2009 HOSPITAL MANUAL /SOPs

The details of the above document is printed below:

 ≠2009 HOSPITAL STANDARD OPERATING PROCEDURES AND GUIDELINES

OUT-PATIENT DEPARTMENT PROCEDURES

OPD PROCEDURES (FLOW CHART) 

EMERGENCY ROOM GUIDELINES

1.     OBJECTIVE(S):

a.    To provide immediate and competent medical care to all who seek treatment at the Emergency Room.

b.    To properly identify and prioritize patients upon entry at the Emergency Room.

                                              i.     To prevent the transmission of specific communicable diseases to other patients and personnel within the Emergency Room

                                            ii.     To minimize unnecessary foot traffic that would impede the mobility of staff in rendering good patient care.

                                          iii.     To efficiently use the Emergency Room’s resources and space.

                                            iv.     To facilitate patient flow in the department.

2.     POLICIES AND PROCEDURES

a.    GENERAL

                                              i.     The Emergency Room shall be available 24 hours a day.

                                            ii.     All patients shall be seen, examined and treated by a physician on duty. Final disposition shall be determined by the attending physician.

                                          iii.     Patients shall be triaged upon entry at the Emergency Room according to the severity of their illness or injury and not on a “first come, first served” basis. Hence, the critically ill and injured shall be given priority. The EMERGENCY ROOM POLICIES AND PROCEDURES on triage will be enforced.

                                            iv.     Patients shall be decked to the appropriate service based on age and presenting problem. All patients below the age 17 yrs and 365 days shall be attended to by Pediatrics; pediatric patient with surgical problems shall be co-managed by Pediatrics and Surgery.

                                              v.     All OB-Gyne cases shall be evaluated by the OB Resident on-duty at the OBIE Room. However, should the problem be life-threatening or unrelated to the patient’s pregnancy treatment, shall be initiated at the Emergency Room where the OB Resident shall see the patient.

                                            vi.     All patients shall be properly documented. The personal information sheet should be filled up by the patient or a responsible relative while the chart shall be scrupulously accomplished by the physician on duty or his designate.

                                          vii.     The use of Personal Protective Equipment (PPE) and universal infection precautions shall be practiced at all times.

                                        viii.     The Emergency Room Policy and Procedures for Infection Control shall be strictly implemented.

                                            ix.     Waste shall be segregated and disposed of according to the hospital’s zero waste management plan.

                                              x.     All data of patients will be completed. All diagnostic test results incorporated in the chart prior to admission to room shall bear the signature of the Resident-on-Duty.

                                            xi.     Only one companion shall be allowed per patient in order to contain traffic within the Emergency Room and minimize the spread of infection.

                                          xii.     Therapeutic Interventions

1.     All therapeutic interventions must have corresponding Doctor’s Orders.

2.     All invasive interventions must always be with a completely filled-up consent form.

3.     Emergency Room Nurse shall assist the Attending Medical Doctor (AMD).

                                        xiii.     Active Participation during CODE 88

                                         xiv.     Under situations of cardiac and respiratory arrest, all medical and nursing staff assigned in the Emergency Room shall participate in the resuscitation of patients regardless of service.

b.    TRIAGE (EMERGENCY ROOM OFFICER)

                                              i.     Policy

1.     All patients shall be registered upon entry at the Emergency Room using the Emergency Room Log Boom.

2.     All patients shall be prioritized according to the severity of their illness or injury. The 3-Tier Triage System shall be used.

PRIORITY LEVEL TRIAGE CODE

Priority 1 Emergent

Priority 2 Urgent

Priority 3 Non-urgent

3.      All patients who may require isolation shall be screened based on the guidelines set forth by the Infection Control Committee.

4.     All patients shall be screened by a Nurse and an ER Clerk upon arrival at the Emergency Room using Triage section of the Nursing assessment form.

5.     An Emergency Room Officer shall triage each patient and determine the priority of care based on the physical, developmental, psychosocial needs and patient flow through the emergency care department.

6.     A rapid systematic collection of data relevant to each patient’s chief complaint, age, cognitive level and social situation shall be conducted to obtain sufficient information to determine patient acuity and any immediate physical or psychological needs.

7.     Information gathered in the assessment phase shall be analyzed to determine the severity of the physical, psychological and developmental needs using a three-tiered priority system.

8.     Patients assigned a priority one (1) shall immediately be placed in an appropriate treatment area.

9.     All patients shall be assessed by the Emergency Room Officer/Resident/Nurse regularly every 30 minutes or as the frequency of which shall depend on the acuity of the case.

10.  The admission staff shall complete registration for all patients in the admitting section.

                                            ii.     Procedure

1.     Patients will be screened by a Registered Nurse upon arrival at the Emergency Room. The Registered Nurse will assess airway, breathing, circulation and chief complaint. The patient will be assigned a triage acuity level.

2.     Patients will be interviewed and will have an age specific triage assessment performed by an Emergency Room Officer based on patient acuity.

3.     The assessment nurse will process data, validate acuity, and initiate appropriate measures:

a.    determine need for and perform first-aid measures

b.    communicate need of registration to registration staff

4.     Direct the patient to the appropriate treatment areas:

a.    Emergent – patients with life-threatening illness or injury.

b.    Urgent – patients with a medical problem that can be temporized for a few minutes or hours without it being detrimental to their status.

c.     Non-urgent – patients whose complaint do not require immediate care and can be disposed of as outpatients with minimal management

d.    Pediatric Area – for patients below the age of 17 and 365 days.

e.    Trauma Area – for victims of trauma

f.      Isolation – for patients who may be suffering from a communicable disease specified by the Infection Control Committee.

                                          iii.     GUIDELINES TO THE ASSIGNMENT OF TRIAGE ACUITIES

1.     GUIDELINES TO THE ASSIGNMENT OF TRIAGE ACUITIES FOR ADULTS

PRIORITY 1: The most EMERGENT of conditions. The patient could experience loss of life or function if immediate intervention is not instituted.

Examples of conditions assigned to the Priority 1 rating include:

a.    Cardiopulmonary arrest

b.    Unresponsiveness

c.     Trauma as per Trauma Team Criteria

d.    Burns as per Burn Team Criteria

e.    Chest Pain as Per Chest Pain Rapid Response Team Criteria

f.      Stroke as per Stroke Team Criteria

g.     Severe respiratory distress which might

                                                                                                    i.     Airway obstruction, partial or complete

                                                                                                  ii.     Absent or unequal breath sounds

                                                                                                iii.     Cyanosis, pallor diaphoresis

                                                                                                  iv.     Respiratory rate > 30, SaO2 < 90%

1.     Shock states as evidence by

a.    Restlessness or altered mental status

b.    Diaphoresis

c.     Pallor

d.    Hypotension and usually, tachycardia

                                                                                                    v.     Significant electrical shock injury

                                                                                                  vi.     Irregular heart rate with palpable Tachycardia > 150 or bradycardia < 50

                                                                                                vii.     Diastolic blood pressure > 120 or

                                                                                              viii.     Symptomatic systolic blood pressure < 90

                                                                                                  ix.     Acute eye injuries or conditions

1.     Chemical exposure

2.     Suspected penetrating foreign body

3.     Acute vision loss

4.     Sudden onset pain

                                                                                                    x.     Reported near drowning or immersion injury

                                                                                                  xi.     Decompression sickness (the bends)

                                                                                                xii.     Symptomatic hypoglycemia and/or glucose < 50

                                                                                              xiii.     Symptomatic hyperglycemia and/or glucose greater than 500 with altered mental status

                                                                                               xiv.     Signs of anaphylaxis

                                                                                                 xv.     Uncontrolled bleeding

                                                                                               xvi.     Occupational exposure to blood borne pathogen meeting criteria for prophylaxis

                                                                                             xvii.     Active gastrointestinal bleeding, with orthostasis, pallor, or abnormal vital signs

                                                                                           xviii.     New onset neuro-vascular impairment or active seizure

                                                                                               xix.     New onset change in level of consciousness (alertness and cognition)

                                                                                                 xx.     Severe acute onset headache, possibly accompanied by fever or neuro status changes.

                                                                                               xxi.     Suicidal or homicidal ideations

                                                                                             xxii.     Ingestion of toxins less than 24 hours

                                                                                           xxiii.     Snake with evidence or envenomation (discoloration/swelling)

                                                                                             xxiv.     Contagious infection not contained by isolation mask causing public health risk (i.e. SARS, chicken pox, measles, etc.)

1.     Patients who are severely immunusupressed

2.     Patients with acute radiation contamination

                                                                                               xxv.     Pose public health risk due to acute radiation contamination

                                                                                             xxvi.     Require cervical spine immobilization (such as any fall, motor vehicle accident or other circumstance)

                                                                                           xxvii.     Sexual assault with 96 hours

                                                                                         xxviii.     Priapsim or acute painful testicular swelling

                                                                                             xxix.     Pregnancy meeting the following Labor & Delivery Transfer Criteria:

1.     At least 16 weeks gestation with vaginal bleeding

2.     At least 20 weeks gestation with symptoms of imminent delivery

3.     At least 20 weeks gestation with conditions which threaten viability

4.     Any of the symptoms of toxemia (swelling, headache, hypertension, seizure)

5.     Fractures or discoloration of femur, hip or pelvis

6.     Heat related complaints with

a.    Temperature > 39°C

b.    Cramping of extremities

c.     Loss of consciousness

d.    Inability to sweat

e.    Delirium

                                                                                               xxx.     Hypothermia < 34°C

PRIORITY 2: URGENT – The patient has an acute condition requiring urgent evaluation.

Examples of conditions assigned to the Priority 2 rating include:

                                                                                             xxxi.     Abdominal pain complaints that do not meet Priority 1 criteria will be assigned as Priority 2 with the following exceptions: Exceptions may include minor and specific complaints not likely to precipitate or deteriorate into other more serious conditions. For example, the following presentation may be triaged as Priority 3:

1.     Chronis abdominal pain > 72 hours duration with no acute exacerbation, no distention or significant tenderness, no dehydration, lethargy or weakness and no vital sign abnormalities.

                                                                                           xxxii.     Laceration and wounds complaints that do not meet Priority 1 criteria will be assigned as Priority 2 with the following exceptions which shall be tagged as Priority 3:

1.     Small, superficial wound not requiring suturing (not gaping) or

2.     Minor wound requiring minor suturing with bleeding under control

3.     Simple wound beyond 12 hours post injury.

                                                                                         xxxiii.     Persons > 64 years of age who do not meet Priority 1 criteria will be assigned as Priority of 2 with the following exceptions: Exceptions may include minor and specific complaints that may not lead to serious conditions. For example the following complaints may be triaged as a Priority3:

1.     Medication refill requests without other complaints

2.     Request for immunization or referral

3.     Minor extremity injuries without evidence of swelling/deformity

4.     Painless mass

5.     Dermatitis

6.     Ingrown toenail

7.     Sinus/ENT complaints with temperature below 97°C

                                                                                          xxxiv.     Pregnancy-related conditions (vaginal bleeding, pelvic pain, passing of tissue)

                                                                                            xxxv.     Eye complaints such as non-penetrating foreign bodies, peiorbital cellulites

                                                                                          xxxvi.     Respiratory complaints with adequate air exchange

                                                                                        xxxvii.     Injuries less than 72 hours with suspected dislocations or fractures

                                                                                      xxxviii.     Allergic reactions <24 hours without airway involvement

                                                                                          xxxix.     Symptomatic hypoglycemia and/or glucose 50 to 100 (patient cooperative/oriented)

                                                                                                  xl.     Excessive thirst, dehydration, elevated FSBG .500 and cooperative / oriented (possible diabetic katoacidosis)

                                                                                                xli.     Dehydration with orthostasis

                                                                                              xlii.     Elevated blood pressure: diastolic 110 to 120 and systolic > 200, or any elevated blood pressure associated with headache and neuro changes

                                                                                            xliii.     Acute epistaxis

                                                                                             xliv.     Febrile illness with neck stiffness, pain

PRIORITY 3: NON-URGENT – The patient has a non-urgent condition requiring evaluation, but is not at risk for deterioration and can tolerate a wait of several hours.

Examples of conditions assigned to the Priority 3 rating include:

                                                                                               xlv.     Simple rash or dermatitis

                                                                                             xlvi.     Allergic reactions without respiratory distress or rapid progression of symptoms

                                                                                           xlvii.     Ingrown toenail

                                                                                         xlviii.     Pinworms or other infestation / muscle pain or spasm without acute neuro vascular / motor changes

                                                                                             xlix.     Allergic rhinitis, simple upper respiratory infection

                                                                                                    l.     Headache > 24 hours with no neuro changes

                                                                                                  li.     Minor eye complaints without vision impairment

                                                                                                lii.     Localized tissue infection

                                                                                              liii.     Simple wounds beyond 12 hours of injury

                                                                                                liv.     Dysuria / Temperature < 38.5°C

                                                                                                  lv.     Medications refill

                                                                                                lvi.     Work excuse

                                                                                              lvii.     Penile or STD exposure

                                                                                            lviii.     Vaginal discharge or STD exposure not pregnant

                                                                                                lix.     Toothache / TMJ

                                                                                                  lx.     Minor localized injuries / sunburn

                                                                                                lxi.     Painless masses or swelling / Suture Staple removal

                                                                                              lxii.     Seizures > 24 hours

                                                                                            lxiii.     Requiring pregnancy test

                                                                                             lxiv.     Injuries > 72 hours with suspected dislocations or fractures

                                                                                               lxv.     Asymptomatic hypertension, diastolic < 100

                                                                                             lxvi.     Nausea, vomiting, or diarrhea without abdominal pain, fever and orthostasis

                                                                                           lxvii.     Simple sprains

                                                                                         lxviii.     Simple ear, eye or throat infections

                                                                                             lxix.     Referred for detoxication and has no acute ingestion or psychiatric symptoms

                                            iv.     GUIDELINES TO ASSIGNMENT OF TRIAGE ACUITIES FOR PEDIATRICS

PRIORITY 1: The most EMERGENT of conditions. The patient could experience loss of life or function if immediate intervention is not instituted.

                                                                                                    i.     Cardiopulmonary arrest

                                                                                                  ii.     Unresponsiveness, including extreme lethargy or decreased mental status

                                                                                                iii.     Trauma as per Trauma Team Criteria

                                                                                                  iv.     Falls in any child less than or equal to 2 years old

                                                                                                    v.     Large or complex lacerations

                                                                                                  vi.     Acute trauma to the limb with impaired neurovascular status, acute pain or obvious deformity

                                                                                                vii.     Burns as per Burn Team Criteria

                                                                                              viii.     Shock states as evidenced by

1.     Restlessness or altered mental status

2.     Diaphoresis

3.     Pallor, poor color

4.     Hypertension and usually, tachycardia

                                                                                                  ix.     Moderate to severe respiratory distress, which might include:

1.     Airway obstruction, partial or complete

2.     Refraction

3.     Absent or unequal breath sounds

4.     Cyanosis, pallor, diaphoresis

5.     Tachypnea, SaO2 <95%

                                                                                                    x.     History of apnea in the past 24 hours

                                                                                                  xi.     Foreign body with respiratory distress

                                                                                                xii.     Signs of anaphylaxis, including acute epistaxis

                                                                                              xiii.     Electrical shock injury

                                                                                               xiv.     History of near drowning or immersion injury

                                                                                                 xv.     Ingestion of any toxins

                                                                                               xvi.     Painful sickle cell crisis

                                                                                             xvii.     History of diabetes with symptoms of diabetic ketoacidosis

                                                                                           xviii.     Requirement for isolation

                                                                                               xix.     Snake or other bite with evidence discoloration / swelling signifying possible envenomation

                                                                                                 xx.     Tissue infection with erythema, red streaking, localized cellulites, or wound infection

                                                                                               xxi.     Neonatal jaundice

                                                                                             xxii.     Seizure activity in progress or history of seizure in the past 2 hours

                                                                                           xxiii.     Severe acute onset headache less than or equal to 4 days ago, vision changes, vomiting or neuro status changes

                                                                                             xxiv.     Acute eye injuries or conditions:

1.     Chemical exposure

2.     Suspected penetrating foreign body

3.     Acute vision loss

4.     Sudden onset pain

                                                                                               xxv.     Fever related complaints with

1.     Temp > 40°C in any child

2.     Temp > 38°C in child less than or equal to 2 months of age

3.     Temp > 38°C in child with immunocompromised status (cancer, HIV, sickle cell, post-transplant, or severe heart disease)

4.     Fever with hypotension or signs of shock, neck stiffness or pain

5.     Fever in a child who clinically looks ill.

                                                                                             xxvi.     Hypothermia <34°C

                                                                                           xxvii.     Gastrointestinal complaints with:

1.     Moderate to severe dehydration, including lethargy, decreased mental status, hypotension, poor color, and dry mucous membranes

2.     Acute urinary retention, trauma to scrotum or testicular swelling

                                                                                         xxviii.     Psychiatric complaints with

1.     Psychiatric history, including homicidal or suicidal ideation

2.     History of sexual or physical abuse

PRIORITY 2: URGENT – Patient has an acute condition requiring urgent evaluation.

                                                                                             xxix.     Ear pain with drainage

                                                                                               xxx.     History of swelling or redness of the eye

                                                                                             xxxi.     Toothache with erythema or swelling of face

                                                                                           xxxii.     Rash less than or equal to 4 days

                                                                                         xxxiii.     Insect stings less than 2 hours with no obvious anaphylactic reaction

                                                                                          xxxiv.     Acute epistaxis with no obvious rapid bleeding

                                                                                            xxxv.     Elevated blood pressure for age

                                                                                          xxxvi.     Chest pain less than or equal to 4 days

                                                                                        xxxvii.     Trauma that does not require trauma team activation

1.     Trauma to the limb greater than 24 hours

2.     All other lacerations not extremely large or complex

3.     Head injury without LOC in child greater than 2 years old

4.     History of trauma to extremity less than 24 hours

5.     Foreign body in orifice

                                                                                      xxxviii.     Respiratory complaints with

1.     History of asthma exacerbation, mild or no symptoms of respiratory distress

2.     Croup or bronchitis with mild symptoms or respiratory distress

3.     History of respiratory symptoms, mild symptoms of respiratory distress

                                                                                          xxxix.     Neurological complaints with

1.     Moderate to severe headache with onset less than or equal to 4 days ago, with no vision changes, vomiting

2.     Neck stiffness or neurological changes

3.     Syncope / dizziness less than 4 days

                                                                                                  xl.     Gastrointestinal complaints with

1.     Acute abdominal pail less than or equal to 4 days

2.     History of gastrointestinal bleed less than or equal to 4 days

3.     History of blood in vomit, sputum, urine, stool

4.     Vomiting, diarrhea with symptoms of mild dehydration (decreased urine output)

                                                                                                xli.     Fever related complaints with

1.     Fever of 38°C to 40°C in child greater than 2 months of age

                                                                                              xlii.     Psychiatric complaints with

1.     No homicidal / suicidal ideation

PRIORITY 3: NON-URGENT – The patient has a non-urgent condition requiring evaluation, but is not a risk for deterioration and can tolerate a wait of several hours.

                                                                                            xliii.     Almost any complaint that has been present for greater than four days with no acute exacerbation

                                                                                             xliv.     Ear pain without drainage

                                                                                               xlv.     Toothache without erythema or swelling of the face

                                                                                             xlvi.     Upper respiratory infection symptoms, sore throat or mouth ulcers

                                                                                           xlvii.     Chest pain greater than 4 days

                                                                                         xlviii.     Rash greater than 4 days

                                                                                             xlix.     Pinworms or lice

                                                                                                    l.     Small impaled objects (splinters, marine objects)

                                                                                                  li.     Ingrown toenail

                                                                                                lii.     Medication refill requests

                                                                                              liii.     Gastrointestinal complaints with

1.     Vomiting / diarrhea with no symptoms of dehydration

2.     Abdominal pain for greater than 4 days

3.     Constipation

                                                                                                liv.     Fever related complaints with history of fever less than or equal to 4 days with no documented fever on exam in the Emergency Room

c.     DISPOSITION OF PATIENT

                                              i.     Admissions

1.     The Emergency Room shall coordinate closely with the Admitting Section regarding room accommodation.

2.     The Admitting Clerk shall inform the Emergency Room and the patient or relative of the status of room.

3.     Private patients shall be admitted under the service of their attending physician regardless of the nature of the complaint.

4.     Charity or service patients may be admitted through the Emergency Room Prior to admission, it shall be the responsibility of the Resident-On-Duty (ROD) to explain the diagnostic and treatment plans.

5.     Admitting Process:

a.    Inform patient / companion of the need for admission.

b.    Fill-up admitting slip and ask companion to proceed to admitting section

c.     If patient has no companion, admitting clerk is instructed by senior nurse to proceed to the Admitting Section for processing of admission.

d.    Transport patients to wards/room via wheelchair or stretcher depending on the case of the patient.

                                            ii.     Handling of Emergency Room Patients (When Room / Bed Is Not Available)

1.     GENERAL POLICY:

a.    COVERAGE: This policy shall apply to patients at the Emergency Room requiring confinement but cannot as yet be accommodated due to unavailability of rooms.

                                                                                                    i.     If no room is available, the patient may wait at the Emergency Room until such time as a bed is ready but this shall not exceed 24 hours.

                                                                                                  ii.     Alternatively, the patient is given the option to transfer to another hospital.

2.     SPECIFIC POLICIES:

a.    The nurse-on-duty fills up the admitting slip and asks companion to proceed to the Admitting Section. If the patient has no companion, an admitting clerk is instructed by Senior Nurse to proceed to the Admitting Section for assigning a room to the patient for admission.

b.    Admitting Clerk shall advice the Emergency Room of the soonest possible time of room/bed availability.

                                          iii.     Disposition of Patients

1.     A patient may remain in the Emergency Room for a maximum of two (2) hours while undergoing observation. During this time, he/she will be assessed regularly as needed.

2.     After this 2 hour period a decision regarding his/her disposition must be made. This may be either:

a.    Admission

b.    Discharge

c.     Transfer to another facility

d.    Expired

                                            iv.     Medico-Legal Cases

1.     The following shall be considered as medico-legal cases:

a.    Rape

b.    Gunshot wounds

c.     Stabbing incidents

d.    Vehicular accidents

e.    Mauling

f.      Poisoning, suicide, hanging, homicide and the like

g.     Drug use and abuse

h.    Death on Arrival (DOA)

i.      Work-related trauma

j.      School-related trauma

k.     Domestic violence

2.     Medico-legal certificates may be released only by the Medical Records Section upon the advice and consent of the Attending Physician. Temporary Medico-legal certificates shall be issued at the Emergency Room.

3.     Diagnostic test results and films may not be released unless the attending doctor provides a written authorization to that effect.

4.     The Security Guard on-duty shall be notified by the Emergency Room staff nurse of all Medico-legal cases which he shall log and report to the local police.

5.     In an unconscious and unidentified patient is brought in by bystanders, good Samaritans or police/government officers, the Emergency Room Officer, Nursing Shift Supervisor, and Security Guard on duty and, if necessary, the NBI must be notified.

                                              v.     Transfers

1.     Transfer to another hospital

a.    Patients may be transferred to another hospital upon their request or that of the responsible relative provided that the patient is stable enough for transport or said transfer will not cause deleterious effects to the patient. Unstable patients may be transferred if the institution to which he will be taken is capable of providing a higher level of care not available at Mandaluyong City Medical Center.

b.    The Emergency Room may recommend transfer to another hospital due to the following reasons:

                                                                                                    i.     The medical center is not capable or equipped to treat or manage the case of the patient concerned. These cases include but are not limited to the following:

1.     Psychiatric cases

2.     Infectious cases enumerated by the hospital’s infection control committee.

3.     Unavailability of specific diagnostic or therapeutic procedures needed for the management of the patient’s case.

4.     Unavailability of specific unit needed for the specific case of the patient (e.g. ICU)

                                                                                                  ii.     Patients for transfer must be properly endorsed to and accepted by the receiving hospital’s physician and Admitting Section prior to effecting the transfer.

                                                                                                iii.     The clinical abstract, all diagnostic test results and plates except in medico-legal case and the transfer slip shall be prepared and ready for turnover upon the release of the patient.

                                                                                                  iv.     Details of the transfer, including the name of the receiving hospital, shall be duly recorded in the Emergency Room logbook.

                                                                                                    v.     Ambulance  Conduction

1.     The Emergency Room staff shall inform the patient or the relatives that an ambulance service is necessary for transfer to another center.

2.     Transfer from another hospitals

a.    Resident on-duty receives a telephone endorsement from the doctor of the other hospital or the attending physician. Only the resident on-duty / Attending Medical Doctor (AMD) shall be allowed to accept the transfer of the patient depending on room availability and condition of the patient.

b.    Patient needs and complaints are immediately addressed.

c.     Initial treatment and orders should be immediately carried out as ordered by the respective resident on duty.

d.    Nurse on duty should process the admission of the patient.

3.     Discharging Patients

a.    Out Patients

                                                                                                    i.     Patients who not require admission shall be sent home from the Emergency Room

                                                                                                  ii.     Patients discharges from the Emergency Room shall be issued:

1.     Written discharge instructions

2.     Prescriptions properly filled out according to the Generics Law that has been properly explained to the patient in a language that he orders.

3.     All prescriptions issued shall be written as stipulated by the Generics Law and signed by the resident physician or Emergency Room Officer.

4.     Regulated drugs used at the Emergency Room must have an accompanying prescription on yellow pad or in triplicate, as the case may be, and signed by the Attending physician with an updated narcotics license (S2).

                                                                                                iii.     Outpatients awaiting results of diagnostic procedures or tests done may opt to come back for the results but must sign a statement on the chart indicating this.

b.    Discharge Against Medical Advice (DAMA)

                                                                                                    i.     Patient who have been advised admission but refuse to do so, despite adequate explanation of the risks of leaving the hospital in his condition, must sign the waiver for admission.

                                                                                                  ii.     All contraptions such as IV lines, O2, etc. shall be removed prior to leaving the Emergency Room

c.     Deaths

                                                                                                    i.     All attempts shall be exhausted to identify deceased

                                                                                                  ii.     Any ante-mortem statements made by the patient shall be documented and attested to by witnesses.

                                                                                                iii.     A Chaplain may be requested to give the Last Rites should the relatives so desire.

                                                                                                  iv.     Issuance of Death Certificate

1.     Death-on-Arrival (DOA) patients or those who expire within 24 hours of entry into the hospital shall be issued a death certificate with an “UNDERTERMINED” cause of death.

2.     If the deceased was under the care of a physician accredited by this institution that is willing to attest to the cause of death and the circumstances pertaining to the death, that physician may sign the death certificate.

                                                                                                    v.     After postmortem care is rendered, the patient shall be taken to the hospital morgue where he will be released to the custody of the immediate family.

                                                                                                  vi.     The body shall be released to the authorized Funeral Parlor only if the deceased has no relative and all efforts have been exhausted to trace and notify them.

                                                                                                vii.     Patients who expire from possible medico-legal causes shall only be released to an NBI accredited morgue. The hospital shall keep an updated list of said morgues at the Emergency Room.

d.    Post-mortem Care

                                                                                                    i.     The deceased is treated as sacred

                                                                                                  ii.     The deceased shall be immediately cleaned, prepared and transferred to the morgue.

                                                                                                iii.     Relatives or companion shall be informed of hospital policy and procedure to be followed with regards to the deceased.

d.    Consents and Waivers

                                              i.     All patients shall sign a general consent to treatment from upon entry at the Emergency Room. Where minors (17 and 365 days old) are involved, the parents or closest responsible adult relative shall sign on their behalf.

                                            ii.     Before the procedure, patients who need to undergo a minor surgical procedure at the Emergency Room shall be explained its benefits and risks, then signs the consent form himself/herself. If unable to do so, the responsible representative may sign in his/her behalf.

                                          iii.     Waivers must be signed by the patient or his responsible representative if:

1.     The patient requires admission but refuses discharge against medical advice.

2.     The patient requires admission but opt to transfer to another hospital

3.     The patient refuses to undergo a diagnostic procedure.

4.     The patient refuses medication or treatment.

3.     ADMINISTRATIVE PROCEDURES

a.    Emergency Department Charges

                                              i.     Fees for medicines supplies and diagnostic tests.

                                            ii.     Patients who are unable to settle their charges prior to discharge shall be referred to the Social Welfare Office / Administrative Office and Director’s Office.

b.    Handling of Personal Belongings of Patients

                                              i.     For unconscious and / or severely ill or injured patients who are unaccompanied, the Hospital Guard shall take custody of the personal belongings of the patient.

                                            ii.     These shall be removed and itemized in triplicate in the presence of the Security Guard and an Emergency Room Nurse, bagged, sealed and stored.

                                          iii.     These personal belongings may be released to an authorized claimant who must countercheck and sign receipt for these items – one copy to the relative, one for Security and one copy to be attached to the patient’s chart.

c.     Proper Documentation (Recording)

                                              i.     All patients seen and treated shall be documented in the Emergency Room Patient logbook.

                                            ii.     All clinical data and treatment procedures shall be documented in the Emergency Room Physician’s Assessment / Treatment Record and Logbook.

                                          iii.     All patients shall accomplish a Patient Information Sheet and sign the authorization.

                                            iv.     A treatment record shall be fully accomplished by the Resident on Duty on the duration of the patients stay in the Emergency Room. Order will be countersigned by the attending nurse.

                                              v.     All treatment records must be signed by the Resident, and Intern or Clerk.

                                            vi.     Emergency Department shall maintain a Philhealth accredited logbook of all patients encountered.

d.    Shifting Endorsements

                                              i.     All important events, complaints for repairs and the likes shall be endorsed and logged at the logbook every shift.

e.    Operation and Maintenance of Medical Equipments

                                              i.     All equipment must be checked for cleanliness and functioning by the incoming shift

                                            ii.     Equipment that needs charging must be fully charged at all times.

                                          iii.     Regular maintenance shall be performed by the Maintenance staff.

f.      Orientation of New Staff

                                              i.     All new staff will be oriented with regards to Emergency Room policies, procedures, protocols and training programs as well as the hospital policies by the head nurse.

                                            ii.     Proper placement and location of equipment be known by the new staff.

                                          iii.     A senior staff will be in charge of the orientation of the new staff.

g.     Students in the area

                                              i.     A maximum of six (6) students per school per shift (maximum of 2 affiliated schools) are allowed to go on duty.

                                            ii.     Affiliating Guidelines as agreed upon with the Training Office.

h.    Conduction of Monthly Meetings

                                              i.      A monthly meeting shall be held with the Emergency Room staff to discuss policies, memo, and important issues or as needed.

i.      Requisition of Stocks from the Warehouse

                                              i.     The Head of the ER Clerk is the only one allowed to make request from the Administrative Office / Director’s Office.

                                            ii.     Requested items are delivered by the Central Supply Section every Fridays and/or as needed.

EMERGENCY ROOM PROCEDURES

EMERGENCY ROOM PROCEDURES (FLOW CHART)

ADMISSION PROCEDURES

ADMISSION PROCEDURES (FLOW CHART)

HOSPITAL CHART GUIDELINES

I       CHART ENTRIES

A      Write or print legibly all entries.

B      Sign above the full name, followed by the position title of the person doing the recording.

C      Erasure by any means or any of the items already recorded is not permitted. In case of error, draw a single horizontal line over the error and affix initials.

II     COMPLETION AND HANDLING OF CHART OF DISCHARGED CLIENTS

A      To check the proliferation and inconvenience of incomplete medical records (including chart without final diagnosis) the following guidelines will be strictly enforced.

B      Are nurses should list all discharges with corresponding name of attending MD/ RN.

C      Nurses will classify and segregate and take note/ log complete from incomplete charts.

D     Medical Records (when collecting) should receive only charts that are properly filled.

E      Charge nurses should return to the attending MD all incomplete charts and observe receiving copy procedures.

F      The list name/ name of NOD completing discharged charts should be relayed to the medical records for future accounting.

G     Accountability of personnel will be observed in handling incomplete charts and shall be noted corresponding administrative action in case of loss or tampering of entries.

H     Client’s medical records are public document, any complaints/ problem pertaining and arising from such shall be subjected to administrative proceedings.

III   CHART HANDLING

A      GENERAL GUIDELINES

1      NO CHART shall be HAND CARRIED by client. Only the following are authorized to bring the chart form one area to another.

i       Doctor

ii     Nurse

iii   Nursing Aide

iv     Admitting Clerk

v       Records Section Clerk

2      Complete discharges Charts must be received by the Records Section within three (3) days after discharged.

3      DOCTORS MUST NOT GET DISCHARGED CHARTS FROM THE NURSE STATION. If badly needed, the discharged chart will be collected by the Medical Record Clerk. The Doctor may then borrow the chart from the Records Section.

4      ALL CHARTS MUST BE BORROWED FIRM AT THE RECORD SECTION – properly signed out and countersigned by the Record Section Clerk, including the date and time. All borrowed charts must be returned by the borrower to the Records Section, properly accepted and checked by the Record Section Clerk.

B      CHART RESPONSIBILITIES

1      DOCTORS:

i       Must complete the following:

·      Front page – (Admission and Discharge Record)

·      Date and time of discharge

·      Number of days of stay

·      Attending Physician/s

·      Admitting Diagnosis

·      Final Diagnosis (DO NOT WRITE “THE SAME”)

·      Signature over printed name and date

ii     History form – all admissions must have complete history and admitting diagnosis. History form may differ from one Department to another.

iii   Post operative cases – complete the following:

·      Operation Record (to be completed by the Surgeon)

·      Technique of Operation (to be completed by the Surgeon)

·      Anesthesia Records (to be completed by the Anesthesiologist)

·      Discharge Summary/ Abstract – different Department may have specific forms.

*Don’t forget your signature over printed name. Complete all information

2      NURSES:

i       Must review the chart’s completeness and request the doctors to complete lacking information needed form them.

ii     Log all complete discharged charts at the DISCHARGE LOGBOOK in the station.

3      ADMITTING SECTION:

i       Admitting Clerk will proceed daily to the Medical Record Section to record patient discharged information at the general logbook.

CADAVER HANDLING GUIDELINES

I       The nurse and utility personnel should institute proper cadaver care after death (mortality) is pronounced/ confirmed by the attending physician. Disposition and release must be coordinated with Administrative Office and the Senior House Officer.

II     Death certificate is issued only to mortality occurring on or beyond 24 hours from admission.

III   In the presence of immediate relatives, arrangement for funeral service/s shall be at their discretion.

IV    Cadavers should be properly disposed within and not beyond 6 hours from death. In case if there are no immediate relative/ caretakers/ claimant, decision for the disposition should be coursed through the Office of the Hospital Director, Administrative Office (during office hours) and SHO (after office hours). These are the only authorities to decide which funeral establishment/s will be entrusted to safe keep cadavers.

V      Cadavers unsettled and are near to 6 hours of stay shall be reported immediately to administrative office/ SHO for proper facilitation.

VI    Only funerals accredited by the hospital, City Health Office, MCMC, NBI, and PNP are allowed handling unclaimed cadavers for safe keeping.

VII  No hospital personnel shall transact or accept any form of ”incentives” or favors from any funeral establishments.

VIII         Cadavers are to be released only to relatives or in case of contested claims. To parties duly authorized by a valid special court order.

IX    All cadavers for release shall be

A      1st logged-out at respective nurses areas record book and official cadaver release forms signed by relative, nurse on duty and SHO prior to issuance by nurse of gate pass.

B      2nd logged-out at the POS station after cadaver release form is presented with proper clearance. The ward nurse, attending physician, senior house officer on duty shall have signed the form. Upon release, the POS should secure the signature of the claiming parties in their logbook; relative or duly authorized party and funeral establishment’s representatives.

C      All cadavers release forms submitted to the SHO after office hours shall be attached to the SHO 24 hours report for submission to administrative office the following day.

D     All cadaver release forms submitted to Administrative Office shall be verified before it is forwarded to the Medical Records Section. These forms are attached to the deceased client’s record.

X      All cadavers shall be released passing thru the back stairs on its way to the hearse. Cadavers MUST NOT pass thru the elevator or main stairs area. Failure of the funeral parlor to comply with this directive shall automatically result in cancellation of its accreditation with the hospital.

THERAPEUTIC MANAGEMENT GUIDELINES

I       All orders for care and treatment of client must be written and signed by the doctors.

II     Only in urgent cases when a doctor due to constraints while needing to immediately address a client’s problem, may be allowed to give verbal order’s (whether directly or over the telephone) on nurse-on-duty. However, such should be officially entered in the chart and signed by the ordering physician, ASAP. The nurse-on-duty should write verbatim the doctor’s order and should witness and confirmed by another nursing staff or third party personnel. The NOD shall be then indicate after the order the doctor’s name and manifest her signature beside the doctor’s legibly written doctor’s name.

III   Termination and discontinuation of order should follow the same as number 2.

REFERRALS TO OTHER HOSPITALS GUIDELINES

I       Referrals to other hospitals are done if the illness of the client needs special or highly special institution.

II     Referrals for special procedures like EEG, CT-scan, ECG and 2D echo are done by coordination of a resident to other hospitals.

III   Inform the client or relative/s about the special procedure such as preparation prior to procedure (and sometimes the amount of the special procedure). Proper signing of consent should be secured.

IV    Referrals to other department within the institution. The resident must accomplish a referral form and communicate the other department. Doctor to Doctor referral system. The nurse just has to follow up the referral if not yet done.

V      Referrals for assistance. A resident physician must assess if client is for assistance by the social service. The attending physician must accomplish a clinical abstract. The nurse has to follow up the referral to the social service assistance.

TRANSFER PER REQUEST TO OTHER HOSPITALS GUIDELINES

I       Guardians who will request transfer to other hospitals by choice are allowed to be transferred provided that arrangements have been made to the other institution by the relatives and coordinated and confirmed by the PROD to the other hospitals.

II     All transferred clients are then conducted by the ambulance either or not to the hospital of choice accompanied a pediatric resident and/or otherwise requested.

III   The pediatric Resident then makes a clinical abstract. This will contain relevant information from the time client was admitted up to discharge for the transfer to the other hospital.

IV    Guardians’ signs the request for transfer then     settle the account to the finance section after which the nurse –on- duty gives them a gate pass.

V      A trip ticket will then be secured from the POS and to be signed by the Senior House Officer for that day.

WASTE MANAGEMENT GUIDELINES

I       Proper waste disposal to be strictly observed implemented and followed.

A      Black plastic bag covered waste can for non-infectious dry wastes:

1      Tin cans

2      Empty boxes

3      Wrapper

4      Styropore

5      Plastic containers

6      Newspapers

B      Green plastic bag covered waste can  for non-infectious wet wastes:

1      Fruits/vegetables peelings/skins

2       Left –over foods.

C      Yellow plastic bag covered waste for infectious dry/wet wastes

1      Used diapers,bandages,cotton balls

2      Blood soaked gauze,blood stained damaged cloth

3      Used gloves,towels and laboratory coats

4      IV tubings,filters and containers

5      Used blood bags

6      Excess urine,feces wastes

7      Placental wastes

D     Red waste  can for collection of sharps

1      Needles

2      Syringes

3      Scalpels blades

NEEDLE AND SYRINGE PRECAUTIONS AND TO LABELING OF SPECIMEN GUIDELINES

I       Proper waste disposal to be strictly observed implemented and followed.

A      Disposable needles and syringes

1      Should be used for clients on blood precautions they must not be reused.

B      Used needles

1      Must be planned in a prominently labeled in pervious pemeture resistant container designated specifically for this purpose.

C      Needles

1      Should not be purposely but, because accidental needle premature may occur.

D     Container

1      Should be double-bagged before being incimemated and should be treated as a contaminated waste.

E      Used Syringes

1      Should be placed in the same similar impervious container.

F      Reusable needle and Syringes

1      Should be avoided if possible. When used they should be rinsed thoroughly in cold water after use. The needle and syringe should be wrapped using the double-bag technique and returned to central service for decontamination and sterilization.

G     Specimen collected from clients under blood precaution

1      Should be prominently labeled with the client’s diagnosis so that the unit, transport and laboratory personnel can take necessary precautions while handling and processing specimen.

HOSPITAL PUBLIC RELATIONS PROCEDURES

The most common and prevalent complaint against hospital is the actuation of some of the staff members public relationship with clients, their companions and visitors which often borders to haughtiness and arrogance.

I       Here are the following guidelines on Public Relations:

A      Clients are always in an anxious and fearful psychological frame of mind and they should be treated with gentleness and compassion. Likewise their relatives or companions share a similar perception and must be dealt with understanding and kindness.

B      The primary cause of misunderstanding is spoken words. Great care must be practical on what to say and how to say these words. The words said may not be to the hearer’s liking but if expressed in the most refined manner, they become acceptable.

C      The principal goal of the hospital is serving which means concern for those who seek relief of their sufferings.

D     It must be remembered that the majority of the hospital clientele belongs to the lower income groups and often times, lack the means to support their treatment, the hospital will share whatever resources it can afford to indigent clients.

E      The most effective support remedy for the sick and the injured is a smile and little gesture of affection. Try them for they do not cost anything.

CLIENT’S COMPLAINTS PROCEDURES

I       All clients’ complaints are entertained

II     Minor on the spot complaints may be settled right away by any available hospital official (at the level of Chief Resident, Senior House Officer, Department Head or Section Chief).

III   If unsettled, complaints are elevated immediately to the level of the Top Hospital Management Officers (Chief of Clinics, Administrative Officer, Deputy Director for Professional Services / Administrative Services or Medical Director).

IV    Written Complaints are submitted to the office of the Medical Director

V      A copy of the complaint is forwarded to other Top Hospital Management Officers who may be delegated by the Medical Director to investigate.

VI    The attention of the Department Head/Section Chief and the employee being complained shall be called immediately.

VII  At a specified time (usually within 48 hours), a written response to the complaint is submitted to the Office of the Medical Director.

VIII         A meeting with the complainant and those involved in the complaint is normally set at the office of the Medical Director or to designated officer.

IX    All efforts are being done settle the problem at the level of the Medical Director.

X      If complainant is not satisfied, he/she may elevate the complaint to the City Government of Mandaluyong (either Personnel Office or any Office of the Mayor) for further action.

XI    If the hospital staff complained to is found to be negligent, the hospital staff shall be given due disciplinary action.

XII  If warranted or if incident needs to be reported to the Office of the Mayor, a written copy may be submitted by the office of the Medical Director.

XIIIIf complaint is directly forwarded to the Office of the Medical Director by the Office of the Mayor, a formal investigation shall be conducted and submit back the report as soon as possible and coordinate with Personnel Office for whatever sanction, if needed.

OPERATING ROOM POLICIES and GUIDELINES

I       GENERAL GUIDELINES:

A      All Operating Departments are assigned a respective day as follows:

            Monday – General Surgery

Tuesday – EENT

Wednesday – Orthopedics, Urology, Neurosurgery

Thursday – General Surgery

Friday – OB-GYNE

Saturday – Pay patients only (AM)

B      Other Departments can make use of the days other that their assigned day provided there is no case scheduled for that particular day or permission is obtained from the Chairman or Chief Resident of the concerned Department.

C      A maximum of six (6) Major elective procedures and five (5) Minor procedures are allowed for a particular regular working weekdays (Monday-Friday).

D     The Operating Room is restricted area. Only those authorized to attend to the patient can enter the OR in proper attire (scrub suit, cap, mask, footwear for OR use only). A smock gown should be worn over the scrub suit if the person concerned will momentarily go outside of the OR.

E      All Emergency or Elective surgery should have a consent form signed by the patient or the closest relative before any procedure is to be scheduled or done.

F      All procedures, emergency or elective, will need to accomplish an OR notification form. This form shall be accomplished fully in duplicate by the physician concerned or his duly appointed designate. One copy shall be for the OR and the other for the patient’s chart. No other form of communication will be honored by the OR staff. The cut-off time for notification of elective procedure is 3: 00 PM.

G     The scheduled time of elective surgery is understood to be the actual cutting time or the time that the initial surgical incision is to be made. The cutting time of all elective operations should not start earlier than 7:00 AM.

H     All procedures done at the OR should be written in the OR Schedule Book. Only the most Senior Nurse is allowed to write in the OR Schedule Book. In his/her absence or incapacity, the next in rank or a duly appointed designate shall take the responsibility.

I       All elective procedures should be scheduled at least one day before the operation. If not scheduled, the senior nurse shall have the right to cancel the operation.

J       All patients undergoing any procedure in the OR is understood to have been previously examined by the attending physicians) responsible for the patient.

K      Emergency cases are done anytime on any day and are given priority over any elective cases.

L       In elective procedures the principal surgeon/anesthesiologist or his/her duly appointed designate should be physically present in the OR and a lag time of one (1) hour to start the operation is allowed before the next patient for the operation will be given priority to use the OR.

M    Patients for elective procedures should be wheeled in the OR accompanied by an OR nurse on duty at least one (1) hour prior to the scheduled time of operation. Emergency cases should be accompanied by an ER/ward nurse on duty after proper notification.

N     Patients undergoing surgery should wear a hospital gown. Slippers used must be for OR use only. Jewelries, false teeth, nail polish and other personal effects should be removed and entrusted to relatives or companions for safe keeping. A logbook for this purpose is provided which includes the date and time, personal data of the patient, the printed name and signature and relationship of the person who received the personal effects.

O     The attending physician or his designate should accomplish the Operating Record and Operative Technique immediately after the operative procedure.

P      A strict aseptic technique should be observed while inside the OR.

Q     All instruments, sponges and other materials to be used for an operation are autoclaved. Sharp instruments are previously soaked in cidex solution.

R      The OR should be cleaned and disinfected at regular intervals with Lysol or any similar disinfectant especially every after operation. Particular attention should be given to the OR and Mayo tables.

II     POLICIES AND DIRECTIVES CONCERNING OPERATING PRIVILEGES OF THE HOUSE STAFF:

A      The surgeons and his assistant are specified for each case of operation. Resident assigned to the case should be in the Operating Room at the specified time.

B      Residents who scrubbed in case should stay in the Operating Room until the patient is transferred out.

C      Consultants should be notified for all cases before they are scheduled for operation. The consultant concerned should give the authorization for the operative intervention as written in the Operating Room and no case shall be accepted for operation unless with the consultant consent.

D     The surgeon who actually performed the operation shall sign the surgical memorandum required for every case shall stated as the surgeon.

E      Surgeon in their sub-specialties may be invited to perform surgery by their respective department.

III   ASEPSIS IN THE OPERATING ROOM:

A      All clothing and accessories on the person in the Operating Room shall conform to the policies and directives defining such.

B      Techniques to conform to the standard of maintaining asepsis in Operating Room and premises shall follow the policies and directives regulating such.

C      “Dirty Cases” are to be scheduled last and the Operating Room should be cleaned and sterilized after every dirty cases.

D     A doctor’s lounge is available besides the Operating Room for the doctors and nurses to rest.

IV    MISCELLANEOUS:

A      Visitors to a particular case shall be limited to professionals; example: Doctors, Nurses, Medical and Nursing Affiliates and Clergymen.

B      Sponges count: Policies and Directives concerning such are to be strictly followed:

1      There must be a standard number of each type of sponge within individual pack prior to sterilization (5 pcs. / pack).

2      Number of sponge counts is recorded in the sponge board and sponge book provided for record purposes.

3      Both scrub nurse and circulating nurse who counted and acknowledged sponge must sign their names in the surgical memorandum and the sponge book.

4      Sponge count is done as follows:

i       Before operation starts, all sponges to be used are counted.

ii     First count is done before closure of any cavity as uterus, urinary bladder, chest cavity and all others where sponges are likely to be left.

iii   Another counting is done before closure of peritoneum.

iv     Second counting is done after the closure of peritoneum.

v       Final counting is done after closure of fascia.

5      After each count the surgeon is verbally informed.

6      Disposition of specimen: all tissues removed at operations should be sent to the laboratory. Specimen shall be accompanied to the laboratory by histopathological request accomplished and signed by the surgeon for the purposes of tissue audit. The surgeon concerned shall not leave the Operating Room without signing the complete histopath request form. Appropriate container and proper labeling of specimen shall be brought to the laboratory by nursing aide or service.

7      Recovery Room: this is solely for use by patients recovering from anesthesia and by patient who through recovered from the effects of the anesthetic agents are in poor or moribund condition room shall require intensive care not obtainable in the patients room shall require the order of the anesthesiologist.

8      Information, notices, notification regarding any procedures, condition of the patient and other data shall not be given, hinted or furnished in whatever manner to visitor’s guest, family, and relatives except by the surgeon or his delegate.

DEPARTMENT OF ANESTHESIOLOGY POLICIES and GUIDELINES

I       GENERAL GUIDELINES

A      Schedule time for elective cases will be from 7:00 AM to 2:00 PM. No operation except emergency cases will be accepted outside of this time.

B      Before any patient is scheduled for surgery the following should be completed:

1      Medical Clearance

2      Signed Consent

3      Complete name and correct ward location

C      “Schedule Time” for an operation shall refer to the “Cutting Time” of such operation. The following shall be observed:

1      Patients will be in the Operating Room table 30 minutes before scheduled time, unless otherwise coordinated by the surgeon.

2      Under no circumstances will anesthesia be induced if the surgeon and or his assistant is not within the Operating Room suite.

3      The surgical consultant and residents are specific for each case or operation.

4      For patients to be operated on under local anesthesia but requires the service of the anesthesiologist such as premedication, for sedations, oxygenation and monitoring, the surgeon in charge should state such in the scheduled notice slip.

5      The tentative type of anesthesia should be written in the schedule. However, the final decision will be done by the Anesthesiologist after the evaluation during the per-operative rounds.

6      When the schedule of operating procedure has been printed, no change of patients should be entertained.

7      No other kind of elective operation should be done in a patient other than what is scheduled unless unexpected, necessary and emergent in nature.

8      Schedule of days of operation of the different departments and surgical sections should be followed strictly except for the following:

i       When two sections in surgery has made a mutual agreement to interchange dates on exceptional cases only.

ii     Priorities as arrangement of schedule of operation:

iii   Major cases should precede minor and local cases.

iv     Pediatric patients should be scheduled as first cases.

v       Clean cases should be scheduled before infected, potential infected or known “dirty cases”.

9      EMERGENCY CASES:

i       In emergency cases, the anesthesia office and the OR nurses should be properly notified by either the surgeon in charge or the ward nurse.

ii     An emergency operation should have a justifiable indication before it can be scheduled as emergency case, otherwise it should be scheduled as an elective.

II     PATIENTS’ ANESTHESIA EVALUATION AND PREMEDICATION

A      All patients scheduled for surgery under anesthesia will be evaluated and given premedication orders by the Anesthesiologist after the official schedule of operation is distributed. If by 8:00 PM a patient is not yet seen by the AOD, the ward nurse should be reminded and notify the AOD.

B      The Surgical Resident should write the pre-operative order prior to the premedication orders.

C      Medical problems or abnormal findings noted by the AOD with bearing and relation to the contemplated anesthesia and surgery should be relayed to the surgeon in charge or the surgical resident on duty and should be threshed out by the surgeon.

D     In case of postponement or cancellation of operations by Anesthesia, it should be discussed with Surgery and in turn it’s the duty of respective department residents to inform their own section chiefs. The ward nurse likewise should inform the OR nurse about the cancellation. In the same manner cancelled cases by the surgeons should be known by Anesthesia and OR Department.

E      Premedication for emergency cases will be given in the OR. For patients requiring immediate surgery, otherwise, the Anesthesiologist will give the premedication orders in the ward.

III   MEDICAL CLEARANCE:

A      All patients 35 years and above whom will undergo regional or general anesthesia or sedation should have a complete medical clearance.

B      ECG and Chest X-Ray should not be more than 6 months old and not more than 1 month old for symptomatic abnormal cases.

C      Patients with Pulmonary problems should have an evaluation and clearance fro the Department of Pulmonary Diseases.

D     Clearance and medical work-ups at the OPD should be incorporated in the chart prior to surgery of a signed true copy.

IV    PRE-OP REQUIREMENTS:

A      All patients should be in the hospital by 12:00 noon the day before the scheduled operation and will not allowed to go out-on-pass from the time.

B      Patients should have their medical clearance granted before they are scheduled for surgery.

C      Consent should be signed by the patient or guardian.

D     A venous cut down is recommended for poor risk patients undergoing major and long operations.

E      A CVP line is preferred in:

1      Patients past 65 years old undergoing major surgery

2      Patients with cardio-pulmonary problems

3      Patients that will need massive blood transfusion and IV infusion during and after surgery

4      Patients in shock

5      Patients for thoracic operation

CARDIO-PULMONARY CLEARANCE POLICIES and GUIDELINES

I       All patients referred for CP clearance must have a completed History and Physical Examination in the chart, ECG strip and/or result, the Chest X‑ray film and/or result and pertinent laboratory results in. Patients for cardio‑pulmonary clearance prior to their contemplated surgical procedures must be 35 years old and above or below 35 years old only if they have significant cardiovascular or pulmonary or other medical problems.

II     Patients who are to undergo STAT surgical procedure must be evaluated by the Senior Medical Resident within one (1) hour from the time of the referral

III   Patients who are to undergo elective surgical procedures must be evaluated by the Most Senior Medical Resident in the Ward. The schedule of the CP clearance is 10 ‑ 12 noon at the Medicine office daily, except on holidays and Sundays. Minimum ancillary procedures that are required are CBC, 12‑lead ECG, Chest X‑ray PA and FBS. However, other laboratory examinations or ancillary procedures maybe requested if such are deemed necessary.

IV    The Senior Medical Resident may suggest to defer the performance of the contemplated surgical procedure if in the course of his/her subsequent examination/evaluation at that time, he/she finds the patient unfit for such operation.

V      The Senior Medical Resident who grants the CP clearance ideally, must be available during the time of operation to answer STAT referrals intraoperatively. In his/her absence, the Senior Medical Resident on Ward duty for the day will assume his/her responsibilities.

VI    Medical problems that surface post‑operatively must be referred back to the Senior Medical Resident on Ward duty by the Attending Surgical Resident.

VII  The medical evaluation shall remain independent of any evaluation by other services, and is not to be construed as superseding any other services opinion, who may concur or assess to the contrary of the given pre‑operative clearance.

VIII         Intra‑operative cardiac monitoring may be done adlib by the Senior Medical Resident on Ward duty. If intraoperatively, the Surgical or Anesthesia decided to have the patient to be monitored cardiacwise, the Senior Medical Resident must see the patient upon notification for the intraoperative cardiac monitoring. Such accommodations may not always be possible. Should cardiac monitoring be needed intraoperatively, on the evaluation of the Surgical/Anesthesia Resident, the matter should be personally discussed with the Medical Resident.

PATIENT INDENTIFICATION POLICIES and GUIDELINES

      I.         OBJECTIVE

To ensure that all patients are correctly identified

    II.         SCOPE

This policy applies to all patients.

  III.         REFERENCE DOCUMENTS

a.    Voter’s ID

b.    Company ID

c.     Drivers License

d.    Passport

e.    Postal ID

f.      PRC ID

  IV.         DEFINITION OF TERM(S)

a.    In-Patient – Admitted patient that requires prolonged care/treatment inside the hospital.

b.    Out-Patient – Patient who are discharged after treatment or does not require prolonged care/treatment.

    V.         POLICIES

a.    All in-patients including those admitted patients waiting in the Emergency Room (ER) shall be given a white-colored identity (ID) bracelet in the limb containing the following identifiers:

                                              i.      Patients Full Name

                                            ii.     Date of Birth (which shall serve as his/her hospital number)

b.    The ER nurse personnel who verifies the patient’s identity shall be responsible for putting the patient ID bracelet:

c.     If no limb is available (e.g. burn patient), patient’s bracelet shall be securely attached to the patient’s clothing visible to everyone. In case there is an operation and the clothing shall be removed, the bracelet must be attached to skin of the patient using the tape.

d.    The nurse assigned to the patient shall ensure that each patient has an identity bracelet throughout his/her hospital stay.

e.    THERE SHALL BE A NO IDENTITY BRACELET NO PROCEDURE POLICY, most especially when performing the following procedures:

                                              i.     Blood sampling, blood letting

                                            ii.     Blood transfusion

                                          iii.     Collection of patient’s bodily fluid sample

                                            iv.     Confirmation of death

                                              v.     Administration of medicine

                                            vi.     Surgical intervention or any invasive procedure

                                          vii.     Transport and transfer of patient

                                        viii.     X-ray and imaging procedure

f.      In case the bracelet is missing, it shall be replaced by a nurse caring for the patient before the procedure done.

g.     No patient shall be moved without bracelet.

h.    Both the mother and baby shall be given an additional identity bracelet with the following baby’s data:

                                              i.     Gender of the baby plus mother’s last name

                                            ii.     Date of birth

                                          iii.     Time of birth

                                            iv.     Baby’s medical records number

i.      All out-patients shall be identified by comparing the data on the ID bracelet versus of that on patient record orders prior to performing any procedure and obtaining the specimens. Asking the patient or relative verbally shall be done to validate.

j.      The following specimen are shall also required to be labeled the 3 patient identifiers:

                                              i.     All laboratory specimens for examination. Example: blood, urine, stool, CSF, sputum.

                                            ii.     All surgical and cytology specimen

                                          iii.     All blood products for transfusion

  VI.         PROCEDURES

a.    TAGGING OF PATIENT

                                              i.     IN-PATIENT

1.      Verify the identity of the patient

a.    Check identity versus any valid ID and information documents

b.    Verbally ask patient/family for full name and birth date

2.      Attach a white identity bracelet on the limb of the patient. Bracelet must contain:

a.    Patient’s full name

b.    Birth date

                                            ii.     MATERNITY PATIENT

1.     Prior to delivery, the mother should be given the white bracelet.

2.     After the delivery, the mother should be given an additional identity bracelet with bracelet with baby’s data as follows:

a.    Gender of the baby plus mother’s last name

b.    Date of Birth

c.     Time of Birth

d.    Baby’s medical record’s number

3.     The baby should be given two bracelets in two separate limbs bearing the following data:

a.    Gender of the baby plus mother’s last name

b.    Date of birth

c.     Time of birth

d.    Baby’s medical record number

b.     HOW TO IDENTIFY THE PATIENT

                                              i.     IN-PATIENT

1.     Check if the patient identifiers on the patient ID band is same of that of that on the patient record/chart and on the orders

a.    Information written

                                                                                                    i.     White bracelet

1.     First name, middle name, last name

2.     Date of birth (e.g. March 3, 2007 (full month, numerical number, year)

2.     Ask the patient for his/her name, date of birth, and check if data is compatible with the bracelet and the patient record/chart for verification

3.     If patient is unable to speak, you may family or companion. Verify the information versus the patient ID band and patient record/chart.

                                            ii.     OUT-PATIENT

1.     Ask the patient or relatives of the patient the complete name and birth date of the patient

2.     Compare the information obtained versus the patient record.

COMMUNICATIONS POLICIES and GUIDELINES

      I.         OBJECTIVE

a.    To ensure that hospital has a system in improving the effectiveness of communication among medical staff

b.    To establish guidelines for accepting, transcribing and confirming verbal or telephone physician’s orders.

    II.         SCOPE

a.    This document covers effective communication policies in relation to physician’s orders and test results transmitted among medical staff.

b.    This document covers also all attending physicians, nurses and other health professionals in the institution who are involved in transcribing, verifying and communicating physician’s order.

  III.         DEFINTION OF TERMS

a.    Effective communication – refers to the transmittal of information (verbal, electronic or written) that is timely, accurate, complete, unambiguous and clear.

b.    Read back – an act of repeating/stating the written information based on the verbal orders/instruction.

c.     Confirmation – an activity to ensure that the information which has been relayed is accurate and complete.

d.    Verbal Order – is an order accepted in an emergency situation when the Physician is present and face with the healthcare professional.

e.    Telephone Order – is an order by telephone accepted from a physician when the patient’s condition does not require the physician’s presence in making medical assessment.

f.      Emergency – A life-threatening situation, such as an acute change in vital signs or patient status that will result in rapid deterioration if not treated immediately.

  IV.         POLICIES

a.    To ensure that all communications done verbally or through phone is accurate and complete, the receiver shall be responsible for writing down, reading back and confirming with the person who gave the information.

b.    Giving order by electronic transmittal of information particularly Short Message Sending (SMS) or text messaging shall be limited in extreme cases, where the use of other means in relaying the message is absent such as telephone calls.

                                              i.     Attending physicians shall be responsible of relaying the message to the resident or fellow physician who will personally write/make the orders.

                                            ii.     Forms of identification such as full name or code which the hospital staff can recognize shall always be indicated in the message.

                                          iii.     It shall be the responsibility of the receiver to acknowledge receipt and confirm the information immediately upon receipt of the message.

                                            iv.     Only approved abbreviations shall be used.

c.     High alert medications shall only be ordered in writing for safety reasons

d.    Doctors shall be responsible for personally acknowledging their orders by countersigning on the patient’s chart within twenty-four (24) hours.

e.    Written Orders:

                                              i.     All orders for treatment or diagnosis made on the Physician Order Sheet and Medication Order and Physician Medication Order Sheet must be signed by the licensed physician.

                                            ii.     All orders shall include the date and time the orders are written.

                                          iii.     Orders should be clear and concise. Medication orders shall include the name of the medication, the dose strength, dose form, the route and the frequency. Generic terminology should be used.

                                            iv.     Only approved symbols and abbreviation shall be used.

                                              v.     When the written order is vague or cannot be deciphered, it should be clarified from the Attending Physician/Resident doctor on duty.

f.      Verbal/Telephone Orders

                                              i.     Telephone Order shall be utilized only where the ordering doctor is not available to write the order. Verbal and telephone orders shall be utilized during emergency in which delay will result in a compromise in patient care.

                                            ii.     Physician verbal and telephone orders may only be accepted by the following healthcare professional. Orders shall be appropriate and within the professional’s scope of practice:

1.     Resident Doctor

2.     Registered Nurse

3.     Licensed Dietitians – for orders relating to diet or enteral nutritional therapy

4.     Licensed Physical & Occupational Therapist – for orders relating to physical and occupational therapies and related equipment.

                                          iii.     The verbal or telephone order shall be documented by the professional who accepts the order and shall include:

1.     Name of patient

2.     Date

3.     Time

4.     Instructions/order, including dose, frequency, route, quantity or duration, age and/or weight of patient when appropriate.

5.     Notation the order was a verbal or telephone order

6.     First and last name of physician issuing the order

7.     Legal signature of healthcare professional receiving the order

                                            iv.     The healthcare professional receiving the verbal medication order shall transcribe the order onto the Physician’s Order Sheet or Physician Medication Order Sheet, identifying the order as a verbal order (VO) / telephone order (TO) and the name of the provider who issued it. The healthcare professional will then sign the physician’s order including his/her title.

                                              v.     The healthcare professional accepting the verbal order shall REPEAT BACK the order in its entirely to the prescribing physician at the time the order is given, documenting that the order was “REPEAT BACK.”

                                            vi.     The healthcare professional accepting the Telephone Order shall “READ BACK” the order in its entirety to the prescribing physician at the time the order is given, documenting that the order was “READ BACK”.

                                          vii.     Nursing staff and other healthcare professionals are permitted to act upon verbal orders provided the orders contain the appropriate information and are within the scope of practice for said healthcare professional.

                                        viii.     Verbal and telephone orders shall be signed or initiated by the prescribing practitioner within twenty-four (24) hours after being given. When the ordering physician is not available, it is acceptable for the Resident on duty to countersign the verbal order.

                                            ix.     Resident doctors on duty may accept verbal orders from their primary physician; the primary physician must countersign these verbal orders within twenty-four (24) hours.

                                              x.     Text message is not acceptable for medication order except for informing the physician regarding his/her patient’s admission and discharge.

    V.         PROCEDURES

a.    The registered nurse receiving the verbal or telephone order shall:

                                              i.     Transcribe “Verbal Order” or “Telephone Order” at the Physician’s Order Sheet and transcribes the medication order onto the Physician Medication Order Sheet, Standing Order Sheet and Medication Administration Record (MAR). Write/enter name of the prescribing physician, the date and time the order was received.

                                            ii.     READ BACK / REPEAT BACK the complete order to the prescriber.

                                          iii.     Identify the first and last name of the physician who issued the verbal order.

                                            iv.     The Charge Nurse / Staff Nurse affix his/her name and signature as the person receiving the order.

                                              v.     Write/enter “TO” for Telephone Order or “VO” for Verbal Order.

                                            vi.     The Attending Medical Doctor / Resident Doctor on duty countersign the order within twenty-four (24) hours.

                                          vii.     When verbal or telephone order are issued, the registered nurse will READ BACK the order to the prescriber, at which time the order will be treated as any other physician’s order and carried out by the registered nurse.