Quality manual

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Qualitymanual 2019 NABHStandardsfor hospitals4th
Edition
NABHpolicy
NABHstandard reference: AAC09,10,11
Policy/versionNo/Issue date CMAH/COP/02/A Version1/14 march,2019
Page No: Page
Preparedby:chairperson, Approvedby:medical superintendent Issuedby:Qualitymanager
Signatures Signatures Signatures
STANDARD OPERATING PROCEDURE OF
EMERGENCY SERVICES

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NABHpolicy
NABHstandard reference: COP2
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Index
S.no Content Page no
1
2
3
4
5
6
7
8
9
10
11

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Amendment Log sheet
Detailed Amendment sheet
(All mid terms Amendment needs to be documented here)
S.no Page
no
Para/line Date of
Amendment
Amendment made Reasons for
Amendment
Authorize
d by

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Introduction
Cygnus Maharaja Aggarsain hospital is a multisuperspecialty hospital located in
Panipat(Haryana) near Opp.Devi Mandir. It is state of the art hospital offering tertiary care
treatment in Neuro,ortho & Cardiology with supportive 24*7 Blood Bank,Path laboratory &
Emergency Services.CMAH is a NABH accredited hospital.
Vision:
To be recognized as secondary care hospital in the district Panipat as providing affordable and
equitable healthcare services to the patients in a ethical safe manner.
Mission:
To establish system of refillable timely and good quality healthcare with patient centered approach.
Values:
We believe in good organizational behavior and evidence based decision making in reference to the
guiding principles of our organization and the customers.
Quality policy:
We are committed to providing customers with service of highest possible level of quality.
Quality Objectives:
 To enhance the safety of both the internal and external customers through
enforcement of standard policies and procedures for all the major activities and
processes involved in the provision of healthcare.
 To optimize the resource utilization.

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 To continually identify and enhance the knowledge and skills of the care providers at
hospital.
2.0 SCOPE:
24*7 emergency services for :
2.1 Neurocasualty
2.2 Cardiac emergencies
2.3 Poisoning ,burning and accident trauma.
2.4 All kind of emergencies including MLCs emergencies & trauma
3.0 PROCEDURE
3.1 To aid clinical diagnosis, samples are collected and sent to lab for analysis and reporting.
Reports shall be sent back to the Emergency department on a priority basis.
3.2 Screening and diagnostic tests shall be recommended and carried out as and when
required in the Triage, keeping in mind the patient’s immediate medical needs; for
example, in the case of a head injury, the RMO shall have to make a quick appraisal of
the criticality of the case and recommend an X-Ray or a CT Scan if he so decides. Tests
are also carried out in concurrence with the consultant for arriving at the clinical
diagnosis.
3.3 Patients are not transferred or admitted or discharged without the RMO reading the
reports of all tests recommended by him or the consultant in the Emergency, unless the
critical nature of a patient’s condition warrants immediate transfer to the operating
theater or a critical care unit.

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4 RECEPTION OF PATIENT
4.1 Emergency staff shall ensure availability of wheelchairs and stretcher trolleys at the
Emergency room (ER) main door.
4.2 In cases where the patient is unaccompanied / unconscious, life, sight and limb saving
measures shall be instituted.
4.1.3 After examining the patient and immediate resuscitative and stabilization care, the
residential medical officer (RMO) shall contact the Consultant on-call in the relevant
specialty by means of the telephone. RMO shall apprise the Consultant of the patient’s
condition and take instructions regarding investigations and treatment.
4.4 RMO advises admission if required and the front office staff shall fill the Admission
Request Form if the patient requires admission. A patient is to be admitted only when
the Consultant advises admission.
4.5 Under the guidance of the treating doctor the concerned nursing staff with the help of
the Front office staff shall call the external blood bank and arrange the required
quantity.
4.6 Patients shall be discharged or transferred to the allocated bed at the earliest after
screening diagnostic test results are available or earlier if the patient condition so
requires.
5.0 Handling Medico legal Cases
5.1 All cases of accidents, burns, assaults, alleged suicide or homicide, poisoning, road traffic
accident, rape, drowning, etc shall be registered as medico legal cases (MLC).

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5.2 All cases registered as medico legal in hospitals where he/she reported first must also be
registered as Medico legal and the outside MLC number recorded on the case file.
5.3 Any case of a cognizable offense as mentioned above even if brought at a later date by
the police must be informed and the case registered as medico legal.
5.4 When a case identified as medico legal is brought to Emergency Dept. RMO shall provide
medical care as required.
5.5 Emergency staff shall inform the Front office staff who will intimate the police. The time
of call and the police personnel spoken to shall also be documented in the front office
register.
5.6 MLC Form shall be filled by RMO in duplicate (one copy for Medical Records Dept. and
one for the Police) MLC report shall be completed and signed as soon as possible after
the patient arrives in Emergency and in all cases before the RMO goes off duty. RMO
shall not be relieved until MLC reports for patients managed in the tenure of duty are
completed.
5.7 An entry must be made in MLC intimation report in case the patient is already registered
as Medico legal in another hospital.

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Infrastructure
The Department of Emergency is situated on the ground floor near to the main entrance of the
hospital.
It is a 6 beded emergency designed in such a way that shifting of patients wards/ICU is less time
taking..
Organogram
Emergency medicine -Head
RMO(1/shft)
Nursing Staff (3/shift)
Job Specification
RMO
 Assessment of the patient.
 First aid treatment .
 Admit the patients as per scope of services of hospital(if need) otherwise transfer the patient
as per policy.
 Inform the patient/attendant about possible treatment to save his/her life.
NURSING
 All staff need to present on duty as per roaster schedule shift.
 Fill all the consent as NABH guideline.
 Maintain data records and assist senior in preparation capa records.

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Departmental standards.
COP2 Emergencies services are guided by policies,procedures,applicable laws and
regulations.
a. Policies and procedure for emergency care are documented CMAH/COP/02/A
b. Policies also address handling of medico-legal cases CMAH/COP/02/A
c. The patients receive care in consonance with the policies CMAH/COP/02/A
d. Policies and procedures guide the triage of patients for initiation
of appropriate care
CMAH/COP/02/A
e. Staff is familiar with the policies and trained on the procedures
for care of emergency patients
CMAH/COP/02/A
f. Admission or discharge to home or transfer to another
organization is also documented
CMAH/COP/02/A
Continuous quality improvement program
There is monthly audit of drugs consuming in emergency department..
Training of CPR Nursing & other staff like GDA on monthly basis .
Infection control programme actively running.
Indicators
Patients fall from beds.
Needle stick injuries
Clinical correlation
Turnaround time.

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