POLICIES AND PROCEDURES FOR AMBULANCE SERVICE

The Sta. Maria Village Hospital presently owns and operates one (1) ambulance unit. This Toyota Hi-Ace
Commuter van was acquired brand new in 2018 and modifications were made to meet the
specifications/requirements given by the Department of Health to qualify as Type I- BLS Ambulance. As
such, it is intended to be used to transport patients who are to be transferred to other hospitals, those
who will be undergoing diagnostic procedures not available in our hospital and those who have been
discharged from our hospital wanting to use the ambulance going back to their homes. Due to the
availability of other ambulances in our locality and in order to prolong the lifespan of our ambulance,
management has decided that it will only be allowed to operate within Oriental Mindoro.

PROCEDURES (SOPs)

1. Minimum of two (2) ambulance personnel (helper and nurse) excluding the driver is required for
every ambulance dispatched.

2. Transfer of patient to another hospital must be coordinated beforehand with the receiving hospital.
Recently, a Health Care Providers Network (HCPN) was created in Oriental Mindoro in which our
hospital is part of.

3. A Hospital Referral Form must be fully and accurately filled out. It will be kept secured and
confidential by the ambulance personnel. Filing of Annual Statistical Report will be done based on
these documents and will be the responsibility of the Ambulance Driver. All filled out forms will be
kept in a folder duly labeled. Retention of these forms is only for two (2) years. Disposal of used
forms will be by burying.

4. A logbook will be provided to record all the trips/dispatches made by the ambulance. It will be
correctly filled out with the following information:
a. Name, sex and age of patient
b. Name of attending physician (when applicable)
c. Origin and destination
d. Date and time of dispatch and return of ambulance
e. Reason for transfer/transport
f. Disposition of patient

5. Retention of records for ambulance service is for two (2) years only. Disposal of records by will be by
burying in a lot owned by the Corporation.

6. DISINFECTION OF THE AMBULANCE. After each trip, all trash shall be removed from the ambulance
and disposed of properly. All bio-hazardous material should be cleaned and disposed of in their
designated containers. A disinfectant solution (Lysol) will be sprayed inside the ambulance after
each trip.
7. PREVENTIVE MAINTENANCE. For the ambulance, this will be scheduled for every 5,000 km.

8. CALIBRATION/PREVENTIVE MAINTENANCE OF AMBULANCE EQUIPMENT. Calibration and

preventive maintenance of all equipment inside the ambulance is done once a year. Repair of
defective equipment will be done the soonest possible time.

9. HANDLING & RESOLUTION OF COMPLAINTS. The complaint must be written in the Survey Form for
Client Satisfaction. The Ambulance Driver and the accompanying Nurse and Helper must notify the
Chief Nurse of the incident. All cases of complaints will be later forwarded to the Medical Director.

10. PERSONAL PROTECTIVE EQUIPMENT. Masks will be worn always by all personnel who will use the
Ambulance. Latex gloves must be worn by Ambulance Personnel when touching the patient and
administering drugs and suctioning.

11. MGT OF TEMPERATURE SENSITIVE MEDS. Temperature sensitive medications will be stored in the
hospital’s pharmacy. The Ambulance Nurse shall secure these medications prior to patient
transport.

PROTOCOL
Considering that most cases that utilize the ambulance are stable cases that need to undergo imaging
studies in other hospitals that are within 1-2 kilometers from our hospital, the following protocol must
be observed:

1. The imaging test to be done must be coordinated by our nurses with the personnel where the
test will be done. Utmost effort to minimize waiting time is of greatest importance.
2. A nurse must always accompany the patient. Vital signs of the patient before he/she is brought
out of the room and once the patient is loaded inside the ambulance must be taken and
recorded(before the ambulance leaves the OUR hospital).
3. Once the ambulance arrives in the referral hospital, vital signs are again taken and recorded
before the patient is brought out of the ambulance going to the imaging room.
4. While undergoing the imaging test, the nurse must always be with the patient to
observe/monitor except inside the CT Scan or MRI room.
5. After the imaging test has been completed, the nurse again takes and records the vital signs and
assess the patient as to after effects of the imaging test.
6. In case of immediate reaction of contrast media, chest pain or dyspnea while the patient is not
yet loaded into the ambulance, the accompanying nurse must coordinate with medical
personnel of the referral hospital for assistance.
7. If no untoward event has happened, the patient is brought back to the ambulance and
immediately transported back to the hospital. Vital signs are again taken once the patient
arrives in his/her room.