Ward Sop 3f4i3u

1 CONTENTS Page List of Acronyms

i

Foreword

iii

1. Emergency Tray

5

1.1. Emergency Tray Equipments for all units

5

1.2. Emergency Tray Medicines for all Units

6

2. issions

8

2.1. ission to in-patient Care in the Ward

8

2.2. ission for operation

8

3. Prescription of Drugs

11

4. istering Drugs

12

4.1. istering Oral Drugs

12

4.2. istering intravenous drugs

12

4.3. istering Chemotherapy

13

5. Operation Theatres

14

5.1. Patient Preparation for Operation

14

5.2. istering Anesthesia

15

5.3. Operation Theatre

16

5.4. Postoperative Care

16

6. Labor Room

17

7. Discharging the Patients

19

8. In-patient Consultation Between Different Units of the Hospital

20

9. Private Rooms

21

10. Out Patient Department (OPD)

22

10.1. General OPD

22

10.2. Ante Natal Care OPD

22

11. Ward Round

24

12. Clinical Audit

25

13. Online indenting of Medicine and Medical and Surgical Disposables from Pharmacy

26

2 14. Zakat

28

15. Baitul Mal

29

16. Indenting of Store items

30

16.1. Indenting of Main Store items

30

16.2. Indenting of Stationary and P & D store items

30

17. Record Room

31

18. Ward Cleanliness and Maintenance

32

19. ICU

34

20. Department of Accident and Emergency Department

35

20.1. Emergency cover in A & E

35

20.2. Emergency Cover in units/wards

36

21. Gastro Intestinal Endoscopies

38

22. Cardiological Procedures

39

23. Radiological Procedures

40

24. Laboratory Investigation

41

24.1. Online Laboratory Investigation

41

25. TMOs/MOs Duty

43

25.1. Duty Rotas

43

25.2. Guidelines for TMOs/MOs Duty

43

3 i

Acronyms SOP IV BD CVP ECG HO SMO TMO MO CMO JR SR OPD OT ICU CT MRI ANC ETT TEE BP PT APTT ICT HIV MLC LP VS VP VG KUB KCL

: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :

Standing Operating Procedure Intravenous Bis Die (Twice a Day) Central Venous Pressure Electro Cardiac Gram House Officer Senior House Officer Trainee Medical Officer Medical Officer Casualty Medical Officer Junior Registrar Senior Registrar Out Patient Department Operation Theatre Intensive Care Unit Computerized Tomography (Refined X-Ray scan) Magnetic Resonance Imaging Ante Natal Care Exercise Tolerance Test Trans Esophageal Echo Cardiography Blood Pressure Prothobim Time Activated Partial Thromboplastin Time Amino Chromatographic Technique Human Immunodeficiency Virus Mixed Lymphocyte Culture Local Purchaser Visiting Surgeon Visiting Physician Visiting Gynecologist Kidney Ureters & Bladder Postassium Chloride

4 ii

FOREWORD To comply with clinical governance requirements, we as healthcare professions are required to put in place strategies for risk management and harm minimisation. The strategies should allow for the continual improvement of standards of service and provide evidence of commitment to protecting patients. Standard Operating Procedure specify in writing what should be done, when, where and by whom. The benefits of SOPs are that they help to assure the quality and consistency of the service, ensure that good practice is achieved at all times, provide an opportunity to fully utilize the expertise of all of the team, help to avoid confusion over who does what (role clarification), provide advice and guidance to new and inexperienced staff and provide a contribution to the audit process. The SOPs in this booklet are general in nature and all the head of the departments and section in charge are advised to prepare SOPs related to their specific sphere of work. Every clinical unit has its peculiar specialty and the SOPs will need to reflect this. The SOPs under normal circumstances, be applicable at all times, i.e. not dependent on the presence of the unit head / professor under whose authority the procedure was prepared. There may be exceptional circumstances where it is necessary to work outside a SOP, e.g. in the event of computer breakdown. In these situations the professional judgement of the doctor in charge must remain paramount. The unit heads and DMSs in charge of sections should anticipate situations where changed circumstances will apply and accordingly prepare separate SOPs to be followed in the event of predictable circumstances, e.g. procedures to be followed in the event of computer breakdown. SOPs should also be clearly marked with the date of preparation/ amendment and should be kept up to date and relevant at all times by the senior registrar who is in day to day charge of the unit/ward. Finally, when SOPs are first drafted, the staff may be asked to sign to say they have read and understood them because besides clarifying staff roles, this can also offer an opportunity for staff training and development. Dr Aftab Akbar Durrani Chief Executive Dated: 1st Nov, 2010

5

SOP 1: Emergency Tray

1.

Every unit will have an emergency medical tray with purpose built portable trolley.

2.

Medical emergency tray will be kept in an accessible place & routinely monitored by staff nurse to ensure that all supplies are replaced & weekly checked by registrar & monthly by hospital inspection team.

All the equipment will be in working condition & emergency life saving drugs up-todate.

SOP 1.1: Emergency Tray Equipments for all units Following equipment will be present in the emergency tray in working condition at all times. 1. Ambu bag at least two, checked for physical integrity once a week. 2. Masks of different types & sizes 3. Flash light with extra batteries 4. Portable small size oxygen cylinders with proper gauge & masks 5. Swabs, sponges, cotton & adhesive taps 6. Gloves 7. Stethescope, blood pressure set of good quality 8. Laryngoscope 9. Disposable oral airways of various sizes 10. Scissors 11. Glucometer with strips(2) 12. Catheters & naso gastric tubes of various sizes 13. CVP lines 14. Lumber puncture needles of different sizes 15. Cat gut, silk & artery forceps 16. Small portable sucker machine 17. Defibrillator(01) 18. ECG machine (01) 19. Nebulizers(02)

6

20. Chest tube with under water seal(03)

21. Ophthalmoscope(1) SOP 1.2: Emergency Tray Medicines for all Units 1. Inj Adrenaline

5

2. Antihistamine

10

3. Atropine Sulphate

5

4. Inj Hypertonic

10

5. Soda bicarbonate & Calcium gluconate vial

5 each

6. Injection Dobutamine & Dopamine

5 each

7. Inj. Hydrocortisome different strength

5 each

8. Inj. Dexamitheseme

10

9. Inj.Lignocaine

5

10. Inj. Diazepam

5

11. Inj lanoxin

10 each

12. Tab. Asprin

10 each

13. Cylyceryltrimitsate

10 each

14. Inj. Frusemide

10

15. Inj. Nalaxone

10

16. Gelation Polypeptide

05

17. Potassium Chloride

05

18. Inj. Isosorbide dimitrate

05

19. Inj. Vitamin K

05

20. Inj. Ranitidine

05

21. Inj. Tranxamic acid

05

22. Solution Salbulamol

01

23. Inj. Aminophyline 250 mg

05

24. Oxygen key

01

7 25. I.V Cannula

02

26. Syrinjes 5cc

05

27. Cutter

01

28. Airway

01

29. Inj Dimenhydrinate

01

30. Inj Oxytocin

01

31. Inj Methylergometrine

01

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SOP 2: issions

SOP 2.1: ission to in-patient Care in the Ward 1. ission from OPD shall be done by the ward registrar or any senior doctor. 2. ission through casualty shall be done by on call member of the team (SHO/ TMO) after proper referral from CMO (Patient shall receive emergency treatment in the casualty, stabilized & only then referred to ward on call). 3. If SHO/ TMO believe there is sufficient reason, the patient shall be itted. 4. If SHO/ TMO can not make a decision, the patient shall be put under observation & the registrar & seniors shall be called while starting requisite treatment of the patient. 5. Casualty shall not be used as OPD nor as portal of ission of non emergency patients to ward on call. 6. Referral from other hospitals and consultants private clinics shall be itted via casualty. 7. On ission, detail history shall be taken by the house officer on arrival, followed by a summary of the patient by the TMO on duty. 8. For medico-legal cases proper official referral & presence of police shall be mandatory 9. Proof of identity shall be must for every patient. 10. Afghans with out registration cards shall be separately marked

SOP 2.2: ission for operation 1. Surgical patients shall have a pre-operative assessment and a provisional diagnosis documented prior to surgery. 2. An informed consent shall be obtained by a qualified member of the surgical team prior to the procedure on formal consent forms of hospital. 3. A quality assurance program will be followed for the surgical services. 4. The plan shall also include monitoring of surgical site infection rates. 5. Patients shall be itted to the ward with the permission of JR and above.

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6. In evening round investigations, patient fitness and OT medicine shall be checked. 7. Deficiencies shall be corrected and those found unfit will be postponed from operation. 8. Children, elderly, diabetic and seriously ill patient will be given priority on OT list. 9. Minor cases, stable patient, infected and hepatitis patient will be put last on OT list. 10. For high risk patient needing ICU care, a bed in ICU will be arranged a day before. 11. For high risk patient anesthetist will be informed a day before. 12. Diabetic patients will be converted to injectable insulin after consultation with an Endocrinologist for major operation. 13. Blood will be arranged a day before surgery and will be made available in the theatre before operation. 14. When the patient arrives in theatre, the consent form, investigations and OT medicine will be again checked by the HOs / Junior doctor authorized by the I/C unit. 15. Patient needing major gut surgery will be itted 2 days before surgery and bowel preparation will be done in ward. 16. In operation theatre investigations, consent and site of operation will again be checked by the operating surgeon. 17. Pre op antibiotics will be given at the time of induction of anesthesia. 18. Detailed operation notes will be written by operating surgeon in patient chart and also written in operation . Post operative treatment shall be written clearly in capital letters on treatment chart. 19. After completion of surgery, patient will be shifted to recovery room in supervision of first assistant until fully recovered. 20. Only after anesthetist consent the patient will be shifted to ward. 21. After operation, SR along with TMOs and HOs will conduct a post op round at 2

10

pm. 22. Evening round will be again conducted by SR/SMO/TMO/HO at 8:30 pm 23. Patient undergoing minor procedure will be mobilized and orally allowed by evening. 24. During induction of anesthesia the first assistant shall be present in the OT with the anesthetist.

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SOP 3: Prescription of Drugs 1. Documented policies and procedures shall exits for prescription of medications. 2. Medication orders shall be clear, legible dated, timed, named and signed. 3. The unit shall define high risk medications orders which shall be verified prior to dispensing. 4. A list of high risk medications shall be defined by the unit / ward. 5. To prescribe a drug is to take responsibility to relieve the suffering of a patient by a doctor. 6. Prescription shall be written in clear hand writing and preferably capital letters. Poor hand writing can result in lethal mistakes. The doctor shall sign each prescription with his/ her name written beneath his/her signature. 7. The drug advised shall be easily available, economical & effective. The word effective means that the drug is considered effective by the institution or the Deptt. or the unit 8. The doctor shall be well versed with the use, interactions & side effects of the drug prescribed 9. The strength of drug, dosage, mode of istration & duration of use shall be clearly mentioned in English / universal technical language, on the in-patient treatment sheet. For out patient prescription, preferably, local language/ urdu shall be used. 10. A leading zero may be used (e.g. .5 mg may be written as 0.5 mg). Avoid using trailing zero which may be misread ( e.g. 5.0mg may be read as 50 mg) 11. The doctor shall also know the cost of medicine prescribed & tailor it according to the socio- economic status of the patient, as it may be the only cause of non-compliance. 12. Drugs available in hospital pharmacy shall be given priority. 13. Drugs from outside the hospital shall only be prescribed when utterly required. 14. Regarding items 7,8,9 & 11 there will be a reference text book to consult. i.e pharma guide, lying in the emergency cupboard of every unit/ward.

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SOP 4: istering Drugs

SOP 4.1: istering Oral Drugs Nurse shall ister oral drugs with attention to the following points 1. Identify the patient 2. Ask the patient about history of adverse reaction to the drug being given 3. Check the name, strength & expiry date of the drug with a team member( nurse) 4. Those shall be verified from the prescriptions prior to istration. 5. Medications istration shall be documented. 6. The patient and family shall be educated about the estimated cost of treatment. 7. Patients and family shall be informed about the financial implications when there is a change in the patient condition or treatment setting.

SOP 4.2: istering intravenous drugs First dose of IV drug shall be given by the doctor on duty with attention to the following 1. Identify the patient 2. Ask the patient about history of adverse reaction to the drug being given 3. Check the name, strength & expiry date of the vial with a team member (Doctor or Nurse). 4. Intradermal test dose 5. Make sure adrenaline, hydrocortisone & antihistamine injections are at hand 6. Document that 1st. dose was given (time, date, doctor name with designation & signature) with no adverse reaction. In case of adverse reaction, a detail must be documented. 7. If a drug needs to be given frequently after the 1st. dose( on the same ission) it shall be given by a nurse who shall follow steps (a-d) document in the nursing note/ treatment sheet 8. If an IV line is blocked, the nurse on duty shall inform SHO/TMO to replace it so that the patient can be given prescribed drug.

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9. Only recognized brands of drugs agreed upon in the unit shall be allowed to be prescribed. Junior doctors and consultants will not prescribe drugs other than authorized trade name. 10. IV valium, IV KCL & other drugs like digoxin shall be checked by the house officer & nurse together.

SOP 4.3: istering Chemotherapy 1. Shall be prescribed by senior registrar and above. 2. Any change in the therapy regime shall be made after discussing with senior colleagues. 3. ive therapy like I/V antibodies, blood transfusion as well as prophylactic therapy ESP of tumor. 4. Lysis syndrome shall be observed strictly by all the doctors in the ward. 5. No chemotherapy shall be done after 1 pm. 6. Chemotherapy vials, shall be checked by medical officer and junior registrar before the start of istering by staff nurse. 7. istering of chemotherapy shall always be supervised by concerned doctor. 8. The timing of injection mesna and injection levocovorin shall be reminded every time by the doctor to the nurse. While istering intrathecal therapies the trolley shall only be having injection I/V lignocane on one side and injection mtx, solucortif, and injection citosar on the other side prepared by a doctor along with a staff nurse.

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SOP 5: Operation Theatres

SOP 5.1: Patient Preparation for Operation 1. A written, informed consent is a must, duly signed by the patient, his/her immediate relative & the HO or MO on the formal consent form of the hospital. 2. Certain aspects must be made in writing, e.g. enucleation, evisceration, exentration & shall be explained to patient & the relatives. 3. Common complications shall also be mentioned in the consent form. 4. Should the patient refuse surgery this shall be in writing in the presence of a relative & signed by the patient’s, relative & doctor. 5. The site of the body to be operated upon shall be marked. 6. The nurse shall make sure that the site to be operated on is shaved, jewelry & dentures removed & all valuables left to a relative. She shall know which patients are due for surgery & that they are shifted to the OT in time. All pre medications & investigations such as fasting blood sugar & early morning KUB shall be positively done & sent with patients. The HO concerned shall make sure that the patients are prepared properly. The HO staying in the ward on OT day shall be present early in the ward & make sure that all these steps are carried out. 7. Any patient who is absent from bed the night before surgery or has no medicines etc, shall be dropped from the list. 8. During the evening round before the OT day, the registrar shall make sure that the patient has the necessary requirements for surgery and calls to any department made if necessary are made. 9. A tentative OT list shall be intimated to the I/C Anesthesia department after OPD and one of the anesthetists shall carry out a round on the day before surgery, so that necessary requirements are fulfilled. The anesthetist shall carry out his round with the registrar at a time convenient to all. 10. All preoperative investigations including hepatitis and HIV screening shall be carried out in the morning after the patient is itted so that they are ready for timely

15

intervention if needed. This will prevent unnecessary delays, wastage of time and resentment on part of the patients for having the surgery deferred. 11. Containers for specimens shall be available with patients and shall be properly marked beforehand by the House Officer concerned showing the name, bed number, ward and specimen name in case of biopsy & scraping for microscopy etc. 12. Informed consent is obtained for donation and transfusion of blood and blood products. Informed consent also includes patient and family education about donation. 13. Transfusion reactions are analyzed for preventive and corrective actions. 14. A brief operative note is documented prior to transfer out of patient from recovery area. 15. The operating surgeon documents post operative plan of care.

SOP 5.2: istering Anesthesia 1.

A documented policy and procedure shall exit for istration of Anesthesia.

2.

All patients for anesthesia have a pre-anesthesia assessment by a qualified individual.

3.

The pre-anesthesia assessment results in formulation of an anesthesia plan which is documented.

4.

Informed consent for istration of anesthesia is obtained by a qualified member of the anesthesia team.

5.

During anesthesia monitoring shall include regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security and patency and level of anesthesia.

6.

Each patient’s post anesthesia status is monitored and documented.

7.

All adverse anesthesia events are recorded and monitored.

The Anesthetist shall be responsible for •

Checking anesthesia machine, oxygen supply, anesthesia circuits, laryngoscope, suction machine, monitors etc.

•

Labeling syringes of anesthesia drugs

16

•

Ensuring stand-by supply of oxygen cylinder, emergency drugs, ambu bag, defibrillator etc.

•

Setting I/V line & starting I/V fluids

•

Setting monitors-SpO2, BP, ECG etc.

•

Pre-medication

•

Induction & maintenance of anesthesia as planned

•

Recovery of patient

•

Shifting the patient from the recovery to ward or ICU according to the patient clinical status

•

Consultation with seniors in difficult situation/complication

SOP 5.3: Operation Theatre 1.

All OT notes shall be completed and then recorded in an OT .

2.

The House Officers shall ensure that all specimens are sent and received in the ward.

3.

The chief OT technician shall be responsible for the cleanliness and discipline of the OT.

4.

Swab & cotton patties count shall be maintained at all times by one member of the operating team i.e. an OT nurse or OT tech. This shall be written on a board.

5.

A House Officer and Trainee of the ward shall be present in the recovery room and ward to respond to unforeseen mishaps.

6.

All post operative patients shall be monitored.

7.

Patients with Hepatitis B or C shall be operated according to set protocol which shall be developed by the Surgical Department and the istration.

SOP 5.4: Postoperative Care 1.

One house officer and TMO shall be available in the ward 24hours a day for care of the patient.

2.

The TMO batch on call shall come after O.T for postoperative round.

3.

The registrar on call shall do a postoperative round after O.T.

17

4.

Postoperative round shall be documented with date and time by H.O, M.O, registrar & consultant on call.

5.

There shall be a protocol for resuscitation in case of any complication & immediate of senior as per protocol.

18

SOP 6: Labor Room

1. Handing and taking over shall be done at 7:45 am. 3rd year TMO & House officer batch on call will do labor room round at 8:00 am along with senior registrar. Batch on call in labor room will stay in labor room for 24 hours. A 4th year TMO along with her batch on call will do round at 1:00pm along with the registrar 2. Labor room round will be done by batch on call of TMOs & senior registrar at 8.00 am. 3. Every 3 hours patient will be assessed by senior TMO on call. 4. Between 1-2 pm registrar / consultant on call will do round of labor room. 5. Evening round at 8.30 pm will be carried out by on call batch together with SR / AP on call. 6. All patients considered high risk shall be discussed with consultant on call. Any adverse events & near misses shall be discussed at the time & then audited the next morning by Head of the Department. 7. Labor ward shall be used only for patients in labor & occasionally for monitoring very high risk pregnancies (not in labor) e.g Fulminating PET, severe clan III, IV cardiac disease, severe hepatitis etc. 8. Post-op / C-Section patients shall be observed in postnatal chamber for at least 6 hours. 9. All patient discharged from labor room will be given a discharged card & asked to report for check up within 10 days to the relevant OPD. 10. The decision of surgery shall be taken only after discussion with registrar / consultant. 11. All high risk patients shall be discussed with the consultant on call. 12. The consultant on call shall also inform about the progress of high risk patients. 13. The head nurse shall make sure that the labor room is clean all the times as it is a place of quick patient turn over. This includes the delivery rooms, instruments, autoclave, drugs, linens, floors, beds, toilets etc. The registrars of the two units shall work in collaboration for maintenance and cleanliness of the labor room.

19

14. The Head nurse and the registrar of the Gynae unit on call shall make sure that the emergency tray in the labor room is complete and up-to-date at all times in order to face any sort of emergency.

20

SOP 7: Discharging the Patients

1. Patient shall be discharged by senior registrar or above 2. The decision of discharging the patient shall be taken a day earlier with intimation to patient & his/ her relatives 3. Discharge summary shall be prepared by the SHO & checked by TMO/ Junior registrar/ SR with particular attention to the following details •

Patient name

•

ission number

•

Date of ission

•

Date of discharge

•

Diagnosis

•

Details of investigations & treatment given

•

Details of intra or interdepartmental consultation

•

Details of treatment to be taken at home

•

Details of follow up

4. There particulars shall be entered by the SHO/TMO in the computer software provided on the nursing counter. 5. Computer generated discharge slip shall be issued to the patient on the software provided to each clinical unit in the hospital. 6. Every patient shall be given a patient registration/ hospital identity number that should be quoted/ used for future visits/ issions.

21

SOP 8: In-patient Consultation Between Different Units of the Hospital 1. Call for consultation to other units will be sent before 11 am. 2. Call in emergency or off hours will be directed to JR/SR 3. Each call to ward/unit will be properly written with clearly identified purpose of consultation along with all investigations. 4. During working hours, SR/ Asstt Prof. will write call to VS, VP or VG and then follow it up to ensure that calls are appropriately written & attended to with desired help to the patient. 5. After working hours, the concerned 3rd. year post graduate trainee, JR/MO will write the call & follow it up 6. The consultant/SR of the call receiving unit shall attend the call. In case of their non availability the JR/MO/TMO shall attend the call with information to the consultant/SR. 7. For very sick patient a junior doctor or a nurse will accompany the patient. 8. Once a unit has taken over a patient through a call then it shall follow that patient through out his/her stay in the hospital & later on through OPD when necessary

22

SOP 9: Private Rooms

ission Criteria: 1. Patient shall be hemo-dynamicaly stable 2. Patient does not require frequent monitoring( monitory devices) 3. Patient does not have violent behavioral issues/ suicidal thoughts. ission Process: 1. Private Room ission will be done on single occupancy basis. 2. Only SR and above can it patients in private room through DMS (Private Rooms). 3. Consultant/SR can shift in-patients from the ward to private room through DMS (Private Rooms). 4. After ission, MO of private room shall take history, send investigations & start treatment as directed by the doctor concerned. Private Rooms Services: 1. One MO shall be present in each duty shift of private rooms. 2. One staff nurse shall be present in each duty shift on each side of private room. 3. 24 hours laboratory & radiological services shall be available 4. Each room shall be connected to nursing station via telecom services 5. Each section shall have emergency trolleys fully equipped with emergency medicines & instruments & placed at an accessible area of the nursing station. 6. The consultant/ SRs shall be authorized to shift the patient from private room to respective ward if needed. 7. The consultant /SRs of the respective unit will conduct the morning round of the respective patients in private room while the JR of the respective unit will conduct the evening round.

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SOP 10: Out Patient Department (OPD)

SOP 10.1: General OPD 1. Patient will receive an OPD chit of the concerned OPD from OPD counter. 2. Patient will be examined properly and evaluated in general OPD. If the case is not complicated, medicines will be prescribed and patient will be disposed off. 3. In case the patient requires further investigations, he/she will be referred to OPD lab. 4. In OPD lab samples will be taken. Routine and simple tests will be done at OPD lab, whereas more elaborate investigations will be sent to the main lab. 5. Cases will be referred to consultant OPD if their condition so demands. 6. Record of referral will be kept at general OPD & a copy sent to the consultant OPD. 7. Patient shall be given time & date to see a consultant under intimation to the consultant. 8. Investigations advised by consultant shall be reported upon before 1.00 PM so that patient does not have to come back the second time to get treatment. 9. If the patient needs to come to the OPD again, he/she will be clearly guided with the day and date given on the prescription chit for their next appointment with the consultant at OPD.

SOP 10.2: Ante Natal Care OPD 1.

All doctors shall be available in the OPD (except the on call batch in Labor room).

2.

The Dispenser & Khala shall make sure that the OPD is clean, the instruments sterilized, disposables available and all equipment and lights etc in working order.

3.

The staff nurse shall make sure that patients are asked to wait for their turn to prevent unnecessary chaos.

4.

Relevant information shall be written on the OPD chit and signed.

5.

All patients due for surgery shall be assessed for co morbid conditions, their BP and

24

6.

pulse noted and chest examined. They shall be referred for an assessment for fitness if needed.

7.

All patients due for surgery shall be advised investigations before ission. These shall be seen and corrected if possible, before the patient is itted.

8.

A waiting list according to the priorities shall be maintained by each ward ideally mentioning the patients number and address if possible. Unforeseen delays shall preferably be communicated to the patient.

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SOP 11: Ward Round

1. Medical staff up to SR level will start seeing patients at the start of their working hours(8.00 am). 2. Consultant along with the whole team will start ward round at 9.00 am. 3. Senior most consultant ( Prof. / I/C of unit) in the team will conduct the ward round. The morning round shall be a teaching round. 4. Other consultant of the team will extend help in the management by giving their opinion on the signs & symptoms of the patient. 5. Evening ward round will be conducted at around 8 pm. 6. Evening ward round will be conducted by Assistant Professor or SR and will be a follow up round of the morning orders. 7. In the evening ward round, the following will be ensured: • Instructions in the morning ward round are carried out. • In the light of new findings, shall the treatment be changed on emergency basis or it can be waited for till next morning when the whole team is around. • If the patient has improved and is ready to be discharged, instruction regarding discharge shall be given as to be included in the discharge summary which shall be ready by next morning.

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SOP 12: Clinical Audit

1.

Statistical record of the ward shall be maintained and regularly checked by the registrar / S.R.

2.

Fortnightly or monthly clinical audit meeting shall be conducted in the ward & supervised by the Professor in-charge of the ward.

3.

Annual appraisal of each unit shall be carried out regarding practices, performances and issues by the S.Rs who shall be trained for conducting audits.

4.

Nurses, paramedics and class-IV staff shall also be involved in the audit process.

5.

Adverse events & recent mishaps shall be discussed in no blame environment to improve patient outcome & shall be notified to the istration.

6.

Protocols for emergencies shall be displayed by all the Units & regularly updated.

7.

Minutes of clinical audit meeting and adverse eateries shall be sent to MS/CE office.

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SOP 13: Online indenting of Medicine and Disposables from Pharmacy The hospital pharmacy will comprise of the Main Store, Satellite Pharmacy A1 (Medical), B1 (ICU), E1 (Casualty Pharmacy), OT Pharmacy, Unit Nursing Counter. The SOP for the online pharmacy will be: 1. The nurse In charge at nursing counter will place online indent to the concerned satellite pharmacy to which they are d. 2. The pharmacist In charge of the satellite pharmacy will the online indent and will issue the available medicines/items to the concerned unit after 11:00 am. 3. The medicine will be collected personally by the Nurse of the concerned unit which has placed the demand or will be delivered by the runner of the satellite pharmacy. 4. The hard copy of the indent will be signed by the pharmacist and the recipient nurse. One hard copy will be retained at the satellite pharmacy while the other copy will be taken into custody by the nurse. 5. Besides medicines, medical and surgical disposables will also be issued by satellite pharmacies. 6. All surgical and allied units will place online demand of surgical/medical disposables and anesthesia medicines to the OT pharmacy. 7. The Pharmacist In charge of the OT pharmacy will the online indent and will issue the available medicines and medical/surgical disposables items to the concerned unit. 8. The medicine/disposables items will be collected personally by the nurse of the concerned unit. 9. The hard copy of the indent will be signed by the pharmacist and the recipient nurse. One hard copy will be retained at the OT pharmacy while the other copy will be taken by the nurse. 10. The satellite pharmacies will replenish their consumed stock by placing online indent to the main pharmacy.

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11. The Chief Pharmacist will the online indent of satellite pharmacies and will issue the demanded medicines/ disposables to the pharmacist concerned. 12. The hard copy of the indent will be signed by the chief pharmacist, pharmacist/recipient nurse. One hard copy will be retained at the main pharmacy while the other copy will be taken into custody by the pharmacist. 13. The Satellite Pharmacy at the Accident and Emergency department will receive direct demands in the form of prescription from patient/nurse on duty. No online demand will be placed to the emergency pharmacy till 2:00 pm. Medicine will be issued directly by the pharmacist to the nurse on duty/patient in Accident and Emergency department and ed/ computerized by the staff present at the emergency satellite pharmacy during all the three shifts. 14. After 2:00 pm and on close holidays the satellite pharmacy of A & E department will entertain online indents from the whole hospital and it will regularize in the same manner as mentioned above. 15. The satellite pharmacy at Accident and Emergency will replenish their consumed stock by placing online indent to the main pharmacy. 16. The Chief Pharmacist will the online indent of A & E pharmacy and will issue the demanded medicines/ disposables to the pharmacist of A & E pharmacy.

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SOP 14: Zakat

1. Zakat forms shall be available with RMO, local Zakat chairman office, district Zakat Chairman. 2. The patient will get the Zakat form signed by the local/district Zakat chairman. 3. The patient will attach the photo copy of the N.I.C with the Zakat form. 4. OPD chit, indent book and procedure advised by the concerned doctor of the unit/department will be attached with the request zakat form. 5. The RMO will counter sign/ the documents. 6. Three copies of the documents are prepared. (original for RMO, one for concerned unit and one for the patient). 7. One photocopy of the request will be signed by the Local Purchase (LP) shop. 8. The drugs received by the patient will be verified by the RMO for indoor/OPD patients. 9. The drugs will be given to the patient/attendant and their signatures of receiving shall be entered in the record book. 10. The bills shall be submitted on monthly basis by the LP contractor. 11. The bills will be verified/corrected by the RMO and after obtaining approval from the competent authority the cheque shall be given to the LP contractor for payment.

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SOP 15: Bait-ul-mal

1. The poor patients will apply to the Pakistan Baitul Mal for financial through the clinicians and hospital management on the prescribed proforma provided by the Pakistan Bait-ul-Mal Department which will be available in the RMO’s officer. 2. The Proforma along with the application will be submitted by the patient to the Pakistan Bait-ul-Mal office, Peshawar. 3. The Pakistan Bait-ul-Mal after verification through its own sources, will send a cheque in the name of the Medical Superintendent for the treatment of the patient concerned. 4. On receipt of cheque the patient will be asked to report to this hospital for treatment, and will be referred to the concerned clinician for treatment. 5. All the items needed, advised by the clinician for the treatment of the patient will be provided by the hospital and payment will be made out of the money sanctioned by the Pakistan Bait-ul-Mal to the LP contractor or supplier, who so ever supplies the drugs/items. 6. A utilization certificate by the controlling officer and prescriber will be issued and copy of it will be attached with the bill. 7. During the treatment if more money is needed for completion of therapy the application process will be repeated by the applicant through his clinician and hospital istration and the Pakistan Bait-ul-Mal will provide more funds. 8. On the completion of the therapy with in the sanctioned amount, the utilization report shall be submitted by the hospital for individual patient/total patients from time to time to the Bait ul Mal.

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SOP 16: Indenting of Store items

SOP 16.1: Indenting of Main Store items 1. The nurse In-charge of ward/units will place online indent to the store. 2. The DMS (Store) will the online indent of wards/units and will issue the demanded stores to the registrar/nurse concerned. 3. The hard copy of the indent will be signed by DMS (store) and registrar/recipient nurse. One hard copy will be retained at the main store while the other copy will be handed over to the nurse.

SOP 16.2: Indenting of Stationary and P & D store items These two areas are not yet fully computerized. 1. The nurse In-charge of ward/units will place demand on indent book to the store. 2. The DMS (P & D)/ RMO will the indent book of wards/units and will issue the demanded stores to the registrar/nurse concerned. 3. Half of the indent book page with received signature of registrar/nurse will be retained by DMS (P & D)/ RMO while the remaining half page will be retained by the indenter as unit record. 4. Main stock will be updated in the main store and sub stock/expense will be maintained and updated by the consumer units/wards.

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SOP 17: Record Room

1. The department/unit will submit the charts on monthly basis with the attached list of patients. 2. Record keeper will collect the charts and sign them. 3. Record keeper will place the charts in order at the specified location for units. 4. The computer operator will enter the chart (with ission number, discharge date and final diagnosis etc) 5. The IT department shall have a dual system for data storage. 6. The record of more than five years old will be disposed off. 7. The medico-legal chart will be prepared by the registrar of the concerned unit. A photocopy signed by the record keeper will be kept by the registrar while the original copy will be kept by the record keeper.

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SOP 18: Ward Cleanliness and Maintenance

1. The hospital shall have a well designed, comprehensive and coordinated infection control program aimed at reducing / eliminating risks to patients, visitors and providers of care. 2. Preferably each ward shall have a designated and qualified infection control nurse(s) for controlling infection. 3. The head nurse in-charge of the ward shall be the designated individual for coordinating and implementing the quality improvement program. 4. The quality improvement program is a continuous process and shall be updated at least once in a year. 5. The head nurse shall make sure that the ward is kept clean at all times. This includes the floors, windows, beds, toilets, galleries, cupboards, side tables etc. The registrar shall ensure that all this is done. 6. All equipment or lights etc that needs replacement must be immediately reported to the Registrar by the head nurse and dispenser. 7. Duty rota on three shift bases will be prepared by the registrar/ head nurse for the class-IV staff deployed in the ward. The rota will be prepared on three shift basis i.e. 8:00 am to 2:00 pm, 2:00 pm to 8:00 pm and 8:00 pm to 8:00 am next morning. 8. The registrar/ head nurse will be responsible for the discipline of their auxiliary staff and report their absentia or lack of interest in duty to the istration for disciplinary action. 9. The head nurse will ensure that ample supply of surf, phenyl and other antiseptics is timely demanded from the main store and is always available in the units. 10. Garbage bins shall be in sufficient quantity in each ward. The head nurse/ registrar will ensure procurement of garbage/ dust bins from the main store. The head nurse will ensure proper disposal of wastes like sharps, dressings, used I/V bottles and drip sets etc. 11. All the glasses, doors, ceiling fans, air conditioners and other ward appliances/ equipments will be kept clean by the orderlies.

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12. The registrar/ head nurse will ensure that visiting hours are strictly observed by patient attendants.

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SOP 19: ICU

1. Patients will be reitted in ICU from different units like medical, surgical, neuro surgery, gynae, ENT and ophthalmology departments who are critically ill. 2. The staff present in ICU will be responsible for all the orders given for medication and nursing care. 3. Once the patient arrives in ICU, the arrival report will be taken by medical officer on duty and will consist of mention of time and date of arrival, history of present illness, past history, family history, and detail of injury, drug history etc, clinical findings, writing investigations and management plan. 4. The medical officer will discuss the new ission with registrar and senior registrar. 5. The doctor on duty will inform relatives of patients and take proper detailed consensus with explanation of any possible procedure if needed as part of patient management. 6. I/C ICU will ensure the provision of necessary facilities/equipment in ICU like. •

Continuous oxygen Supply

•

Suction facility.

•

Bed side monitor

•

Arterial blood gases analyzer (ABGs).

•

ECG machine.

•

Defibrillator.

•

Mechanical ventilator.

7. I/C ICU will develop & implement a protocol for keeping ICU infection free and clean.

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SOP 20: Accident and Emergency Department

SOP 20.1 : Emergency cover in A & E Department 1.

The casualty Department shall have all important emergency drugs and equipment available in it as mentioned in SOP-1.

2.

Beside A & E department shall also have •

Anti-Snake Venom serum.

•

ARV(Imuno globulin vaccine, Human diploid cell Immune serum)

•

Effective & efficient ambulance service at function round the clock.

3. All patients coming to emergency will be attended by the CMO. 4. Record of medico legal patients will be maintained in MLC . 5. Elective patients coming to emergency department before 1:00 pm will be politely

directed to the concerned outpatient department (OPD). 6. Chief complaints and provisional diagnosis of the patients shall be clearly mentioned

on the prescription chit and vital signs recorded on the same. 7. Medicines prescribed and istered in the casualty shall be recorded on the chit. 8. After initial treatment and resuscitation, all patients will be shifted to the concerned

unit for definitive care when the vital signs are stabilized. All the referrals shall be entered in a referral . 9.

In case of serious emergencies when the patient is not stable enough for shifting, the doctor from concerned unit will be called for opinion.

10. Careful & swift emergency treatment shall be followed by consultation/referral to the concerned specialty, immediately, without wasting time in experimentation. 11. The relevant documents shall accompany the patient and the doctor in concerned department shall be given prior information to make necessary arrangements. 12. Carbon copy of the prescription chit will be retained in Casualty for record. 13. In case of serious emergencies when the patients are not stable enough for shifting, the doctor from concerned unit will be called for opinion.

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14. In case of any ambiguity or istrative problem I/C casualty or shift DMS will be

immediately informed. 15. All drugs in the casualty will be prescribed by the CMO and will be istered in

the casualty and record shall be maintained. 16. No drugs will be given to the patient for istration/use elsewhere. 17. Doctors on duty in casualty shall refrain from prescribing uned drugs, or drugs

on patient preference, not indicated otherwise. 18. All the medical claims and bills will be duly checked and signed by the I/C casualty. 19. Following investigations shall be generously utilized where ever needed:-

20. Radiographs of chest and pelvis and cross table lateral view of cervical spines 21. ECG 22. FAST (Focal assessment sonography in trauma) 23. CT Scan for head injury 24. Pulse oximetry 25. DPL (Diagnostic peritoneal lavage)

SOP 20.2: Emergency Cover in units/wards 1. The surgical, Gynae, medical, paeds, cardiolgy units/wards will provide emergency OPD cover. 2. Patient coming via emergency will be seen by doctors on call (HOs and TMOs both) in their respective wards.. 3. Those who need ission will be clerked, investigated, managed, resuscitated in the emergency chamber. 4. Those who need emergency surgery will stay in the chamber pre and post operatively. Rest of the patients will be shifted to regular beds. 5. Those patients needing operations shall be notified to the SR before shifting to the theatre.

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6. Patients will be re-itted in ICU from different units like medical, surgical, neurosurgery, gynae, ENT and ophthalmology departments if they are critically ill. 7. Only stable patients will be shifted out of the ward for important investigations. 8. Important surgical interventions shall be done on the same day if the condition of the patient permits.

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SOP 21: Gastro Intestinal Endoscopies 1.

The patients who are advised endoscopy by the consultant for procedures like ER, Polypectomy banding, dilatation, colonoscopies etc. will be referred to GI lab for a date and appointment

2.

When patients arrive on the date of procedure, proper check up of the patient will be done to get information that whether the patient is hemodynamically stable or not for the procedure which is to be performed. After that consent will be taken and risk, benefits, and alternatives explained to the patient.

3.

When procedure is performed, it shall be clearly written on the treatment chart, and post procedure orders shall also be mentioned.

4.

Every patient on whom procedure has to be performed will be screened for Hepatitis B & C & HIV.

5.

If biopsy is taken it shall be properly labeled and sent to the Histopathology department.

6.

Before the procedure the patient attendant will be given a receipt and sent to the ission counter to deposit the procedure fee.

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SOP 22:Cardiological Procedures

1. For outdoor patients consultant/ senior doctors in OPD and for indoor patients consultant/seniors in unit will advise the procedures like ETT, ECG, Echo, Holter, TEE etc 2. Before the procedure the patient’s attendant will be given a receipt and sent to the ission counter to deposit the procedure fee. 3. When patients arrive on the date of procedure, proper check up of the patient will be done to get information. 4. When procedure is performed, it shall be clearly written on the treatment chart, and post procedure order shall also be mentioned.

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SOP 23: Radiological Procedures 1.

Patients coming to the Radiology department will have investigation forms duly filled in and advised by the treating doctors and will get his examination ed at the fee counters in the department.

2.

The department will run in three shifts.

3.

Evening and night shifts will provide cover to casualty and ward emergency cases only.

4.

X-rays and ultrasound will be done round the clock

5.

CT-Scan will be done round the clock and reported daily.

6.

All the above radiological procedures shall be free for indoor patients in the morning shift.

7.

MRI is a paid service both for indoor, outdoor and emergency cases. MRI will be done daily upto 8:00 pm and shall be reported on the same day except that a few cases are kept for teaching purposes.

8.

For emergency cases these investigations shall be provided free round the clock.

9.

Imaging results shall be available within a defined time frame.

10. The HOD will document policies and procedures for emergency care. 11. Critical results shall be intimated immediately to the concerned personnel.

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SOP 24: Laboratory Investigation

1. Scope of the laboratory services shall be provided as per the requirement of the patient. 2. Adequately qualified and trained personnel shall be available to perform and supervise the investigations. 3. Laboratory tests not available in the hospital shall be outsourced to organization(s) based on their quality assurance system. 4. All the samples collected in the ward will be properly labeled 5. All the routine/baseline investigations which do not need the orders of the Professors I/C of the concerned unit (like blood complete, urine exam, blood urea, blood sugar etc) will be sent in time to the laboratory before 11:00 am. 6. Specialized investigations or any other test advised may be sent to the laboratory up to 12:00 noon. These investigations will be compiled and reported upto 2:00 pm. 7. Emergency investigations will be entertained any time round the clock. 8. All the pre operative patients shall be screened by Elisa test. The ICT quick method will be utilized only for dire emergencies. 9. Samples from the wards for Elisa tests shall reach laboratory from 9:00 am-4:00 pm. 10. Blood for PT/APTT will be sent in citrated tube in proper volume in the ratio of 0.2 ml reagent and 1.8 ml blood. 11. Patient for fasting blood sugar must have 12:00 hrs fasting and random glucose checked after lunch/dinner.

SOP 24.1: Online Laboratory Investigation 1.

All the routine indoor free investigation will be booked online at unit nursing counter.

2.

All the paid indoor investigations will be booked at pathology counter.

3.

After 2:00 pm all the investigations will be booked at pathology counter

4.

All the samples must reach the laboratory before 11:00 am.

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5.

Investigation results will be entered by TMOs/laboratory technicians in pathology lab computers.

6.

The results will be retrievable on units nursing counter round the clock as per online booking of the investigation time.

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SOP 25: TMOs/MOs Duty

SOP 25.1: Duty Rotas 1. These shall be made by the SR or Assistant Professor of the ward & shall include duties in OPD, OT,& ward 2. The doctors on duty have to be physically present in the ward. 3. The HO & TMO shall leave the ward after their duty is over only when the next doctor on duty has arrived. However doctors on duty in the afternoon & night shift shall all be present in the evening round. 4. Doctors shall communicate with each other at the time of change of duty i.e. they shall inform the next doctor on duty about the status of serious patients etc

SOP 25.2: Guidelines for TMOs/MOs Duty 1.

All the doctors are required to come to ward at 7:45 am in the morning.

2.

TMO's will countersign the DPR of HOs and write down their own comments before each round.

3.

TMO will write brief arrival reports of allotted beds on the day of ission.

4.

TMO on duty on operation day will write arrival report of post operative patient.

5.

The calls will be written by TMOs not by house officers. In case of bed case the concerned TMO will call to the concerned unit and verbally discuss.

6.

The home treatment and follow up in the discharge slip will be written by TMOs and counter signed by JR/SR.

7.

All doctors will put their names along with signature on every document of the patient.

8.

The TMO who has done night duty will be exempted from routine round next

9.

morning. All the TMOs / HOs shall be present in evening round conducted by registrar/SMO/SR and shall mark their presence on attendance otherwise they will be considered absent.

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10. TMO will ensure the OT medicine are made available to the patients on OT list. In case of any deficiency, they will be responsible. 11. A written and informed consent will be taken by TMO from the patient in presence of an adult relative. 12. Post operative patients coming to the ward will be assessed by the TMOs and HOs and their vital sign, level of consciousness and status of the drain will be noted in arrival report. 13. Investigation request forms will be filled by TMOs and the specimens will be sent to histopathology. 14. Post operative patient with significant bleeding will be managed in emergency chamber and their vital signs, drain and Hb will be checked regularly 15. Senior will be informed immediately if the patient becomes unstable. 16. TMOs will actively participate in academic activities i.e. ward presentation, journal club, morbidity / mortality meetings and hospital seminars etc. 17. TMO and HO will stay in the emergency chamber during their duty hours. 18. All blood transfusions will be done by doctors. 19. In surgical units a separate for operations i.e. ‘elective and emergency’ will be kept up to date and will be checked by the JR daily. 20. Call will be kept up to date and will be checked three times a day after each ward round. 21. Non emergency routine calls from other units will also be noted in this .