropriate
medication use or harm to a patient, like Errors in the prescribing, transcribing,
dispensing, administering, and monitoring of medications, Wrong drug, wrong
strength, or wrong dose errors, Wrong patient etc.

All the cases of medication error should be reported and analysed.

Adverse Events

An adverse effect is a harmful and undesired effect resulting from a medication or

other intervention such as surgery.

All the cases of adverse events should be reported and analysed.

Near Miss

A near miss is an unplanned event that did not result in injury, Illness, or damage,
but had the potential to do so.

Errors that did not result in patient harm, but could have, can be categorized as near
misses.

All the cases of near miss should be reported and analysed.

Audits

In addition to above indicators medical record audit/ death audit/ prescription

audit should be routinely conducted on sampling basis.

5.0 OUTCOME INDICATORS

The facility should measure productivity Indicators on monthly basis.

Total Number of Total number of Total number of

Total Number of
Emergency Cases trauma cases poisoning cases
Trips per
per thousand treated per 1000 treated per 1000
ambulance
population Emergency cases emergency cases

Total number of Total number of Total number of

Proportion of
Cardiac cases Obstetric Cases resuscitation
patients attended
treated per 1000 treated per 1000 done per 1000
at Night
emergency cases emergency cases population .

45
6.0 EQUITY INDICATORS

The facility should measure Equity Indicators Periodically. The following

indicator should be measured:

Proportion of BPL Patients

7.0 EFFICIENCY INDICATORS ENSURING STATE/NATIONAL BENCHMARK

The facility should measure Efficiency Indicators monthly. The following

indicator should be measured:

Average Turnaround Proportion of Patient

time: Average time a referred by State
Response time of
patient stays at the owned 102
Ambulance
emergency ambulance per 1000
observation bed referral cases

Death Rate LAMA Rate Absconding Rate

46
 Chapter -5
STANDARD PROTOCOLS FOR EMERGENCY
DEPARTMENT

47
 Chapter- 5

STANDARD PROTOCOLS FOR EMERGENCY

DEPARTMENT
1.0 LIST OF STANDARD PROTOCOLS

The following protocols have been enumerated in the standard protocols for Emergency Department
in this chapter:
1. Receiving of the patient

2. Registration of the patient

3. Identification of the patient

4. Initial assessment of patient

5. Reassessment of patient

6. Shifting/ transfer of patient within hospital

7. Referral of patients

8. Discharge of the patient

9. Patient care protocols

1. RECEIVING OF THE PATIENT

Purpose: To avoid delay in treatment of critical patients and to facilitate their safe transfer
inside emergency department.

Responsibility: On duty staff at entrance of emergency.

Procedure:

Receiving area at emergency department is ensured of the availability of

wheelchairs and stretchers.
Whenever a non-ambulatory patient reaches near the emergency door, on duty
staff on the gate shifts the patient on stretcher or wheelchair depending on
patients condition and shift the patient inside to the consultation area.
In case of walk-in patients, patients walk in directly to the consultation area.

48
2. REGISTRATION OF THE PATIENT

Purpose: To provide a mechanism to facilitate registration and admission of the patient in the
hospital.

Responsibility: Registration clerk

2.1 OUT PATIENT REGISTRATION:

In case of critical patients, they are immediately directed to the consultation area and
registration is done afterwards at the emergency registration counter.
All critical patients coming to emergency are registered at emergency registration counter.
During OPD working hours if a non critical patient walks into emergency he is directed to go
to concerned OPD after registration at the general OPD registration counter of the hospital,
whereas during odd hours and holidays all patients walking into hospital are registered at
the emergency registration counter except in those hospitals where evening OPD is
functional.
Following parameters are captured during emergency registration:
Name, age, sex, address and time of admission.
For referred in patients same is mentioned on the OPD card along with details of facility
from where referred and reason for referral. Referral slip if available is retained in hospital
record.
For medico legal cases MLC is mentioned on the OPD card.
After registration an OPD number is given to the patient.
In addition to OPD number, all the medico-legal cases are separately identified by a
centralised MLC number. MLC number is provided either manually at the registration
counter or generated by computer.
Police information is sent for all the medico legal cases by the doctor on duty.
All unidentified patients are registered as medico legal cases and the information regarding
this is sent to police and once the patient is identified, information is updated in the records.
After doctors assessment a provisional or actual diagnosis is entered on the OPD card by
concerned doctor both for MLC and non MLC cases.

2.2 IN PATIENT REGISTRATION:

Responsibility: Registration clerk

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

If it is decided by the treating doctor that the patient needs to be admitted then patients
attendants are directed to emergency registration counter where admission file is prepared
and another number is generated.
Following information is captured on patient file- Name, age, sex, address, speciality under
which admitted, provisional diagnosis , date and time of admission.
An ID band is applied to patients wrist having following details
a) Name
b) Age
c) Sex
49
d) IPD registration number
 3. IDENTIFICATION OF THE PATIENT

Purpose:

For correct identification of the patient before initiating patient care.

Responsibility:

Any hospital staff concerned with patient treatment like doctor, staff nurse, lab technician and
registration clerk.

3.1 OUT PATIENT IDENTIFICATION:

The patient is identified by dual identifiers; one is patients name and other is OPD Number.
The hospital uses sound clinical judgement to ensure the patient identification at all the
times before :
Consultation
Before administering medicine
Giving sample in the phlebotomy area
Before any procedure

3.2 IN-PATIENT IDENTIFICATION:

Identification bands are provided to all the patients at the time of admission with the
help of which he/she is identified during his/her stay irrespective of the condition
(conscious /unconscious).
Different types of coding is followed to avoid any error that is
White colour band for all patients
Pink colour band for baby girl
Blue colour band for baby boy
V is written on white band by staff for Vulnerable patient
Identification band is non-transferable and affixed on the patients wrist.
ID band consists of :
Patients Name, Age, Sex and Registration Number
Patient and his/her family members are educated about the importance of the band and
not to remove the band.
ID band is checked before any consultation, investigation, procedure and administration
of medication. Patient name is also asked to confirm the patient identification.

3.2 IN-PATIENT IDENTIFICATION:

50
Identification bands are provided to all the patients at the time of admission with the
help of which he/she is identified during his/her stay irrespective of the condition
(conscious /unconscious).
Different types of coding is followed to avoid any error that is
4. INITIAL ASSESSMENT OF PATIENT:
Purpose:
To follow a uniform protocol for initial assessment of patient coming to emergency
Responsibility:
Doctor on duty, nurse on duty.

Procedure:

4.1OUT PATIENT ASSESSMENT:

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

In case doctor is not immediately available the patient is assessed by staff nurse on duty
and then seen by doctor as soon as possible.
Vital signs are recorded by the doctor/ nurse within five minutes and then every 30
minutes or as the patients condition warrants.
Treatment is given according to the doctors orders.
Specialist consultation is sought by doctor on duty, if required. Consultation may be
provided in person or telephonically.
In case of verbal or telephonic orders, they are duly verified prior to implementation.
Initial assessment includes
a. Detailed patient history
b. Vital examination
c. History of any allergy or drug reactions
d. Systemic examination as indicated from history
(For details refer to initial assessment form attached as annexure-II).
Initial assessment leads to a working diagnosis.
A documented plan of care is made after initial assessment.
In case the patient needs referral to higher centre, findings of initial assessment are
captured in the OPD record and patient is stabilised before referral.
All the patient records are dated, timed, named and signed by the concerned person.

4.2IN PATIENT ASSESSMENT:

All the patients admitted under a particular speciality are examined by a specialist
within 12 hours of admission.
Patient assessment is recorded as per IPD assessment form attached as annexure-.
All the patient records are dated, timed, named and signed by the concerned person.

51
5. REASSESSMENT OF PATIENT

Purpose:
To monitor clinical progress of patient and to modify care of plan as and when required.
Responsibility:
Doctor on duty, staff nurse, concerned specialist

5.1OUT PATIENT REASSESSMENT:

All the critical patients are kept under observation in the observation area/room.
These patients are reassessed by the doctor on duty every 30 minutes or as and when
required.

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

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

5.2IN-PATIENT REASSESSMENT:

All the admitted patients are reassessed by doctor on duty at least twice during each
shift or more frequently if the patient is critical.
All the parameters are assessed as mentioned in reassessment form ( Attached as
annexure-II)
All the admitted patients are reassessed by specialist of concerned department
at least once during each shift.
If an admitted patient is to be referred, decision to refer is taken in consultation
with the concerned specialist, however in life threatening conditions the doctor
on duty can refer the patient on his own and then inform the concerned
specialist.

All the notes on patients records are to be dated, timed, named and signed by the
concerned doctor.

6. SHIFTING/ TRANSFER OF PATIENT WITHIN HOSPITAL

Purpose:
To ensure that emergency beds are available for needy and unstable patients. No patient is kept
in emergency area beyond 24 hours.
Responsibility:
Doctor on duty, concerned specialist
Procedure:
All the admitted, stable patients are shifted to respective wards within 24 hours if a bed
is available.
All the concerned specialists take round of A&ED at least twice a day and shift all the
stable patients to respective wards. 52
7.REFERRAL OF PATIENTS

7.1REFERRED IN
Purpose:
To ensure that all the patients being referred to hospital from periphery and other institutes are
promptly treated if services required are within scope of the hospital.
Responsibility:
Doctor on duty, staff nurse on duty
Procedure:
All the patients referred from periphery and other institutes are promptly treated at the
hospital if the services required are within scope of A&ED of hospital.
If the services required are not in the scope of hospital then these patients/ attendants are
explained the same and also guided about the alternatives. The protocol for referred out
patient is followed.
All the referred in patients are registered in the hospital and their record is maintained
separately as per format provided in annexure.

7.2REFERRAL OUT

Purpose:

Patients who do not match scope of the services of the hospital are referred to higher centre without
unnecessary delay.

Responsibility:

Doctor on duty, concerned specialist

Procedure:

Once doctor on duty decides that the patient requires referral to higher centre for further
treatment he/she contacts the concerned specialist on telephone or through a written call. If
required specialist doctor visits the patient and assess condition of patient and then take the
decision to refer the patient.
If the patient is critical and any delay in treatment may endanger life of patient, he/she is
referred by doctor on duty.
If the patients condition is unstable, he should be stabilized in the emergency department
before referring out.
Doctor on duty ensures availability of bed in the hospital where patient is being referred.
In case of non-availability of beds alternatives are explained to the relatives of the patient and
decision is made accordingly.
EMT accompanies the patient in case of critical patient.
Fully filled referral card is provided to the patient at the time of referral with details like
reason for referral, investigations done if any.(Attached as annexure-I)
Ambulance used is fully equipped with resuscitation equipment and with trained staff who has
training in BLS.
Entry is made in the refer-out register.

53
8. DISCHARGE OF THE PATIENT:

Purpose:

To provide guidelines for the discharge from the hospital in order to minimise waiting time for
discharge.

Responsibility:

Doctor on duty, concerned specialist

Procedure:
Discharge process is discussed with patient and family.
The concerned doctor, discharging the patient documents the discharge instructions in the file at
the time of discharge.
Discharge summary is prepared on a standardised format and signed by the concerned doctor.
The discharge summary contains :
Diagnosis
Brief progress notes
Significant findings
Investigations results
Procedures performed (if any)
Condition at the time of discharge
Discharge medications and follow up instructions
Instructions about when and how to contact in case of emergency
8.1 DISCHARGE AGAINST MEDICAL ADVICE/ DISCHARGE ON REQUEST:

Purpose:

To provide guidelines for discharge of those patients who are not willing to stay in the hospital
despite doctors advice to the contrary.

Responsibility:

Doctor on duty, concerned specialist

Procedure:
In case the patients and relatives wish to get discharged from the hospital before complete
recovery, the provision of the same is made.
The doctor on duty/ specialist discusses the consequences and risk to the patient and
relatives. The patient, relatives, concerned doctor and the nurse on duty sign the consent
for discharge against medical advice.
A discharge summary is handed over to the patient/relative with the medical advice and it is
mentioned on the discharge card that patient is being discharged against medical advice.

8.2 ABSCONDED PATIENT:

Purpose:
To provide guidelines to be followed in case the patient absconds from hospital without
informing concerned staff.
Responsibility:
Doctor on duty, concerned specialist, staff nurse
Procedure:
If a patient absconds from hospital without informing any concerned staff member
then this information is mentioned in the patient record. 54
In medico legal cases information is sent to police about absconded patients.
9. PATIENT CARE PROTOCOLS

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

9.1RESUSCITATION ROOM CARE

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

9.2 OBSERVATION ROOM CARE

The Category-II patients are referred to Observation Room.

Purpose:

To Provide a standardised protocol to be followed in case of critical patients kept under

observation in observation area and to ensure that all the equipments in the observation area
are functional at all times.

Responsibility:
Doctor on Duty, Nurse on Duty

Procedure:
Initial Assessment of the patient is done as per the initial assessment protocols already
described.
The doctor on duty reassesses the patient every 30 minutes or more frequently as per
patients condition.
Decision is taken to admit, shift, discharge or refer the patient within four hours.
The staff nurse on duty also monitors the patient as per doctors instructions.
All the investigations (Laboratory, Radiology, etc.) are done as soon as possible and reports
are made available on priority.
Doctors and nurses follow ethical code of conduct and universal precautions.
Proper written handover of patients is done as the shift changes.
Drugs and equipments are checked and monitored at the start of every shift.
Hygiene and sanitation is maintained at all times. Infection control and waste management
protocols are strictly followed. (Attached as annexure-V)

55
10. MEDICO- LEGAL CASES

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

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

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

10.1INTIMATION OF MEDICO-LEGAL CASES TO THE POLICE:

Purpose:

To provide intimation to police for all the medico legal cases in a uniform format and to comply
with statutory requirements as mandated by court of law.

Responsibility:

Doctor preparing medico legal report

Procedure:
The privacy of the patient should be ensured first.
The doctor on duty examines the patient and prepares medico legal report in computerized
format. In case doctor is unable to provide computerised report immediately, manual report is
provided to the patient and computerised report is provided within one week.
The police authorities are intimated giving brief details of the case in a written format.
The reporting time and date is also mentioned in the police information.
MLC police information form is filled in duplicate and one copy is handed over to the police
person and one copy is retained in the hospital record.
Receiving is taken from police person who receives the information.
Wherever required various specimens are collected, sealed and handed over to the police
authorities after sealing the same. A receipt of the items sealed and handed over to the police is
taken. Patient case file is stamped as medico-legal case.
* For more details refer to Haryana medico legal manual

56
11. SAFETY OF THE PATIENT BELONGINGS:

Purpose: To ensure safety of patients belongings while in the hospital.

Responsibility: Staff nurse on duty.

Procedure:

Patients are advised to leave all valuables at home or send them home upon admission to the
hospital; this includes jewellery , cash etc. That would be considered a loss if misplaced
Signature of the relative is taken upon handing over of patient belongings
If attendant is not available the nurse on duty keeps the valuables under lock and key. They are
not kept at patient bedside
A receipt is provided for collection of the items upon discharge.
Patient is informed to take care of their belongings that they bring along such as mobile etc.

12. TRIAGE IN THE EMERGENCY DEPARTMENT: (Refer to section on Standard Concepts in

Accident and Emergency Department)

57
 Chapter -6
DISASTER MANAGEMENT

58
 Chapter-6

DISASTER MANAGEMENT Disaster is a Situation or

event which overwhelms
local capacity; necessitating
1.0 DEFINITION a request to national or
international level for
external assistance.
According to WHO - A disaster is defined as a series disruption of
functioning of the society, causing widespread human, material and
environmental losses which exceeds the ability of the society to
cope with its own resources.

1.1 AIM AND OBJECTIVES:

To provide effective medical care to the maximum possible

people in order to minimize morbidity and mortality from
any mass causality.
To prepare the staff and resources of the hospital for
effective performance in different disaster situation.
To provide the opportunity to plan, prepare and when
needed enables a rational response in case of disaster.

1.2 TYPES OF DISASTERS:

Several types of hazards pose a threat to the community and
eventually to hospital:
1. Internal disasters, which takes place in the hospital like
fire, explosions, and hazardous material spills.
2. External disasters : Incidents involving a large number of
casualties like vehicular accidents, train accidents, fires,
bomb blasts, flood, tsunami, hurricane etc.
3. Disaster threats affecting the community like warfare, gas
leaks etc.
4. Disasters in other communities in the vicinity like outbreak
of disease etc.

59
2.0 ESSENTIALS OF DISASTER MANAGEMENT

Disaster management committee (Details related to the committee are given below)
A documented Disaster Management Plan
Emergency /disaster alert codes
Fully equipped Ambulance with first aid equipment.
Flexible space and beds should be ensured to accommodate patients and relatives.
Medico-legal responsibilities should be defined.
Procedure to ensure availability of drugs i.e. Emergency kit / Disaster kit and other supplies
(Example Antibiotics, ORS, IV fluids, Analgesics, Disinfectants etc.) at the casualty department.
Operation Theatre to be kept ready for an emergency.
Job card should be assigned to each staff member explaining the exact role of that person during
disaster.
All staff instructed that on receipt of warning they should immediately report to the hospital
without any delay
Mobilisation of disaster management team members and other ancillary staff.
Names and contact numbers of the staff and their position according to the plan (list of
emergency contact number, adjoining hospitals, fire brigade, Police station.)
Training and mock drill.

3.0 GENERAL CONSIDERATIONS:

3.1 LINES OF AUTHORITY: The following persons, in the order listed, would be in charge:
1. Medical Superintendent
2. In charge of casualty(head of disaster management committee)
3. Emergency medical officer
4. Matron.
5. Nursing In charge on duty at time of disaster.
6. Security head of hospital.
3.2 DISASTER MANAGEMENT COMMITTEE

3.2 (a) LIST OF MEMBERS IN DISASTER MANAGEMENT COMMITTEE

INCLUDE:

1. Principal Medical Officer

2. Hospital Administrator
3. Resident Medical Officer
4. Anaesthetist
5. Causality medical officer
6. Surgeon/Physician/Orthopaedician
7. Pharmacist
8. Matron /Nursing sister
9. Laboratory in charge
10. Security supervisor

60
 3.2 (b) FUNCTIONS OF DISASTER MANAGEMENT COMMITTEE:

Disaster management committee has to be formed in every hospital much before a disaster

3.3 DISASTER MANAGEMENT PLAN

Functions are assigned to members and the members prepare and update the disaster
management plan.
Code activation,
Major decisions to be taken during disaster
Manage disaster management events
Supervise training and mock drills

1. A siren/ public address system is available and working in the emergency department to
notify all staff of any emergency.
2. Casualty medical officer will inform casualty- in- charge who is head of disaster management
committee, who in turn will inform medical superintendent and hospital administrator.
3. Other members of Disaster management committee will be informed by hospital
administrator/casualty in charge depending on extent of disaster.
4. Various department Heads will notify their key personnel depending on extent of disaster
and need.
5. Matron shall be notified by the nursing sister on duty.
6. A Command Centre will be set up at the PMO/MSs office to handle and coordinate all
internal communications. All department heads will report to this office and call as many of
their employees as needed.
7. Hospital administrator will assign a clerical staff who will answer all telephone calls from
this station. .
8. The class IV/ Security Guard will be assigned to the telephone operator to deliver messages,
obtain casualty count from triage, etc.
9. The class IV/Security Guard will be assigned to act as a runner to all departments to advise
them of the type of disaster and number of victims and extent of injuries when this
information is available.

In the event of disaster the following will be set up:

I. Reception centre:
For moderate load: Present casualty OPD will function as reception area.
For heavy load: Main hall of OPD will function as reception area.
Police and security persons on duty will act as traffic controllers.
II. First aid and sorting ( Triage):
For moderate load: Existing casualty team will function for First aid and sorting.
For heavy load: The centre will be manned by one or more teams each consisting of-
One general surgeon
One orthopaedic surgeon

61
 One physician
One anaesthetist
Two sisters
Two nursing orderlies
One sweeper

The responsibilities of first aid centre will be-

Quickly sorting out causalities into:

Priority 1: Needing immediate resuscitation

Priority 2: Needing Immediate surgery

Priority 3: Needing first aid and possible surgery

Priority 4: Needing only first aid.

ACTIONS:

Priority 1 will be attended to in casualty department and if needed will be sent

to I.C.U.
Priority 2 will be transferred immediately to OT.
Priority 3 will be given first aid and admitted if beds are available or
transferred to other hospital.
Priority 4 will be given first aid and discharged home.

III. Morgue Facilities:

1. Patients brought in dead (BID) will be tagged with a black Disaster Tag. Their personal
belongings will be secured in plastic bags and stored along with dead body with ID Labels.
2. Bodies will be stored in a designated place by Security with care and respect. Security
Personnel will remain with bodies until removed by proper authority.
3. After bodies have been identified, the information will be filled on the Disaster Tag and
Medical Records will be updated.
4. The bodies and their belongings will be handed over to the relatives after proper
identification in presence of representatives from the police department. Bodies which
remain unclaimed will be handed over to the police after following the required procedures.
All the activities to be supervised by forensic expert or designated person.
5. All staff must be trained to be sensitive while preserving and handing over bodies/
belongings.

62
 IV. Visitor waiting area:
It will be set up in the front lobby of hospital, relatives of casualties will be instructed to wait
there until notified of patient's condition. Normal visiting hours will be suspended during the
disaster situation.
o A hospital staff member will update and counsel the family members.
o A list of the visitor's names in association with the patient they are inquiring about
will be kept. Volunteers may be needed to escort visitors within the facility.
V. Telephone lines:
Telephone lines will be made available for outgoing and incoming calls. The hospital
administrator will designate assigned staff to monitor the phones.
VI. Additional bed space:
Extra bed space will be created as follows-
1. Utilization of pre operative beds (to be authorized by PMO/ M.S.)
2. Any vacant beds available in hospital (to be authorized by PMO/ M.S.)
3. By discharging following categories of patients (to be authorized by matron and
assisted by staff nurses on duty)-
Convalescent patients needing only nursing care.
Elective surgical cases.
Patients who can have domiciliary care or OPD services.
4. Ward side rooms and seminar rooms will be used if required.

VII. (a) Supplies and Equipment:

1. Extra supplies will be obtained from store or through purchasing personnel under
supervision of store- in- charge. Separate room will be earmarked for this purpose
2. Outside supplies will be ordered by the store- in-charges and brought into the hospital.

VII. (b) Valuables and Clothing:

1. Large paper or plastic bags will be made available in the treatment Areas and the storeroom for
patient's clothing and valuables.
2. All the bags will be labelled with patients name and C.R. number as far as possible. A staff nurse
will be assigned for this purpose.
VIII. Public Communication Centre:
1. A communication centre for giving information to the press and relatives will be set up in PMO
office. All the press releases will be handled by hospital administrator or designated person.

IX. Responsibilities of Individuals and Departments:

A. PMO/Medical superintendent: In a major disaster will do the following-
Appoint triage coordinator and medical coordinator for ward, casualty and O.T.
Will assign an M.O. to go to site if required, along with mobile medical team.

63
 B. Hospital Administrator:
In a major disaster will do the following functions:
1. Check with local authorities to verify the disaster and obtain additional information.
2. Authorize announcement of disaster to hospital personnel.
3. Ask for help from local police and volunteer organizations as deemed necessary.
4. Stay in the area of administrative offices to be available as and when required.
C. Nursing In charge:
1. Is responsible for determining the extent of the disaster, whether it is a "major" or a "minor"
disaster. If it is a major disaster, then the PMO/ MS and Matron will be notified (if not present
at time of disaster).
2. Will attempt to find adequate numbers of nursing personnel. Have them keep a list of those
notified.
3. Will be responsible for making available prearranged admission ward and as many beds as
possible by discharging the categories of patients as explained above.
.
D. Department head or designee will call in their own personnel as needed after having
reported to the Command Centre.

E. Admitting office
1. Will not accept routine non-emergency admissions.( refer to nearest hospital)
2. Refer all enquiries and press to desk in Reception Area.
3. Assign an admissions person to aid with discharge of hospital patients from the wards, if
requested by Medical Team.
F. Emergency blood bank:
Efforts will be made to ensure availability of all types of blood groups in adequate quantity.
Volunteers will be contacted. Responsibility rests with Blood Transfusion Officer (B.T.O.)/ Asst.
Blood Transfusion Officer (B.T.O.)
G. Documentation centre:
For moderate load: Documentation will be done in casualty itself.
For heavy load: Documentation will be done at central registration office of OPD staffed manned
by staff of registration counter and nurses.
H. Dietary
1. The Department in charge or designee will call in their own personnel as needed after
reporting to Command Centre.
2. Prepare to serve nourishments to ambulatory patients, in-house patients and personnel as
need arise.

I. Maintenance
1. Department head or designee will call in their own personnel as needed after reporting to
Command Centre.

64
2. Maintain full operation of all facilities.
3. All doors should be locked immediately except in case of fire. Doors to Emergency
Department and front lobby to be kept open. Prevent entrance of extra persons/ relatives
and security is reinforced.

J .Housekeeping and Laundry

1. Department head or designee will call in their own personnel as needed after reporting to
Command Centre.
2. Be available to help clean receiving area, and clean rooms between cases in treatment areas.
3. Know current empty bed count and number of personnel available
4. Will make wheelchairs / trolleys available.

K. Operating Room, CSSD

1. Supervisor or Nurse will supervise Operating Room and call all needed personnel after
reporting to Command Centre.
2. Call additional surgeons as needed.
3. Check area for supplies and equipment
4. Notify anaesthetists who will maintain adequate anaesthesia and drug supplies.

L. Medical Imaging

1. The department head or designee will find out the number of patients involved and any other
pertinent information from the Command Centre.
2. The department head or designee will be responsible for calling in any and all personnel
needed to sufficiently handle the patient load.

M. Laboratory
1. Department Head or designee will call in their own personnel as needed after reporting to
Command Centre.
2. Call personnel from nearby hospitals and clinics as necessary.
3. Have arrangements made to obtain additional equipment and supplies from area agencies.

N. Pharmacy
1. Report to Command Centre, and then remain in department.
2. Have list of drug suppliers that can provide emergency supplies quickly
3. Keep minimum supply of emergency drugs on hand at all times.
4. Pharmacy remains open and has a runner to deliver needed medicines to areas.

65
O. Security
1. Report to Command Centre.
2. Assist staff as needed.
P. Ambulances:
All the ambulances will be kept well equipped and shall be available at casualty department along
with drivers.
Q. Engineering and maintenance department:
Engineers will make sure that water and electricity is made available without interruption.

66
 Chapter-7
INFECTION CONTROL PRACTICES FOR EMERGENCY
DEPARTMENT

67
 Chapter-7

INFECTION CONTROL PRACTICES FOR

EMERGENCY DEPARTMENT
A nosocomial infection also known hospital acquired
A nosocomial /
infection or Hospital Associated Infection (HAI)
Hospital Acquired
infection is defined as
1.0 STATISTICS OF HOSPITAL ACQUIRED
an infection acquired
INFECTIONS in hospital by a
patient who was
admitted for a
Nosocomial/Hospital Acquired infections occur worldwide and affect reason other than
both developed and resource-poor countries. that infection.

They are among the major causes of death and increased morbidity Also an infection
among hospitalized patients. A prevalence survey conducted under the occurring in a patient
auspices of WHO in 55 hospitals of 14 countries representing 4 WHO in hospital or other
Regions (Europe, Eastern Mediterranean, South-East Asia and Western health care facility in
Pacific) showed that on an average of 8.7% of hospital patients had whom the infection
nosocomial infections. was not present or
incubating at the time
At any time, over 1.4 million people worldwide suffer from infectious of admission can be
complications acquired in hospital. classified as HAI.

1.1 IMPORTANCE OF HAI IN EMERGENCY ROOM

Staff posted in emergency rooms is more prone to HAI because:

The patients coming to emergency are critical and need urgent
interventions.
There is an increased risk of exposure to various types of body
fluids in emergency staff.
Since time is a critical factor in emergency, chances of ignoring the
standard precautions is more.

1.2 COMPONENTS OF INFECTION CONTROL

Infection control encompasses both structural as well as procedural

components.

68
The structural aspects will be covered in other section in detail. However, few important points are given
below:

The surfaces, be it floor, walls or work surfaces, should be such that they do not
encourage the accumulation of dust and are easily cleanable/ washable.
Adequate space should be there between the beds in patient care areas to reduce
chances of cross infections.
Properly constructed & maintained isolation facilities for infectious diseases as well as
for immune-compromised patients will result in reduced morbidity & mortality from
primary disease as well as HAI.
HVAC system which are properly designed and regularly maintained would reduce the
burden of infection in healthcare settings.
Keeping two or more patients on one bed greatly increases chances of Infections.

1.3 HOSPITAL ASSOCIATED INFECTIONS

1.3.1 DEFINITION OF HOSPITAL ASSOCIATED INFECTIONS/NOSOCOMIAL

INFECTION 4

According to World Health Organisation

1) An infection acquired in hospital by a patient who was admitted for a reason other than that
infection.
2) An infection occurring in a patient in a hospital or other health care facility in whom the infection
was not present or incubating at the time of admission. This includes infections acquired in the
hospital but appearing after discharge, and also occupational infections among staff of the facility
3) Nosocomial infections, also called hospital-acquired infections, are infections acquired during
hospital care which is not present or incubating at admission. Infections occurring more than 48
hours after admission are usually considered nosocomial.

1.3.2 ACCORDING TO CDC

HAI is a localized or systemic condition resulting from an adverse reaction to the presence of an
infectious agent(s) or its toxin(s). These infections are not incubating at the time of admission
and usually manifest after 48 hours of admission or hospital contact.

1.3.3 TYPE OF HOSPITAL ASSOCIATED INFECTIONS

Simplified criteria for surveillance of nosocomial infections according to World Health Organisation:

S No. Type of Infection Prominent features

Discharge, Abscess and Spreading

1 Surgical site infection Cellulitis at the site of operation within one month of operation.

Symptoms like burning pain while micturition, frequency of

2 Urinary tract infection
micturition,

4Prevention of hospital-acquired infections WHO/CDS/CSR/EPH/2002.12 A practical guide 2nd edition

Page 1, 4

69
 fever or finding organisms in urine >
105/ml.

Minimum two symptoms:

Cough
3 Respiratory infection Sputum
Positive findings in chest X-ray

Some of the important processes which can go a long way to decrease the burden of HAI are listed below:

An Infection Control Committee provides a forum for

1.34 HOSPITAL multidisciplinary input and cooperation, and information
sharing. This committee should have wide representation
INFECTION CONTROL from relevant departments.
COMMITTEE

SUGGESTIVE STRUCTURE OF INFECTION CONTROL COMMITTEE

Medical Superintendent of the hospital ( Chairperson)

Heads of the various clinical departments i.e. Surgery, Medicine, and Paediatrics, Gynaecology,
Orthopaedics and any other department.
Head of laboratory preferably microbiologist or pathologist to act as infection control officer
Hospital administrator
Designated nurse(s) specially trained in infection control.
Head of engineering and maintenance services (if any)
Any other member may be co-opted as per local need or interest like housekeeping supervisor.

FUNCTIONS OF INFECTION CONTROL COMMITTEE

To review and approve a yearly programme of activity for surveillance and prevention.
To Institute appropriate control measures when there is considered to be a danger to patients
or personnel.
To provide suggestions and provisions of resources like manpower, materials, logistics, training,
monitoring and reporting about infection control activities and services.
To review epidemiological surveillance data and identify areas for intervention.
To ensure appropriate staff training in infection control and safety.
To review and provide input into investigation of epidemics.

The committee can form a subcommittee for day to day functioning which can be designated as infection
control team.

An Infection Control team is responsible for day to day

1.34 HOSPITAL functions of infection control. They may be administratively
part of different units, (e.g. microbiology laboratory, medical
INFECTION CONTROL or nursing administration, public health services).
TEAM

70
 SUGGESTIVE STRUCTURE OF INFECTION CONTROL TEAM

Infection control officer

Infection control nurse
Hospital administrator
Senior OT attendant
Lab technician
CSSD in charge
Housekeeping supervisor

FUNCTIONS OF INFECTION CONTROL TEAM

To prepare the yearly work plan for review by the infection control committee and
administration.
To provide technical support like:
Surveillance and research
Developing and reviewing policies
Day to day supervision
Evaluation of material and products
Control of sterilization and disinfection
Implementation and conduction of training programme.
To conduct patient satisfaction surveys.
To ensure adherence to standard precautions.
To educate patients and relatives on infection control.

ROLE OF THE INFECTION CONTROL NURSE

Infection Control Nurse is a vital component of Hospital Infection Team, a dedicated nurse with
experience in Infection Control or preferably a short course in Infection Control is suitable for the
position of an Infection Control Nurse. Infection Control Nurse is responsible for the supervision of
Implementation of patient care practices for infection control is the role of the nursing staff.
Infection control nurse is responsible for:

Participating in the activities of Infection Control team.

Developing training programme for members of the nursing staff along with nursing
administrator.
Supervising the implementation of techniques for the prevention of infections in specialized
areas such as emergency, operating suite, intensive care unit, maternity unit etc.
Monitoring of nursing adherence to policies.
Identifying nosocomial infections.
Surveillance of hospital infections.
Participating in outbreak investigation.
Participate in development of infection control policy and review and approval of patient care
policies relevant to infection control.
Ensuring compliance with local and national regulations.

71
 ROLE OF NURSING IN CHARGE OF EMERGENCY

The Nurse-in-Charge in Emergency Department is responsible for the implementation activity of

infection control activities. Nurse In-charge is responsible for

Implementing and maintaining hygiene, consistent with hospital policies and good nursing
practices in the emergency department.
Implementing and monitoring aseptic techniques, including hand washing and use of isolation
precautions in the emergency department.
Reporting promptly to the attending physician any evidence of infection in patients in the
emergency department.
Limiting patient exposure to infections from visitors, hospital staff, other patients, or equipment
used for diagnosis or treatment in the emergency department.
Maintaining a safe and adequate supply of emergency equipment, drugs and patient care
supplies.
Participating in training of personnel of the emergency department.
Ensure that bed linen is clean and regularly changed.

ROLE OF THE LAUNDRY SERVICE IN EMERGENCY DEPARTMENT

The laundry is responsible for:

Maintaining appropriate supplies of linen.

Developing policies for the collection and transport of dirty linen.
Defining the method for disinfecting infected linen, either before it is taken to the laundry or in
the laundry itself.
Developing policies for the protection of clean linen from contamination during transport from
the laundry to the area of use.
Ensuring appropriate flow of linen, separation of clean and dirty areas inside laundry.
Recommending washing conditions (e.g. temperature, duration)
Ensuring safety of laundry staff through prevention of exposure to sharps or laundry
contaminated with potential pathogens.

ROLE OF THE CSSD SERVICE IN EMERGENCY DEPARTMENT

The CSSD department is responsible for:

Maintaining appropriate supplies of sterile equipment and instruments.
Developing policies for the collection and transport of dirty and sterile equipment/.
instruments
Defining the method for autoclaving the dirty equipment/ instruments.
Ensuring appropriate flow of equipment / instruments from and to the emergency
department.
Ensuring safety of CSSD staff through prevention of exposure to items contaminated
with potential pathogens.

A nosocomial infection / HAI prevention manual, compiling

1.35 INFECTION recommended instructions and practices for patient care, is
CONTROL MANUAL an important tool.
The manual should be developed and updated by the infection
control team, with review and approval by the committee. It
must be made readily available for patient care staff, and
updated in a timely fashion.

72
 The components of the Infection Control Manual include various components including
sterilisation and disinfection policies, role of hospital acquired infections in the hospital, role of infection
control tea, outbreak protocol etc.

2.0 TRAINING

2.1 TRAINING Importance of frequent and careful washing of hands.

REQUIREMENTS OF Use of PPE.
Standard precautions
EMERGENCY STAFF
Segregation and Safe transportation of biomedical waste.
FOR INFECTION
Cleaning methods (e.g. sequence of rooms, correct use of
CONTROL equipment, dilution of cleaning agents, etc.) for
housekeeping staff.

3.0. RISK ASSOCIATED WITH INFECTIONS IN EMERGENCY DEPARTMENT

Staff working in emergency is at an increased risk of infection

3.1 RISK FROM BLOOD from blood born diseases since risk of exposure is more in an
BORNE DISEASES emergency care setting. Risk of infection varies according to
the type of exposure.

3.2THE FOLLOWING LIST PUBLISHED BY THE CDC CAN BE USED TO EVALUATE

RISK LEVELS. RISK DECREASES FROM TOP TO BOTTOM

Blood/Body fluid contact to intact skin.

Contaminated needle stick injury (large-bore, hollow

needle carries more risk than small bore solid needle).

Cuts with sharp objects covered with blood/body fluid.

Blood/Body fluid contact with an exposed area of skin.

Blood/Body fluid contact to the mucous membrane surface

of the eyes, nose, or mouth.

In order to minimize the risk of transmission emergency

service personnel must continue to adhere to protection
strategies.

73
3.3 RISK PREVENTION STRATEGIES

USE OF STANDARD PRECAUTIONS

HAND WASHING/HAND HYGIENE

SHARP SAFETY

a) USE OF STANDARD PRECAUTIONS

Use of standard precautions for all patients, which are as follows:

Wash hands promptly after contact with infective material.
Use no-touch technique wherever possible.
Wear gloves when in contact with blood, body fluids, secretions, excretions, mucous
membranes and contaminated items.
Wash hands immediately after removing gloves.
All sharps should be handled with extreme care.
Clean up spills of infective material promptly.
Ensure that patient-care equipment, supplies and linen contaminated with infective
material is either discarded, or disinfected or sterilized between each patient use.
Ensure appropriate waste handling.
If no washing machine is available for linen soiled with infective material, the linen can be
boiled.

b) HAND WASHING:
Hand washing is the single most important procedure for preventing infection. Contaminated
hands are frequently implicated as a means of transmission of nosocomial outbreaks in acute
care settings.

The consistent application of soap and water or alcohol-based waterless hand sanitizer is the
best way for emergency staff to protect their families, colleagues, patients, and themselves
from dangerous diseases.

Washing with soap and water should be used for the first and last hand-wash of the shift,
when hands are visibly soiled and after every five applications of alcohol-based waterless
hand sanitizer.
The mechanical action of washing, rinsing and drying is the most important contributor to
the removal of transient bacteria that might be present.
Alcohol based hand rubs can be used when hands are NOT visibly soiled because the
effectiveness of alcohol is inhibited by the presence of organic material.
Health care workers are frequent hand washers and time should be taken to use
moisturizers to prevent the skin from becoming dry and cracked. Skin that is dry, cracked or
suffering from rashes can be a portal of entry for disease. Healthy, intact skin is an effective
barrier to infection.

74
 Care should also be taken to ensure non-intact skin is covered while at work. If non-intact
skin is on the hands, two pairs of medical gloves should be worn as additional protection.

HAND HYGIENE SHOULD BE PERFORMED:

Before and after patient contact.

During and after PPE removal.
Before and after invasive procedures.
After vehicle check
After cleaning equipment/vehicle.
Just after leaving the emergency department.
Before and after handling food.
Before and after smoking.
After using the bathroom or other personal body functions (sneezing, coughing if into
hands).
Any time hands are visibly contaminated.
Before and after your shift.
Any time you cannot remember when hands were last washed.

Criteria for good hand hygiene:

Remove all jewellery.

Use adequate amounts of soap or alcohol-based waterless hand sanitizer if available.
If soap is to be used, wet hands first before applying cleaning product.
Bar soap is not considered appropriate for cleaning hands in the health care environment as
the bars can accumulate bacteria. Liquid soap is to be preferred if available.
Rub hands to create friction for at least 15 seconds.
Rinse soap from hands with clean running water and dry preferably with disposable towel.
Use disposable towel to turn off taps and to open bathroom door handle to prevent re-
contamination.
In case of alcohol based hand rub, rub the hand sanitizer until it is dry.
Use moisturizer after hand washing, if possible, to prevent skin breakdown.
Refrain from habits such as nail biting or tearing of skin of cuticles.
Avoid touching mucous membranes and conjunctiva to help prevent self-infection.
Refer to annexure for recommended steps of hand washing.

c) SHARPS SAFETY:

According to the Association for Professionals in Infection Control (APIC) the most frequent
cause of blood-borne infection in healthcare settings is through needle stick injuries.
There are an estimated 600,000 needle stick injuries to health care workers each year in the
United States; but the exact number is not known as injuries often go unreported.
In order to help prevent needle stick injuries it is imperative to have an effective sharps
safety system in place.

Average risk of acquiring infection after needle stick injury:

Occupational risk of transmission is of HIV infection following needle stick injury from an
HIV-positive patient is 0.2% to 0.4% per injury and about 0.3% when the patient is infected
with HIV. The probability of HBV infection by needle sticks injury range from 1.9% to 40%
per injury and is 3% when the patient is infected with HCV.

75
 SAFE HANDLING OF SHARPS INCLUDES:

ii) Immediate disposal of sharps into a puncture proof container by the user.
iii) Never re-cap a contaminated needle.
iv) Never pass an exposed needle.
v) Never accept a used sharp, such as a lancet from a patient or another health care
provider.
vi) Minimize proximity of other persons before exposing a sharp.
vii) No bending of needles.
viii) Proper disposal of sharps containers when they are 2/3 full.
ix) Use needle-less systems whenever possible.

LIST OF POTENTIALLY INFECTIOUS BODY FLUIDS

EXPOSURE TO BODY FLUIDS CONSIDERED EXPOSURE TO BODY FLUIDS CONSIDERED NOT AT

AT RISK RISK

Blood Tears unless these secretions

Semen sweat contain visible blood
Vaginal secretions Urine
Cerebrospinal fluid faeces
Synovial, pleural, peritoneal, pericardial fluid saliva
Amniotic fluid
Other body fluids contaminated
with blood

STEPS TO BE TAKEN IN CASE OF NEEDLE STICK INJURY

If a needle stick injury occurs: Do not sqeeze blood from the wound and wash site with soap
and water, alcohol based, waterless hand sanitizer and/or an antiseptic swab as soon as
possible.

Staff must report the injury to their supervisor/ Staff Nurse on duty and then,report to
the doctor on emergency duty. The doctor on emergency duty is available for advice on
risk assessment, counselling and need for post exposure prophylaxis (PEP).

The first dose of PEP should be administered preferably within 2 hours but not later than
48 hours of exposure and the risk evaluated as soon as possible. If the risk is insignificant,
PEP could be discontinued, if already commenced

In all cases an accident/ incident record form should be completed within 24 hours by the
SN on duty.

(For details of PEP refer to NACO guidelines.

76
CATEGORISATION OF RISK AS PER TYPE OF EXPOSURE

TYPE OF EXPOSURE EXAMPLES PROTECTIVE BARRIERS

Low Risk Injections Gloves helpful but not

contact with skin with no Minor wound dressing essential
visible blood
Medium Risk Insertion or removal of Gloves, Gowns and
probable contact with blood; intravenous cannula Aprons may be necessary
splash unlikely Handling of laboratory
Specimens
Large open wounds
Dressing
Venipuncture ,spills of blood
Vaginal examination
High Risk Major surgical Gloves
probable contact with blood, procedures and other minor Water-proof Gown or Apron
splashing, uncontrolled surgical procedures Eye wear
bleeding Mask

MANAGEMENT OF EXPOSURE SITEFIRST AID

For skin - if the skin is broken after a needle-stick or sharp instrument:

Immediately wash the wound and surrounding skin with water and soap, and rinse. Do not
scrub.

Do not use antiseptics or skin washes (bleach, chlorine, alcohol, betadine).

After a splash of blood or body fluids:
To unbroken skin:

Wash the area immediately

Do not use antiseptics
For the eye:

Irrigate exposed eye immediately with water or normal saline

Sit in a chair, tilt head back and ask a colleague to gently pour water or normal saline over
the eye.
If wearing contact lens, leave them in place while irrigating, as they form a barrier over the
eye and will help protect it. Once the eye is cleaned, remove the contact lens and clean them
in the normal manner. This will make them safe to wear again
Do not use soap or disinfectant on the eye.
For mouth:

Spit fluid out immediately

Rinse the mouth thoroughly, using water or saline and spit again. Repeat this process
several times
Do not use soap or disinfectant in the mouth

Table 49mof and dont

77
Summary of Dos and Donts
Do
Remove gloves, if appropriate
Wash the exposed site thoroughly with running
water
Irrigate with water or saline if eyes or mouth
have been exposed
Wash the skin with soap and water
Donts
Do not panic
Do not put the pricked finger in mouth
Do not squeeze the wound to bleed it
Do not use bleach, chlorine, alcohol, betadine,
iodine or other antiseptics/detergents on the
wound

78
 Chapter-8
MANAGEMENT OF MEDICATION

79
 Medication use has become
Chapter-8
increasingly complex in
recent times.
MANAGEMENT OF MEDICATION
Medication error is a major
cause of preventable patient
harm.
1.0 INTRODUCTION Incidence of Medical errors
Greater focus is needed on improving patient safety in modern leading to patient death are
healthcare systems and the first step to achieving this is to reliably much higher than previously
identify the safety issues arising in healthcare. thought, and may be as high
as 400,000 deaths a year,
Medication Management is essential in Accident and Emergency according to a new study in
(A&E) department as it is considered to be a problematic the Journal of Patient Safety.
environment where safety is a concern due to various factors, such
as the range, nature and urgency of presenting conditions and the
high turnover of patients.

The latest numbers are dramatically higher than those in

the Institute of Medicine's 1999 report.

To Err is Human: Building A Safer Health System, which estimated

that up to 98,000 people a year die because of medication errors

2.0 PROCESS CONTROL FOR MANAGEMENT OF

MEDICATION

List of medicines which should be

2.1 EMERGENCY available in the Emergency
DRUG LIST department

The list of medicines available in the Emergency department is

given at Annexure-VII. The list can be pruned or expanded
depending upon the need of the hospital.

A crash cart containing all the life

2.2 CRASH saving/ resuscitation medicines
CART and consumables must be
available in the ED for use in case
of need.

80
 A suggestive list of drugs and equipment in the crash cart is given as below:

First Drawer
Top
Inj. Atropine 1mg/10mL (1)
Defibrillator Inj. Adenosine 6mg/2cc (2)
Electrodes Inj. Calcium Gluconate 1gm/10mL (1)
Suction machine Inj. Adrenaline 1:10,000/10mL (2)
Adult and paediatric Ambu bags Inj. Dexamethasone 4mg/1mL (1)
Stethoscope Inj. Digoxin 0.5mg/2mL (1)
CPR book Tongue blades (5)
Oxygen wrench
On the side of the Crash Cart : Thermal paper
Oxygen tanks with one regulator
Second Drawer
Inj. Dextrose 50gm/50mL (1)
Fifth Drawer
Inj. Amiodarone 150mg/3mL (2)
Laryngoscope handle
Inj. Nitroglycerine 50mg/10mL (1)
Miller Blade #2 (1)
Inj. Sodium bicarb 8.4%/50mL (1)
Miller Blade #3 (1)
Inj. Dopamine 400mg/10mL (1)
Macintosh Blade #2 (1)
Suction tubing (2)
Macintosh Blade #3 (1)
ET Tubes 4 (1)
ET Tubes 7 (1)
Third Drawer
ET Tubes 8 (1)
Inj. Furosemide 40mg/10mL (2)
Airways 6 (1)
Inj. Magnesium sulfate 5gm/10mL (1)
Airways 8 (1)
Batteries C (2)

Fourth Drawer
Gloves 6-1/2 (3)
Sixth Drawer
Gloves 7-1/2 (3)
D5 NS 250cc (1)
Tape
Lactated Ringers 500cc (2)
IV Canula 22ga (2)
NACL 0.9% 500cc (2)
IV Canula 20ga (2)
IV tubing (5)
Tourniquet (1)
Alcohol Swabs
Syringes 60ml (2)
Syringes 20ml (2)
Syringes 10ml (5)
Syringes 5ml (5)
Syringes 3ml (5)
Needles 18ga (10)
Conductivity gel
Inj. Normal Saline 50ml (2)

81
 There should be a policy to ensure availability of
2.3 EMERGENCY DRUG emergency medicine all the time in adequate quantity
STOCK with documented procedure to check it at fixed intervals.
There should be a documented method to replenish the
stock timely.
The hospital should calculate minimum buffer stock of
each drug according to patient load.
The list should be displayed in store along with its buffer
stock and there should be responsibility assigned to a
person to monitor the buffer stock regularly.

There should be documented procedure for emergency

2.4 EMERGENCY purchase of drugs. The procedure to be adopted and
PURCHASE person authorized to do so should be specified. A
tentative list may be made from which purchase is
permitted. Such purchase should be monitored on
monthly basis.

The drugs should be stored as per manufacturers

2.5 STORAGE OF DRUGS instructions. Drugs like insulin cannot be stored at room
temperature; hence refrigerators with back up are a must
for ED.

Such drugs should be stored under lock & key to avoid

2.6 NARCOTIC & pilferage. Proper records need to be maintained
PSYCHOTROPIC DRUGS regarding their use to avoid chances of misuse/abuse.
E.g. Morphine, Pethidine, Fentanyl

There should be Drug Formulary for emergency drugs

2.7 DRUG FORMULARY with documented procedure to add new drugs in the list.
It should be available as pocket manual for the medical
and paramedical staff.

Format for preparing Drug Formulary is given below:

S.NO DRUG FORMULATION DOSE

1. Diazepam Injection, 5 mg / ml
Suppository 5 mg
2. Paracetamol Injection 150 mg / ml

82
 Standard treatment protocols should be made and
2.8 STANDARD compiled in the form of small hand book. Flow charts of
TREATMENT GUIDELINES common emergencies should be made and displayed in
the department for ready reference.
List of paediatric doses should be displayed.
A manual on Standard Treatment Guidelines has been
developed by HSHRC, Common Treatment Protocols in
Common Medical Emergencies may be taken for display
on charts, an example on Shock is given below for
information. For details of Standard Treatment Guidelines
kindly visit HSHRC website link-
http://hshrc.org/stg-haryana/

SHOCK
(Undetermined aetiology)

Assess Airway-Breathing-Circulation
Supplement-Oxygen
Secure IV access
Give isotonic crystalloid [(20 ml/kg over 3-5 min) NS, RL]

REASSESS

No improvement Improved BP
- Peripheral perfusion
Repeat isotonic crystalloid - Urine passed
(20 ml/kg over 3-5 min)
REASSESS: (ventilation, acid base balance,
electrolytes)

No improvement Improvement - Establish aetiology

- Continue fluids
- REASSESS frequently
Assess cardiac status (CxR, ECG)

Place central venous catheter

CVP < 10 mmHg CVP > 10 mmHg CVP > 15 mmHg

Repeat isotonic
crystalloid
Or colloids
(5-10 ml/kg)
- Inotrope
- Reassess Consider
Continue fluid under - Vasodilator Diuretics
CVP monitoring - Establish aetiology Dialysis
Consider alternate - Careful fluid replacement
aetiology

83
 There should be antimicrobial use policy documenting the
2.9 ANTIMICROBIAL level of expertise required for prescription of higher
POLICY antibiotics.
The protocols for prescribing first line antibiotics
empirically by Emergency Medical Officer and of higher
generation antibiotics after consultation with specialist
should be made and followed.
Where the facility of Culture and sensitivity is available,
hospital specific antimicrobial policy may be made after
considering sensitivity patterns of microrganisms

A procedure of prescription audit should be set up to

2.10 PRESCRIPTION ascertain rational use of medicines specially antibiotics.
AUDIT

There should be a policy for near miss audit, medication

2.11 MEDICATION error reporting and adverse drug reaction monitoring.
ERRORS/ADR All the above events should be defined, reported,
collected, analyzed and based on the above information;
MONITORING corrective as well as preventive measures should be
taken.

84
The following are some of the possible errors that can occur either in the prescribing, dispensing or
administration processes, and which should be monitored:

Prescribed medication not given by staff nurse

Administration of a drug that was not prescribed

Medicine given to the wrong patient

Wrong medicine or iv fluid administered

Wrong dose or strength given

Wrong dosage form given, for example eye drops instead

of ointment

Wrong route of administration

Wrong rate of administration, for example iv infusion

Wrong time or frequency of administration

Medicine given for the wrong duration

Wrong preparation of a dose, for example incorrect

dilution of a dose, not shaking a suspension

Incorrect administration technique

Medicine given to a patient with a known allergy.

85
 SOME WAYS OF PREVENTING MEDICATION ERRORS IN HOSPITALS ARE:

Introducing a punishment-free system to collect and record information about medication errors

Developing written procedures with guidelines and checklists for the administration of
intravenous fluids and high-risk drugs

Confirming patients identity before administering a drug

Allowing verbal or telephone orders only in an emergency to prevent errors

Legible handwriting and complete spelling of a drug name

Using of standardized notation

Dose units written in one way only, for example mcg not g or g not gm

Use of leading zeros for values less than 1 (0.2 instead of.2) and avoidance of trailing zeros for
values more than 1 (2 instead of 2.0)
The route of administration and the complete directions (for example daily not OD) be written
on all drug orders (prescriptions)

2.11 PREVENTION OF Medication error prevention protocols involve various

MEDICATION ERRORS parameters

a) Look Alike Sound Drugs (LASA drugs):

The drugs which look alike or sound alike should be stored carefully so that a clear
distinction can be made between them.
While making labels for all the drugs especially LASA drugs capital letters should be used. In
the store/sub-store they should be stored away from each other.
The list of such drugs should be displayed so that adequate precautions can be taken while
issuing them.

E.g. of Look Alike Sound Alike Drugs

1. Tab.Ondansetron Tab.Chlorphenaramine
2. Tab.Atenolol Tab. Chlortrimazole
3. Tab.Digene Tab.Paracetamol
4. Tab.Amoxycillin Tab.Omeprazol
5. Tab.Metaclopramide Tab.Mebendazol
6. Tab.Metrogyl Tab.Cotrimoxazol
7. Tab.Dicylomine Tab.Isosorbide mononitrate
8. Tab Clopidrogril Tab. Rantac
9. Tab Phenytoin Tab. Ondansetron
10. Tab Albendazol Tab. Divol
11. Tab Calcium gluconate Tab. Paracetamol
86
 12. Inj Atropine Sulphate Inj Vit. K
13. Inj Rantac Inj Drotaverine
14. Inj T.T Inj Atropine sulphate
15. Inj Tramadol Inj Metaclopramide
16. Inj Phenytoin Inj Lasix

Sound alike medicine: The following is the list of drugs when purchased locally with trade name causes
confusion
1. Tab.Epsoline(Phenytoin) Tab.Efcorline (hydrocortisone)
2. Inj Syntac Inj Rantac
3. Tab.PCM Tab.PAM
4. Inj Tramadol Inj Haloperidol

Spell alike: The following is the list of drugs commonly causing confusion if name of the Drug is not
written properly.
1. Syrup Azithromycin Syrup Amoxy, Amoxy clav
2. Tab. Clopidrogril Tab. Cephadroxil
3. Cap Cephalexin Cap Cephadroxil
4. Tab. Lasix Laxative
5. Tab. Pentazocine Tab Pantoprazol
6. Tab. Diclofenac Tab. Dicylomine
7. Inj Isolyte P Inj.Isolyte G, Isolyte M, Isolyte E
8. Duolin Respule Tab.Duodiline
9. Tab.Dobutamine Tab.Dopamine
10. Tab.Cefotaxime Tab.Ceftriaxone
11. Tab.Frusemide Tab.Fomatidine
12. Tab.Glimipride Tab.Glibenclamide
13. Tab.Metrogyl Tab.Metoclopramide
14. Inj Dobutamine Inj Drotaverine
15. Tab. Domperidon Tab. Daflon
16. Inj Lupinox Inj Lasix
17. Tab. Ciplox TZ Tab. Cebexin Z

b) Drugs with narrow therapeutic window:

A list of drugs with narrow therapeutic window or with known severe adverse effects should
be made and displayed at nursing station in a prominent colour, maybe red, to alert nursing
staff who administers such a drug to be conscious of the dose & route of administration.

c) Electrolyte solution:
The doctors and nursing staff should be trained and supervised for ordering and
administering variety of electrolyte solutions since a wrong electrolyte solution may be
detrimental to patients health.

d) Orders over phone:

A Policy has to be developed regarding receiving orders over phone. In case of emergency if
an order has been given over phone, the nursing staff should repeat the name of the drug &
route of administration. For any drug which is sound alike drug or with narrow therapeutic
window, it should be confirmed by spelling out the name, dose and route of administration.
The verbal orders should be endorsed/ confirmed in the medical records by physician within
a specified time maybe within 12 hours.
Some drugs are more prone to cause serious medication errors. So while prescribing,
preparing and administering these drugs, special precautions like checking dose, strength,
dosage form, frequency of administration and strict monitoring after administration should

87
 be taken. Following is the list of drugs and should be displayed in the emergency to avoid
errors.

e) High Risk Medication:

List of high risk medication more likely to be involved in serious medication errors
Epinephrine
Phenylephrine
Norepinephrine
Propranolol
Metoprolol
Labetablol
Warfarin
Low-molecular-weight Heparin
IV unfractionated Heparin
Fondaparinux
Chemotheraputic agents
Chloral hydrate
Opiates like morphine
Theophylline
Midazolam
Dextrose, hypertonic, 20% or greater
Concentrated Potassium Chloride

It is required that availability, access, prescribing, preparation, distribution, labelling,

verification, administration and monitoring of these agent be planned in such a way that
adverse effects can be avoided.

f) Use of Abbreviations:
Use of abbreviations should be discouraged as it may lead to medication errors E.g AZT
may be misunderstood for Azathioprin causing further immune suppression in patients
of AIDS.

g) Near Expiry and Expired Drugs:

There should be documented procedure to dispose off expired medicine and to transfer
near expired medicine.
List of drugs causing serious adverse drug reaction if administered after expiry date; like
Tetracycline should be displayed.

h) Preparation of drugs:
a. The injectables should be prepared at the bed side. The practice of filling syringes at the
nursing station & then administering them at the bed side can lead to errors.
b. If an Injection has to be given as Infusion after mixing with NS/DNS/RL etc. the bottle
should be labelled with the drug that has been added.
c. The strips of tablets should not be cut and then stored/given as single tablet to the
patients as this can lead to errors since important information regarding dose, date of
expiry etc. is lost.
d. If labels are made for storage they should be clear, legible and no over writing or cutting
should be done.
i) Labelling of prepared drugs:
Whenever the drugs are prepared after mixing with diluents, it should be labelled
properly.
All prepared medications, medication containers e.g. syringes, bottles etc. should be
labelled with specified format including name of drug, strength, time of preparation,
name of person who prepared and signature of the person who prepared and time after
which to be discarded.

88
Name of the drug ---------------------------------------------------

Strength ---------------------------------------------------

Time of preparation ---------------------------------------------------

Time at which unused solution should be ---------------------------------------------------

discarded

Name of person who prepared it ---------------------------------------------------

Signature ---------------------------------------------------

Solution should be labelled immediately after constitution.

Unlabelled solution should be discarded, if found.

Before administering the prepared solution, the label should be checked.

89
 BIBLIOGRAPHY

1. Literature Review of emergency department Staffing Redesign Frameworks

Undertaken for NSW Health, Northern University October 09

2. Policy and Guidelines for Hospital Accident and Emergency Services in Ghana
Ministry of Health A&E Services, GHANA, October, 2011
3. Guidance on safe nurse staffing levels in the UK, Royal College of Nursing

4. Dammam Medical Complex Emergency Department Policy and Procedure

Revised and Compiled, Ministry of Health Saudi Arabia, 2005

5. Operational Guidelines on Quality Assurance for Public Health Facilities, National

Health Systems Resource Centre, 2013

6. Emergency Department Clinical Quality Indicators: - A CEM guide to implementation

7. The College of Emergency Medicine Patron: HRH The Princess Royal Incorporated by
Royal Charter, 2008
8. Hospital emergency response checklist An all-hazards tool for hospital administrators and
9. emergency managers, World Health Organization, 2011

10. Centre for Disease Control and Prevention (CDC) Updated U.S. Public Health Service
Guidelines for the Management of Occupational Exposures to HIV and
Recommendations for Post-exposure Prophylaxis MMWR Recommendations and
Reports, Volume 54, Number RR-9

11. Centre for Disease Control and Prevention (CDC) National Institute for Occupational
Safety and Health, ALERT, Preventing Needle Stick Injuries in Health Care Settings

12. Guidelines for Essential Trauma Care World Health Organization, 2011

13. Emergency care in India: the building blocks, Imron Subhan & Anunaya Jain, 4
August 2010

14. Accidental Deaths and Suicides in India, National Crime Records Bureau,
Ministry of Home Affairs, 2011

15. Adult emergency services: Acute medicine and emergency general surgery
Commissioning standards, September 2011

90
16. American College of Emergency Physicians, Advancing Emergency Care
Emergency Department Policy Statement Planning and Resource Guidelines,
October 2007

17. University of Northern Carolina, Department of Emergency Medicine, Emergency

Medicine Policies and Procedures Manual, 27 July 2009

18. Emergency Department Service Standards for General Hospitals, Ministry of

Health Jordan

19. Essential Trauma Care Project Checklists For Surveys Of Trauma Care
Capabilities, Injuries and Violence Prevention Department, World Health
Organization and International Association for the Surgery of Trauma and
Surgical Intensive Care (IATSIC), International Society of Surgery / Socit
Internationale de Chirurgie 14-Sept, 2004

20. Prevention of hospital-acquired infections a practical guide 2nd Edition

WHO/CDS/CSR/EPH/2002.12 World Health Organization Department of
Communicable Disease, Surveillance and Response, 2001

21. Guide To Managing an Emergency Service Infection Control Program FA-112 /

United States Fire Administration 2002, Guide To Managing An Emergency
Service Infection Control Program, January 2002

22. Report of the Working Group on Emergency Care in India Ministry of Road
Transport & Highways, Govt. of India, 2010

23. Guidelines on Emergency Department Design, Australasian College of Emergency

Medicine, March 2007

24. Emergency Design Document, Health Authority Abu Dhabi, Emergency Unit, June
2011

91
ANNEXURES

92
 Annexure-I

PATIENT REFERRAL/ TRANSFER REQUEST

(Please strikeout the one that is not applicable)
(Form No. XYZ /B/18/...)

NAME OF PATIENT: _________________________ AGE & SEX _________________

Specialty __________________Ward No. _______________ Bed No. __________________

Diagnosis:_____________________________________________________________________
Date of Referral: _______________________ Time of Referral________________________

Doctor In-charge of the case: ___________________________________________ Nature of

Referral (Please tick one only): Immediate/ Urgent/ routine
Reasons of Referral:

Referral request made to (Specify institute name/ Dept): _______________________________

Brief clinical notes:

Signatures of referring person

________________________________________________________________________

93
 Annexure-II

OPD/INITIAL ASSESSMENT FORM

Form No. XYZ/DH/.....
CR No...............................................................Date:-................................Time...................................
Mode of Arrival - Ambulance/ Ambulatory/ Any other......................................................................
Patient Name: ............................................... Age/Sex ( M/F):..............................................................
Address:-.................................................................................................................................................
......................................................................................................................................................
................................................................................................................................................................
Presenting Complaints & History:-....................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

Provisional/ Definite Diagnosis:-...................................................................................................

General Examination:- Systemic examination:-

Temp:
Pulse
BP:

Pallor:
Icterus: Rx

History of chronic illness:

Details of any regular

medication intake:

History of any Allergy:

Require referral Y/N

Reason for referral:

Medical Officer: -.......................................

DH: ...................., Dist:-.................................

Time: ..............., & Date:......./......./................

94
Annexure-III

95
 Annexure-IV

Basic Life Support Protocol

96
 ANNEXURE-V

BIOMEDICAL WASTE SEGGREGATION CHART

COLOUR OF BIN TYPE OF WASTE ACTION/ ATTENTION

Blood or Body Fluid infected tubings, Blood and Urine

Bags, I/V Sets, Syringes, Catheters,
Disfigure and disinfect by
Cannula, Drains, Plastic I/V Bottles, Discarded Plastic
RED soaking in 1% Sodium
Sheets & McIntosh for patient care, Gloves after
Hypochlorite Solution
disinfection

Human Tissue, Dressings, Gauge, Bandages, POP

Plaster, Cotton Swabs, Dressing Tapes, Discarded
YELLOW House-Keeping Mops/ Clothes, Bed- sheets & Disfigure before disposing
Blankets (Blood Soaked)

Sharps, Needles after destruction, Broken Glass,

BLUE Disfigure before disposing
Unbroken Glass Vials/ Bottles/ Ampoules
Kitchen Waste, Paper, Polythene, Card board,
Aluminum Foil, Disposable Glasses/ Bottles/ Plates,
BLACK Vegetable & Fruit Peel & Left Over Food Do not litter the place

97
 Annexure-VI

CLEANING CHECKLIST

DH NAME ____, DISTRICT NAME FORM NO. ______________

CHECKLIST FOR CLEANING AREAS

Cleaning Areas/ Material Used Responsibility Daily Cleaning Remarks
Equipment Done/ Not
Done
Beds / bed rails 1% Sodium 2 TIMES
Hypochlorite
Bed side trolleys 1% Sodium 2 TIMES
Hypochlorite
Ventilators 1% Sodium 2 TIMES
Hypochlorite
Dressing trolleys 1% Sodium 2 TIMES OR AS
Hypochlorite PER REQRMNT
Crash carts 1% Sodium 2 TIMES OR AS
Hypochlorite PER REQRMNT
Cardiac Table 1% Sodium 2 TIMES OR AS
Hypochlorite PER REQRMNT
ECG trolley 1% Sodium ONCE
Hypochlorite
IV Stands 1% Sodium 2 TIMES
Hypochlorite
Nursing Stations 1% Sodium 2 TIMES
Hypochlorite
Chairs 1% Sodium ONCE
Hypochlorite
Mops Soap and Water 3 TIMES
solution
Fans Soap and Water
solution
Mirrors 1% Sodium Daily
Hypochlorite

98
 ANNEXURE-VII

WHO Generic Essential Emergency Equipment List

This checklist of essential emergency equipment for resuscitation describes minimum

requirements for emergency and essential surgical care at the first referral health facility

Capital Outlays Quantity Date checked

Resuscitator bag valve and mask (adult)
Resuscitator bag valve and mask (paediatric)
Oxygen source (cylinder or concentrator)
Mask and Tubings to connect to oxygen supply
Light source to ensure visibility (lamp and flash light)
Stethoscope
Suction pump (manual or electric)
Blood pressure measuring equipment
Thermometer
Scalpel # 3 handle with #10,11,15 blade
Scalpel # 4 handle with # 22 blade
Scissors straight 12 cm
Scissors blunt 14 cm
Oropharyngeal airway (adult size)
Oropharyngeal airway (paediatric size)
Forcep Kocher no teeth 12-14 cm
Forcep, artery
Kidney dish stainless steel appx. 26x14 cm
Tourniquet
Needle holder
Towel cloth
Waste disposal container with plastic bag
Sterilizer
Nail brush, scrubbing surgeons
Vaginal speculum
Bucket, plastic
Drum for compresses with lateral clips
Examination table
Wash basin
Renewable Items
Suction catheter sizes 16 FG
Tongue depressor wooden disposable
Nasogastric tubes 10 to 16 FG
Batteries for flash light (size C)
Intravenous fluid infusion set
Intravenous cannula # 18, 22, 24
Scalp vein infusion set # 21, 25
Syringes 2ml
Syringes 10 ml
Disposable needles # 25, 21, 19
Sharps disposal container

99
 Capital Outlays Quantity Date checked
Capped bottle, alcohol based solutions
Sterile gauze dressing
Bandages sterile
Adhesive Tape
Needles, cutting and round bodied
Suture synthetic absorbable
Splints for arm, leg
Urinary catheter Foleys disposable #12, 14, 18 with bag
Absorbent cotton wool
Sheeting, plastic PVC clear 90 x 180 cm
Gloves (sterile) sizes 6 to 8
Gloves (examination) sizes small, medium, large
Face masks
Eye protection
Apron, utility plastic reusable
Soap
Inventory list of equipment and supplies
Best practice guidelines for emergency care
Supplementary equipment for use by skilled health
professionals
Laryngoscope handle
Laryngoscope Macintosh blades (adult)
Laryngoscope Macintosh blades (paediatric)
IV infusor bag
Magills Forceps (adult)
Magills Forceps (paediatric)
Stylet for Intubation
Spare bulbs and batteries for laryngoscope
Endotrachael tubes cuffed (# 5.5 to 9)
Endotrachael tubes uncuffed (# 3.0 to 5.0)
Chest tubes insertion equipment
Cricothyroidectomy

100
 ANNEXURE-VIII

SUGGESTIVE EMERGENCY DRUG LIST

Following medicines should be available in the Emergency department for the patients for effective and
immediate management of their conditions:

The list can be pruned or expanded depending upon the need of the hospital.

Emergency Drug List

Sr. Drug Formulation Strength
No.
1 Oxygen Medicinal Gas Inhalation
2 Thiopentone Sodium Injection Powder 0.5 g
3 Lignocaine Hydrochloride Jelly sterile 2%
4 Lignocaine Hydrochloride Injection 2%
5 Atropine. Injection (sulphate) 0.5 mg/ml
6 Diazepam Injection 5 mg/ml
7 Diclofenac Injection 25 mg/ml
8 Ibuprofen Tablet 400 mg
9 Paracetamol Tablet 500 mg
10 Paracetamol Syrup 100 mg/5 ml
11 Paracetamol Injection 150 mg/ml
12 Morphine Sulphate Injection 10 mg/ml
13 Tramadol Hydrochloride Tablet 50 mg
14 Tramadol Hydrochloride Injection 50 mg/ml
15 Cetrizine Tablet 10 mg
16 Cetrizine Suspension 5 mg/ml,60 ml
17 Pheniramine maleate Injection 22.75 mg/ml
18 Dexamethasone Disodium Injection 4 mg/ml
19 Hydrocortisone Sodium Powder for injection 100 mg vial
Succinate
20 Adrenaline Injection 1 mg/ml (1:1000)
21 Charcoal activated Tablet 250 mg
22 Antisnake venom Injection 10 ml vial
23 Calcium gluconate Injection 100 mg/ml
24 Naloxone Hydrochloride Injection 400 mcg
25 Pralidoxime (PAM) Injection 1 gm vial
26 Lorazepam Injection 2 mg/ml
27 Magnesium sulphate Injection 500mg/ml
28 Phenobarbitone Injection 200 mg/ ml
29 Phenytoin Injection (sodium) 50 mg/ml
30 Amoxicillin + clavulanic acid Injection 500 +100 mg
31 Ampicillin Sodium Injection powder 500 mg
32 Benzathine penicillin Injection powder 6 lacs IU vial

101
33 Benzathine penicillin Injection powder 12 lacs IU vial
34 Cefotaxime Injection 250mg
35 Cefotaxime Injection 500 mg
36 Ceftriaxone Powder (sodium) Injection powder 250 mg
37 Ceftriaxone Powder (sodium) Injection powder 1 g vial
38 Amikacin Injection 500 mg/2 ml
39 Ciprofloxacin Injection IV 200 mg/ 100 ml
40 Gentamycin Sulphate Injection 40 mg/ ml, 2 ml
vial
41 Metronidazole Injection 500 mg/ 100ml
42 Heparin sodium Injection 5000 IU/ ml
43 Ethamsylate Injection 250 mg/2 ml
44 Vitamin K Injection 10 mg/ml, 1 ml
ampoule,
45 Plasma Volume Expander Injection 500ml
46 Diltiazem Injection 5 mg/ml
47 Glycerine trinitrate Tablet (sublingual) 500 mcg
48 Glycerine trinitrate Nitro Injection 5 mg/ ml
Glycerine
49 Isosorbide mononitrate Tablet 20 mg (SR)
50 Isosorbide dinitrate Tablet (sublingual) 5 mg
51 Adenosine Phosphate Injection 3 mg/ ml
52 Dobutamine Injection 125 mg/ 5 ml
53 Dopamine Hydrochloride Injection 40 mg/ ml
54 Streptokinase Injection powder 1500000 IU
55 Potassium permanganate Aqueous solution 1 : 10 000
56 Silver sulfadiazine Cream 1%
57 Calamine lotion Lotion 8%
58 Povidone iodine Solution 5%
59 Povidone iodine Ointment 5%
60 Furosemide Injection 10 mg/ml
61 Mannitol Injectable solution 20%
62 Ranitidine Injection 25 mg/ml
63 Metoclopramide Hydrochloride Injection 5 mg/ ml
64 Prochlorperazine Injection 12.5 mg/ml
65 Ondansetron Injection 2 mg/ ml
66 Promethazine Hydrochloride Injection 25 mg/ml
67 Promethazine Syrup 5 mg/ 5 ml
68 Hyoscine butyl bromide Injection 20 mg/ ml
69 Glycerine Saline Enema
70 Oral Rehydration Salts Powder for solution As per IP
71 Insulin (soluble) Injection 40 IU/ml
72 Intermediate-acting insulin Injection 40 IU/ml

102
 (Lente)
73 Anti Rabies Immunoglobulin Injection 3000 IU /ml
74 Tetanus vaccine Injection 0.5 ml Ampoule
75 Anti Rabies vaccine Injection ID
76 Neostigmine Injection 500 mcg/ ml
77 Ciprofloxacin Eye Drops 0.3%
78 Atropine Sulphate Eye Ointment 1%
79 Tropicamide + Phenylepherine Eye Drops 0.8% + 5%
80 Sodium Carboxymethyl Cellulose Eye Drops 0.5% w/v
81 Saline Nasal Drops 0.6%
82 Xylometazoline Nasal Drops 0.05%,
83 Glycerin Solution 500 gm bottle
84 Oxytocin Injection 5 IU in 1 ml
ampoule
85 Haloperidol Injection 5 mg
86 Alprazolam Tablet 0.25 mg
87 Aminophylline Injection 25 mg/ ml
88 Ipratropium bromide aerosol Nebulizer Solution
89 Salbutamol Sulphate Nebulizer solution 5 mg/ ml
90 Etophylline + Theophylline Injection 169.4 mg + 56.6
mg/2 ml
91 Budesonide Nebulizer solution 15 ml vial
92 Glucose/dextrose Injectable solution 5%, isotonic
93 Glucose/dextrose Injectable solution 10% isotonic
94 Glucose/dextrose Injectable 25%
95 Glucose with sodium Injectable solution 5% glucose +
chloride/saline 0.9% sodium
chloride
96 Potassium chloride Injectable solution 11.2% in 20ml
97 Ringer lactate Injectable IV solution
98 Sodium bicarbonate Injectable IV solution 7.5%
99 Sodium chloride Injectable solution 0.9% isotonic
100 Water for injection Injection 5ml ampoule
101 Artesunate Injection 60 mg/ml
102 Artemether Injection 80 mg/ml, 1 ml
amp
103 Quinine (Dihydrochloride) Injection 300 mg/ ml, 2ml
ampoule
104 Chloroquine phosphate Injection 40 mg / ml
105 Amiodarone Injection 50 mg/ml (3 ml
ampoule)
106 Digoxin Injection 0.25 mg/ml
107 Pantoprazole Injection 40 mg

103