PHC Guidelines

for Emergency Departments

of Referral Hospitals – Secondary and
Tertiary care settings in the Punjab

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 ©Punjab Healthcare Commission-2022
This is a restricted document for use of persons
implementing the Minimum Service Delivery Standards in
hospitals; and the surveyors. Reproduction of this
Document in any form for any intent is not allowed,
without written permission from the PHC; except
photocopying and use within the same hospital /
healthcare establishment for which it is issued.
Clarification or quarries, if any may be addressed to the
Directorate of CG&OS, PHC

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 PHC Guidelines
for
Emergency Departments
of Referral Hospitals:

Secondary and Tertiary care settings in the Punjab

(December, 2022)

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 Table of Contents
Sr. No. Content Page No.
1 Table of Contents 2
2 List of Acronyms and Abbreviations 5
3 Preamble 10
4 National Scenario 11
5 Provincial Scenario: year 2000 onwards 13
6 PHC Regulatory Framework: Minimum Service Delivery Standards 17
7 State of Emergency Departments in Pakistan 21
8 Levels of Care for Injured / Emergency Patient 24
9 Golden Hour Management 25
10 Planning of Emergency Services 31
11 Major Functional Areas in the Hospital Emergency 34
11.1. Triage: Concept and Application 46
11.2 Triage Scale (TS) 49
11.3 The Triage Tool 50
11.4. Discriminator List 51
11.5 Interventions to be carried out at Triage 52
11.7 Categorization of patients according to Seriousness of the Problems 55
11.8 Levels of Hospital Emergency Departments 56
12 Physical Setting Requirements 57
13 Continuous Professional Development 60
14 Admission Policy for the Emergency Department 61
15 Disposition of Patients from the Emergency Department 62
16 Code Blue 64
17 Power Failure in Hospital Emergencies 67
18 Policy Recommendations of Emergency Experts Consultation 69
19 Emergency Department Check list 71
20 Hospital Emergency Departments Operational Model 76
20.1 Department of Emergency 76
20.2 Training 80
20.3 Transfer of Patient to other Hospital 83
20.4 SOPs –Infection Prevention and Control in Emergency 87
20.5 Anaphylactic and drug reactions, asphyxia, electric shock and drowning 88
20.6 Management of Cardiopulmonary Arrest 89
21 Annexures
Annex-I: Triage Sheet 91
Annex-II: Code Blue Feedback From 92
Annex-III: Resuscitation Form 93
Annex IV: Equipment & Supplies 94
Annex-V: Essential Medicines list 96
Annex-VI: The CTG discriminator list (adult version) 97
Annex-VII: Children Triage Score (3-12years, 96 -150cm) TEWS 98
Annex-VIII: Infant Triage Score (<3 years, < 95 cm) TEWS 99
Annex-IX: Examples of triage systems internationally in vogue 100
Annex-X: PHC Guidelines for Referral 105
Annex-XI: power Failure and SOPs to ensure patient safety in the wake 111
of power failure
Annex-XII: List of Emergency Experts Consulted 114
22 References and Bibliography 115

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Figures and Plates:

Sr. No Title Page

Fig 1 Level of Emergency Facilities 16
Fig 2 Algorithm of activities in Accident and Emergency 20
Fig 3 Glasgow Coma Scale 27
Fig 3 Sample Outlay of Small Emergency Unit: minimum 5 to 10 37
treatment beds
Fig 4 Sample Outlay of medium size Emergency Unit: minimum 11 to 30 38
treatment beds
Fig 5 Sample Outlay of Large size Emergency Unit: minimum 31 or 100 39
or more treatment beds
Flow chart Interventions to be carried out at Triage 52
Flow chart Flow Chart of the Care process at the Emergency Departments 54

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 ACRONYMS and ABBREVIATIONS

A&E Accident and Emergency

AAC Access, Assessment, and Continuity of Care
ABG Arterial Blood Gas (test)
ACR Annual Confidential Report
ACLS Advanced Cardiac Life Support
ADL Activities of Daily Living
ADR Adverse Drug Reaction
AGPR Accountant General of Pakistan Revenues
AIN Asset Identification Number
ANC Ante- Natal Care
APPM Accounting Policies and Procedures Manual
AST Aspartate Amino Transferase
ATLS Advanced Trauma Life Support
AWP Annual Work Plan
BCF Bromo Chloride Fluoromethane
BHU Basic Health Unit
BoM Board of Management
BTS Blood Transfusion Service
BLS Basic Life Support
C&W Communication and Works Department
CABG Coronary-Artery Bypass Grafting
CCBs Citizen Community Boards
CDC Centers for Disease Control and Prevention (US government)
C-EmOC Comprehensive Emergency Obstetric Care
CFAO Chief Finance and Accounts Officer
CFO Chief Financial Officer
CIs Confidence Intervals
CMC Complaint Management Committee
CMO Causality Medical Officer
CME Continued Medical Education
CNIC Computerized National Identity Card
CoA Chart of Accounts
COMS Clinical Outcomes Measurement System
CPOE Computerized Prescriber Order Entry
CQI Continuous Quality Improvement
CRP C-Reactive Protein
CSOs Civil Society Organization
CSSD Central Sterilization Services Department
CT Computerized Tomography

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 DDO Drawing and Disbursing Officer
DG Diesel Generator
DGHS Directorate General of Health Services
DHIS District Health Information System
DHMT District Health Management Team
DHQH District Headquarter Hospital
DoB Date of Birth
DoH Department of Health
DRA Drug Regulatory Authority
DVT Deep Venous (Vein) Thrombosis
ECG Electro Cardiography
ED Emergency Department
EDL Essential Drug List
EMO Emergency Medical Officer
EMR Electronic Medical Record
EMS Emergency Medical Services
ENC Essential Newborn Care/ Emergency Neonatal Care
EmOC Emergency Obstetric Care
EmONC Emergency Obstetric and Neonatal Care
EQA External Quality Assessment
FAR Fixed Asset Register
FFP Fresh Frozen Plasma
FGI Facility Guideline Institute
FHT Family Health Team
FMS Facility Management and Safety
FP Family Planning
GAAP Generally Accepted Accounting Principles
GATHER Greet, Ask, Tell, Help, Explain, Return
HAOP Hospital Annual Operational Plan
HCE Health Care Establishment
HCP Health Care Provider
HEPA High Efficiency Particulate Air
HIC Hospital Infection Control
HID Health Institute Database
HMIS Health Management Information System
HOD Head of Department
HRD Human Resource Development
HRM Human Resource Management
HTC Hospital Transfusion Committee
HVAC Heating, Ventilation, And Air Conditioning (System)
IBC International Building Code
IC Infection Control

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 ICC Infection Control Committee
ICD International Classification of Diseases
ICN Infection Control Nurse
ICO Infection Control Officer
ICP Infection Control Practitioner
ICT Information and Communication Technology
ICT Infection Control Team
ICU Intensive Care Unit
IEC Information, Education and Communication
IFRS International Financial Reporting Standards
IMNCI Integrated Management of Neonatal and Childhood Illnesses
IMPAC Integrated Management of Pregnancy and Childbirth
IMS Information Management Systems
IPD Inpatient Department
IPM Integrated Pest Management
ISMP Institution for Safe Medication Practices
JCAHO Joint Commission on Accreditation of Healthcare Organizations
JD Job Description
KCl Potassium Chloride
KPIs Key Performance Indicators
LAMA Left/Leaving Against Medical Advice
LASA Look-Alike, Sound-Alike
LDH Lactate Dehydrogenase
LHV Lady Health Visitor
LHW Lady Health Worker
LSC Liquid Scintillation Counting
MAR Medication Administration Record
MCH Maternal and Child Health
MD Medical Director
MDR Multiple Drug Resistance
MIS Management Information System
MLC Medico-Legal Cases
MLR Medico-Legal Report
MOM Management of Medication
MRI Magnetic Resonance Imaging
MRSA Methicillin Resistant Staph Aureus
MS Medical Superintendent
MSDS Minimum Service Delivery Standards
N.B. Nota Bene (Note well)
NFPA National Fire Protection Agency
NGO Non-Government Organization
NICU Neonatal Intensive Care Unit

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 NMNCHP National Maternal Newborn and Child Health Promotion
OEM Original Equipment Manufacturer
OPD Outpatient Department
OR Operating Room
OSHA Occupational Safety and Health Administration
OT Operation Theater
OTA Operation Theatre Assistant
OTMC Operation Theatre Management Committee
PACS Picture Archiving and Communication System
PACU Post Anaesthesia Care Unit
PALS Paediatrics Advanced Life Support
PAR Post Anaesthesia Recovery
PEPP Payment Error Prevention Program
PGD Patient Group Direction
PHC Punjab Healthcare Commission
PIP Patient Identification Procedure
PMDC Pakistan Medical & Dental Council
PNC Pakistan Nursing Council
PNC Post - Natal Care
PNRA Pakistan Nuclear Regulatory Authority
PO Purchase Order
POD Patients Own Drugs
PPE Personal Protective Equipment
PPRA Punjab Procurement Regulatory Authority
PRE Patient Rights and Education
PTBA Punjab Blood Transfusion Authority
QA Quality Assurance
QC Quality Control
QI Quality Improvement
RBS Random Blood Sugar
RDL Role Delineation Level
RHC Rural Health Centre
RIS Radiology Information System
ROM Responsibilities of Management
RTAT Radiology Turn Around Time
RTI Reproductive Tract Infection
SAM Self-Administration of Medicine
SMPs Standard Management Protocols
SOPs Standard Operating Procedure
SPSS Statistical Package of Social Sciences
SSI Surgical Site Infection
SSIR Surgical Site Infection Rate

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 SSIS Surgical Site Infection Surveillance
STI Sexually Transmitted Infections
SVD Spontaneous Vaginal Delivery
SWOT Strengths, Weaknesses, Opportunities, Threats
TAC Technical Advisory Committee
THQH Tehsil Headquarter Hospital
TNCC Trauma Nursing Care Course
V/Q Ventilation/Perfusion
WHO World Health Organization
WM Waste Management
WMO Woman Medical Officer
WMT Waste Management Team
ZBB Zero-Based Budgeting

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 Preamble
The Emergency Departments of healthcare establishment has pivotal role in providing access to
emergency medical care, and backup support to the primary health care facilities including BHU, RHCs,
and the family Physicians and smaller hospitals settings in the private sector. The Emergency
Department is also an important interface for a variety of indoor and outdoor services operating in
the healthcare establishment, as a large proportion of total admissions to inpatient wards are via
Emergency Departments.

These guidelines are only intended to provide an outline towards integration of clinical requirements,
functional needs and practical logistic and space requirements for an Emergency Department of a
typical hospital. The document is not intended to provide an exhaustive guide or a prescriptive list of
medical equipment and other requirements, as such information is essentially dynamic and can
become outdated quickly. Rather these guidelines are aimed to highlight critical aspects, mode of care,
and optimal patient pathways leading to smooth flow of patients and eliminating the chances of mis-
management or poor or un-intended outcome.

No matter how much diligence is observed in planning a hospital emergency department, models of
care may rapidly change in the real case scenario, as a result of change in government policy, new
initiatives, change in staffing of the Emergency Department in view of change in patients’ needs and
demographics, technology, physical and social environment related factors. In the private sector, the
Emergency Department and Emergency Care is influenced by a number of factors including the
business model, etc. The Emergency Physicians, nurses, allied health staff actually working in the
Emergency Departments being the key stakeholders can provide valuable inputs during designing
phase1 of the hospital emergency services.

As per the JCI Survey Process2, Hospitals providing services that are available 365 days a year, and
ensures that all direct patient care as well as ancillary and support services as needed for emergent,
urgent, and/or emergency needs of patients, such as diagnostic testing, laboratory, and operating
theatre, as appropriate to the type of acute care hospital are operational 24 /7 basis are eligible to
apply for JCI accreditation.

Emergency Department of the hospital is often the gateway to healthcare system and point of first
contact for many patients coming with acute illnesses or are suffering from some imminent
complication of chronic health problem. Commonly presenting emergencies include obstetric cases,
complications during pregnancy and post-partum, non-communicable diseases e.g. asthma, heart
attacks, strokes, surgical issues, road traffic accident, environmental and man-made disasters
exacerbations of acute life threatening infections e.g. sepsis, Covid-19, dengue, Congo Hemorrhagic
Fever, and psychiatric illnesses etc.
These Guidelines are intended to supplement the requirements mandated under the Minimum
Service Delivery Standards prescribed by the Punjab Healthcare Commission (PHC) and notified by the
Government of the Punjab, to improve quality of health services delivery in the hospitals and to ensure
patient and provider safety. The Health Facilities will be required to give effect to the provisions of the
guidelines as applicable within their declared scope of work, and in terms of the provisions of the
License granted by the Punjab Healthcare Commission.

1 Emergency Department Design Guidelines by Australian College for Emergency Medicine, 2014
2 JCI Survey Process Guide (7th Edition, 2021),

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 National Scenario
Whenever an injured person is brought to a hospital, it is mandatory to provide medical aid without
delay on priority basis. This medical aid will be provided irrespective of any other consideration
including medico legal formalities and no police officer shall interfere during the period an injured
person is under treatment in a hospital3. The Injured Persons (Medical Aid) Act, 2004 further explains
“injured person” as a person injured due to traffic accident, assault or any other cause who is in need of
an immediate treatment. The Act in terms of Section 6 also provide that an injured person shall not be
shifted from a hospital until he is stabilized or the requisite treatment is not available in such hospital
and while shifting to another hospital, the doctor concerned shall complete the relevant documents
with regard to the clinical conditions of the patient and hand over such documents to the concerned
doctor of the receiving hospital.

In order to provide for early transport of the injured or ill person in a life threatening situation, section
5 of the Punjab Emergency Service Act, 20064 empowers Rescue Service to arrange transport
(transport vehicle or ambulance) where necessary for carrying persons requiring emergency medical
treatment to the nearest hospital emergency or healthcare unit having such arrangements. Section
17 of the said Act also enables the Emergency Officer or the Rescuer to administer such life safety
procedures as are consistent with their training and competence.

National Reference Manual on Planning and Infrastructure Standards5 formulated by the Government
of Pakistan provided long term goal of 5 hospital beds per thousand population, whereas the sixth five
year plan envisaged a target of 0.63 beds per 1000 population. As a general guide, Standards for Health
Facilities envisaged a Tehsil hospital of 60 beds having three basic specialties and dentistry service,
whereas every district should have one 100 to 250 bedded referral hospital with all medical facilities
including 6 to 10 specialties. In larger cities, in addition to one district hospital, one general hospital
of 100 to 250 beds with all medical facilities and 5 to 10 specialties was also envisaged.

On provincial and regional basis, the standards provided for teaching hospital having all specialties in
a 500 to 1000 bedded facility, whereas in metropolitan cities and hill stations, specialized hospitals
e.g. Mental hospitals, T.B Sanatoriums were envisaged. The standards also considered the scope of
private clinics to take some load in larger urban centres and in upper income communities thus
reducing the need for public provision.

The National Reference Manual also provided that coordination with other emergency services was
crucial for a comprehensive efficient service and thus required that a hospital should at least be in
communication with police, ambulance and fire services, and the ambulance service should be
focused on district/general hospital upwards in the hierarchy. The Guidelines provided that there
should be adequate parking near emergency wards/cardiology units, and access should be separate
for ambulances from the main public entrance.

The Reference Manual also provides Elements and Covered areas of health facilities that require
10,576 square meters covered area for a 250 bedded district hospital, and 10% beds to be in single
rooms for intensive care with space requirement per bed: 16.5 sq meters for adults and 18.5 Sq meters
per bed for children ward. The Manual requires 464 Sq meter space for Accident & Emergency

3 Injured Persons Medical Aid Act, 2004

4 Punjab Emergency Service Act, 2006
5 National Reference Manual on Planning and Infrastructure Standards, Ministry of Housing and Works,
Environment and Urban Affairs, Government of Pakistan 1986

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Department of such a secondary referral hospital and 30 to 35% of the net area to be allocated as
circulation space and facilities for the ward.

In order to review the prevailing situation and to make recommendations for improvement, a working
group comprising of the local emergency care experts was constituted by the Ministry of National
Health Services and Coordination, Islamabad to undertake assessment of Emergency System in
Pakistan in collaboration with the WHO. After detailed review and inputs from the key informants, the
report submitted by the working group6, inter-alia, made the following recommendations:
I) Implement use of system-wide standardized clinical forms /SOPs in Emergency Units
II) Establish minimum standard guidance / standardized clinical forms for use in emergency
based on WHO standards
III) Establish an emergency registry platform in the Ministry to provide guidance on emergency
care and for pre-hospital care; and a coordination mechanism at national and provincial
level for collecting, analyzing and utilization of emergency care data at policy level
IV) Standardize criteria and process for designation of trauma centres
V) Set standards for first aid kit, and provide standardized training
VI) Establish single national universal access number for emergency healthcare; and
implementation of accreditation mechanism and oversight for ambulances (public and
private)
VII) Establish national level minimum service guidance on clinical care and communication
protocols for inter-facility emergency transfer
VIII) Implement formal emergency unit triage process at every district hospital and tertiary care
level in line with WHO tools
IX) Implement dedicated training in basic emergency care for front line emergency care
providers
X) Establish core or dedicated (non-rotating personnel) clinical response teams at emergency
units of all levels
XI) Establish minimum standards & guidelines for emergency Units regarding level of services,
processes (triage, length of stay, handover or discharge), infrastructure, staffing,
equipment, supplies at national level
XII) Integrate emergency care training in undergraduate medical and nursing curricula, and to
initiate additional medical emergency specialty training programmes
XIII) The federal regulatory council to make it mandatory for ongoing practice a basic emergency
care training for healthcare professionals providing services in emergency units
XIV) Provide a mechanism for enforcement of accreditation standards in the emergency care
elements in public and private hospitals
XV) Develop pre-hospital and in-facility security plans at all levels of service delivery to protect
staff, patients and infrastructure from violence
XVI) Conduct regular assessment of the capacity of emergency care system to mobilize resources
in case of disasters, outbreaks and large scale emergencies, and to strengthen such capacity
by prior planning and coordination at national and provincial level.

6 Assessment of Emergency System in Pakistan, 2014

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Provincial Scenario: year 2000 onwards
In Punjab province, the mainstay of emergency services rests with the public sector hospitals, which
provide round the clock free medical cover for all incoming patients, while no patient is denied
emergency care. Emergency Departments of the Teaching and tertiary care hospitals provide basic
and specialized medical cover round the clock, while most of the district and tehsil hospitals provide
24/7 hour basic medical and surgical cover in the emergency departments, including medico legal
services. Similarly, the rural health centers are open for 24/7-hour basic medical cover, and medico-
legal services.
Since late 1990’ and early 2000, the Cardiology Institutes and Pediatric hospitals provide specialized
coronary and pediatric care in cities like Lahore, Multan, Faisalabad and Rawalpindi. However, these
facilities draw their strength and backup from the regular set ups provided in the neighboring public
sector tertiary care hospitals for other specialties’ services. In 2002-2003, a major initiative was
undertaken by the government when emergency departments of seven major teaching hospitals were
planned for upgradation. In order to optimize operation of the upgraded emergency facilities, a
Manual of Standard Operating Procedures (SOP)7 was framed by the Health Department, Government
of the Punjab in October, 2003. The Manual inter-alai, contained the following important
recommendations:
(i). Establishment of Ambulance Stations on highways /major intersections and provide linkage
with ambulances and the referral hospitals, with a target time of 20 minutes to reach at
accident site
(ii). Purchase, equip and staff the ambulances with basic life support facilities
(iii). Improve the DHQ hospitals by commissioning intensive care of at least 4 beds capacity with
equipment and trained staff
(iv). Increasing the number of general surgeons, orthopedic and neurosurgeon in each DHQ
hospital, and ensure 24 hours availability of operation theaters
(v). An additional medial superintendent as in-charge of emergency in DHQ hospital
The Manual also provided the job descriptions of key staff members including CMO, Nursing staff, and
documented procedures for reception, registration, and management /transfer of patients in the
emergency department. It also included 50% extra pay for regular emergency staff and provisions and
procedures for emergency lab, radiology and blood bank facilities. The Manual also provided a
summary of existing capacities in RHCs, THQ Hospitals, DHQ and Teaching hospitals, and the desired
performance levels /capacity to be achieved as a result of the government initiative. The manual also
provided a monitoring instrument / check list as per WHO guidelines.
In 2016, the Primary and Secondary Healthcare Department undertook baseline assessment of 25
district headquarter hospitals and 15 tehsil headquarter hospitals towards getting these hospitals
licensed with the Punjab Healthcare Commission. As a result, a substantial transformation programme
was undertaken with focus on upgrading the following:
i). Medical infrastructure
ii). Hospital infrastructure
iii). Human resource
iv). technology / EMR

7Standard Operating Procedures (S.O.P) Manual for Emergency Medical Services in Teaching Hospitals of the
Punjab; Department of Health, Government of the Punjab, October 2003

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 v). Outsourcing of non-clinical services
vi). Implementation of best practices /SOPs
Following hospitals were included in the transformation programme
DHQ Hospitals THQ Hospitals
1. DHQ Attock 2. DHQ Muzzafargarh 1. THQ Hazro
3. DHQ Bahawalnagar 4. DHQ Nankana Sahib 2. THQ Chistian
5. DHQ Bhakkar 6. DHQ Narowal 3. THQ Ahmedpur East
7. DHQ Chakwal 8. Additional DHQ Okara 4. THQ Taunsa Sharif
9. DHQ Chiniot 10. DHQ Okara 5. THQ kamoke
11. DHQ Hafizabad 12. DHQ Pakpattan 6. THQ Mian Channu
13. DHQ Jhang 14. DHQ Rajanpur 7. THQ Noorpur Thal
15. DHQ Jhelum 16. DHQ Sheikupora 8. THQ Esa Khel
17. DHQ Kasur 18. DHQ TT Singh 9. THQ Shuja Abad
19. DHQ Khanewal 20. DHQ Vehari 10. THQ Kot Addu
21. DHQ Khushab 22. DHQ Mandi Bahauddin 11. THQ Arifwala
23. DHQ Layyah 24. DHQ Mianwali 12. THQ Chichawatni
25. DHQ Lodhran 13. THQ Daska
14. THQ Gojra
15. THQ Burewala

In 2021-22, the Government of the Punjab envisaged to develop 250 bedded new emergency and
trauma centre in Jinnah hospital Lahore, and a new hospital near Arfa Kareem tower in Lahore with
an estimated bed strength of 1000, and having 250 bedded emergency department as per the
following suggested breakup:

Departments Proposed Bed Count

General Surgery 36+36 beds
General Medicine 60 beds
Orthopedic/Spinal surgery 24 beds
Modular Surgical ICU/Modular Medical ICU 14 beds
High Dependency Unit 21 beds
Emergency Dialysis Room 06 beds
Triage Accidents & emergency 48 beds
Code Blue Room 06 beds
Total Beds 251 beds
Modular OT Suites 06 beds
Minor OT 03 Tables

The above schemes are in the scrutiny process before approval under the Annual Development
Programme (ADP), and once approved, will be setting new standards for emergency care in Punjab.
On the contrary, dedicated emergency set ups in private hospitals are comparatively less developed,
barring a few. It is primarily due to the fact that private hospitals are never sure that all clients in
emergency would be affording to pay all expenses.

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As per the need assessment of Trauma Centres undertaken in the Punjab8, there were 20 dedicated
trauma centres in Punjab, out of which 8 were non-functional, while accident and emergency
departments of teaching hospitals in Punjab were providing round the clock access to trauma care.
The study observed that while there was no level-I specialized state of the art trauma care facility in
Punjab as per WHO guidelines, the DHQ hospitals in Punjab were providing services equivalent to
level-III trauma centres, whereas services at independent trauma centres were of level-IV.
The study revealed that there were no neurosurgeons in the trauma centres, while only 25% trauma
centers had anesthetists. Only 17% of the DHQ hospitals and 63% of the teaching hospitals had
neurosurgeons. Only 17% DHQ hospitals had the CT scan facility. Due to such shortages, there were
frequent referrals to the higher level health facilities. In addition to the budgetary constraints, the
independent trauma centres at Phool-nagar, Bhakkar, Layyah, Bahawalpur and Shuja abad had no
specialized trauma team. Only 60% of the independent trauma centres had access to blood bank
services. Only 25% of trauma centers were providing acute surgical care.
The study concluded that establishing new trauma centres was not a viable option, till the shortages
in the existing facilities were met. It was emphasized that management of trauma patients requires a
multidisciplinary approach, and specialized trauma care teams. It was recommended that formal
education and specialized training in trauma care be introduced, and be made mandatory for
personnel involved; PM&DC may introduce special courses of trauma care, and regular capacity
building sessions be arranged for trauma care service providers, and be made essential for dealing
with emergencies. The study also recommended to develop and update trauma protocols, regular
trauma team training sessions.
The study concluded that if at all the trauma centres were to be established, these must be done in
the existing DHQ Hospitals, which are more accessible for road accident victims, and where basic
infrastructure and backup support is already available. The study also recommended to lay emphasis
on proper stabilization of the road accident cases at nearest level 4 trauma facilities located around
the main roads in Punjab, before referral for definitive management.

8 Need Assessment of Trauma Centres in Punjab, 2018 by Punjab Economic Research Institute (PERI)

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 Level 1
Level 1 facilities provide the highest level of trauma care for patients. These facilities have a
full range of all types of specialists and equipment available 24 hours a day. These facilities
also offer teaching and research-components.

Level II
Level II facilities provide the same services as Level I facility without the research
component or a surgical residency programme. Level II facilities may not have specialist on-
hand 24/7, but they have them on call.

LEVEL Ill
Level Ill facilities do not have the full availability of specialists as Level I & Level II centres
do, but they do have resources for emergency surgery and intensive care. In some cases,
the facility might have to transfer patients.

Level IV
Level IV facilities provide initial evaluation, stabilization and diagnostic capability but will
likely have to transfer the patient to a trauma care centre with a higher designation.

Fig-1: Levels of Emergency Facilities 9

9 Need Assessment of Trauma Centres in Punjab, 2018 P: 24

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PHC Regulatory Framework: Minimum Service Delivery Standards
The Punjab Healthcare Commission (PHC), established through promulgation of the Punjab Healthcare
Commission Act, 2010 framed the first Minimum Service Delivery Standards (MSDS) for hospitals in
2012. Based on a comprehensive, internationally accepted framework, the MSDS encompass all
aspects of service delivery and focus on inculcating a culture of Clinical Governance, integral to the
healthcare systems based on the principles of responsibility and accountability. While standards are
broadly categorized as pertaining to ‘clinical care’ or ‘operational management’, the procedures and
practices prescribed within are interdependent and when implemented together, they deliver a
patient centered system of care that prevents avoidable errors and protect the patients from harm.
The MSDS prescribed by the PHC lay due emphasis on provision of emergency services in accordance
with law, with the objective to ensure patient safety and better treatment outcome. The Standard 3,
under the functional area titled ‘Care of Patients (COP)’, require the healthcare establishments (HCEs)
to develop Policies, Procedures and SOPs for provision of the Emergency Services. The standards
further require to ensure that services are guided by and provided in accordance with Policies,
Procedures, SOPs, the Applicable law and Regulations. As such, the hospitals need to have an
Emergency Care Policy and plan, covering all the aspects including, the administration of the
emergency area, triage, waiting times, admission/registration, legal reporting requirements, discharge
and patient transfer etc.
The guidelines provided in the Reference Manual10, explain further the standards that require the
HCEs to have well thought out and documented policies and procedures for emergency care, in line
with statutory requirements. These policies and procedures, developed in the light of applicable laws,
shall guide and encourage patient safety as the overall principle for providing healthcare services to
patients.
These policy documents should include SOPs/Protocols to provide both, general emergency care as
well as management of specific conditions, e.g. myocardial infarction, acute abdomen, poisoning etc.
and shall address both adult and pediatric patients. The procedure shall incorporate at least
identification of patients, assessment and provision of care. The HCE policy should spell out and ensure
availability of all the necessary equipment in the Emergency Department (ED) in working order and
functional round the clock (24/7) without interruption of its services and in accordance with the
international standards.
As per the reference manual, the Emergency Department should be appropriately staffed and must
have one to two Emergency Medical Officers (EMOs)/ CMOs depending upon the patient load of the
HCE in each shift of 8-1/2 hours, with a half hour overlap of duties for handing/taking over of charge.
Instead of night duty of 12 hours i.e. from 8PM to 8AM, a uniform duty of 8-1/2 hour must be enforced.
It should be mandatory to have sufficient experience and/or a house job in Medicine/Allied and
Surgery/Allied specialties and preferably training in advance basic life support (ABLS), advance trauma
life support (ATLS) and advance cardiac life support (ACLS) for the appointment of CMO/EMO.

As per the guidelines provided in the Reference Manual with the MSDS for hospitals, the Hospital
should make policies and develop SOPs/SMPs, on at least the following topics:

10 Minimum Service Delivery Standards Reference Manual, 2013

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 1. Triage 2. Admission of patient for definitive care
3. Patient assessment and care 4. Return of admitted patients to the
Emergency Department
5. Emergency Department design 6. Length of stay in the Emergency Department
beyond 8 hours (as prescribed)
7. Initial screening exam 8. Injury prevention of unconscious, confused
or irritable patients
9. Staffing of emergency services 10. Social works services consultation
11. Emergency medical services (EMS) 12. Release of information to media
13. Continuing education 14. Poisonings / Pesticide poisoning
15. Disaster plan 16. Patient discharge
17. Medications 18. Infection control
19. Equipment and supplies 20. Blood borne pathogen exposure in patients
presenting to the Emergency Department
21. Electrical safety and Power failure 22. Visitors/ attendants
23. Fire plan 24. Medical records
25. Security/traffic control 26. Elective sedation and analgesia
27. Inter-hospital transfers 28. Patients pronounced dead in the Emergency
Department
29. Laboratory down time procedure 30. Tetanus prophylaxis
31. Consent 32. Rabies prophylaxis
33. Confidentiality of patient information 34. Major adult trauma
35. Shock-trauma area 36. Major paediatric trauma
37. Patients’ belongings and valuables 38. Adult Medical Resuscitations
39. Standing orders 40. Paediatric Medical Resuscitations
41. Integration of diagnostic radiology with 42. Paediatric Medication Administration
Emergency Department
43. Integration of operating room with 44. Emergency Department Control Register (ED
Emergency Department log)
45. Integration of special care units with 46. Quality Control
Emergency Department
47. Reporting of criminal injury/ medico 48. Follow-Up programme - Call Back
legal cases
49. Invasive procedures 50. Patient Follow-Up procedure
51. General anaesthesia 52. Continuous Quality Improvement (CQI)
53. Special procedures 54. Admission of patient for definitive care
55. Patient transport for radiological 56. Return of admitted patients to the
procedures Emergency Department

As per the Indicator 16 provided under the above said standard, the hospital policy shall be in line with
legal requirements with reference to documentation and intimation to the police. Medico Legal Cases/
Medico Legal Reports (MLC/MLR) will be defined by the HCE in the light of the statutory rules.
MLC/MLR must be handled by the medical officers of the Forensic Department where it is available,
as in teaching hospitals; vis-a-vis where a Forensic Department is not available then CMOs must be

D5 14-12-22 Page 18 of 117

given capacity building training. Female victims of medico-legal cases must be dealt by female doctors.
If not available in the Emergency Department, then a female doctor from the Gynaecology
Department must be appointed in the emergency department, with her name and telephone number
noted. An approved Government Policy/Procedure is to be followed while handling and reporting
Medico Legal Cases. Details are provided in the SOPs11 developed by the Project Management Unit,
Primary & Secondary Healthcare Department, Government of the Punjab.
The Indicator 17 would require that the hospital staff receives awareness and training regarding the
emergency policies and procedures. Similarly, Indicator 18 requires that the hospital policies and
procedures guide the triage of patients for initiation of appropriate care. The Guidelines provided by
the Punjab Healthcare Commission with the above said standards provide that for efficient
management of patient workload, the following points need to be spelled out by the administration
in consultation with Head of the Emergency Department:
i. Criteria for identification of “non-emergency cases” presenting to the ED and requiring little or no
clinical care and not needing assessment by a consultant at the ED. The criteria should enlist
inclusions and exclusions and specified timelines for management
ii. A policy/procedure to sort and manage non-emergency patients
iii. Assessment criteria should include evaluation of vital signs, age, mobility and absence of co-
morbidities
iv. Ensure that SOPs regarding Triage and Treatment are well defined and understood by all staff
v. The SOPs should include management protocols for each category of patient viz. cardiac, road
traffic accident and poisoning etc.
vi. Ensure clearly defined Roles and Responsibilities.

The Reference Manual provided with the MSDS for hospitals further explains that the patients are
TRIAGED on the Basis of the Urgency with which they need medical attention. The Triage Nurse
allocates a Triage Category to a patient based on the statement and/or the condition of the patient
as evaluated by the Emergency Medical Officer. The guidelines under indicator 19 and 20 also
elaborate that the hospital staff is made aware of, and trained on providing emergency care, while all
admissions and discharge / referrals are documented.

11 Section 14, 37, 38 & 42 of the A&E Department SOPs, 2019

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 ALGORITHM OF ACTIVITIES IN ACCIDENT AND EMERGENCY
DEPARTMENT
ARRIVAL OF PATIENTS

TRIAGE SYSTEM

Critical Urgent Semi Urgent Non Urgent

Resuscitation
Investigate Investigate Investigation
Investigate

Shift to ICU Emergency Treatment Emergency Treatment Emergency +

Definitive Treatment

Stabilize Patient Urgent Treatment

Shift to Specialist Unit Shift to Specialist Unit Shift to Specialist Unit

Definitive Treatment Definitive Treatment Definitive Treatment

Discharge Discharge Discharge Discharge

Fig-2: Algorithm of Activities in A&E Deptt: how does Triage System work?

D5 14-12-22 Page 20 of 117

State of Emergency Departments in Pakistan
Health systems in all countries evolve within the Table 1: Presenting characteristics and emergency
prevailing social norms, cultural value system, and Services of patients in the Pakistan National Emergency
Department Surveillance Study.
sustain within the bounds of economic Characteristics N (%)
Sex (n ¼ 66,961)
and social development. While it is an established norm Male 47,070 (70.3)
Female 19,891 (29.7)
that the healthcare services in private sector are only Age (n ¼ 64,951)
accessible to those who can afford to pay, emergency 0 9 years 4308 (6.6)
10 19 years 12,472 (19.2)
services in public sector hospitals are considered to be 20 29 years 21,342 (32.9)
30 39 years 11,891 (18.3)
free to all, and accessible to every walk-in customer, and 40 49 years 8585 (13.2)
must be attended at the earliest without regard to the 50 59 years 3813 (5.9)
60+ years 2540 (3.9)
number of medics available on duty, number and Hospital (n ¼ 68,390)
Lady Reading, Peshawar (public hospital) 23,567 (34.5)
seriousness of patients already in the emergency, and
Benazir Bhutto, Rawalpindi (public hospital) 14,538 (21.3)
available bed-strength. Shifa, Islamabad (private hospital) 2540 (3.7)
Mayo, Lahore (public hospital) 8186 (12.0)
Sandeman Provincial, Quetta (public hospital) 5015 (7.3)
In our public sector teaching and tertiary care hospitals, Jinnah Medical Center, Karachi (public hospital) 12,820 (18.7)
emergency departments are purpose built facilities, Aga Khan, Karachi (private hospital) 1724 (2.5)
Mode of arrival to the ED (n ¼ 64,686)
where full time medical, nursing and allied staff is On foot 27,292 (42.2)
appointed in shifts, to attend the emergencies. The Public or private transport 32,061 (49.6)
Ambulance 5333 (8.2)
specialist services like surgery, medicine, obstetrics, Features of the index visit (n ¼ 62,434)
First visit to ED for this incident 60,194 (96.4)
pediatrics, neurosurgery, orthopedics, are provided by Follow-up 2240 (3.6)
the visiting / consulting staff on rotation basis, usually Received any treatment for index injury in last 72 h(n ¼
64,466)
through pre-determined rosters as to which unit will be No 59,882 (92.9)
on emergency duty on a specific week-day. Dedicated Yes 4584 (7.1)
Discharged from any hospital in last 7 days (n ¼ 59,957)
pharmacy, blood bank, radiology and Lab services for No 58,401 (97.4)
Yes 1556 (2.6)
emergency cases are available round the clock in such Number of ED visits for any reason in last 1 year excluding
hospitals. In smaller private and public sector (first index
visit (n ¼ 48,022)
referral or secondary referral) hospitals, usually there is 0 visits 27,918 (58.1)
One visit 13,875 (28.9)
one medical officer on emergency duty with Two or more visits 6229 (13.0)
paramedical staff, during off hours on shift basis. Services received
Triage (n ¼ 59,302)
However, there are many concerns regarding quality of Done 10,920 (16.0)
care in the emergency departments. Not done 48,382 (70.7)
Vitals noted (n ¼ 15,789)b
Blood pressure (at least systolic or diastolic) 11,632 (17.0)
Results of a multicenter large scale emergency room Pulse 9055 (13.2)
surveillance12 of trauma cases entertained in the year Temperature 8802 (12.9)
Respiratory rate 7091 (10.4)
2010-11 in seven tertiary care hospitals of Pakistan are Glasgow Coma Scale (GCS) 1287 (1.9)
Physical examination performed 57,231 (83.7)
depicted in Table 1 here. The study results reveal that Imaging performed (X-ray, CT, other) 34,225 (50.0)
most patients (70.7%) were not triaged. Only 23.1% had Laboratory investigation performed 4989 (7.3)
Outcome of the ED visit (n ¼ 55,520)
any vital sign noted; while 50% of patients had some Discharged 26,020 (38.0)
form of physical examination performed. All the Outpatient follow-up 17,202 (25.1)
Detained for observation/admitted 9443 (13.8)
hospitals included in the study had formal emergency Referred to other facility 1978 (2.9)
Expired 679 (1.0)
departments operational 24 hours a day, with heavy Left ED 198 (0.2)
patient load exceeding 75,000 patients annually, and a CT, computed tomography; ED, emergency department.
a For ‘Service received’ and ‘Outcome of ED visit’
daily patient to physician ratio of over 25:1. These characteristics,
percentages were calculated using total sample size (68,390) as
hospitals included two private and five public sector denominator, while all other percentages used available sample
tertiary care hospitals. size for each characteristic as denominator.
b One patient could have more than one vital sign recorded

According to the statistics provided in 201913 the number of emergency cases entertained by the 18
public sector teaching hospital of Punjab rose from 8,449,334 patients attended in 2015 to 11,043,824

12 Hyder A.A., He. S., & Zafar W.et al “The Royal Society of Public Health” 2017
13
Annual Report 2019, District Health Information System, DGHS Punjab.

D5 14-12-22 Page 21 of 117

patients in the year 2019. The DHQ hospitals in Punjab attended 6,556,530 emergency cases in 2019
while the THQ hospitals managed 7,741,555 emergency cases in year 2019. Bed occupancy in teaching
hospitals of Punjab remained 94%, and in the DHQ hospitals 91% during 2019. Given this amount of
workload, it is no wonder that parameters for quality of care would have suffered.

A number of pilot studies conducted in local hospitals have documented introduction of triage system,
e.g., implementation of South African Triage Scale in the Emergency Department of Fatima Memorial
Hospital Lahore in 201714; establishing triage desk in AKUH-ED in year 200015; implementation of a
triage score system in an emergency room in Timergara, Pakistan in June, 201116 have demonstrated
an improvement in safe disposal of patients and better patient satisfaction. However, need for making
adequate provisions of staff trained in emergency procedures has also been established.

Mr. R. Rehmani from the Aga Khan University Karachi17in his Editorial published in the Journal of
Pakistan Medical Association in May 2004, highlighted the need to initiate residency training programs
in emergency medicine. The College of Physicians and Surgeons Pakistan approved FCPS training
programme in Emergency Medicine in 2010. The program started at Aga Khan University Hospital
Karachi and Shifa International Hospital. Presently, 13 institutions in Pakistan have been approved by
the College of Physicians and Surgeons Pakistan (CPSP) for such training. However, public sector
institutions in Punjab are lagging behind in taking up emergency medicine fellowship training
programme. Lately, one year Certification Programme in Emergency Medicine (CPEM) was also started
by Indus Hospital in 201818, in collaboration with Brigham & Women Hospital (a teaching affiliate of
Harvard Medical School Boston).

Taking an account of what is the current status of emergency care in hospitals of Punjab compared to
the working of hospital emergency departments in Australia, Dr. Naveed Aziz (a Pakistani doctor
settled in Australia)19 stated that an emergency department cannot work successfully without the
whole hospital behind it supporting its performance and backing it up. While declaring the current
hospital emergency departments’ model operational in Pakistan as an obsolete version fraught with
danger, as young doctors are put in emergency with no formal training or supervision in managing
emergency, resulting in low level of care.

Dr. Naveed stated that in the first hour “the golden hour” you need senior and experienced clinicians
who can manage critical emergencies in an organized and methodical manner. He concluded that the
emergency departments should be managed by doctors trained in emergency medicine who should
provide leadership and ownership of the department. Dr. Naveed also recommended to inculcate
triage practice, based on urgency (and not essentially on severity of disease); and advised to
implement the triage practice fairly, with an attempt to distribute available resources equally and
equitably. Dr. Naveed suggested to organize hospital emergency departments with these major
functional sub-divisions internally:

14
Muhammad L.A.et al PJMHS Vol.12, No.4 Oct-Dec 2018
15
Munawar K et.al J Ayub Med Coll Abbottabad 2015; 27(3)
16
M.K. Dalwai et.al PHA 2013, 3(1) 43-45
17
R. Rehmani JMPA Vol.54., No.5 May 2004
18
Syed G Saleem et al, West J Emerg Med 2020 Mar 21(2)
19 Email by Dr. Naveed Aziz dated 28th Feb, 2022

D5 14-12-22 Page 22 of 117

 Reception
Easy access, close to public transport, and adequately sign posted

Triage
Triage should be done by specially trained nurses

Resuscitation Rooms
With 2-3 beds with oxygen ports, suction outlets, airway/breathing and
circulation resuscitation equipment;
Nursing ratio 1:1

Acute beds
With monitoring equipment
Nursing ratio 1:3

Sub-acute beds
Intermittent monitoring (to assess deterioration or escalation periodically)
Nursing ratio 1:5

Consultation Rooms

Procedure Rooms

 Suturing

 Plaster application

 Procedures under Minor anesthesia

Allied Facilities like staff room, conference / education room, offices for
Nursing, medical and admin staff, distressed relatives room, security, stores
and toilets

D5 14-12-22 Page 23 of 117

LEVELS OF CARE - INJURED/EMERGENCY PATIENT
Following are the progressive stages of care for the patients falling in an emergency situation.
Preparedness and ability of those in attendance to respond appropriately can greatly reduce the
extent of damage that is possible as a final outcome of trauma or emergency situation.

a) Pre-hospital care

1. Detection/Notification/Announcement
2. Early intervention
3. Transportation

b) Hospital care

1. Emergency care
2. Critical care
3. Definitive Treatment

c) Rehabilitation

Countries and communities where the populations have developed good understanding and foresight
into possible causes and events leading to the emergency situation, and have developed
understanding amongst the people to identify the early signs, and to act smartly towards seeking help;
and have social structures capable of being helpful (e.g., calling 15 or 1122 for ambulance service,
rescue service, fire service, civil defense, etc.) can minimize the risks of fatality or help to reduce
morbidity. Equally important is education and capacity building of volunteers and general public about
“what to do” in an emergency scenario, before the medics can take over the care of patient.

Availability of good emergency services in hospitals is a cost and resource intensive activity and it takes
years of sustained input and efforts to develop high tech and efficient surgical or medical teams and
systems to meet the challenge. The medical doctors, nurses and allied health professionals, all need
to be trained on life saving skills, and use of technology in time, to be effective.

Finally, once the emergency situation is over, the victim may very often need rehabilitation services
to become fully functional. Such services are obligatory to the institutional care of serious trauma
patients like spine injuries, head injury, burns, stroke, etc. Even though such services fall outside the
scope of emergency services, these services, coupled with social support networks, are extremely
important to harvest maximum benefit from the life-saving efforts of emergency services.

Public Policy owners, therefore have the responsibility to design and build the whole systems in a way
that is comprehensive, and is able to deliver best possible outcome while working in work in tandem
and harmony to achieve ‘health’ status for the population. in this regard, importance of life saving
measures to be undertaken during first hour after trauma or injury cannot ne over emphasized.

D5 14-12-22 Page 24 of 117

Golden Hour Management
Golden Hour is the critical period of one hour after an injury, accident or trauma, as the mortality
would considerably increase if efficient care was not provided within sixty minutes after the trauma
20
. Trauma in many countries is the leading cause of death during the first four decades of life 21. In
cases where death occurs within seconds to minutes due to laceration of brain stem, heart or large
vessels, it is difficult to save such lives.

In the second common mode, death may occur within minutes to hours later, as a result of diverse
injuries like haemo-pneumothorax, rupture of spleen, subdural hematoma or long bone fractures
leading to massive blood loss. Here an aggressive and appropriate timely management can save many
lives. The concept of Golden Hour has come out of this scenario.

Tri-modal Distribution of Death from Trauma

Source: Gill Cryer MD

The concept of Golden Hour lays emphasis on time, promptness and provision of life saving services
at the earliest, during the first hour of injury or trauma. This is only possible if well trained medics and
paramedics are available on call, 24 hours a day at various locations in the urban locations. The system
would require availability of well-equipped ambulances with necessary logistics and staff deployed
throughout the year. The quality of emergency care during golden hour would also depend upon the
stringent training protocols and drills. In this regard, availability of 1122 rescue service in Punjab is a
substantial input towards saving lives during golden hour.

Third common mode of deaths would occur days or weeks after the initial injury and would be most
commonly the result of sepsis, or multiple organ failure. Such deaths may sometimes be inevitable
due to subsequent complications of trauma, poor definitive or follow up or as a result of pre-existing
medical conditions predisposing to poor survival. The very basic principles in early management of
trauma are as under:

i). treat the greatest threat to the life first;

20 Adonis N et al, 2020

21 Kundavaram P. A & A. Sivanandan, 2020

D5 14-12-22 Page 25 of 117

 ii). lack of a definitive diagnosis should never stop from starting an indicated treatment;
iii). a detailed history is not a pre-requisite to begin the evaluation of an acutely injured patient
Following are the order of priority for management of trauma in the Golden Hour:

A: Airway
B: Breathing
C: Circulation

The primary assessment of the trauma patient is undertaken in a sequential manner to identify life
and limb-threatening injuries. The primary assessment and resuscitation is often undertaken together,
in the following manner:

o Assess patency of airway first; clear speech in a conscious patient is a good indicator
o Noisy breathing is an indication of airway obstruction – suction of mouth with a chin lift or jaw
thrust maneuver will prevent the airway from obstruction in most cases
o Oro-pharyngeal airway will be helpful to maintain airway in in comatose patient
o Endotracheal intubation may be considered in severe cases (for expert hands only)
o In patients where endotracheal intubation is not possible, surgical airway may have to be
established without delay, in case such patients appear to have lost airway protective reflexes
and have risk of gastric aspiration
o Measures to establish airway should also include protection of the cervical spine
o In a case with altered level of consciousness having blunt injury above the clavicle, or a patient
with multisystem trauma, always assume that the patient has a cervical spine injury
o Undertake manual in-line stabilization of the neck ( by an assistant) in such cases to prevent
un-intentional movement of the cervical spine during oro-tracheal intubation
o Once the airway is established, oxygen may be administered; followed by inspection,
palpation, and auscultation of the patient’s chest
o No chest wall movement with abdominal breathing may indicate a cervical cord lesion
o Observe for chest excursions and symmetry of breathing: paradoxical chest wall motion may
indicate the presence of a flail chest injury
o Massive hemothorax, tension pneumothorax and open pneumothorax need to be treated
immediately (consider needle thoracotomy as emergency measure)

Once the airway has been taken care of, assess pulse, blood pressure and neurological status
 Rapid and thread pulse is early sign of hypovolemia
 A restless or an unusually cooperative patient is usually because of decreased cerebral
perfusion
 Immediately secure IV line with two large bore branula for infusing fluids rapidly in case it is
needed.
 Apply pressure to obvious external bleed
 In case of hypotension, bolus of one to two one liter of Ringers Lactate may be life-saving.
 In case the hypotension persists, look for a continuing bleed – Hemorrhage must be controlled
before proceeding with rest of the primary assessment

D5 14-12-22 Page 26 of 117

  Be cautious: Raising blood pressure to normal in the presence of an ongoing bleed may cause
more damage
A rapid neurological evaluation should be performed during primary assessment; Glasgow Coma Scale
(GCS) can help to assess consciousness level

Fig 3. Glasgow Coma Scale Illustration

D5 14-12-22 Page 27 of 117

  Complete disrobing of the patient is mandatory of occult injuries are to be identified;
undergarments may be retained after the physical examination, if there is socio-cultural
sensitivity
 Examination of the external genitalia and rectal examination is part of the secondary
assessment
Resuscitation should follow the ABC pattern of primary assessment, and should be performed
simultaneously.
o if the airway is compromised, primary assessment should be suspended till the airway is
secured
o Compromised breathing may require decompression if there is a tension pneumothorax, or a
massive hemothorax.
o Endotracheal intubation and mechanical ventilation may be required if not breathing
adequately
o During resuscitation of circulation, if there is indication of blood loss, blood sample for cross-
match, serum electrolytes and hemoglobin assessment may be needed.
o ECG monitoring is essential for all trauma patients, so that volume loss (indicated by increasing
heart rate) and arrhythmias (due to blunt injury to the chest) can be identified
o The pulseless electrical activity evident from ECG trace without a palpable pulse can be due
to tension pneumothorax or cardiac tamponade
o Monitoring by Pulse oximetry is an indirect means of measuring the adequacy of ventilation

Following are the goals of primary assessment and resuscitation:

 Airway established and maintained
 Supplemental oxygen initiated
 Cervical spine immobilized
 Two large-bore intravenous lines started
 Blood drawn for baseline investigations and cross-match
 External hemorrhage control achieved
 Electrocardiography (ECG), blood pressure, and SaO monitoring
 Brief neurological examination completed
 Full exposure and environmental control done.

The secondary assessment should be performed after the completion of the primary assessment. It
is a head-to-toe systematic and comprehensive evaluation of all organ systems. Patient’s detailed
history can be obtained during this phase. This would include screening for
o Allergies
o Medications (especially anticoagulants, insulin, and cardiovascular medications)
o Previous medical/surgical history
o Last meal (time)
o Events (recall of) leading to injury or bio-mechanism of injury.
o Examination of the head and face

D5 14-12-22 Page 28 of 117

Immobilize the neck with a hard cervical collar until the cervical spine X-ray is done and cleared. With
an assistant immobilizing the head, remove the cervical collar and examine the neck for any
lacerations, tenderness, bogginess, or step deformities indicating the possibility of a cervical spine
injury
 Scalp lacerations tend to bleed profusely because of abundant vascular supply. Apply direct
pressure to control any bleeding.
 Check the continuity of the cranium with a gloved hand, palpating gently with the fingertips.
Beware of small puncture wounds of the scalp, which may indicate penetrating injury of the
brain
 Assess the GCS
 Examine the nose and ears for bleeding and leakage of cerebrospinal fluid
 Inspect the mouth for lacerations, broken teeth, or vomitus since they could jeopardize the
airway.
Examination of the thorax
Although assessed during the primary assessment, the thorax should again be reviewed for injuries.
Check SpO2 to assess peripheral oxygen saturation.
Examination of the abdomen; abdominal assessment includes inspection for contusions, abrasions,
and distension. Discoloration of the flanks may indicate retroperitoneal bleeding. Any wound above
the umbilicus may have penetrated the thorax
o Femoral pulse should be simultaneously palpated bilaterally and assessed for equality
o The integrity of the pelvis should be evaluated by pushing on the wings of the iliac bone to
determine if this action elicits pain
o Examine the urinary meatus for the presence of blood, which may indicate ruptured urethra
o Perform a digital pelvic examination in females to look for the presence of vaginal bleeding
o The patient should be logrolled with the head aligned to the body and the spine evaluated for
asymmetry and the presence of tenderness
o During the logroll, perform a rectal examination to evaluate the sphincter tone and presence
of blood.
Examination of the extremities
o Palpate the extremities for tenderness, crepitus, and deformities
o Evaluate for quality and integrity of pulses. Diminished pulses suggest disrupted blood vessels.
Traction generally restores blood flow
o If the patient is conscious, assess sensory and motor functions
o Suspected fractures and dislocations should be splinted for further radiographic and
diagnostic evaluation.
Adjuncts to secondary assessment
 A urinary catheter is a vital adjunct for poly-trauma management. The urine output is an
excellent way of assessing perfusion in patients with an intact renal function. Moreover, blood
in the urine may indicate renal trauma.
 The urinary catheter should be inserted only after ensuring that there are no pelvic fractures
that could have injured the urethra.

D5 14-12-22 Page 29 of 117

  Blood in the meatus, perianal hematoma, or a high-riding prostate on rectal examination
should raise suspicion of urethral injury.
 Under these circumstances, urinary catheterization should only be attempted after an
ascending urethrogram
 The nasogastric tube needs to be inserted to avoid stomach distension and to reduce the risk
of aspiration.
 When a base of skull fracture is suspected, the gastric tube should be inserted orally to prevent
the intracranial passage
 If available, obtain an ABG to assess the Haematocrit, PaO2, and the degree of acidosis.
 Mandatory radiology in trauma evaluation for all high-velocity accidents includes the chest,
lateral cervical spine, and pelvis.
 Focused assessment with sonography for trauma (FAST) is indicated if an intra-abdominal
injury is suspected.
Pre-hospital care plays a vital role in the early resuscitation of trauma victims. There is an urgent need
to train paramedics in trauma management, and to put resources in deploying the trained medics in
resuscitation, at locations from where they can reach to the accident site, and evacuate the injured
persons to hospital emergency departments / trauma centres for definitive treatment. The system
would require connectivity of well-equipped ambulances with adequate logistics, so as to improve
mortality and morbidity associated with trauma, and to optimize the care of injured during the Golden
Hour, to save maximum number of lives.
The system would also require geographically accessible hospitals that are well equipped, well
prepared, with available bed capacity and trained and qualified human resource ready to take up the
trauma cases, operational for 24 hours a day and seven days a week.

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 Planning of Emergency Services
Planning for making provision of Emergency Services is based not merely on a piece of land and a fancy
design, rather on the following pragmatic considerations:
Demand of Services, as evident from statistical data comprising inflow of patients, number of
emergency patients visiting in the area hospitals, their average length of stay and the type and nature
of emergencies being received, or referred. The demand is calculated for a period of time into the
future (Time Horizon over the base year data). The planning of facility includes recommendations for
the following parameters:
a. Number of beds for a variety of types (acute beds, recovery beds, etc)
b. Number of operating rooms,
c. Number of Labor rooms,
d. Consultation/examination rooms
e. Emergency treatment beds /areas
f. Diagnostic facilities (Labs, Radiology, Angiography, etc)

Similarly, planning for emergency services would also take into account the supply side, i.e., current
supply of health facilities and the range of services they cater for; and identifying potential gaps for
making provisions accordingly. This process would include needs analysis, feasibility and devising
appropriate business model.
The hospital emergency building design should cater for natural light, privacy (including acoustic
privacy in areas of confidential conversation), noise reduction, and ergonomic factors for occupational
safety of employees. Services should include telephone lines, IT/Communication facilities including
data connections, and facilities for teleconferencing, etc. The planning should also take into account
the local building design, and safety regulations22. A lot will depend upon local customs and traditions,
for example, providing access to recovery area for family and relatives, separation of male and female
treatment areas, recovery areas, and waiting areas; prayer rooms, and independent male and female
inpatient units for accommodating patients in a culturally appropriate mode.
Clear access ways and designated parking lots need to be demarcated clearly. For service vehicles
like delivery and waste management vehicles, loading docks should be designed compatible with the
type of vehicles (clean versus dirty). In rush hours, traffic control arrangements may be needed for
segregation of vehicles according to priority of use, and patient access is not interfered with
emergency and service vehicle access. Similarly, parking facility should also cater for ease of access for
the disabled, and those with special needs. Such parking areas should have a firm, plane surface and
a continuous accessible path of travel should be provided between each parking space to an accessible
entrance or the lift, identified with the international symbol of access for people with disabilities
The International Health Facility Guidelines, 2017 provide sample layout designs as per the following
requirements:
a) Small Emergency Units Minimum 5 to 10 treatment spaces
b) Medium Minimum 11 to 30 treatment spaces
c) Large Minimum 31 to 100 or more treatment spaces

22 Indian Health facility Guidelines, July 2014

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Calculation of the areas should take into account the space required for departmental corridors, Plant
rooms, fire hose reels, Fire stairs, Lift shafts, Service Cupboards and ramps. The location of parking
areas require proximity to staff, patients and other users, location of main waiting area. For private
and emergency vehicles, the car park or drop off areas should be in accordance with the local building
authority guidelines. For ambulances, designated ambulance drop-off and parking is essential.
An electronic Emergency Information system may be installed to support clinical management,
patient tracking and departmental administration. Sufficient number of terminals, peripheral devices,
keyboards, drives and printers should be provided to support functioning of the emergency
departments. An intercom and public address system that can reach all areas of the emergency
department would be greatly helpful. All patient spaces and clinical areas including beds, patients
toilets and bathrooms, treatment areas and lounges should have access to the emergency call facility,
so that help can be called through a central module situated adjacent to the staff station.
The following IT/ Communications systems shall be provided within the Emergency Department:
a. Voice and data points for telephones and computers/ internet
b. Data provision for electronic medical records and patient management systems as required
c. Access to a Picture Archival Communications System (PACS) in clinical areas
d. Queue management system.
e. Nurse and emergency call systems should be installed in all clinical areas including patient
lounge areas and patient toilets to assist staff and patients
f. A duress alarm system should be designed into Reception, Interview rooms and Cashier
positions.
Entry points, doors and openings to the Admission and Discharge area should be a minimum of 1200
mm wide, unobstructed, and doors used for bed transfers should be a minimum of 1400mm wide,
unobstructed23. Doors must provide acoustic privacy, and door openings must allow risk free passage
of patients, staff and maneuvering space for equipment, wheelchairs and trolleys where necessary.
The Emergency Department should be at ground floor for ease of access, and accessible by two
separate entrances; one for ambulance patients and the other for ambulant patients24. Each entrance
area should have a separate foyer that can be sealed remotely by activating the security doors, and
both entrances should direct the patient flow to the reception / triage area. It is recommended that a
decontamination area is provided near the ambulance bay, and provided with shower hose spray, and
floor drain.
The Entrance to the Emergency Department must be at grade-level (same ground level), well-marked,
illuminated and covered. A ramp should be provided for pedestrian and wheelchair access. At the
Emergency Entrance, waiting area should provide sufficient space for waiting patients as well as
relatives, and have adequate seating capacity. The area should be open and easily observed from
triage and reception areas. Space should be allowed for wheelchairs, prams and walking aids. Children
play area, television, health literature and access to drinking water is desirable. Fittings must not
provide the opportunity for self-harm or harm to staff. Waiting area should have access to triage and
reception, toilets, light refreshments, and telephone.
The Triage facility should be co-located with the reception desk and ambulance entry. In a smaller
facility, the triage nurse may interview the patients, perform observations and provide first-aid in

23 International Health Facility Guidelines, Part 2; Oct 2016

24 International Health facility Guidelines, Version 5, 2017

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relative privacy in the triage area (bed-bay or cubicle). Another senior nurse may manage the patients
in the waiting area after triage, and awaiting treatment. After the triage and registration, patient may
be transferred into a separate clinical area called “early treatment zone” where patients are to be
managed for a short time before they are moved to the appropriate area (acute care or waiting-for-
discharge area)
Some health facilities dedicate a separate “fast-track or Urgent Primary care” after the triage point,
usually on the model of extended late hour GP service. Patients who are ambulant with non-complex
conditions such as contagious diseases, minor injuries, and pediatric illnesses are mostly managed
here. The facility includes a consultation / examination area, basic resuscitation, stabilization and
minor procedures taken care by senior GPs and Registered Nurses. The patients who may need more
specialized care are transferred to the main emergency department.
In larger tertiary care hospital settings patients may be managed in different areas according to the
specialty of service they require, i.e., grouping of patients by specialty. The examples include separate
bay for Chest pain paediatrics, obstetrics, or acute treatment with complex investigation and discharge
pathway. Patients may be triaged from a central arrival point, or from separate ambulance entry
points. Such a model would require separate staffing for each area, and separate workspaces for staff.

Another functional model provides grouping by patient acuity or urgency, where patients of similar
intensity are treated in the same zone. Such facility may have separate areas for resuscitation, acute
monitoring beds, acute non-monitoring beds and ambulatory treatment bays allocated separately.
The facility may have separate entry points or triage points for different areas, with separate staff
allocation. Short stay wards / emergency medical unit or observation bays may be incorporated into
one emergency unit, thus allowing sharing of staff and support facilities.

A significant proportion of patients attending Emergency Departments can also be managed in general
practice easily25. In England, policies require such patients attending the Emergency Departments to
be directed or ‘streamed’ to General Practitioners working in or parallel to the Emergency
Departments.

25 Anderson H et al, 2021

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Major Functional Areas in the Hospital Emergency
A: ENTRANCE / RECEPTION / TRIAGE:
 Receiving of patients and visitors and administration
 Assessment for patients
 Designated area at the entrance for holding wheel-chairs and patient trolleys along with
porters ready to receive the patient and shifting the patient to appropriate treatment area
after triage

B: PATIENT TREATMENT AREAS:

Assessment and treatment areas including Resuscitation, Acute Treatment bays/ rooms,
Seclusion Room and Decontamination Facility, Paediatric patient areas, Procedure Rooms
Short-Stay Ward/ Emergency Medicine Unit/ Observation Unit;
 Primary Care Area - for patients with low acuity conditions;
 Stepdown Area - for patients awaiting test results, considered safe, but requiring observation
prior to admission or discharge.
C: STAFF AND SUPPORT AREAS
o Clean and Dirty Utility Rooms
o Store rooms
o Linen
o Waste Holding/ Cleaners rooms
o Staff amenities, administrative and teaching functions;
o Ambulance facilities.
The main aggregation of clinical staff will be at the Staff Station in the Acute Treatment/ Resuscitation
Area. This should be the focus around which the other clinical areas are grouped. The
Entrance/Reception Area is the focus of initial presentation.
D: ADDITIONAL DESIGNATED AREAS
In addition to standard treatment areas, some departments may require additional, specifically
designed areas to fulfil special roles, such as:
o Management of paediatric patients
o Management of major trauma patients
o Management of psychiatric patients
o Management of patients following sexual assault
o Extended observation and management of patients
o Undergraduate and postgraduate teaching
o Transport and retrieval services
o Tele-medical referral/ consultation service

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

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F: WAITING AREA
Waiting Area should provide space for patients in waiting, as well as relatives/ escorts. The area should
be open and easily observed from the Triage and Reception areas. Seating should be comfortable and
adequate. Space should be available for wheelchairs, prams, walking aids and for patients being
assisted. There should be an area where children can play.

G: SUPPORT FACILITIES
Support facilities, such as a television should be available. Fittings must not provide the opportunity
for self-harm or harm towards staff. Waiting Areas shall be negatively pressured.
From the Waiting Area there must be access to:
o Triage and Reception Areas
o Toilets; Baby Change Room
o Light refreshment facilities which may include automatic beverage dispensing machines
o Telephone and change machines; Health literature

It is desirable to have separate waiting areas particularly for children. Child play areas may also provide
equipment suitable for safe play activities, including a television. It shall be separated for sound from
the general Waiting Rooms and must be visible to the Triage Nurse. The area should be monitored to
safeguard security and to ensure patient’s wellbeing.

H. RECEPTION / CLERICAL AREAS

The Reception Area should accommodate for:
o Reception of patients and visitors
o Registration interviews of patients
o Collation of clinical records
o Printing of identification labels.
The counter should provide seating and be partitioned for privacy at the interview area. There should
be direct communication with the Reception / Triage area and the Staff Station in the Acute Treatment
/ Observation Area. The Reception/Clerical Area should be designed with due consideration for the
safety of staff. This area requires a duress alarm.

I. RECEPTION / TRIAGE
The Reception / Triage and Staff Station shall be located where staff can observe and control access
to treatment areas, pedestrian and ambulance entrances, and public waiting areas. This area requires
a duress alarm. The Emergency Unit should be accessible by two separate entrances: one for
ambulance patients and the other for ambulant or walk-in patients. It is recommended that each
entrance area contains a separate foyer that can be sealed by remotely activating the security doors.
Access to Treatment Areas should also be restricted by the use of security doors. The Ambulance
Entrance should be screened as much as possible for sight and sound from the ambulant patient
entrance. Both entrances should direct patient flow towards the Reception/Triage Area.
The Reception / Triage area should have clear a vision to the Waiting Room, the children’s play area
(if provided) and the ambulance entrance. The Reception / Triage Area may perform observations and
provide first aid in relative privacy.

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INTERNAL LINKAGES
The Hospital Emergency Department would require ready access to the following key functional
areas:
 Medical Imaging Unit
 Operating Unit - rapid access is highly desirable for surgical emergencies
 Coronary Care Unit
 Pathology / Blood Bank Unit
 Clinical Records Unit
 Inpatient Accommodation Unit
 Pharmacy Unit - proximity is required
 Outpatients (if an outpatient service is provided adjacent to the Emergency Unit)
 Mortuary

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Fig.4 Sample Outlay of Small Emergency Unit: minimum 5 to 10 treatment beds

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Fig.5 Sample Outlay of medium size Emergency Unit: minimum 11 to 30 treatment beds

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Fig.6 Sample Outlay of Large size Emergency Unit: minimum 31 or 100 or more treatment beds

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There should be a separate negatively pressured waiting area for use by patients presenting with
suspected pandemic infections. Otherwise, the emergency department should have appropriate air
conditioning that allows control of temperature and humidity within each functional area. For the
purpose of Infection control, hand-basins should be located in close proximity to each treatment bays
and must be included in each enclosed bay or treatment room. All hand-basins in clinical areas should
be of surgical type-A with hands free activation. Dispensers for non-sterile latex gloves should be
available in the vicinity of each hand-basin and each treatment area.
The resuscitation Room or bay requires adequate space for resuscitation bed, enough to provide 360
degree access to all parts of the patient for un-interrupted procedures, and circulation space to allow
movement of staff and equipment around the work area. The resuscitation area should care for
maximum visual and auditory privacy for the occupants, other patients and relatives. This area should
be close to ambulance entrance and separate from the patient circulation area, with easy access to
the staff station of the acute treatment /observation area. The facility should include full range of
physiological monitoring and resuscitation equipment. In case partitions are required form other
areas, these should be solid. Each resuscitation bay should be equipped with physiological monitors
with facility for ECG, Non-invasive blood pressure monitoring (NIBP), SpO2 monitoring, temperature
probe, CO2 monitor, a procedure light, equipment to hang IV fluids and to attach infusion pumps. The
resuscitation area should have a resuscitation patient trolley, and clinical scrub basin with paper
towel and soap fittings. The imaging facilities should include overhead X-ray or mobile digital x-ray, X-
ray screening (lead lining) of walls and partitions between beds, and patient resuscitation bed, with X-
ray capability.
Once the patient has been triaged and resuscitated, he or she is moved to Acute or Non Acute
Treatment Areas, depending upon the condition. Acute Treatment Areas are meant for management
of acutely ill patients, whereas the patients who are not critical but require observation or
investigation prior to discharge are managed in non-acute treatment area. Essential requirements are
bed bays to fit a standard mobile bed, storage space for essential equipment and supplies to be used
at the bed side, and space to allow for monitoring equipment.
Wall mounted air/vacuum Suction points, or mobile Sucker machines; and Medical gases may be
provided within selected recliner/ bed bays as required by the facility’s operational policy. All
treatment bays in the hospital emergency department including triage are, would require the
following facilities:
a. Service panel with medical gases, power and data
b. Examination light, focused with a power output of 30,000 lux to illuminate field size of at least
150 mm
c. Wall mounted sphygmomanometer
d. Waste bins and sharp containers
e. Emergency call facilities (e.g., 15 or 1122)
The Acute and non-acute patient areas must provide the patient toilet / Ensuite facilities as under:
No. of beds / treatment bays Number of Toilets /Ensuites
Up to eight treatment bays two patient toilets / Ensuite facility for; one each for male and
female patients
Between 9 and 20 treatment bays Four patient toilets / Ensuites (2 male, 2 for female)
Between 21 to 40 treatment bays Six patient toilets (three each for male / female)
More than 40 treatment bays Eight patient toilets (four each for male/female)

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At least two of the above toilets /Ensuites should be accessible to wheelchair; one for male and one
for female.
Design and dimensions of counters and workstations should ensure privacy and security for patients,
visitors and the staff. Same counter heights should be made for both patients/ visitors and staff to
enhance communication and to minimize aggressive behaviour. Seating in the waiting areas should
be provided at a range of heights to cater for the different mobility levels of patients. The following
security issues shall be addressed when designing the Emergency Departments:
a. Counters should be designed so as to enable unobstructed vision to waiting areas26
b. Duress alarm and access to egress points must be provided at reception counters
c. Waiting areas shall have no visibility to the staff and/or cashier area behind the counter
d. Controlled after-hours access to prevent un-authorized entry and theft
e. Provision of CCTV to monitor movement and behaviour within the Unit
f. Provide training to staff on procedures to follow during an armed hold-up
g. Design should maximize observation of waiting area by the staff
Colors should be chosen for Internal finishes of the emergency department, especially where patient
observation is critical, in such a way that these do not alter the observer’s perception of skin color.
Acoustic properties, durability, ease of cleaning, infection control, fire safety and ease of movement
of equipment are key features in selection of materials. The floor finishers in patient care areas, and
corridors should be non-slip, impermeable to water, and body fluids, durable, easy to clean and of
such acoustic properties that reduce sound transmission, and help to absorb shock to optimize staff
comfort, but facilitate bed movement. All wall surfaces that come into contact with mobile equipment
or beds should be reinforced and protected with buffer rails. Windows should be durable and easy to
clean, and may use double glazing with integral blinds, tinted glass, reflective glass, exterior overhangs
or louvers to control the level of lighting.

The Hospital Emergency Departments receive a large number of patients and their relatives /visitor,
many of whom may be distressed agitated, intoxicated or have tendency towards violence. The
hospital management has a duty of care to provide for the safety and security of employees, patients
and visitors. Hence, policies should be in place to minimize injury, psychological trauma and damage
or loss to property after undertaking a detailed security risk assessment. The security office should
preferably be located near the entrance, allowing clear view of the waiting room, triage and reception
area, while allowing remote monitoring of other areas by CCTV and immediate response to staff
duress alarm.

Height of the counter should be at 850 mm (=/-20 mm) to allow for standing interactions, and reduced
to 720 mm if a seated position is required. Depth of the counter should not be more than 1400 mm.
Usually the standard hospital bed (97 cm or 36 inch wise) is enough27. However, for patients having
Body Mass Index of more than 45 kg/m2 should be put on larger bariatric beds.

A minimum of 1400 mm clear opening is recommended for doors requiring bed/trolley access.
Treatment bed area should be at least 2.4 meters of clear floor space between the centres of each
bed and a minimum of 900 mm clear space at the sides and foot of each bed. Hospital corridors should
allow the passage of two hospital beds without difficulty.

26 International Health Facility Guidelines, May 2016

27 Neal Wiggermann et al, 2017

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The Emergency Medical Ward is typically a short stay facility. Patients requiring observation,
diagnostic services, therapy or follow up that may take up to 24 hours. Mostly such patients would be
discharged home or admitted to an in-patient unit, in case their condition does not allow them
discharge to home.

A number of hospitals have separate areas or blocks allocated for pediatric emergencies, In case there
is no such allocation, a separate zone with restricted access should be designated for pediatric
assessment and treatment. Such unit should have beds/cot bays and chair bays for nebulizer therapy,
and pediatric consultant rooms.

For patients coming up with mental health issues, or behavioral problems, the emergency department
should have adequate facilities for reception, assessment, stabilization and initial treatment. Such
facility would not be meant for prolonged observation of uncontrolled patients, but rather to provide
a safe and appropriate space to interview and stabilize the patient. Environment of a busy medial
emergency department may not be conducive to the care of patients with acute mental health crises,
whereas such patients have the potential to disrupt the normal operations of the emergency
department. The acute mental health and behavioral assessment area should be separate enough
from adjacent patient care areas to allow privacy for the mental health patient and protection of other
patients form potential disturbance or violence. Following are the recommended settings for such
facility:

Interview Room (Mental Health) with

 Two exit doors, swinging outward and lockable from outside, to allow for the escape of staff
members when one exit is blocked; one door should be large enough to allow a patient to be
carried through it; consideration should be given to solid core doors with safety viewing glass
 Design that permits observation of the patient by staff outside the room at all times; this may
be backed up with closed circuit television for the safety of staff
 Acoustic shielding from external noise
 Soft furnishings with no hard edges
 No patient access to air vents or hanging points
 Smoke detectors fitted
 Duress alarm at each exit.
Treatment room (Mental Health) with the following features:
o The room should be immediately adjacent to the Interview room and should contain adequate
facilities for physical examination of the patient; however, the inclusion of unnecessary and
easily dislodged equipment should be avoided; a lockable retractable door or panel to services
is recommended.
o If operational policy dictates that intravenous sedation is to occur in this area, the room should
include appropriate facilities and monitoring equipment, mounted out of reach of a
potentially violent patient. The room should contain the minimum of additional fittings or
hard furnishings that could be used to harm an uncontrolled patient. It should be of sufficient
size to allow a restraint team of five people to surround a patient on a standard Emergency
Unit bed and should be at least 14 m2 in floor area.
Patient flow should be separated and a separate secure entrance for use by community emergency
mental health team and police may be required. Patient should be under continuous observation
directly or through CCTV, and assistance when required, should be readily available. The area should
not have the objects that can be thrown at staff. The area should be free of heavy or breakable
furniture, sharp of hard surfaces which could injure an uncontrolled patient, and should incorporate
tamper resistant electrical fittings. There should be two separate exit doors opening outwards, and

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should be lockable from outside. The window drapes or blinds should be operable from outside. All
areas should have easy access to duress alarms.
Additional facilities in the Hospital Emergency Department may include vital signs room having
weighing scale, stadiometer for height measurement, and vital signs monitoring equipment, holding
room for the storage of bodies of the deceased patients.
In-house radiology facility and easy linkages with main radiology department of the hospital should
exist, for detailed investigation where necessary.
The in-house facility of blood bank and provision of blood preparations, or an appropriate linkage with
the main blood bank facility of the hospital should be available.
Similarly, basic pathology testing through an in-house lab facility, including point of care services, or
a connected set up with the main hospital laboratory (through a shoot or duct) should be operational,
ensuring safety of samples, time saving and efficiency.

Triage System
Triage is a French word meaning to sort or to choose. Triage is therefore a process whereby each
patient is prioritized amongst the randomly approaching patients in the Accident & Emergency
Department/rescue area for emergency care. Sorting of patients into priority categories is often
performed by an experienced doctor/surgeon or a senior health professional/nurse.

The triage nurse/health professional shall quickly assess the patient’s condition, interpret the clinical
features and then exercise interventions in the early phase to prevent deterioration and death. The
objective of the triage is to defer a patient who can wait, while give priority to those who are in
imminent danger, and whose life can be saved by a timely intervention.

How Does Triage Work

The triage system is meant to be implemented in all Accident & Emergency Departments (A&EDs) so
as to help and determine the relative priority of individual patient needs. Emergency patients are to
be given immediate treatment, while those with non-acute symptoms may have to wait longer.
Assessment process during the triage need to be balanced with the extent of patient flow, as
expanding the assessment process during triage may slow down the patient flow and may lead to
delay in emergency service provision28.

Upon arrival at the A & E department, the patients will first be assessed by a health professional like
an experienced doctor/triage nurse, according to the severity and nature of their medical conditions,
and priority will be given to urgent cases. The Patients are divided into the following four categories
according to their medical condition:

 Critical
 Urgent
 Semi urge
 Non urgent
Critical patients, who are in life threatening condition, are accorded top priority and attended
immediately by medical and nursing staff without delay. The non-urgent cases will be treated in the
order of their arrival and should expect a longer waiting time.

28 Ajani K., JPMA 2012

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Objectives of the Triage.
 Ensure early recognition and assessment of patient’s condition and prioritize the
treatment according to severity of the condition
 Reduce unnecessary delay of treatment
 Give brief first aid advice
 Initiate immediate diagnosis test intervention and nursing treatment
 Allow effective utilization of staff and resources by allocating patients to appropriate
treatment according to their condition
 Improve patient staff relationship and departmental image through greeting and
communication during process of triage
 Promote public relationship by immediate interview with patients
 Enable direct communication with pre-hospital care providers
 Provide staff training and decision making

In order to understand the proportion of resources a health facility can commit for the Emergency
Department, capacity of the hospital in terms of the following parameters need to be understood.

Hospital Treatment Capacity (HTC): the number of casualties that can be treated in the hospital in an
hour and is usually calculated as 3% of total number of beds.

Hospital Surgical Capacity (HSC): the number of seriously injured patients that can be operated upon
within a 12 hour period, i.e. HSC=Number of operation rooms x7x0.25 operations /12 hours.

Surge Capacity: The ability of a health service to expand beyond normal capacity to meet increased
demand for clinical care. It is an important factor of hospital disaster response and should be
addressed early in planning process. Following factors are critical to augment surge capacity of a
hospital:

i. Total number of beds available

ii. Human resource
iii. Essential equipment, logistics and supplies
iv. Adaptability of available facility space for critical care
v. Estimating the increased demand on hospital resources
vi. Options or available methods of expanding hospital inpatient capacity, considering
available physical space, staff, supplies and processes
vii. Designating areas for care in case of patient overflow, e.g. auditorium, lobby
viii. Outsourcing the care of non-critical patients to appropriate alternative treatment facilities
ix. Assigning home care for non-critical patients and chronic care facilities for long term
patients
x. Availability of vehicles for transportation of patients, contingency plan to transfer patients
in case the traditional methods of transportation fail
xi. Identify potential gaps and address the gaps, especially in critical care in coordination with
hospital networks/neighborhoods
xii. Identify additional sites for converting onto patient care units e.g. convalescent homes,
hotels, schools, community centres, gyms, etc.

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 xiii. Prioritize or cancel non-essential services e.g., elective surgery, adapt hospital admission
and discharge criteria and prioritize clinical interventions according to available treatment
capacity and demand
xiv. Designate an area for use as a temporary morgue and ensure availability of adequate
number of body bags, and formulate a contingency plan for post-mortem care with
appropriate partners.

Emergency situation can be classified keeping in view, either the total number of similarly disposed
patients received in the Emergency Department in a given time, or based on type of casualties being
received.

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Triage: Concept and Application
Internationally, there are a number of triage concepts. Simple triage is used at accident scene where
patients are sorted to identify those who need critical attention and immediate transport to the
hospital. During this process, each patient is labelled with identity and triage tags if available, or with
marker pen, with display of assessment findings, and assigned priority for medical treatment. Triage
should be a continuous process, as successful initial management may help to re-categorize such
patients to a lower priority in the short term. Hence, the priority or category once assigned, should be
checked regularly/periodically to ensure that the priority remains correct, unless there is change in
patient’s condition.

In advanced triage, usually in case of mass scale disasters, like earthquakes, storms, terrorist attacks,
bomb blasts etc., the specially trained doctors, nurses and paramedics may decide to defer advanced
care for some very seriously injured people that are unlikely to survive. This ensures that scarce
resources are not exhausted on patients having little chance of survival that can rather be preserved
for others with higher likelihood to survive. Such patients having poor prognosis may be offered
palliative care only, set aside the hopeless victims and avoid trying to save one life at the expense of
several others.

In a real case scenario, it is acceptable to over-triage /over-estimating the severity of illness up to 50%
and assigning higher priority for care rather than under-triage /under-estimating the urgency of care
for patients that actually need immediate care as first priority which should not be more than 5%.
Reverse triage is used to discharge a number of admitted patients who may not need immediate care
in the wake of a major wave of new patients arriving in the hospital upon occurrence of a natural
disaster, so as to make hospital beds available for new critical patients.
Secondary triage is done when the patients arrive at hospital emergency, by the emergency nurses or
skilled paramedic. Based on the availability of immediate care, a person with amputation injury may
be assigned “red” or immediate category as surgical re-attachment would only be possible if offered
within minutes, while patient may not be at the risk of dying without a thumb or a hand.

Ethical Dilemma in Triage

How the VIPs and celebrities should be cared for in the emergency department, is a big question.
Giving special considerations or deviating from the standard medical protocol for VIPs or celebrities
at the cost of suffering of others is unethical. However, it may be morally justifiable as long as their
treatment does not hinder the needs of others after assessing overall fairness, quality of care, privacy,
and other ethical implications. Keeping in view the ethical dilemma involved in the triage process,
individuals involved in triage must take a comprehensive view of the process to ensure that values of
fidelity, veracity, justice, autonomy, and beneficence are safeguarded.

It is advised for emergency departments to preemptively plan strategies so as to mitigate the

emotional burden on the triage responders. However, while doing so, standards of care must be
maintained and safety of both patients and providers be kept as the foremost consideration.

There are different Scoring Systems for assigning priority for treatment and /or evacuation of the
injured / affected persons in a disaster situation, during rescue and subsequently in the hospitals, for
the purpose of prioritizing them for providing medical care. Different countries and teaching / training
institutions use different triage schemes and techniques. Country wise selected examples of Triage
Scoring Systems internationally in vogue are summarized at Annex-IX:

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Sarah R et al, 201429 have observed that the triage scales and the triage tools widely used in the
developed countries were not applicable as such in the hospitals in developing countries having much
lower number of nurses and doctors. The South African Triage Scale (SATS) was thus developed for
such setting with the objective to have an accurate measure of urgency based on physiological
parameters and clinical discriminators that can be easily adopted in the low resource settings.
Experience with Nurse-led triage, apart from saving waiting time for patients in emergency, has shown
high level of sensitivity and specificity in such settings.

Triage Early Warning Score (TEWS) helps to measure physiological aspects of triage on a scale of 0 to
3 based on temperature, heart rate, respiration and systolic blood pressure, while also taking into
account conscious level, mobility and exposure to trauma. This scoring requires only a blood pressure
cuff, a thermometer, and a scoring card for accurate and uniform assessment of both medical and
trauma patients.

When patients arrive to the Emergency, the triage nurse interviews the patient to assess for
presenting complaint, mobility and AVPU score (A = alert, V = responds to voice, P = responds to pain,
U = unresponsive). Pulse rate, blood pressure, respiratory rate and temperature are measured and
recorded. The Triage Early Warning Scale (TEWS) score is then matched to a SATS discriminator list,
and an appropriate triage color is assigned. Further patient management is undertaken as per assigned
priority based on such information.

In the international literature, two research articles have documented use of triage system in Pakistan.
Firstly, the Aga Khan University Hospital Karachi has been reported to have implemented the concept
of triage for the first time in year 2000 (Munawar K. et al, 2015) 15, as there was no triage system in
place at local or national level and patients are being catered on first come first basis. The Aga khan
University Hospital Karachi, a 550 bedded tertiary care private hospital, with nearly 48,000 patients
visiting annually started with a single room emergency in 1983. The Emergency Department of the
AKU now became a 51 bedded dedicated emergency facility with resuscitation area, adult critical care
area, adult non critical care area, and a well designated 10 bedded pediatric care area.
Initially, the physicians and nurse both were assigned to triage desk for sorting out the patients
according to presenting complaints, on a manual recording system, and in accordance with the locally
developed triage priorities. The AKU experts’ team observed that the triage protocols like Emergency
Severity Index (ESI), Canadian Triage and Acuity Scale (CTAS), Australian Triage Scale (ATS) had limited
applicability in developing countries. The AKU experts came up with four level priority (P1-life
threatening, P2-Emergency, P3-Urgency and P4-stable walk-in) for triage.
In 2008 the triage system at AKU hospital was expanded and responsibility of triage was shifted to the
nursing staff. Specific triage protocols were developed for guidance of the staff; and to ensure
uniformity of care. The triage data was computerized by using a software platform. Thus it became
possible to monitor the triage process by using quality care indicators like total number of patients
triaged, triage category, lag time reports and ‘left without being seen by physicians’.
The AKU Hospital triage data analysis also documented that around 12.73% “left without been seen”
were those patient who upon arrival were triaged by the nurse, but while waiting to be taken inside
emergency department and seen by physician for evaluation, they left. This Indicator is considered
very important in modern emergency for measuring overcrowding and call for better management of
patient flow. This data led the AKU Emergency Department to establish a dedicated Emergency Clinic

29 Sarah R et al, AFJEM, 2014

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in afternoon for follow up and for walk-stable category of patients when the flow of patients was at
peak.
Subsequently, in June 2011, The South African Triage Scale (SATS) system was pilot tested in the
Emergency Department of Timergara district headquarter hospital, lower Dir, Khyber Pakhtunkhwa
province16. The emergency department of Timergara DHQ hospital consisted of 18 beds, with a
monthly caseload of about 4,000 patients. The results concluded with 86% triage forms filled without
error, and in 3% cases the patients were under triaged, and in 1% cases the patients were over triaged.
The study concluded that the SATS can be implemented successfully and used accurately by the nurses
in the Emergency Departments in Pakistan.

The adopted version of the South African Triage Scale (SATS), has been described in the subsequent
sections in detail.

Lately, in Brazil Portugal and many other European countries, the Manchester Triage System (MTS)
has been wide disseminated30. The MTS establishes five categories or clinical priorities for the purpose
of risk stratification, depicted as under:

Sr. No. Color code Level of urgency Max waiting time

1 Red Emergent Immediate service
2 Orange Very urgent 10 minutes
3 Yellow Urgent 60 minutes
4 Green Not urgent 120 minutes
5 Blue Not urgent 240 minutes
6 White* category used in Brazil & Portugal to identify patients using Emergency Service as
gateway for elective or scheduled procedures

30 APS Jesus et al, 2021

D5 14-12-22 Page 48 of 117

 Triage Scale (TS)
Introduction
The Triage Scale (TS) is a scale for rating clinical urgency and is designed for use in hospital-based
emergency services31. Although, primarily a clinical tool for ensuring that patients are seen in a timely
manner, commensurate with their clinical urgency, the TS is also a useful case-mix measure. The scale
directly relates triage code/colour with a range of outcome measures e.g. inpatient length of stay, ICU
admission, mortality rate and resource consumption (staff time, cost). It provides an opportunity for
analysis of a number of performance indicators in the A & E (operational efficiency, utilization review,
outcome effectiveness and cost).

What is Hospital Emergency Triage?

A method of ranking sick or injured people according to the severity of their sickness or injury in order
to ensure that medical and nursing staff and facilities are used most efficiently; assessment of injury
intensity and the immediacy or urgency for medical attention.
Benefits of Triage:
i. To expedite the delivery of time-critical treatment for patients with life-threatening conditions
ii. To ensure that all people requiring emergency care are appropriately categorized according
to their clinical condition
iii. To improve patient flow
iv. To improve patient satisfaction
v. To decrease the patients’ overall length of stay
vi. To facilitate streaming of less urgent patients
vii. To be user-friendly for all levels of health care professionals

Application of Triage Scale

Procedure
All patients presenting to an A & E should be triaged on arrival by a specifically trained and experienced
registered nurse. The triage assessment and TS code/colour allocated must be recorded. The triage
nurse should ensure continuous reassessment of patients who remain waiting, and, if the clinical
features change, re-triage the patient accordingly. The triage nurse may also initiate appropriate
investigations or initial management according to organizational guidelines. The triage nurse applies
a TS category in response to the question: “This patient should wait for medical assessment and
treatment no longer than….”

Environmental and Equipment Requirements

The triage area must be immediately accessible and clearly sign-posted. Its size and design must allow
for patient examination, privacy and visual access to the entrance and waiting areas, as well as for
staff security. The area should be equipped with emergency equipment, facilities for standard
precautions (hand hygiene facilities, gloves), security measures (duress alarms or ready access to
security assistance), adequate communications devices (telephone and/or intercom etc.) and facilities
for recording triage information.

31 The MOH Ghana A&E Services Policy & Guidelines, 2011

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The Triage Tool
Three versions of the Triage Score22
There are three versions of the Triage Score (TS), depending on whether the patient is an adult or not.
The children have different values of heart rate, respiratory rate and blood pressure. The adults have
their own version while there are two pediatric versions, one for infants (50cm to 95cm – one week
to almost 3 years), and one for children (96cm to 150cm – 3 years to around 12 years). Neonates aged
one month or younger should be seen immediately by a doctor.

The Two Parts of the Triage Tool

The TS consists of 2 parts: The Triage Early Warning Score (TEWS) and the Discriminator List as placed
at (Annex-VI, VII & VIII). The discriminator list follows after the TEWS and the provider needs to
calculate the TEWS before moving on to the discriminator list.

Triage Early Warning Score (TEWS)21

In order to generate a total score, the provider has to observe the basic vital signs of the patient. Each
vital sign monitors a different physiological system:
 Blood pressure and Heart rate monitor the cardiovascular system (heart and blood flow).
As the provider are interested in the systolic value only, that is the top value of the blood
pressure (BP=120/80, systolic BP or SBP=120)
 Respiratory rate monitors the respiratory system (lungs)
 Temperature monitors thermoregulatory system (infections, hypothermia)
 Alertness, Verbal response, Reaction to pain and Unresponsiveness (AVPU) monitors the
central nervous system (brain)
 Mobility monitors the musculoskeletal system (bones and muscles)
 Trauma refers to the presence of any injury (bump, bruise, cut etc.)

By comparing the observed basic vitals of the patient with a parameter on the TEWS calculator
(horizontally) a score can be read off (vertically) adding together the scores gives the provider the total
TEWS.

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Discriminator List
The second part or the discriminator list is the part that generates the actual triage colour (red, orange,
yellow, green, blue) which will determine urgency level and also when the patient will be attended to
essentially. As with the TEWS, there are separate versions of this for infants, children and adults
respectively.
The TEWS will only identify and classify a patient into an appropriate triage code if the physiology of
the patient is altered from normal. The TEWS will be effective for most of the cases presenting to the
triage provider.
There are however, some discriminators that require special attention. It has been found that
physiology alone does not pick up and classify patients with these discriminators safely and effectively.
These discriminators therefore, serve as a safety net for those patients with severe pathology to be
seen more urgently, but for anyone whose physiology did not respond to the insult and therefore, did
not generate an urgency appropriate TEWS, they are reclassified after the TEWS has been calculated.

The Stepwise Approach

The Stepwise flowchart poster shows how simple it is to calculate the triage code for a patient by
simply following the stepwise approach. This approach allows the triage provider to code patients
both effectively and safely in the minimum time period. Triage providers should always use this
approach unless directed otherwise by the senior health care professionals.

Triage Interventions and Management Aids

Management of the patient starts with the triage provider’s analysis. It is therefore, critical that this
management continues after the triage process has been completed. The table below indicates
appropriate management of different triage categories by the triage provider:

COLOUR ACTION
RED Refer to the resuscitation room for emergency management
ORANGE Refer to the patient waiting area for urgent management
YELLOW Refer to the patient waiting area for management
GREEN Patient for potential streaming
BLUE Refer to doctor for certification

It is also possible for the triage provider to commence management when treatment is readily
available and the provider’s qualification allows the intervention. Appropriate interventions directed
at observed abnormalities during triage decreases the patient’s morbidity and increases patient
satisfaction.
A triage provider may also, use triage aids to enhance the triage sensitivity if the time so permits.
Triage aids will assist the senior health care professional later, after the patient has been referred
according to the above set criteria. Triage aids (compulsory) should be performed, whenever available
if the time permits but is not essential for the triage itself. The triage interventions and management
aids poster indicates appropriate interventions that must be commenced by the triage provider as
well as triage aids that can be used to enhance the triage process.
Tools for help in undertaking triage process are placed at Annex-I, Annex-Vi, Vii & VIII

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INTERVENTIONS TO BE CARRIED OUT AT TRIAGE

FLOWCHART

STEP 1
Take a brief history directly at the main complaint and document this

STEP 2
Measure vital signs and document the findings

STEP 3
Calculate the TEWS and document the total value

STEP 4
Match the score to the discriminator list and observe the discriminator
list for possible discriminators not picked up by the TEWS

STEP 5
Document the triage code and act accordingly

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 Problem Compulsory Optional
Respiratory rate scores 1. Pulse oximetry (saturation)
1 point or more 2. Finger prick gluco-test if patient is disable
3. Refer to anteroom and give oxygen
Temperature 38.5® or 1. Paracetamol 1g orally stat
more (document in the notes)
(children-discuss with sister or doctor)
Temperature 35® or
1. Blankets
less
Altered level of 1. Refer to anteroom and hand over the
consciousness (AVPU patient to senior healthcare professional
score other than A) 2. Finger prick glucotest
Unable to sit up/ need 1. Refer to anteroom and hand over the
to lie down patient to senior healthcare professional
2. Finger prick glucotest
Chest pain 1. Immediate ECG and present to senior health
care professional
1. Apply pressure to site of trauma with a dry
Active bleeding dressing and take to anteroom
2. HB to obtain baseline
1. Refer to anteroom and hand the patient to
Active seizure/ fitting senior healthcare professional
2. Finger prick glucotest
3. IV access (NO intramuscular)
History of diabetes 1. Finger prick glucotest
Diabetes and
1. Urine dipsticks to check for ketones
Hyperglycaemia
(glucotest 11 or more)
Hyperglycaemia 1. Refer to anteroom and hand over the 2. If the patient is alert, give
(glucotest 3 or less) patient to senior healthcare professional food or drink orally
History of bleeding 1. Finger prick hemoglobin
Bleeding PR, PO or
from a site of trauma 1. Finger prick hemoglobin
Abdominal pain or
1. Urine dipsticks
backache: male
Abdominal pain or 1. Urine dipsticks
backache: female 2. Urine pregnancy test
1. Urine dipsticks
PV Bleeding 2. Urine pregnancy test
3. Finger prick hemoglobin

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 Flowchart of the Care Process at the Emergency Departments

PATIENT

Triage

MSE* + Assessment & Evaluation Primary Survey

Emergency Non-Emergency

Resuscitation and/or Stabilization

Further Assessment & Evaluation Secondary Survey

Treatment

Disposition

Ward Hospital Admission

International Transfer Discharge & Referral

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 Categorization of Patients according to Seriousness of the
Problems

1. Mild: (Non-urgent)
These patients have blunt injuries, small cuts, abrasions etc. and need reassurance and first
aid treatment, and are straight away discharged.

2. Moderate: (Semi-urgent)
These patients have injuries that require treatment which can be provided in Accident and
Emergency Department of any hospital i.e. simple fractures dislocations, small wounds etc.
These patients are discharged from the Emergency Department.

3. Serious: (Urgent)
These patients after emergency treatment need admission in the hospital for definitive
treatment and / or observations. After definitive treatment these patients are discharged.

4. Critically Serious: (Critical)

These patients have risk to life if active intensive critical care is delayed or is not proper. These
patients are resuscitated, provided basic life support in A & E Department and are straight
away shifted to intensive care unit.

After stabilization of the patient’s condition, patient is shifted to specialist ward for definitive
treatment, from where patient is discharged after treatment.

Pre-Hospital Triage Categories: An example

PATIENT TRIAGE GUIDELINES

Needs immediate help and/or evacuation within 30 minutes, unstable patient,
Red mechanically ventilated (outside of OR environment), or requiring significant
cardiac or pulmonary resuscitation

Can wait 30 min-2 hr for evacuation, relatively stable patient but requiring
Yellow
ongoing supportive care or continuation of procedure beyond 30 min

Can abort or finish procedure within 30 min… OR…can wait > 2 hr for evacuation,
Green
patient otherwise stable

Blue Can be discharged home within 30 min, stable patient

Black Deceased

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LEVELS OF HOSPITAL EMERGENCY DEPARTMENTS
The designated Emergency Department of the hospital is distinguished by the immediate availability
of specialist staff inter-alia including, surgeons, anesthetists, physicians, nurses and resuscitation and
life support equipment on a twenty-four hour and seven days a week basis. Three levels of accident
and emergency services are defined on the basis of capability from lower to higher levels32.
LEVEL I
Level I Accident and Emergency (A&E) Department performs all functions as level II but has
Anesthetist, physicians and Surgeons on site 24 hours, and include specialized facilities like burn units
and spinal cord injury units. These centers are also involved in Education and research activities. Level
I Accident and Emergency Departments are located in all the teaching hospitals and must maintain
their expertise by treating at least 1000 patients per hospital every year (83 per month).
LEVEL II
Level II Accident and Emergency Department can resuscitate the patients, perform emergency
procedures including surgery, treat the patient in intensive care unit, and provide rehabilitation. These
hospitals have anesthetists, physicians and surgeons not on duty in the emergency department but
on call. Level II Emergency facilities are available at most of the Tehsil (THQ) and District Headquarters
Hospitals. Keeping in view the available resource, such facilities must be able to treat at least 600
patients a year (50 per month).

LEVEL III
Such Emergency Department can receive, resuscitate, and stabilize a patient while arranging for
transfer of patient to a hospital that can provide definitive surgical/medical care. Level III Emergency
facilities are available at BHUs, RHCs, and such other health facilities with no specialist cover, and
limited indoor capacity.

The International Health Facility Guidelines, 2017 now classify the Health Facilities according to Role
Delineation Level (RDL) on an ascending scale. For example, a major metropolitan hospital having
Teaching and Research facility status providing intensive care services will be at RDL 6. The same
service provided at small general hospital without teaching and research facilities will be at RDL 4. At
higher RDLs, the service provision will require access to higher levels of skill and additional
complementary services. Thus surgery at RDL 5 will require intensive care services plus many
supporting services. The number, type and size of rooms for an ICU service at RDL 6 will thus be
different to one at RDL 4. Similarly, schedule of accommodation in a birthing unit (obstetric facility),
the international Health Facility Guidelines depict the following number of rooms for the ascending
RDL.

RDL : RDL 2 RDL 3 RDL 4 RDL 5/6

Entry /reception 2 rooms 4 rooms 8 rooms 12 rooms
Birthing Suite (patient area) 2 rooms 4 rooms 8 rooms 12 rooms
For the purpose of this work, the scheme of Level 1, Level 2 and Level 3 as contained in the
Government of the Punjab Health Department SOPs for Emergency Medical Services as prescribed in
2003 has been retained.

32 Emergency Medical Services in Teaching Hospitals of Punjab, DOH Oct, 2003

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 PHYSICAL SETTING REQUIREMENTS
Accident and Emergency Department should be located in such a way that it is easily accessible for
the public. It should be close to parking area and preferably have a separate entrance. Accident and
Emergency Department should always be on ground floor with easy access to indoor facilities and
the OPD, and should be adjacent to diagnostic facilities like laboratory and Radiology Department.
Both stairs and ramps, clearly designed for patient arrival and departure, should ensure smooth access
to the facility. The pathways should facilitate free movement of patient’s trolley, stretcher etc.
Adequate space for wheelchairs and patient trolleys should be ensured with the availability of porter
service. The Emergency Department must be able to accommodate transportation of large number of
patients in case of a disaster. Effective and standard signage for the guidance of patients should be
ensured. Accident and Emergency Department must have an easy connections to the following
units:
i. Blood bank
ii. Main Pharmacy
iii. Technical support services especially Biomedical Department.
iv. Clinical Laboratory
v. Imaging services

The Functional Areas of Hospital Emergency Department

A standard Hospital Emergency Department (Level-I) should have the following facilities:

i. Ramp and stairs ii. Area for porters

iii. Area for stretchers, trolleys and iv. Sufficient space for parking of
wheelchairs ambulance and unloading of patients
v. Triage area vi. Security office
vii. Emergency Department viii. Resuscitation Room
reception/patient registration counter
ix. Nursing station x. Minor Operation Theatre
xi. Patient care area xii. Procedure Room
(Medical/Surgical/Pediatric)
xiii. Lab counter with LCD display of tests xiv. Major Operation Theatre
xv. X-Ray /USG xvi. Doctor’s office
xvii. Facilitation Counter xviii. Nurses office
xix. Pharmacy Services xx. Administration office

Depending upon the available workload at some of the smaller, Level-II Emergency set ups, and on
the basis of available / committed resources, some of the above facilities may be regarded as optional,
or made available on shared basis with the main health facility. Following segregated structural
requirements are essential for the Emergency Unit:

i. Triage area
ii. A functional resuscitation area for patient stabilization
iii. A transient area for patient observation for not more than 24 hours
iv. Procedure room for minor cases/Theatre

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 v. Waiting area
vi. Ambulance bay

Minimum / Mandatory Requirements to be Met by all Hospitals (public and private)

i. At least 10% of the total bed strength to be allocated in the Hospital Emergency Department
ii. In the Emergency Departments of multi-specialty Tertiary care / Teaching hospitals and
Secondary referral (DHQ level+) facilities with 24-hour availability of specialist cover, the
following services should be made available in the Emergency Departments:
a. Primary care of burn patients in Emergency
b. Paediatric Surgery / primary trauma care for children
c. Integrated Diagnostic (Lab & Radiology) services to be accessible to the emergency
patients
d. Maintaining Electronic Medical Records
e. Appointment of dedicated staff including doctors having post-graduate qualification
in Emergency Care (FCPS Emergency Medicine or equivalent)
f. Incentivized pay package and career structure for the staff in the emergency
department
g. Similar incentivized service structure for nurses having post-graduate qualification
and training in ICU, CCU & Accident & Emergency nursing, etc., and working in such
areas

iii. Location of the Emergency Department should be easily accessible from Entry Point without
any physical barriers / obstructions; and movement of the patient through
trolley/stretcher/hospital bed or wheelchair should be without obstacles
iv. The facilities in the Emergency Department should be integrated with diagnostic and
support services of the hospital, to provide ease of access for staff and the patients
v. There should be dedicated staff (Doctors, Nurses & allied) allocated for emergency
department, and must be trained in life saving skills as applicable (ACLS/ATLS/ALSO/BLS);
and the list of staff for each shift must be displayed in the emergency office
vi. Duty Roster of Medical, Nursing & Allied staff to be on duty in the Emergency should be
displayed, providing for adequate overlap in time for smooth handing over and taking over,
which must be documented, and verifiable.
vii. Minimum set of dedicated equipment as per the declared scope of service by the hospital
administration should be available in the Emergency Department
viii. Physical Environment and infrastructure should be so designed and so provided, to allow
for smooth and un-obstructed, safe movement of patient for the purpose of shifting,
referral or discharge, of for the purpose of diagnostic tests or procedures
ix. The Emergency Department should have easy access to public utility area, i.e., waiting room,
toilets, etc.
x. The physical environment should provide segregated utility area with sufficient privacy, to
the medical and nursing staff for refreshment / changeover, with permitted bathroom break
period (e.g., 20 minutes each during six hours duty; with allowance for conditions like
pregnancy, or other medical conditions posing limitations) .

Equipment and Supplies

Time is an essential factor in emergency treatment, therefore, Accident and Emergency Department
typically must have their own diagnostic equipment to avoid waiting for equipment installed

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elsewhere in the hospital. Ideally, the Level-I Emergency facility shall have a dedicated Laboratory for
basic laboratory tests or the Emergency may be supported by uninterrupted 24-hour service from the
hospital’s main laboratory.

Standards for Management of Equipment

Facilities and services at the Emergency Department should comply with national / prescribed
standards with respect to all the equipment installed and used in the Emergency Department in terms
of number and specifications. The preventive periodic maintenance programme should be
documented and implemented. All equipment must conform to the relevant safety standards and be
regularly calibrated. All staff must be appropriately trained, competent and familiar with the use of
equipment.
Type and number of equipment and quantity of consumables will vary with the Level, size and function
of the department and must be appropriate to the workload of the unit as judged by the contemporary
standards. The sample list of basic equipment and supplies needed for effective operations at Level II
Emergency Department is attached in Annex-IV:
Selection of equipment
Criteria for the selection, purchasing, storage, servicing, sterilization, and replacement of durable
equipment should be predefined by the hospital management committee including senior
consultants, nurses, and biomedical engineers. A continuously updated selection policy in respect
of durable equipment is recommended. Medical and nursing staff should review available equipment
by assessing it in use, with a view to eventual purchase also considering it’s compatibility with existing
equipment.
Technical advice on performance and service of the equipment should be sought from the hospital
electronic/medical engineers. Methods of sterilization must be compatible with existing hospital
facilities, and there should be documented contracts with manufacturers/vendors supplying such
items to provide all requite technical support / information and training of the staff handling these
equipment. Other equipment supplies not listed in the above Annexure may be supplied from the
hospital store and pharmacy as and when needed.
Procurement
The users should agree with the manufacturer/vendor which items e.g. in a modular system will
actually be required. The list should include all recommended spares, extra copies of instruction books
and a stock of consumables/disposables if needed. The order, which will normally be handled by a
supplies officer, should define clearly which items are to be supplied, any commissioning or installation
work required, acceptance procedure, delivery date and other conditions of supply.

Medicines
The inventory of essential medicines for the Emergency Department should be based on the
anticipated workload, and case-mix usually presenting in the hospital emergency department. A
tentative list of essential medicines needed for effective running of the level II Emergency
Department is placed at Annex-V. The medicines and supplies not listed in the above Annexure may
be supplied from the hospital pharmacy as and when needed.
Human Resource

The Emergency Department should be appropriately staffed and must have one to two emergency /
casualty medical officers (EMOs /CMOs) depending upon the patient load of the Healthcare

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Establishment in each shift of 8-1/2 hours, with a half hour overlap of duties for handing/taking over
of charge.
Night duty of 12 hours i.e. from 8PM to 8AM, currently in vogue for the hospital interns in the
Emergency Departments hampers the quality of service by increasing the chances of human error,
due to fatigue. Therefore, in a high turnover facility, a uniform duty of 8-1/2 hour should be preferred.
Alternatively, four hourly rotating shifts (with few hours break in between the successive shifts) can
be scheduled, provided there is sufficient provision of rest area in the facility. It should be mandatory
to have sufficient experience and/or a house job in Medicine/Allied and Surgery/Allied specialties
along with special training in ABLS, ACLS and ATLS for the appointment of CMO/EMO.
Training
i There should be arrangement, preferably a national pool of resource persons available to
train accident and emergency teams.
ii This training will first be geared towards hospital Emergency teams
iii All doctors and nurses shall be trained in basic and advanced life support

iv All other health professionals shall be trained in basic life support by accredited trainers
v For uniformity and standardization all training shall be done in selected centers of
excellence and by accredited trainers
vi Re-certification shall be done every three years

Continuous Professional Development

Core Staff
The core staff working at the Emergency Department should be re-certified every 3 years by
accredited training teams and institutions. All institutions must ensure strict adherence to this
provision. Hospital Management should ensure that all those working in the Emergency Department
have training in emergency care. Core Team members (e.g. doctors, physician assistants and nurses)
should at least be trained in:
 Basic Life Support
 Advance Cardiac Life support
 AED (automated external defibrillator)
 Advance Trauma Life Support
 Pediatric Advance Life Support
 Triaging
 Recognition and Management of the critically ill

Training of other (Non-Core) Staff

 Enrolled Nurses (Health Assistants) should undergo at least BLS + AED (automated
external defibrillator)
 Healthcare Assistance: At least BLS + AED (automated external defibrillator)
 Orderlies & Porters: BLS and Patient transport
Accident and Emergency Team(s)
1. An emergency core team, physically present at all times should comprise the emergency
physician/doctors, physician assistants, Emergency Nurses, Critical Care Nurse, triage personnel,
porters and cleaners. The Expanded Team should comprise the following:
i. Surgeons, Trauma/Orthopedic Surgeon, Neurosurgeons,

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 ii. Radiologist, Anesthetist, Intensivist,
iii. Pharmacist and others as required.

2. The Unit shall be headed by an Emergency Physician (EP) and in the absence of the EP a
Medical Officer with requisite skills in emergency care shall be the head.
3. The head of the unit in collaboration with the Emergency Department Head Nurse shall see to
the day-to-day running of the unit.
4. It is desirable that the staff should have had qualification/ training in Quality
Assurance/Customer Care.
5. Staff job descriptions should be clearly stipulated, discussed and written copies given to them.

Periodic Review Meetings/reviews

There shall be at least the following review meetings:
i. Monthly Clinical updates organized by the Emergency Department
ii. Bi-monthly mortality meeting.
iii. Quarterly inter-departmental or inter-unit meeting/reviews

Ethics for Emergency Staff

All citizens have the right to emergency medical care and in order to fulfil this right, emergency care
providers shall:
 Abide by institutional code of ethics and patient’s charter.
 Respond promptly and expertly, without prejudice or partiality, to the need for emergency
medical care.
 Respect the rights and strive to protect the best interests of their patients, particularly the
most vulnerable and those unable to make treatment choices due to diminished decision-
making capacity.
 Communicate truthfully with patients and secure their informed consent for treatment, unless
the urgency of the patient's condition demands an immediate response.
 Respect patient privacy and disclose confidential information only with consent of the
patient/guardian or when required by an overriding duty such as the duty to protect others
or to obey the law.
 Deal fairly and honestly with colleagues and take appropriate action to protect patients from
healthcare providers who are impaired or incompetent, or who engage in fraud or deception.
 Work cooperatively with other stakeholders in the care of emergency patients.
 Engage in continuing medical education to maintain the knowledge and skills necessary to
provide high quality care for emergency patients.
 Act as responsible stewards of the healthcare resources entrusted to them.
 Support societal efforts to improve public health and safety, reduce the effects of injury and
illness, and secure access to emergency and other basic healthcare for all.

Admission Policy for the Emergency Department

Only patients whose assessment during triage as per Triaging Guidelines falls under Red, Orange and
Yellow may be admitted to the Emergency Department for further management. It is the
responsibility of the triage officer/nurse to refer all patients whose triage assessment falls under
Green to the general outpatient or an appropriate health facility for further management. Patients

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that are at the end stage of a severe disease will be placed in categories green or blue, and will ''only''
receive palliative measures that accompany the dying process.
Internal Consultations and Referrals to other Hospitals
The emergency doctor on duty may request consultation with another specialist for a patient in the
Emergency Department. The request shall follow established internal arrangements such as the use
of SMS, phone calls, etc. and shall be attended to immediately. All consultation requests should be
written in the patient’s medical notes indicating time, date, and signature.
Referral to other Hospitals
The procedure for referral should follow the HCE Policy Guidelines. Only the emergency
physician/specialist or senior doctor on duty has the authority to refer patients to other hospitals. The
emergency doctor on duty should provide a written consultation regarding his recommendation for
treatment and disposition on the emergency record.

Disposition of Patients from the Emergency Department

Transfers

Transfer of patients into and out of the Emergency Department shall be in compliance with the health
facility transfer policy. The attending doctor must personally evaluate a patient in the Emergency unit
prior to transfer to another ward. All safety measures and appropriate care shall be provided during
the transfer of patients. The transferring doctor is responsible for completing the appropriate
documentation who should also ensure that a mutual decision with the receiving department/unit has
been reached.
Discharge Home

Patients not requiring hospital admission should be given written and verbal instructions regarding
follow-up care. The doctor at the time of discharge is responsible for providing the patient with verbal
or written instructions as necessary.
Leave against Medical Advice /Refuse treatment

Patients refusing further management should be requested to complete and sign the Leave -Against-
Medical-Advice (LAMA) Form that should be attached to the patient’s Emergency folder. This Form
records the doctor’s explanation of the consequences of the patient’s action.
Refusal to sign the LAMA form should be documented on the form and witnessed and placed in the
Emergency folder. A patient who leaves the unit prior to treatment should have such information
noted on the folder along with the reason of leaving if known, and should be timed and signed.
Deaths in the Emergency Department and those brought dead

Death of the patients do happen in the emergency departments of the hospitals, very often due to
the pathology or the cause responsible to bringing the patient in. However, in certain un-expected or
un-explained cases, the family of the deceased may get agitated and resort to violence against the
hospital staff.
Patient must be examined before declared brought-in-dead and the EMO/ CMO should be responsible
to initiate lawful procedure. There should be a team of senior hospital staff including nursing, allied
and administration etc. to take the charge of situation, isolate the body of the deceased person from
common area, and to counsel the family of the deceased. Such a role demands extra restrain,
somnolence, and exhibiting regard and respect to the emotions of the family in a passionate manner.

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The family should be assisted in documentation, clearance and disposal of the formalities in an
expeditious manner.
in case of complaints, the complaint redress mechanism should be adopted up to the satisfaction of
the complainant as far as his/her genuine grievance are concerned, and with due empathy, by
reassuring of a fair process of hearing, and disposal as per rules.
Collaboration/Links with other departments and hospitals (within and without)

The Emergency Department should have links with other departments/units of the hospital. The
facility management on the occasion should also have links with pre-hospital Emergency services
and all relevant emergency services providers within the catchment area.
Emergency Records

The medical records of patients in Emergency Departments is to be maintained, and secured in the
manner similar to that being prescribed and implemented under the Functional area, Information
Management System ‘IMS’ provided in the Minimum Service Delivery Standards MSDS) and subject
to review and quality control, as prescribed in the MSDS, for continuous quality improvement.
The emergency files / folder should include all pertinent bio-medical data on standard format as per
policy pertaining to the Medical Records of the hospital. The medical record of medico-legal cases
need to be specially secured and held confidential, with restricted access.
The patients or the families also have a right to obtain a copy, or summary of medical record
accordingly, and there should be systems in place to make it possible when so required.
Emergency Preparedness Plan

All hospitals shall have an emergency preparedness plan for meeting un-foreseen incidents, disasters,
violence, or unnatural events, like earthquake, disruption of supplies, or services like power failure,
failure of transport, water or sanitation services.

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 Code blue
Purpose
 To provide immediate life saving measures in case of life threating emergencies
 Saving lives at the moment notice.
 To provide a plan for response to medical emergencies.
 The purpose of the Code Blue team is to assure prompt and skilled cardiovascular and cerebral
resuscitation of persons who suffer a cardiopulmonary arrest.
Definition
 It is an event of utmost emergency, a mode of alerting all medic, nursing, paramedic, and
security staff.
 Code blue is a term hospital and medical professional use to describe a situation where a
patient will need to be resuscitated.
 Code blue is announced when a patient is unresponsive, meaning him or her not breathing or
heart stop beating.
 Medical Emergency is an event requiring the rapid assessment and intervention of trained
medical personnel which may include but is not limited to serious injury, unconsciousness,
serious respiratory symptoms, symptoms of cardiac crisis.
Equipment/Material
 Cardiac monitor with pulse-oximeter
 Defibrillator
 Ambu bag
 Air way/s
 Air way maintaining equipment (air way, LMA, ETT, etc.)
 Oxygen flow meter with humidifier
 Suction regulator with suction bottle and suction catheter
 Emergency crash cart with all medical supplies and Emergency Drugs
 For documentation (Patient files, Resuscitation form, Code blue monitoring form)

Staff Responsibility
 Employees who witness or are first on the site of a medical emergency will take immediate
action, including CPR and basic First Aid if trained to do so, summon medical assistance and
assist as directed.
 “Code Blue” announcement will be made by Charge Nurse or the doctor who discover patient
irresponsive. Announcement includes department, bed number, gender, and floor/Area.
 RN will take the Emergency Med Cart or medicine tray and ensure that emergency equipment
is transported to Code site.
 RN will ensure that the Code event is recorded and that equipment is ready for use.
Emergency medications and equipment will be inventoried and Re-stocked on a weekly basis
and following a Code.
 Shift Supervisor will ensure emergency medications and equipment are inventoried and
restocked on a weekly basis and following a Code.
 Or an emergency Kit may be ready in ICU after announcement of code blue team member
from ICU will reach at location with emergency KIT.
 Code Blue must be announced for the following Departments:
1. Emergency
2. OPD

D5 14-12-22 Page 64 of 117

 3. MSW
4. FSW
5. FMW
6. MMW
7. Cardiology
8. Nephrology
9. Paediatrics
10. OTs/Anesthesia offices
11. ICUs duty rooms
12. Gynecology
13. Oto-Laryngo-rhinology (ENT)
14. Physiotherapy Dept.
15. Radiology Department.
16. Admn Deptt
17. Pharmacy
18. Cafeteria

Team Members
 The team who are responsible to run the code blue includes:

i. ICU specialist ( ACLS certified )

ii. ICU Nurse (Assigned for Code team BLS or ACLS certified)
iii. Department on call MO
iv. Primary Consultant (if on duty during code)
v. H/N or Registered Nurse on duty from Department
vi. Nurse supervisor
vii. Security
viii. Pharmacy staff (if available for medicine preparation)
ix. Lab technician (to take urgent samples for ABGs etc.)
x. Support staff (Ward Boy, Ward Helper etc.)

 Respond to the Code site is to assist with assessment of the patient/victim, determination of
severity of the emergency, and provision of emergency care and treatment.
 Medical Superintendent/ Medical Director, and Nursing In charge will ensure review of each
Code to identify opportunities for improvement.
Policy
 Hospital will follow its policy/procedure in providing for the emergency medical needs of
patients, staff and visitors.

Procedure
 The first person on site recognizing an emergency medical situation will follow the basic
guidelines for assessing the situation, summoning assistance and starting Cardiopulmonary
Resuscitation (CPR) as appropriate and/or rendering First Aid.
 A nurse at the site will assess the situation and determine the severity of the emergency.
i. Stay with the patient/victim if the situation is life-threatening and requires direct
emergency care
ii. Call or delegate a staff member to call on a given number to instruct the staff to
announce a “Code Blue” for the specific Department, Bed no, gender, and Floor or
Area) and intimated by pager
iii. This announcement is to be made regardless of the time of day
iv. Assure all member of code blue team are present as soon as code is called

D5 14-12-22 Page 65 of 117

 v. Take the Emergency cart and equipment required to the site,
vi. Upon arrival ICU Nurse will assist Code leader for intubation and medication
administration
vii. Follow ACLS guidelines to administer medicines and other treatment as per patient
condition
viii. To continue Code depends on the patient response to the treatment at least 30 –45
minutes
ix. If patient revive shift to ICU after making necessary arrangement in ICU e.g availability
of bed, Ventilator, etc.
x. Nurse supervisor will record, or delegate RN, to record the event on the Emergency
Response Sheet. The Emergency Response sheet will be placed in the patient record
and copy forwarded to Quality Assurance Department
xi. Following the use of the cart, replace all used items and notify the pharmacy to
arrange for the timely restocking of medications to be ready for next use
xii. Convey information and/or seek assistance regarding the Code situation with the
Nurse Supervisor
xiii. Attach cardiac monitor and defibrillator for recharging
xiv. Refilling of portable oxygen cylinder

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Power Failure in Hospital Emergencies
Electrical power to the Accident & Emergency Department can fail, either as an isolated event (e.g.,
tripped circuit breaker or blown fuses), or as a part of larger event, like regional power shutdown, or
as an outcome of a natural disaster. In countries like Pakistan, where imbalances in demand and supply
of electric power, coupled with fuel shortages or poor cost recovery mechanisms leading to
accumulation of circular debt, thus causing un-planned load shedding. Hospitals therefore, need to
have emergency plan33 to cope with such power outages so as to sustain smooth operation of the
facility, and to avoid risk to lives of the patients undergoing procedures or recovering through
mechanical assistance/ventilation support. Hospitals need to define Standard Operating Procedures
appropriate for each kind of power failure scenario, and the hospital staff should be well prepared to
act accordingly in case of such emergency as per plan34.
Most hospitals have two lines connected to the power grid; while larger hospitals in Pakistan may have
electric supply from two different power grids. If one goes down, the facility can still run at least on
half capacity. Hospitals also have backup generators to help bridge the gap, especially for the high
priority areas, like operation theatres, intensive care units, etc. Following are the hazards35 in smooth
operation of the hospitals in case of power failure:
 Loss of respiratory devices and other critical equipment for patients in intensive care,
neonatal, or cardiac units.
 Loss of lighting for high-risk surgical procedures and potential black out of rooms with no
emergency lighting.
 Loss of pressure in water distribution systems.
 Potential loss of access to other hospitals and healthcare facilities if they are also affected.
 Inability to access electronic patient medical records and other hospital data.
 Loss of patient signaling system for assistance by medical and hospital staff.
 Potential loss of access to medication, vaccines, and other medical supplies requiring keyless
entry.

Following is a checklist for the hospital management to assess their capability and capacity to
overcome the challenges involved in case of extended power failure situation:
 What is the electric utility’s contact information in the event of a power outage?
 Where is the facility located on the electricity distribution network? What other hospital
facilities are located on the same circuit?
 How reliable is the electricity distribution network where this facility is located?
 Have you discussed with your utility if they consider your hospital facility to be a priority
when responding to a power outage or shortage of electricity supply?
 Have you considered participating with your utility when they conduct drills or exercises to
respond to a loss of power?
 Do you have partnerships in place with other local healthcare facilities in case of an
extended power outage?
 Have you determined your energy usage under normal operating conditions?

33 SOPs for Labs Electrical Power Failure; Purdue University Indiana

34 KHSC Emergency procedures SOP-EP-01; Dec 2017
35 Healthcare Facilities and Power Outages, August 2019

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  Have you identified your essential functions and minimum electricity needs and sized your
backup generators appropriately?
 Do you have procedures to prioritize emergency power allocation to key resources (i.e.
HVAC systems, ventilators, patient monitors)?
 How often is your emergency generator system tested to assure reliable startup and
sustained operation?
 How long will your supply of emergency generator fuel last, and how can you be assured of
continued fuel delivery in the event of an extended power outage

Following table provides general guidance to the hospital staff to identify the type of equipment which
have good battery backup; and the type of equipment which usually do not have much power backup

Anesthesia patient Safety Foundation, Circulation 122,210 • Volume 30, No. 3 • February
2016

D5 14-12-22 Page 68 of 117

Policy Recommendations for Improving the Emergency Services
In order to optimize the quality of emergency services, following measures are hereby recommended
to be initially undertaken by the Health Departments /hospital owners / management:

I. Improvement in the infrastructure of the emergency department in terms of number of

beds, accessibility, waiting area etc

II. Provision of trained / qualified, special cadre staff i.e. Doctors, Nurses and allied staff in the
hospital emergency department round the clock

III. on site presence of senior level consultant (minimum Assistant Professor) within the
premises of public sector teaching hospitals;

IV. Ensure availability of essential equipment and lifesaving medicine;

V. Ensure availability of Integrated Diagnostic services (Lab and Radiology) and pharmacy

VI. Ensure maintenance of Electronic Medical Record of the patients.

Infrastructure

I. At least 10% of the total bed strength to be allocated to the Emergency Departments in all the
Hospitals;

II. Establish dedicated chest pain clinics in the emergency departments;

III. 24-hour availability of specialist cover, along with the following facilities to be available in
Emergency Departments of multi-specialty Tertiary care I Teaching hospitals and Secondary
referral (DHQ level+):

(a) Primary care of burn patients in Emergency

(b) Paediatric Surgery / primary trauma care for children
(c) Integrated Diagnostic (Lab & Radiology) services
(d) Doctors having post-graduate qualification in Emergency Care (FCPS Emergency
care or equivalent)
(e) Initiate diploma courses in Emergency medicine for doctors and nurses

IV. Improve physical ambience in the emergency departments to enhance their efficiency and
ensure smooth flow of patients;

V. Provision of fast track/ urgent primary care through extended / late hour OPD clinics for the
bulk of patients presenting with ambulant non-complex conditions;

VI. Location of the Emergency Department to be easily accessible from Entry Point without any
physical barriers / obstructions for hassle free movement of the patients through
trolley/stretcher /hospital bed or wheelchair;

VII. The facilities in the Emergency Department should be integrated with diagnostic and support
services of the hospital, including the laboratory, radiology, operation theaters, pharmacy,
blood transfusion (if not provided separately in the Hospital Emergency Department); for easy
access to the staff and the patients;

VIII. The functioning of the Emergency Departments and care provision must be monitored
through CCTV cameras;

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 IX. Physical Environment and infrastructure should be so designed, so provided, to allow for
smooth and un-obstructed, safe movement of patients for the purpose of shifting, referral or
discharge, of for the purpose of diagnostic tests or procedures;

X. The Emergency Department should have easy access to public utility area, i.e., waiting room,
toilets, etc.

XI. Provide segregated utility areas with sufficient privacy to the medical and nursing staff for
refreshment / changeover, with permitted break period (e.g., 20 minutes each during six
hours' duty etc.);

HR Requirements

I. Incentivized pay package and career structure for the doctors, working in the Emergency
Departments

II. Incentivized service structure for nurses having post-graduate qualification and training in
ICU, CCU & Accident & Emergency nursing, etc.

III. Doctors having post-graduate qualification in Emergency Care (FCPS Emergency care or
equivalent) be appointed as on-site consultants/shift in-charges

IV. Increase induction of medical graduates in the postgraduate Programme: FCPS in

Emergency Medicine as approved by the College of Physicians and Surgeons Pakistan
(CPSP);

V. There should be dedicated staff (Doctors, Nurses & allied) allocated for emergency
departments and those must be trained in life saving skills as applicable (ACLS/ATLS/ALSO
/BLS);

VI. Duty Roster of Medical, Nursing & Allied staff on duty in the Emergency should be
displayed, preferably on LCD;

VII. Duty roster should provide for adequate overlap in time for smooth handing over and
taking over of patients, which must be documented, and verifiable;

Trainings

I. Initiate diploma courses in Emergency Medicine for doctors and nurses

II. Imparting formal hands-on training skills to the hospital emergency staff on life-saving
skills and various emergency procedures;

III. As a first step, initiate three weeks hands-on training to head nurses as "Triage Nurse"
for placing them in public sector hospitals' emergency departments on pilot basis.

Equipment and Supplies

I. Minimum set of dedicated lifesaving equipment, inter-alia, including the cardiac monitors,
defibrillator, ventilators, as per the declared scope of service should be available in the
Emergency Department;

II. There should be adequate arrangement of medical gases, preferably through central
supply and central suction with back up;

III. Generator set for back up in case of electricity failures should be ensured;

D5 14-12-22 Page 70 of 117

 Emergency Department Check list
Applicability for Emergency Department
Sr Criteria (tick √, No or Not Applicable (NA)
Level I Level II Level III
1. Hospital Emergency Plan Mandatory Mandatory Recommended
 developed
 displayed / available
 and in operation
2. Hospital Emergency Building Map / Layout Mandatory Mandatory Recommended
 available & displayed
 directions displayed for smooth patient
flow
3. Dedicated Entry for ambulances & patient Mandatory Mandatory Recommended
transport vehicles
 available
 sufficient space available for ambulance
parking and to unload patients
4. Parking facility available for Mandatory Mandatory Recommended
 ambulances,
 patients
 staff cars
5. Ramps & clear way for movement of Mandatory Mandatory Recommended
patients available for all service area
6. Area for Stretchers & wheel chairs Mandatory Mandatory Recommended
 wheel chairs
 stretchers

7. Stretcher boys/Porters Mandatory Mandatory Recommended

 available
8. Triage area available and identifiable Mandatory Recommended NA
 direction signs displayed
9. Hospital staff available at Mandatory Recommended Desirable
 reception/registration
 help desk
 dengue counter (in season)
 COVID desk (in season)

10. Triage SOPs Mandatory Recommended NA

 notified (in smaller
private hospitals
 triage physician / triage nurse / trained triage
experienced paramedic notified and nurse may be
available sufficient)
11. Triage system in practice Mandatory Recommended NA
 Triage sheet available with patient
registration slip /treatment chart duly
filled as per protocol
 Triage category /code assigned

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12. Resuscitation Room / area designated for Mandatory Mandatory Desirable
resuscitation of critically ill patients has
wall mounted or stand by
 Suction units,
 Oxygen supply,
 Monitors
 ECG
 BP apparatus,
 Defibrillator
13. Acute care area / beds allocated for major Mandatory Mandatory NA
emergency cases has
 Suction units
 Oxygen supply
 ECG
 monitors
 BP apparatus
14. HDU / ICU facility (for seriously ill patients Mandatory Mandatory NA
like DHF, dengue shock Syndrome, etc.)
15. Isolation facility (suspected infectious Mandatory Mandatory NA
conditions like covid-19 / H1N1, etc.)
16. Beds / area allocated for management of Mandatory Mandatory NA
burn patients
 air condition room with stainless steel
bath and mechanical hoist
 plenum-ventilation of dressing room
with an exhaust ventilated air lock
17. Step down area for patients already Mandatory Recommended NA
managed and awaiting test results and
requiring observation prior to admission or
discharge
18. Special treatment rooms (preferable) for Mandatory Recommended Desirable
 pediatric patients
 obstetric patients
 major psychiatric disorders
 Eye /ENT & dental rooms
19. Hand wash facility in all areas Mandatory Mandatory Desirable
20. Decontamination area (preferable) Recommended desirable NA
21. Primary care facility Mandatory Recommended Desirable
 for management of the low acuity
conditions
 suture room / minor OT
22. Nursing Station Recommended Recommended Desirable
 ease of monitoring patients
 limited privacy
23. Observation area/patient beds designated Recommended Recommended NA
(for short stay after evaluation)
24. Holding area /waiting area for non-injured / Mandatory Recommended Desirable
patients relatives
 open and easily observed from the

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 triage & reception area
 negatively pressured
 Counsellor/Social worker/ volunteer for
re-assuring relatives/family of seriously
ill
 TV / information display
 visitors toilets
25. Staff & support area Mandatory Recommended Desirable
 staff room & utility rooms
 Staff change room with
▪ lockers
▪ pantry & retiring area
▪ shower & lavatories,
▪ storage of soiled linen
 store rooms for hospital equipment &
linen
 waste holding & cleaners room
26. Doctors office Mandatory Recommended Desirable
Nurses office
Administration office
Security office
27. Director Emergency Mandatory Recommended NA
 notified
 available on duty
28. Authorization for medico-legal work NA in private
available Mandatory in Mandatory in sector
 necessary support staff and logistics Public sector Public sector
available for medico legal work General General (only at RHCs
Hospitals Hospitals or such public
 Authorized Lady Doctor available for sector HCEs
female patients medico-legal work duly authorized
 (MLC register) for the given
 Mortuary (only if type of
medicolegal
 Mortuary Assistant authorized by
work)
Government)
 Post-mortem kit
 preservation jars, bottles and
preservative liquids available
29. EMO/ CMO available Mandatory (Recommended NA
 Emergency Shift In-charge available in Pvt,
mandatory in
Public sector)
(as per declared
scope)
30. Duty Rosters available / displayed for Desirable
 Doctors on duty All Mandatory Recommended
(as per declared
 Nurses on duty scope)
 Pharmacy, Radiology, Laboratory,
Blood Bank, Engineering support staff
(for lifts and equipment, electricity &
supplies, etc.)

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31. Roster for on-call staff is available /
displayed All Mandatory Recommended
 Physician on call (as per declared Medical Officer
scope) & Registered
▪ (respective PGR/MO on call in after Nurse trained
–hours) in emergency
 Surgeon on call service
▪ (respective PGR/MO on call in after provision
–hours) recommended
 Anesthetist on call
Specialist cover
▪ (respective PGR/MO on call in after Not
–hours) recommended
 Obstetrician on call
▪ (respective PGR/MO on call in after
–hours)
 Pediatrician on call
▪ (respective PGR/MO on call in after
–hours)
 Neurosurgeon on call
▪ (respective PGR/MO on call in after
–hours)
 Orthopedic Surgeon on call
▪ (respective PGR/MO on call in after
–hours)
 Cardiologist on call
▪ (respective PGR/MO on call in after
–hours)
▪ (respective PGR/MO on call in after
–hours)
32. Roster for paramedic & support staff
available
 Electrician All Mandatory Mandatory
 lift operator
 Dispensers
 Ward master Mandatory
 Ward boys Mandatory Recommended
 Cleaners
33. Diagnostic Services available as per
declared scope Recommended
 Radiology & imaging Mandatory Mandatory (regional x-ray
facility)
▪ X-ray
▪ Ultrasound / Doppler
▪ CT scan Recommended
 Pathology Laboratory Mandatory Recommended
 Blood bank services Mandatory Recommended
34. Pharmacy services available
 Essential live saving & emergency use All Mandatory Mandatory Recommended
medicines and supplies as per standard (basic
list finalized by the hospital committee emergency life
saving
▪ Emergency tray Mandatory
medicines)
▪ Resuscitation trolley
Recommended
▪ Anti-snake venom
▪ Morphine antidote Recommended

D5 14-12-22 Page 74 of 117

 ▪ Anti-rabies vaccine
▪ Anti-rabies immunoglobulin Recommended
▪ Immunoglobulin for tetanus
▪ Inj Streptokinase Recommended

D5 14-12-22 Page 75 of 117

 Hospital Emergency Departments
Operational Model for Public and Private Sector (first referral facilities)

Hospital Emergency Departments Operational Model

The Project Management Unit, Primary and Secondary Healthcare Department, Government of
Punjab in 2019, has developed a comprehensive set of Manual on Standing Operating Procedures for
the Emergency Departments of the public sector District and Tehsil Headquarter hospitals. The
Manual not only provides guidelines regarding essential components of hospital emergency and
related provisions but also provides guidelines for conduct of patients emergency management,
medico-legal work and job descriptions of hospital emergency staff.
The Director General Health Services, Dhaka in Bangladesh, has developed a training manual for
healthcare service providers on Standard Hospital Emergency Management Guideline. The
Bangladesh Society of Emergency Medicine has contributed significantly towards development of
this manual. The manual provides guidelines on management of common medical and surgical
emergencies, and emergency equipment and drugs checklist templates.
Indian Health Facility Guidelines, March 2014 also provide an excellent account of minimum
requirements for design of health facilities and setting physical benchmarks of quality. The guidelines
have incorporated Indian Public Health Standards. There are separate volumes of guidelines for
community health centres, the primary health facilities, the Sub-divisional level hospitals having 31
to 100 beds and district hospitals from 200 to 500 beds.
The Australian College for Emergency Medicine has also developed Emergency Department Design
Guidelines in October, 2014. These Guidelines cover in detail, the clinical requirements of an
emergency department, and integrate these requirements with functional need and practical size
requirements of the emergency department. These guidelines also explain the important
relationships of the emergency department with other departments of the hospital.
An Operational Model of a Hospital Emergency Department is added, as a template that can be
adopted for a 100 + bedded private hospital for providing 24 hour emergency cover for basic medical,
surgical and allied health facilities.

Department of Emergency
While the physical dimensions, and the quantum of resources deployed for the Emergency
Department of a hospital may vary depending upon the population mix being served, financial outlay
and the range of health services offered and availability of suitable human resource, the emergency
department is the single most important entity in the hierarchy of hospital departments. As such,
emergency department is the face of hospital and its operational strength is dominant factor in
shaping up the image and profile of the hospital. The role of Emergency Department becomes critical
during after-hours when regular OPD services are closed, and workload of the hospital shifts to the
emergency department. Emergency department is functionally divided into following major divisions:

Reception / registration & Triage Medico-legal section

Medical Emergency
Main Emergency
Surgical Emergency
Chest Pain Center* Pediatric Emergency*
* (subject to requisite patient flow and availability of relevant specially trained staff)

D5 14-12-22 Page 76 of 117

 Hospital Emergency Departments
Operational Model for Public and Private Sector (first referral facilities)
The Main Emergency and Pediatric Emergency at the hospital should be adequately equipped to
manage common medical emergencies and should be able to provide resuscitation and initial
management of all surgical emergencies. A detention ward or Resuscitation Room should be provided
in its detention ward. Minor surgical procedures/operations are carried out in its minor operation
theatre. For major surgical emergencies patients are admitted / evacuated to the hospital after life-
saving/necessary resuscitation at the Emergency Department.

The Chest pain centre / unit would comprise of an acute pain management area, evaluation (Triage)
area and an observation area combined with patient education programme. The Chest Pain Centre
should be linked with community education programme of Early Heart Attack Care (EHAC) under
supervision of the Department of clinical / interventional cardiology of the main hospital.

SOPs for Reception and Patients Management

i. Patient comes to the Emergency Department

ii. If patient is critically ill, he/she is shifted on trolley or wheelchair, by the ward boy deputed
for this purpose, on the main gate and reception
iii. At the reception, the patient/relative will be asked to get his patient name registered,
whereupon an Emergency Room slip will be issued along with a clinical notes
sheet/Emergency Room admission slip. The reception clerk will make entries of the patient’s
credentials in the computer as well as the register and send the patient to the MER
iv. In-charge Nursing in the Emergency will assess the patient to assign due priority as per the
TRIAGE guidelines/SOPs
v. In case the patient needs resuscitation the CMO will announce the CODE BLUE.

Emergency flow /process for disposal of patients

The emergency department will be oriented towards patient management. Emergency / Casualty
Medical Officers (EMOs/CMOs) and other staff at the Emergency Department should not only possess
clinical knowledge but they will also apply it with promptness, precision and empathy towards
patients.
The EMOs/ CMOs and the Emergency staff will be familiar with the hospital policies procedures,
service rules and regulations and every day matters of Law as applicable. The hospital management
shall ensure proper orientation of the Emergency staff (clinical and support staff) with the clinical
knowledge, expertise and understanding so that their performance in the Emergency Room is
optimum. Such expertise will enable the Emergency staff to avoid involvement in unenviable
entanglements un-necessarily, while not indulging in patient neglect, or lose their mannerism, and
shall remain polite towards the patients and their families
The EMO/ CMO and other clinical / nursing and allied/support staff in Emergency Department will
not leave the Emergency Department even if his/her duty hours are over, till the arrival of the reliever.
Changeover of duties between the Emergency /Casualty Medical Officers will take place punctually.
Moreover, both handing/taking over of patients and important administrative matters and their
pending disposal if any, between these medical officers will take place physically and in a methodical
way every day, and on every change of shift. This will include an OK report to be given in person by
the medical officer handing over to the medical officer taking over. Emphasis is laid on this change
over of duties with a view to obviate patient neglect and/or any embarrassment to the management,
on both counts of which no pretext can be acceptable.

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 Hospital Emergency Departments
Operational Model for Public and Private Sector (first referral facilities)
Change over time on work days and closed Holidays

Change Over Time Days / Shifts

07:30 hrs Between the night EMO/ CMO/Registrar and the morning EMO/
CMO/ Registrar
13:30 hrs Between the morning EMO /CMO / Registrar and the Evening EMO
/CMO /Registrar
19:30 hrs Between the day evening EMO /CMO/ Registrar and the night EMO
/CMO /Registrar
17:00 till 23:00 hrs Evening 2nd EMO /CMO (Additional) will work along
Typical Duty Roster of Medical Staff in Emergency Shifts

From 07:30 hrs till 14:00 hrs Nos.

Director Emergency In-charge Medical Emergency / Registrar 1
Emergency /Causality Medical Officers 3
On Call Staff: Medical Officer/PGR (Medical ward) 1
Medical Officer/PGR (Surgery) 1
Medical Officer/PGR (Cardiology) 1
WMO /PGR (Gynecology/ Obstetrics) 1

From 14:00 hrs till 20:00 hrs Nos.

In-charge Medical Emergency / Registrar 1
Emergency/Causality Medical Officers 3
Medical Officer/PGR (medical ward) 1
Medical Officer/PGR (surgery) 1
On Call Staff:
Medical Officer/PGR (Cardiology) 1
WMO/PGR (Gynecology/Obstetrics) 1

From 19:00 till 23:00 Additional Causality Medical Officer 1

From 20:00 hrs till 07:30 hrs Nos.

Night EMO /CMO (Emergency /Causality Medical 3
Officer)
Medical Officer/PGR (Medical ward) 1
Medical Officer/PGR (Surgery) 1
On Call Staff:
Medical Officer/PGR (Cardiology) 1
WMO /PGR (Gynecology /Obstetrics) 1
Typical Duty Roster of Nursing & Allied Staff in Emergency Shifts

From 07:30 hrs till 14:00 hrs Nos.

Nursing In-charge Emergency / Head Nurse 1
(On week days she will remain available till 15:30 hrs)
Charge Nurses (numbers depending on workload) 7*
Nurse Aids 2
Male Nurse 1
Paramedics ECG Tech 1
Ward Helpers 4
Cleaner / sweeper 1+1
Stretcher boys / wheel chair helpers (main gate to emergency) 3

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 Hospital Emergency Departments
Operational Model for Public and Private Sector (first referral facilities)
From 14:00 hrs till 20:00 hrs Nos.
Nursing In-charge Emergency / Head Nurse 1
(She will remain available from 13:00 till 20:00 hrs on week-days)
Charge Nurses (numbers depending on workload) 7
Nurse Aids 2
Male Nurse 1
Paramedics ECG Tech 1
Ward Helpers 4
Cleaner / sweeper 1+1
Stretcher boys / wheel chair helpers (main gate to emergency) 3

From 20:00 hrs till 08:00 hrs Nos.

Nursing In-charge Emergency / Head Nurse 1
(She will remain available from 19:00 till 08:30 hrs on week-days)
Charge Nurses (numbers depending on workload) 7
Nurse Aids 2
Male Nurse 1
Paramedics ECG Tech 1
Ward Helpers 4
Cleaner / sweeper 1+1
Stretcher boys / wheel chair helpers (main gate to emergency) 3

BASIC FACILITIES

While the obstetric emergencies shall be directly routed to the Labor Room and the infants shall be
sent directly to the Pediatric Ward for management, the remaining bulk of patients reporting to the
Emergency will be assessed and managed for the imminent care in the main Emergency Department.
The Hospital Emergency Department will provide the following basic facilities to the patients reporting
in the emergency:
i. First Aid and emergency management including resuscitation
ii. Necessary diagnostic facilities /investigations
iii. Detention for short periods (to a maximum of 4 hours) of cases requiring observation, I/V
therapy, nebulization, relief of pain etc., or pending disposal by specialists on call
iv. Facilities of minor surgical operations/procedures will be provided by the minor operation
theatre functioning in the Emergency Department. These include dressing, stitching, incision
and drainage, application of Plaster of Paris (POP) etc. All outdoor and indoor patients
requiring the same will be attended here
v. Administration of Intravenous infusion/injections etc.
The EMO/CMO will examine the patient and if the patient is suffering from minor ailment then will
advise treatment on clinical note sheet as well as ER admission slip and send the patient to Charge
Nurse for injection (it needed), after which patient is sent home and the clinical note sheet will be
taken by the Charge Nurse. If the patient needs admission, he/she will be referred to the concerned
Medical/Surgical unit for admission in ward/ICU. The referred patient will be attended by the MO/PGR
of the concerned specialty (Medical/Surgical). The House Officer of the concerned unit will follow and
carry out the instructions of the MO/PGR. The MO/PGR/SR of the concerned unit will write down the
treatment plan on the clinical note sheet and sign it.
No treatment plan will be written on the E.R. slip which is to be kept with the patient for final disposal.
The investigations will be ordered by the CMO/MO/PGR/SR and House Officer is responsible to send

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these investigations to the Lab/Radiology department. If the patient is admitted in the ward, both E.R.
slip and clinical note sheet will be attached with the admission documents. The patients will be
managed in the emergency as per the following SOPs:
i. In case of serious patients, the treatment plan should be discussed with the consultant on call
ii. If the patient is discharged/expired after treatment the clinical note sheet will be kept as
record in the Emergency Room and the Head Nurse/Charge Nurse of Emergency Room is
responsible to keep this record
iii. In case of expiry of the patient EMO/CMO/PGR will prepare the death certificate and sign it
and will also write down the death summary in the death register of Emergency Department
iv. The treatment of discharged patients should be written on the Emergency Room slip, duly
signed by the EMO/CMO and handed over to the patient for follow up
v. No House Officer is allowed to discharge the patient without the knowledge of SR/PGR after
approval of primary consultant
vi. Dispenser on duty in the Emergency Room is responsible for the entry of these patients in the
Master / duty sister Register

TRAINING
The Director Emergency /Registrar In-charge Emergency Department will ensure continuous training
of the emergency staff on improving their professional skills, proper handling of the patients, patients
safety, infection prevention and control. The trainings should also cover management of
stress/anxiety, and improving their communication skills. The ward master will ensure that the staff
deputed in the Emergency Department is physically fit, efficient and energetic. This staff will not be
changed without the concurrence of the Director Emergency / Registrar In-charge Emergency. The
training of the staff in the Emergency Department will essentially include the following:

i. Cardio-Pulmonary Resuscitation (CPR)

ii. The management of Acute Emergencies
iii. Admission documentation procedures
iv. Medico-Legal Policy
v. Quality Standards and indicators

The ward master will ensure that all ward helpers available in the hospital are once rotated for duty
to the Emergency Department so as to be properly trained on stretcher bearer duties.

Basic Equipment

The I/C Nursing staff will ensure that all life supporting emergency equipment at least the following
in the number commensurate to the number of beds/ workload is available and in working order:

Sr List of Equipment Tentative Quantity / Nos.

i. ECG Machine 5
ii. Defibrillator 1
iii. Nebulizer 2
iv. Oxygen Cylinder (11 litres with key, gauge and 2
flowmeter)
v. BP apparatus 10

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vi. Sucker Machine Manual 10
vii. Sucker Machine Electric 2
viii. Peak flow meter 2
ix. Weighing machine 2
x. IV stands 12
xi. Stretchers 4
xii. Wheel chairs 10
xiii. Cardiac Monitors 4
xiv. Sheller Monitor 1
xv. Pulse Oximeter 4
xvi. Electricity Generator (stand by) 1

Power Failure

Ideally, in case of power failure, the power generator should automatically switch on so as to maintain
un-interrupted power supply to the sophisticated medical devices, like ventilators, anesthesia
machines, etc. In case otherwise, the electric generator will be switched on promptly.

Code Blue

In case of any emergency, the concerned Ward Nurse will press CODE Blue N0. 0000
On intimation from the concerned area nurse, the telephone operator will announce “code blue”
three times, loudly and clearly. When “Code Blue” is announced all physicians in that building will
respond. However, 2 medical officers i.e. MO medicine of the area and MO anesthesia will stay at site.
Any other responding physician will leave once these two people are present.
First physician (any department, any level) arriving will conduct the CPR till the MO Medicine of the
area, Registrar Medicine, or the Consultant in Medicine arrives, in which case most senior of the three
will be supervising and conducting the CPR. This person will be responsible for giving all orders, others
can suggest but would not give direct orders. Following SOPs will be observed:

i. To avoid overcrowding it is recommended that people not in CPR team unless directly
involved in patient care, should leave the area.
ii. ECG technician will stay till end of CPR.
iii. Cardiac massage, breathing and defibrillator etc. will be the responsibility of only following
person once they arrive:
a. MO Medicine of the area
b. MO Anesthesia
c. Nurse Incharge of the area
d. Assistant Nurse of the area
A. Supply of medicine, oxygen supply, suction apparatus, CVP Line, intubation equipment etc.,
will be the responsibility of Nursing Supervisor. The nursing team will think forward and will
ensure continuous supply and replenishment of medicine and supplies if running out of stock.

B. IF after 15 minutes of efforts the CPR result is poor and the patient does not respond even
after 20-30 minutes, the CPR shall be discontinued and the telephone operator will declare
“Code Blue Over” on microphone as advised by the CPR team leader.

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Code Blue Team

i MO Anesthesia
ii MO Medicine
iii MO cardiology
iv Nursing Supervisor
v ECG Technician
vi Bio-Medical Technician
vii Ward Master
viii Security In-charge

Triage Categories

As soon as the patient is rushed into the Emergency Department of the hospital, the Head Nurse or a
senior charge nurse assigned as “Triage Nurse” for the shift shall immediately assess the patient
empirically in line with standard Triage protocol.

a. Immediate Resuscitation

Patients who need treatment immediately or within two minutes are categorized as having a life-
threatening condition. Most of them would have arrived in the Emergency Department by
ambulance and would probably be suffering from a critical medical condition, serious injuries or may
have sustained a cardiac arrhythmia / cardiac arrest.

b. Emergency

Patients who need to be treated within 10 minutes are categorized as having an imminently life-
threatening condition. This group of patients includes those suffering from a critical illness or are
very severe pain e.g. chest pain, difficulty in breathing and fractures etc.

c. Urgent

This group of patients requires treatment within 30 minutes and is categorized as having a
potentially life-threatening condition. These include patients suffering from severe illnesses,
bleeding heavily from cuts/wounds, have major fractures, or are dehydrated.

d. Semi-Urgent

Patients in this group are having a potentially serious condition with less severe symptoms or
injuries, such as a foreign body in the eye, sprained ankle, migraine or earache etc. and need to be
treated within one hour.

e. Non-Urgent

This category includes patients who have a less urgent condition and need to have treatment within
two hours. This includes those having minor illnesses or symptoms which may have been present for
more than a week such as rashes or minor aches and pains.

Notes and Evaluation

• EMOs /CMOs are primarily responsible for managing patients in Emergency.

• Referred patients should be seen within I0 minutes of referral by CMO.

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• The Charge Nurse will immediately check vitals before digging through old record, lab results
and old discharge.
• Summary and old charts.
• Proper documentation of symptoms.
• Management and diagnosis will be done for every patient. Serious patients should be
immediately seen and resuscitated. Procedure of referral and consultation will proceed side
by side. Monitoring notes should be properly maintained including fluids given and output of
patient.

Admissions from the Emergency Department

• Duty registrar should decide all admission through ER.
• After assessment and patient's examinations complete admission orders including drug
Prescription should be written clearly and immediately.
• Duty registrar will inform nursing staff for stat labs immediately or carry out by himself.
• Notes on history and examination file should be completed before shifting to In-Patient.
• Complete shifting notes shall be recorded before shifting the patient to the ward.
• Paramedic staff should accompany every admitted patient during shifting to the ward.
• In case of serious patient, concerned MO of the department should accompany the patient.
• Before shifting, inform the ward staff on call.
• If beds are not available in wards, retain patients in ER till arrangement are made, If required
discuss with consultant on call or Registrar ER.

Discharge from the Emergency Department

• No patient should be discharged without being evaluated by the duty registrar.
• Keep in mind pending labs issued; and results awaited.
• Communicate with all involved parties for smooth discharge.
• Give clear instructions regarding medicines schedule/side effects/precautions
• Clear instruction regarding Restrictions on activities/travel/diet in Urdu/local language make
sure by repetition that Patient can repeat/recall your instructions. Write discharge diagnosis
clearly.
• Notes should include chief complaints and history of present illness, hospital stay, course,
name of examining doctor, Hospital Medical Record Number /provisional and secondary
diagnosis and Procedures. The discharge certificate should also mention follow-up
plan/condition on discharge and attach diet chart if required.

Transfer of Patient to other Hospital

Patient Transfer to Other Facilities

• Once decision is made to transfer the patient to the other hospital for management, contact
the concerned doctor/staff there first on telephone and discuss the case in detail and request
to make sure the bed is available for the patient.
• Note down the contact person's name and designation.

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• Provide detailed notes on the referral slip.
• Provide ambulance preferably by the hospital through coordination with DMS/CMO, and if
patient is serious, a doctor allied staff should accompany while transportation.
• Ambulance should be equipped with resuscitation equipment.

Death / Expirations/Receive Dead

• On being called to pronounce death the doctor must perform certain steps.
• On arrival to bed site observe for respirations, auscultate for heart sound, palpate for carotid
pulse, and check pupil and corneal reflex.
• Complete death notes on progress sheet and fill death certificate as early as possible.

SOP for Medico-Legal Cases

The private or trust hospitals do not deal with medico legal cases per se. However, in the
circumstances where a patient presents with life threatening condition and delaying and/or referral
to any other hospital will endanger the life or result in the death of the patient, the hospital ER will
provide care to the patient that is essential for continuity of life. However, once the treatment is no
more required for continuity of life and patient is stable, he may be referred to other Government
health services for medico legal formalities.

With immediate effect, no Medico-Legal case will be admitted in the hospital without Medico Legal
Certificate (MLC).

Medico legal cases:

i Poison
ii Fire arm injury
iii Burn cases
iv RTA
v Physical Assault
vi Rape
vii Sexual Assault
viii Fight
Occupational Risks
Standard barrier nursing and isolation techniques should be employed in cases of patients with
infectious communicable diseases. These measures include:
 Gloves
 Masks
 Careful needle/sharp object handling
 Prophylaxis in cases of exposure if indicated (e.g. Meningococcemia).
 In case of mishap/exposure, event should be reported to consultant on call, immediately.

Accountability
In case of an incident, a committee comprising of consultants will review the entire case in detail and
decide about warning/penalty as the case of may be.

Ethical Issues
Best interest of the patient should be watched, in case of conflict or confusion, issues should be
discussed with consultant on call.

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Confidentiality of Patient's Data
Patient's record and data should be kept confidential to watch his/her interests and
diagnosis/prognosis should not be discussed with attendants without permission of patient/close
attendant.

Senior Consultation
On call consultant/senior registrar should be contacted on phone if required by the registrar on call.
If he/she may request to see the patient, then on call consultant should try to attend the patient
personally at the earliest or within I hour of the request.

Consultations from Other Departments / Urgent Scans

Consultants and scans should be decided by the duty registrar and call to the respective department
should be written with clear indications, exact questions to be observed and urgency of the
consultation.

Record Keeping

• ER register shall be filled properly with composite diagnosis or relevant differential for every
patient.
• Duty registrar will sign register at the end of duty, and to be counter-signed by covering
consultant for that day before morning meeting.
• Record of consultations provided to other department should be kept in the registrar.
• Death notes for patients who expired in ER should be written in the ER register immediately
after the event.

Drugs and Investigations

List of drugs and lab profile available in hospital for ER patients should be available to each shift of
ER staff.

BLS/ACLS Training
House officers and registrar should be trained in BLS/ ACLS before performing duties in E.R.

Dress Code
Dress should be conservative and modest and no informal clothing (jeans and T-shirts for males),
party wears or excessive jewelry (for females) should be allowed, during duty hours.

Every doctor should wear neat and clean overall, with properly displayed ID card or name plate.

Medicines
a. Sufficient stock of life saving medicines will be kept in the medicine trolley of the ER.
b. Stock utilized will be recouped immediately and on regular basis.
c. Controlled medicines will be demanded on a daily basis so as to recoup the stock
utilized in the previous 24 hours.
Transport
a. The following will be available at MER and will move under orders of the EMO/ CMO I/C
MER:
i. Ambulances for transporting the patients.
ii. The drivers employed on 8 hourly shifts.

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b. When moving to collect the specialist the driver will be issued a duty slip bearing his/her
residential address and telephone number.
c. On return to the hospital this duty slip with the mileage covered will be put up to Manager
Administration.
Patient Kit and Belongings
In case there is no attendant with the patient at the time of his admission then an inventory of his
personal belongings will be made and the belongings will be kept in the hospital pack store and a
receipt will be issued to the patient. In the event that the patient is unconscious, delirious or of
unsound mind and there is no attendant with him the Nursing Supervisor will make an inventory of
his personal belongings in the presence of a medical officer.

Paediatric Emergency
Paediatric emergency is divided into three portions

a. Reception and waiting area

b. Screening and examination area
c. Causality area/Short stay

It should preferably be covered by two doctors in each shift i.e. Medical Officer/FCPS/MCPS Trainee.
One doctor covering the screening clinic and the other one taking care of patient for
admission/short stay and for procedures.

• Wearing of white coat with hospital I.D card is mandatory.

• Medical Officer/FCPS/MCPS Trainee must reach well in time in emergency ward to take
proper over of short stay/Causality area cases.
• Consultants coverage time is from 8.00 am to 8.00 am.
• Patients arrival time must be mentioned on the ER card.
• Short stay/ Causality area cases should remain admitted for not more than or up to 3 hours.
Patient needing prolonged stay should be advised admission by the ER doctor.
• Doctor must carry a red marker, pocket book, stamp, and stethoscope.
• All Trainees (FCPS/MCPS), Medical officer are supposed to be in in emergency department
during their duty hours in emergency.
• ER doctors is supposed to run the screening clinic, complete the admission procedure,
including detail history and physical examination of the child, blood sampling and initial
management plan.
• Before deciding to admit the patient, doctor should be able to assess the socioeconomic
status, reminding parents about hospital charges.
• In case of any help needed from the seniors (Consultants, Sr. Registrar, Registrar) all are
available physically or by telephonic to help in diagnosing and managing the patient)
• Critically sick patients are always on priority.
• Medical Officer/FCPS/MCPS Trainee must inform every critical situation and seriousness of
patient to the Sr. Registrar/Registrar on call.
• Critically sick patients must be escorted by the doctor, staff nurse and ward helper to avoid
the mishaps occurring on the way.

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SOPs – Infection Prevention and Control in Emergency

Waste Disposal of Emergency Department Oversight
Responsibility
Categorization of Waste
No-Risk Waste
a. General waste such as papers, unused tubing, packing of drugs
and infusion bags etc.
b. UN -consumed food.

i. Infected Waste
a. Human Blood and blood products. Specialist
b. Collections from Drains. in-charge
c. Empty Syringes. (Note: ALL SYRINGES MUST BE CUT BEFORE Emergency
DISPOSAL.)

ii. Sharps:
a. Used and unused hypodermic needles.
b. (Note: ALL NEEDLES MUST BE CUT BEFORE DISPOSAL.)
c. Stylets of peripheral cannulae and central venous lines.
d. Empty glass ampoules.

iii. Chemical Waste:

a. Expired drugs
b. Disinfectants and germicides used for cleaning.
SENIOR
Separation and Disposal
NURSING
Separate the waste according to following colour coding system
ASSISTANT
a. No Risk waste: Throw it in white coloured bucket containing White
IC
coloured polythene bag and when filled dispose of this white bag.
b. Risk Waste: Throw it in yellow coloured bucket containing yellow
(coloured polythene bag. When filled dispose of this black bag.

Notification to the Infection Control Officer (ICO)

Following MUST be notified to ICO
a. Fever of more than five days whether shown a positive culture or not.
b. Outbreak of infection.
Specialist
I/C
Outbreak of infection is defined as
EMERGENCY
1. Occurrence of two cases of Methicillin resistant Staphylococcus
Aureus (MRSA) Infection anywhere in the hospital.
2. Occurrence of one case of Diphtheria
3. Occurrence of three consecutive cases of septicaemia

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Anaphylactic and drug reactions, asphyxia, electric shock and drowning

Following catastrophic situations demand immediate and proper systematic interventions /
treatment:
a. Complete cerebral anoxia over 4 minutes will cause permanent damage and beyond
6-8 minutes will cause death.
b. Cessation of normal circulation causes rapid cyclic deterioration which is
characterized by hypoxia, lactic acidosis and hypercarbia. Pre-existing heart disease,
electrolyte imbalance, medication or anesthetics may precipitate the collapse.
c. The reflex vagus-induced arrests secondary to stimulation of the esophagus and
tracheobronchial tree and similar arrest may occur during rectal and proctoscopic
examination.
d. Pre-anesthetic doses of atropine may have worn off by the end of a long (4 hour)
operation and may make the patient more susceptible to the complication
e. Electrolyte imbalance, mainly hyperkalemia either from endogenous or exogenous
sources, is critical. The ration of ionized serum calcium to potassium and their
antagonistic actions on the myocardium are important during massive transfusion of
banked blood as it is high in potassium as well as calcium-binding citrate.
f. Other causes of cardiac arrest include; pulmonary emboli, electrocution or any cause
of hypoxia.
g. Primary ventilatory failure is caused by hypoxia, central nervous system or spinal cord
trauma and respiratory depression from narcotics.

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Management of Cardiopulmonary Arrest

a. Emergency Measures (A for Airway)
i. Begin treatment if there is no obtainable blood pressure or pulse for 10 seconds
ii. Place patient in supine position on a hard surface (metal or plastic tray under the chest)
iii. Establish a clear airway
a. Clean out mouth and pharynx (manually or by suction)
b. Tilt head back and pull chin forward.
c. Insert an oropharyngeal airway or endotracheal tube, if necessary.

b. Establish Ventilation (B for Breathing)

i. Mouth-to-mouth: A handkerchief may be interposed between the operator’s mouth
and patient.
ii. Use “Ambu” bag and mask.
iii. Provide an adequate tidal volume in accordance with the optimal chest excursion rate
as under:
a. Adult-12 times per minute.
b. Children-20 times per minute.
c. Infants-30 times per minute.
d. Ventilate adults until chest expands to beyond normal size.
e. Children require less force, approximately that needed to inflate an ordinary toy
balloon.
f. Infants are given only short puffs.

c. Closed Chest Cardiac Compression (C for Circulation)

i. Anatomic Considerations:
Pressure on the sternum compresses the heart and reduces the sizes of the thoracic
cavity. This forces blood out of the ventricles and expels air from lungs. On release,
blood flows into the large veins of the chest and into the atria and air enters the lungs.

ii. Method
a. Patient remains in a supine position on a hard surface such as a tray or the floor,
if necessary.

b. The heel of the right hand with the heel of the left on top is placed on the lower
third of the sternum just above the xiphoid.

c. Firm pressure is applied downward and body weight brought forward to secure
sufficient pressure. The sternum should move 4-6 cm, toward the vertebral
column in adults. The force is transmitted directly to the heart behind the
sternum. DO NOT exert pressure on rib cage or epigastrium.

d. Hands should be quickly removed after each placation of pressure to allow

intrathoracic venous fillings and the lungs to expand.

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e. Rate of pressure application should be 80 times per minute, slightly faster in
children and infants. Also, the force applied must be moderated to fit the elastic
properties of the thoracic cage. All that is needed is simple first and middle finger
compression in the newborn infant.

f. Observations for the signs of restoration of flow include a full carotid or femoral
pulse, constricted pupils, return of skin color, spontaneous ventilation and
movements.

g. A systolic blood pressure of 60-80 mm Hg can be obtained if cardiac compression

is correctly performed.

h. The ratio of lung inflation (mouth-to-mouth breathing) to cardiac compression

should be 1:5 when there is an assistant, and 2:15 (lung to heart) before help
arrives.

d. Ventricular Fibrillation
i. Immediately upon recognition of ventricular tachycardia or fibrillation, a sharp
precordial thump with the closed fist is delivered as this important first maneuver is
sometimes effective by depolarizing the myocardium and allows for a normal rhythm
to develop

ii. If infective, electrical defibrillation is performed in which after applying conductive jell
the defibrillation paddles are firmly placed on the chest, one over the upper sternum
and the other to the right of the lower sternum (cardiac apex)

iii. Only capacitor discharge (DC) defibrillators should be used, AC defibrillation is

hazardous and may cause serious burns

iv. The matter is set at about 400 watt-seconds (joules), all attendants are instructed to
stand clear of the bed or supporting structures, the ECG machine must be turned off if
it is not internally grounded during counter-shock

v. Considerably less voltage is applied to children or to the exposed heart

vi. Secure an electrocardiographic tracing as soon as possible and continue specific

therapy as indicated by the tracing

vii. Give epinephrine or isoproterenol and sodium bicarbonate as these drugs strengthen
the contractions and permit easier defibrillation

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Annex-I

Triage Sheet

Patient Name:………………………………………………………………………………………………………………………

Age……………………Gender: M F

Chief complaints:……………………………………………………………………………………………………………

Date…………………………………Time of Arrival………………………………………

Part 1: Triage Early Warning Score (TEWS)

Triage Parameter Measured Value TEWS Score
Mobility
Respiratory Rate
Heart Rate
Blood Pressure
Temperature
AVPU
Trauma

TEWS Score:……………………………………………………………………………………………………..

Initial Triage Colour: RED ORANGE YELLOW GREEN BLUE

Part 2: The Discriminator List

1. Does the patient need to be triaged to a higher colour based on the discriminator
list? Yes NO

2. What was the discriminator?.........................................................................

Part 3: Final Triage Colour:

RED ORANGE YELLOW GREEN BLUE

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Annex-II

Code Blue Feed Back Form

Patient Name: _________________ MR#: ____________ Date: ____________
Age/Sex: _________________ Department: ____________
Time --------------------
1. Code blue announced at (Time) ---------------------------------------------
2. Code blue announced twice ---------------------------------------------
3. Code blue announced thrice ---------------------------------------------
4. Code blue team arrival times ---------------------------------------------
5. ICU on duty MO /SR ---------------------------------------------
6. ICU on duty Nurse ---------------------------------------------
7. Dept. on duty Doctor ---------------------------------------------
8. Dept. on duty H/N, S/N ---------------------------------------------
9. Shift supervisor ---------------------------------------------
10. Security ---------------------------------------------
11. Ward boy/Ward helper ---------------------------------------------
12. Cleaner --------------------------------------------
13. Cardiac board placed ---------------------------------------------
14. Resuscitation initiated @ ----------------------------------------------
15. CPR Done ----------------------------------------------
16. Oxygen attached ---------------------------------------------
17. Intubated ---------------------------------------------
18. Medicines given Yes No
19. Total Resuscitation time ----------------------------------------------
20. Code ended @ ---------------------------------------------
21. Patients response ----------------------------------------------
22. Code Blue team Leader ----------------------------------------------

REMARKS
--------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------------
--------------------
Shift supervisor Name:

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Annex-III

Resuscitation Form

Patient name: Age/Sex:______________________ MR NO______________

Diagnosis: ____________________ Department:____________________ Bed.

No:___________

Attending consultant:
_________________________________________________________________________

Time of arrest: _____________ Date of arrest:_________________ Time resuscitation start:______

Time resuscitation end______________Resuscitated by (Dr/Nurse Name)

______________________________

Total Duration Resuscitation: _______________ Type of Arrest:__________________________

Drugs / IV fluids Time Route sign Remarks

Others:
DC shocks
Intubation

Ventilation

Result patient: Revived: Yes / No Expired: ________________Disposal to: ICU / Morgue

1. Attending Doctor Name (ICU)_______________________ Signature:_____________

2. Attending Doctor Name (MO/SR from Deptt)_____________Signature:_____________

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Annex-IV

Equipment and Supplies

This is not an exhaustive list and is rather, a tentative list based on common, minimal
needs of 1st or 2nd referral Hospital. The Essential list of basic equipment and supplies
needed for effective running of such an Accident & Emergency Department are listed
below:

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

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

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Annex-V

Essential Medicines
A tentative list of Essential medicines based on common, minimal needs of 1st or 2nd
referral Hospital needed for effective running of such an Accident & Emergency
Department are listed below:

1. 50% Dextrose 2. Hydrocortisone

3. Adrenaline 4. IM Glucagon
5. Nor-adrenaline 6. Insulin
7. Anti snake venom serum 8. IV calcium Gluconate
9. Aspirin 10. IV Dopamine
11. Atropine 12. IV Fluid - all type
13. Anti Tetanus Serum 14. IV Frusemide
15. Dextran/ voluven 16. IV KCl
17. Diazepam 18. IV Vit K
19. Dobutamine 20. Labetalol
21. Etomidate 22. Lignocaine
23. Fresh Frozen Plasma 24. 10% xylocaine spray
25. Gelofusin 26. Magnesium Sulphate
27. Group O neg whole blood 28. Mannitol
29. Heparin 30. Midazolam
31. Hydralazine 32. Morphine
33. Naloxone 34. Phenylephrine
35. Nitroglycerine 36. Propofol
37. Oral Rehydration Salt (ORS) 38. Salbutamol
39. Oxygen supply 40. Sodium bicarbonate
41. Pethidine 42. Suxamethonium

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Annex-VI

The CTG discriminator list (adult version)

(Cape Triage Score)

D5 14-12-22 Page 97 of 117

Annex-VII

Children Triage Score (3-12 Years, 96-150CM) TEWS

3 2 1 0 1 2 3
Stretcher/Im
Mobility Walking With Help Mobility
mobile
Less
RR than 15-16 17-21 22-26 27 or more RR
15
Less
HR than 60-79 80-99 100-129 130 or more HR
60
Cold or Under Hot or Over
Temp 35-38.4 Temp
35 38.4
AVPU Confused Alert Reacts to Voice Reacts to Pain Unresponsive AVPU
Trauma No Yes Trauma
3 to 12 years old/96 to 150 cm tall

Children (3-12 Years.’ 96-150CM) Discriminatory List

COLOUR RED ORANGE YELLOW GREEN BLUE
TEWS 7 or more 5-6 3-4 0-2 DEAD
Target time
to treat
Immediate Less than 10 mins Less than 60 mins Less than 240 mins
Mechanism
of injury
High energy transfer
Shortness of breath
Drooling Stridor
Wheeze
Hemorrhage-
Hemorrhage-Uncontrolled
Uncontrolled
Seizure – Current Seizure – Postictal
Focal neurology-acute
Level of consciousness
reduced
Exhaustion
Purpura ALL OTHER
Presentation DEAD
Dislocation - finger of PATIENTS
Dislocation - other joint
toe
Fracture – compound Fracture - closed
Burn over 10%
Burn – face / Burn – electrical
Burn - other
inhalation Burn – circumferential
Burn - Chemical
Poisoning / Overdose Abdominal pain
Hypoglycemia – Diabetic – glucose over 11 Diabetic – glucose over
glucose less than 3 & ketonuria 17 (no Ketonuria)
Dehydration Inappropriate history
PR bleeding Inappropriate history
Pain Severe Moderate Mild

Senior Healthcare Professional’s Discretion

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Annex-VIII

Infant Triage Score (<3yrs, <95CM) TEWS

3 2 1 0 1 2 3
Normal for Stretcher/Im
Mobility Mobility
Age mobile

Less than
RR 20-25 26-39 40-49 50 or more RR
20

Less than
HR 70-79 80-130 131-159 160 or more HR
70

Cold or
Hot OR Over
Temp Under 35-38.4 Temp
38.4
35

Reacts to
AVPU Alert Reacts to Pain Unresponsive AVPU
Voice

Trauma No Yes Trauma

Younger than 3 years / smaller than 95 cm

Infant (<3yrs, <95CM) Discriminatory List

COLOUR RED ORANGE YELLOW GREEN BLUE
TEWS 7 or more 5-6 3-4 0-2 DEAD
Target time
to treat
Immediate Less than 10 mins Less than 60 mins Less than 240 mins
Mechanism
of injury
High energy transfer
Drooling Shortness of breath
Stridor Wheeze
Hemorrhage-
Hemorrhage-Uncontrolled
Uncontrolled
Seizure – Current Seizure – Postictal
Focal neurology-acute
Level of consciousness
reduced
Floppy infact
Purpura
Dislocation - finger of
Dislocation - other joint
toe
Fracture – compound Fracture - closed ALL OTHER DEAD
Presentation
Unable to weight bear PATIENTS
Burn over 10%
Burn – face / Burn – electrical
Burn - other
inhalation Burn – circumferential
Burn - Chemical
Poisoning / Overdose Abdominal pain
Hypoglycemia –
glucose less than 3
Vomiting - persistent
Dehydration Not feeding
Not urinating
Inappropriate history
PR bleeding Prolonged or
uninterrupted crying
Pain Severe Moderate Mild

Senior Healthcare Professional’s Discretion

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Annex-IX

Examples of Triage systems and Triage Scoring Systems

internationally in vogue
Scoring System Countries /regions
The “Triage Revised Trauma Score or TRTS” , Western Europe
Developed in
The Injury Severity Score (ISS)
Maryland, USA and
Score based on severity of injury to the human body from 0 to 75 is internationally
assigned into the following categories: used to determine
A: Face / neck / head severity of trauma
B: thorax / abdomen and probability of
C: extremities / external / skin mortality
Each category is scored from 0 to 5, using the abbreviated injury scale
(from un-injured to the critically injured) which is then squared and
summed to create the ISS. A score of 6 for un-survive-able can also be
used for any of the three categories and automatically set the score to
75 regardless of other scores

United Kingdom United Kingdom

In the UK, Smart Incident Command System is the commonly used triage
system, where casualties are graded from Priority 1 (needs immediate
treatment) to Priority 3 (can wait for delayed treatment), with an
additional Priority 4 (expectant, where patients are likely to die even
with treatment). However, only senior medical authority can assign and
pronounce such category.

 Dead – patients with trauma score 0 to 2 & are beyond help

 Priority 1 – patients who have a trauma score of 3 to 10 (RTS)
and need immediate attention
 Priority 2 – patients with trauma score of 10 or 11, can wait for
transport to definitive medical attention
 Priority 3 – patients who have a trauma score of 12 (maximum
score) and can be delayed before transport from the scene

Finland: Finland
Triage is performed by a paramedic or an emergency physician using
the four level scale given as under:

Can wait
Has to wait
Cannot wait
Lost

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 France France
The Pre-hospital triage is undertaken in France by using the following
four level scale
DCD Deceased
UA Urgence absolute
UR Urgence relative
UMP Medical – psychological urgency (lightly wounded or
just psychologically shocked)
Germany Germany
The Preliminary assessment is done by the first ambulance crew on
scene, and then by the first doctor arriving the scene. At the treatment
facility, a 90 second full body assessment is done followed by triage as
per following classification:
T1 Acute danger for life : immediate transport and
immediate treatment
T2 Severe Injury (constant observation, early
transport and rapid treatment)
T3 Minor or no injury : treatment when practical
T4 No or small chance of survival: observation &
Analgesia
Deceased : (injuries not compatible with life)
- identification
United States of America United States of
First responders could be police, fire rescue, paramedics, or community America
individuals with disaster training, trained to perform first aid, by using
basic lifesaving and rescue techniques.

 Immediate: The casualty requires immediate medical attention

and will not survive if not treated soon. Any compromise to the
casualty's respiration, hemorrhage control, or shock control could
be fatal.
 Delayed: The casualty requires medical attention within 6 hours.
Injuries are potentially life-threatening, but can wait until the
immediate casualties are stabilized and evacuated.
 Minimal: "Walking wounded," the casualty requires medical
attention when all higher priority patients have been evacuated,
and may not require stabilization or monitoring.
 Expectant: The casualty is not expected to reach higher medical
support alive without compromising the treatment of higher
priority patients. However, care should not be abandoned, as they
would deserve time and resources available after Immediate and
delayed patients have been treated.

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 Canada Canada
(Started as triage by Primary Care level paramedics, in Victoria General
Hospital, Nova Scotia, Canada )
Canadian Triage and Acuity Scale (CTAS)
This model is being used by paramedics and emergency room nurses for
routine emergencies, and allows for pre-arrival notifications, too. This
model contemplates categorization of all incoming patients by using
both injury and physiological findings, and ranks by severity from 1
(highest) to 5 (lowest). The system is not being used for mass casualties.
Level Description Should be seen within:
1 Resuscitation 0 minutes
2 Emergency 15 minutes
3 Urgent 30 minutes
4 Less urgent 60 minutes
5 Non-urgent 120 minutes
The Australian Triage Scale (ATS) formerly National Triage Scale Australia and New
Zealand
The scale ranges from level 1 (most critical) to level 5 (least critical or
non-urgent, with assigned priorities as under:
Level Description Should be seen within:
1 Resuscitation 0 minutes
2 Emergency 10 minutes
3 Urgent 30 minutes
4 Semi-urgent 60 minutes
5 Non-urgent 120 minutes
Simple Triage And Rapid Treatment (S.T.A.R.T) California
Being very simple, even the emergency personnel with little training can Emergency
use. Workers in
earthquakes
Triage separates the injured into four groups: (community
 The expectant who are beyond help emergency
response teams)
 The injured who can be helped by immediate transport
 The injured whose transport can be delayed
 Those with minor injuries who need help less urgently
Triage also sets priorities for evacuation and transport as follows:
Deceased are left where they fell. These include those who aren't
breathing and repositioning their airway efforts were unsuccessful.
 Immediate or Priority 1 (red) evacuation by Airlift if available
or ambulance as they need advanced medical care at once or
within 1 hour. These people are in critical condition and would
die without immediate assistance.
 Delayed or Priority 2 (yellow) can have their medical evacuation
delayed until all immediate people have been transported.

D5 14-12-22 Page 102 of 117

 These people are in stable condition but require medical
assistance.
 Minor or Priority 3 (green) are not evacuated until
all immediate and delayed persons have been evacuated.
These will not need advanced medical care for at least several
hours.
Continue to re-triage in case their condition worsens. These people are
able to walk and may only need bandages and anti-septic.

Jump Start (pediatric) Triage

This Mass Casualty Incidents (MCI) triage tool is a variation of the
S.T.A.R.T model, designed for triaging children from infancy to eight
years of age.

Hospital (in-patients) Triage Systems

On arrival of the patient in the Emergency, as a first step, the hospital
triage nurse would assess the patient, so as to determine priority for
admission in the emergency and for treatment.

In every larger, tertiary care hospital having a significant patient flow

into the Emergency Department, there should be a well-defined process
of decision making regarding admission and discharge/referral (internal
and /or external) in the Emergency Department. There should be a
process owner body or team to manage available bed strength that may
include Head Nurse of the floor, and the senior internal medicine
specialist (full time Emergency Physician). The team should have a
defined process and a well-considered operational plan, so as to
facilitate the emergency room physicians and nurses towards deciding
which patients have been stabilized and can be transferred, and
simultaneously which / how many requests for new admissions can be
accommodated.
Decision regarding admission or referral is made by the Emergency
Room Physician, by also considering available bed space and hospital’s
capacity. Similar decision making is done by the surgical, orthopedic and
neurosurgical (if available) teams in the Emergency Department.
Conventional Classification of the Triage process
 Black/ Expectant: These are the patients so severely injured that
they will die of their injuries in hours or days. Examples include large
area burns, lethal radiation dose, severe trauma to head or chest,
or in life threatening medical crisis, that are unlikely to survive
(cardiac arrest, septic shock etc.)
 Red/Immediate: Such patients cannot wait, and require immediate
surgery or other life-saving intervention, and have first priority for

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 treatment, or transport to the advanced facility level. Such patients
are likely to survive with immediate treatment.
 Yellow / Observation: Such patients are stable for the moment, but
require watching by trained persons and frequent re-triage.
 Green / Wait: (Walking wounded) these are the patients requiring
doctors’ care in several hours or days, but not immediately.
Examples include soft tissue injuries, fracture of small bones (not a
compound fracture).
 White/ dismiss: (walking wounded) such patients may have minor
injuries where first-aid and home care would suffice and the injuries
may include scrapes, minor burns or superficial cuts.

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 Referral Guidelines
Annex-X

GUIDELINES FOR REFERRAL / TRANSPORT OF

CRITICALLY ILL / INJURED PATIENTS

Preamble
As per the internationally accepted Standard Operating Procedures (SOPs), referral is a process
whereby the healthcare provider of a health facility seeks assistance of healthcare providers having
better expertise and higher-level facilities to take over the responsibility to manage the particular
clinical condition of the patient. Typically the health facilities where patients are referred from other
facilities are supposed to have better infrastructure, more qualified human resource and advanced
technology for diagnosis and management of patients requiring specialized care. While referral of
patients in need of specialist advice from a general practitioner to a specialist clinic or hospital is a
norm, referral of critically ill patients from one health facility to the other is an issue of concern. The
referral therefore, need to be regulated in order to ensure safety of the patient during transit, and
upon arrival at the place of referral.

The Public Sector Healthcare system in Pakistan comprises of primary, secondary, and tertiary level
healthcare facilities. The Primary health care facilities include basic health units (BHUs), rural
dispensaries, mother and child health centers (MCHCs) and the rural health centers (RHCs). These
facilities are manned by essential staff to provide preventive and promotive healthcare bedsides,
treatment of minor ailments. The services are delivered through facility-based staff supported by
outreach teams. Secondary level healthcare facilities, include District Headquarter (DHQ) and Tehsil
headquarter (THQ) hospitals, which provide specialized care on both outpatient and in-patient basis
in addition to the primary healthcare package. The DHQ and THQ hospitals also take referrals not only
from the RHCs /BHUs but also from the private healthcare providers/ healthcare facilities. Tertiary
care health facilities are mainly located in mega cities and are affiliated with undergraduate and
postgraduate teaching and research institution. Secondary and tertiary care facilities are generally
open on 24/7 basis and provide specialized and super specialized healthcare to the patients directly
approaching these facilities as well as to the referrals from the public and private sector.

Although the Government is the largest single provider of the healthcare services, the private sector,
has emerged in a big way during the three decades by establishing small, medium and mega private
hospitals in addition to the clinics of general practitioners (GPs). The private sector facilities, providing
varied range of healthcare have grown as for-profit business ventures over the years particularly in
the peripheral districts. Most of these for-profit facilities except for those located in metropolitans
however, are generally deficient in terms of infrastructure, qualified human resource and equipment
required for providing specialized healthcare and handling complications of medical problems.

The poorly equipped and inadequately manned peripheral health facilities would more often, initially,
accept any incoming patient, and would attempt definitive treatment / procedure, e.g. normal vaginal
delivery, or an appendix surgery etc. However, during the subsequent course of treatment, in case of
complications, the treating person would try to shift the patient in a precarious condition, by making
a hasty referral to the nearest (often a public sector) secondary level healthcare facility. The secondary
level facility in turn, would refer such cases to the nearby tertiary care facilities including the provincial
capital. As such, insufficient backup facilities, inadequately qualified and trained human resources,

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 Referral Guidelines
and lack of facilities for 24/7 critical care at such peripheral health facilities is the most common reason
of referrals.

Referring patients from lower level to the higher-level facilities for specialized care to the patients and
for handling the complicated cases is a common practice both, in public as well as private sector. Major
bulk of referrals is however, made to the tertiary care hospitals in the public sector. Since neither the
catchment area of the public and private sector facilities is prescribed, nor the referral pathway is
defined, the referrals are made based on the discretion of the referring facilities or sometimes based
on the choice of the patients/ families. The referral should be an important tool to ensure continuity
of care provided to the patients by ensuring access to relevant services for physical, psychological and
social needs through all the stages of referral process. All referrals to higher-level facilities for
specialized care, whether for the critically sick or the elective cases, should contain essential
documentation regarding the disease condition. The documentation should inter-alia cover the
preliminary assessment, treatment provided, lab investigations performed and the pertinent
information regarding the referral facility along with the purpose of referring. In case, the referred
patient needs medical care during transportation that should be accordingly managed.

Following guidelines need to be practiced by all healthcare facilities both, public and private in
letter and spirit while referring the patients:

i. A typical referral would require stabilizing the patient, informing the patient’s family,
identifying the need for a nursing escort (if so required), identifying a caregiver, and prepare
for the transport.

ii. The referral documents must contain patient’s identity, medical details and the general
condition.

iii. The Injured Persons (Medical Aid) Act, 2004 explains “injured person” as a person injured due
to traffic accident, assault or any other cause who is in need of an immediate treatment. The Act
(in terms of Section 6) further provides that an injured person shall not be shifted from a hospital
until he is stabilized or the requisite treatment is not available in such hospital and while
shifting him to another hospital, the doctor concerned shall complete the relevant documents
with regard to the clinical conditions of the patient and hand over such documents to the
concerned doctor of the receiving hospital.

iv. Such record referred above shall be maintained by the referring hospital as well as the
receiving hospital and the In-charge of the hospital shall be responsible for ensuring that such
record is kept in a safe custody where it cannot be tampered with; provided that where
necessary an injured person shall not be shifted unless he is accompanied by a doctor of the
referring hospital.

v. Section 5 of the Punjab Emergency Service Act, 2006 empowers Rescue Service to arrange
transport (transport vehicle or ambulance) where necessary for carrying persons requiring
emergency medical treatment to the nearest hospital emergency or healthcare unit having
such arrangements. Section 17 of the said Act also enables the Emergency Officer or the
Rescuer to administer such life safety procedures as are consistent with their training and
competence.

vi. The Minimum Service Delivery Standards (MSDS) prescribed by the Punjab Healthcare
Commission, under its regulatory framework, provide clear mechanism and SOPs regarding

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 Referral Guidelines
referring any type of patients to other hospitals for specialized care. The following provisions
are relevant and are to be followed mandatorily by the HCEs while making referrals of the
patients:

Standard &
Relevant provision
Indicators
Care of Patients i. Discharge to home or transfer to another organization is
documented
(COP-1): ii. The referral record must contain advice and information for the
Standard 3 patient and the other clinician or treatment facility adequate to
ensure support, recovery, ongoing treatment and follow up that is
Indicator 20
clinically required

COP-3: i. The HCE defines and displays whether high risk obstetric cases can
be cared for, or not
Standard 5
ii. It is imperative for the hospital to inform its obstetrical patients of
Indicator 26 the high risk and its capability to provide services for these cases
iii. The hospital also has to inform about its capability to provide care
to high risk obstetric cases to those practitioners and facilities that
might refer such patients
Information i. When a patient is transferred to another hospital, the medical
Management record should contain the date of transfer, the reason for the
System transfer, and the name of receiving hospital
(IMS-2.10) ii. The referral medical record of such patients should contain the
Standard 29 results of any diagnostic investigations and any treatment rendered
Indicator 151 prior to transfer and the clinical status of the patient

vii. The MSDS Reference Manual, 2013, provided with the MSDS prescribed by the PHC entails
that, in case of transfer to another facility, details regarding medical history of the patient,
investigations / procedures performed, treatment provided, reasons for referral and name of
the hospital to be referred will be recorded in the prescribed referral form. It further provides
that in such cases, SOPs regarding patient transfer shall be strictly followed in order to ensure
proper care during transportation and handing over of the patient to the referred facility.

viii. Accordingly the ambulance for transportation of the critically ill patient upon referral must be
adequately equipped and staffed to manage the patient during transit, and to sustain the life
of the patient without putting him/her to extra risk during transportation. In addition to the
provisions of Section 6 of “The Injured Persons (Medical Aid) Act, 2004” the provisions of the
other applicable law are reiterated as under:

a. The rescue vehicles, ambulances and patient transport vehicles must comply with the
minimum standards and code of conduct prescribed by the Punjab Emergency Service in
terms of the provisions of Section 5(1) (n) of the Punjab Emergency Service Act, 2006
b. In terms of Section 22 of the Punjab Emergency Service Act, 2006; the Emergency
ambulance and rescue vehicles have to satisfy such requirements as laid down by the
service; and where a vehicle does not fulfil the requirements laid down by the Service, it

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 Referral Guidelines
shall be used as a patient transport vehicle, and shall not use any siren or a warning light
other than a round yellow warning light.
ix. The Reference Manual further explains the detailed requirements for the HCEs claiming to
provide care of high-risk pregnancies. These inter-alia, include an established laboratory with
facility to perform all relevant tests, the blood bank facility that ensures availability of all rare
blood groups and blood products, and an intensive care set up with multidisciplinary team for
critical cases.

x. In case the facilities, human and material resources available in the hospital are considered
in-sufficient, referral of the patient must be made at the earliest to the nearest competent
health facility.

xi. There should be close professional links with the referral hospital/s providing specialized
services to, ensure provision of necessary emergency care including maternity services not
available in the referring hospital. Further, there should be a roster to indicate 24-hour
arrangements for on-site availability of a suitably qualified and experienced doctor and an
anesthetist in case of an emergency; in addition to other required essential staff.

xii. The MSDS further provide that in case of referral to another hospital, there should be a written
communication from the referring facility, and it should have acknowledgment from the
receiving hospital in its record.

xiii. There shall be written procedures to be followed by staff to arrange consultation with
physician, surgeon and pediatrician for patients with medical or surgical needs.

xiv. As such, all patients who present with an emergency medical condition, irrespective of their
ability to pay, must receive treatment to the extent that their emergency condition is
medically stabilized so that no material deterioration of the condition is likely within
reasonable medical probability.

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 Referral Guidelines
PRE-CONDITIONS FOR A GOOD REFERRAL

Present Disease
AND AND AND
Condition
Present Disease Favorable The patient (and /or the family)
Condition is life prognosis is also expresses consents to the
threatening present in the proposed referral
OR Adequate place of referral,
There is Risk of treatment is not and will be
irreversible loss of / no more accessible/
Functions available in the available to
OR present facility/ patient if referred
Available Treatment area
in the present health
facility has failed
OR

The clinical condition

presents a significant
obstacle to leading a
normal life and
achieving self
sufficiency
(Construed from Standard Operating Procedures of Medical referral of Persons of Concern in Ethiopia, UNHCR
March, 2015)

xv. Medical conditions where referral may not have any advantage or the referral may not be
justifiable and in cases where treatment is particularly costly and/or in cases of uncertain
prognosis, referral should not be considered. Hence, referral should not be recommended, for
such conditions that include the following:
a. degenerative diseases and for which there is no known or little likelihood of cure;
b. chronic diseases which do not benefit from referral within the national / provincial health
system;
c. healed and inactive lesions resulting from past illnesses or injuries such as an
asymptomatic bullet in the body;
d. terminal diseases, including terminal cancers, chronic liver diseases and end-stage renal
failure;
e. irreversible disabilities for which rehabilitative service is locally available or which cannot
further benefit from any form of treatment;
f. irreversible neurological damage for which rehabilitative service is locally available or
which cannot not further benefit from any form of treatment;
g. other health conditions requiring sophisticated surgery and medical care exceeding what
is normally available to the general public, e.g. kidney, liver or heart transplant, and major
skeletal reconstruction (in such cases, other options such as disability
compensations/palliative care/alternative medicine may have advantage, or more
suitable to the patient);
(Reference: Standard Operating Procedures of Medical referral of Persons of Concern in
Ethiopia, UNHCR March, 2015)

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 Referral Guidelines

xvi. Responsibility / role of Hospital receiving the referral:

a. It should be necessary to communicate impending referral to the receiving facility in
order make an appointment or other arrangements for the referral, or to let them know
of the pending arrival of an emergency case.
b. In case the patient is very ill, it might be necessary for a health worker to accompany
them to the receiving facility.
c. The Emergency or OPD section of the receiving facility will make necessary preparatory
arrangements in anticipation of arrival, to accept and manage the number of such
referrals
d. Preferable to have separate counters for receiving the referrals and necessary referral
documents
e. To provide necessary level of specialized care to the patients and document the
treatment provided
f. Plan rehabilitation / discharge to home or refer back to the original health facility for
follow up treatment
g. Provide feedback to the referring hospital and to the central system if so established
h. Maintain update data and records of patients received through referral
i. Ensure complying with the medico legal requirements as applicable

Role of the Specialized Healthcare and Medical Education Department and the Primary and
Secondary Healthcare Department Government of Punjab
The Specialized Healthcare and Medical Education Department as well as the Primary and
Secondary Healthcare Department Government of Punjab may circulate the above stated
Guidelines /SOPs amongst all the teaching / tertiary care hospitals and the THQ/DHQ hospitals for
compliance in letter and spirit.

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 Power Failure: SOPs to ensure patient safety in the wake of power
failure

Annex-XI

Power Failure and SOPs to ensure patient safety in the wake of

power failure

Reports of intraoperative power failure. Abbreviations: OR – operating room; PACU – post-anesthesia

care unit; ESU – electrosurgical unit; ICU – intensive care unit; CABG – coronary artery bypass graft; CPB
– cardiopulmonary bypass; ACT – activated clotting time; TOF – train-of-four; TIVA – total intravenous
anesthesia

Year Scenario Root Cause Outcomes Recommendation

• Complete loss of • Fault within the • Anesthesia monitors • An uninterruptible power
power on two switching panel failed and “clinical supply system for the OR
consecutive days that controlled monitoring” was should be installed as this
• 9 operations in whether the used until portable would allow at least one
progress hospital used transport monitors hour of power in the ORs in
• Outage lasted 13 municipal power arrived order to complete ongoing
minutes on day 1 or emergency • Video towers and procedures
2010

and 9 minutes on generator power imaging systems • Staff should be familiar

day 2 • Unclear if failed with power requirements
generators • Surgical lights, of equipment
worked ventilators, gas
delivery systems and
CPB continued
because of built-in
batteries
• Partial hospital • During
power failure with construction of a
loss of power to phase loss relay
emergency in main hospital
(generator) circuit become
system dislodge,
• 8 operations in simulating loss of
progress, including municipal power
a craniotomy, • A critical branch
Whipple transfer switch
2010

procedure, and then connected

kidney transplant hospital power
• Outage lasted 15 to an emergency
minutes generator that
was disabled for
servicing
• “Red outlets”
that were
supplied by
generator lost
power

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 Power Failure: SOPs to ensure patient safety in the wake of power
failure
• Complete loss of • Multistate power• Room lights failed • Anesthesiologists have a
hospital power outage • Anesthesia machine critical leadership role in
• Emergency (Northeast display and monitors the OR during crisis. Clear
generators failed blackout of worked, but communication and
in wing of hospital ventilator bellows thoughtful planning are key
2003) to avoiding panic
with operating could not be seen in
room, but the dark • Daily equipment checks
functioned • TIVA initiated. should include flashlights
elsewhere Patient ventilated and batteries in every room
• Complex oral and with self-inflating • The battery life of
maxillofacial resuscitation bag and anesthesia equipment
operation in tank oxygen should be determined
progress • Once portable lights • Consider resuming
• Outage lasted confirmed normal spontaneous ventilation
2005

days bellows function and under anesthesia as a

pipeline gas supply, safety precaution in case
anesthesia machine anesthesia machine battery
resumed ventilation fails7
with volatile agent
• Operation was
suspended, patient
was left intubated
and transported to
PACU
• Operation completed
the next day in a
different building
which had generator
power
• Complete loss of • Fire in electrical • Flashlight used for • Create emergency staffing
hospital power vault light source in ORs plan that identifies specific
• 3 operations in • Electricity still • Anesthesia machines staff member
progress: ankle supplied to responsibilities and roles
continued to
fusion, pelvic building by • Battery operated ESUs and
extenteration, and municipal power function on battery suction should be available
radical neck but unable to be • Wall suction failed • Perform mock disaster
dissection distributed and portable suction drills quarterly
• Outage lasted >1 throughout unit used • Pharmacy services should
week, requiring hospital have a plan to ensure
• Electrosurgical units
evacuation of all • Main and backup failed and battery- availability of medications
2001

hospital patients generators powered bipolar eye to operating rooms

destroyed by fire electrosurgical units • Flashlights and paper
and vessel ligation intraoperative records
were used to achieve should be available in ORs8
hemostasis
• Automated drug
supply cabinets
failed
• All operative
procedures were
near completion and
incisions were closed

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 Power Failure: SOPs to ensure patient safety in the wake of power
failure
• Complete loss of • Construction • Room lights failed • Emergency generator
hospital power workers except for one light planning should take into
• Both emergency accidentally with a back-up account the load placed on
generators failed drove a steel pile battery one generator in case a
• Carotid through the • Anesthesia machine second generator fails9
endarterectomy in hospital’s main ventilator continued
progress incoming power to function
cables • Patient monitors
• Outage lasted 30
minutes • The first failed, including gas
generator did analyzer and
not start at all. capnography.
The second Surgeon watched
2000

generator pulsations of the

started, but was carotid artery until a
quickly portable monitor
overloaded and was available
then failed • Capnography and
agent monitoring
remained
unavailable
• The case was
aborted, and the
patient was taken to
the ICU
• Complete loss of
hospital power
• Ongoing cardiac
case with patient
on CPB
1995

• Outage lasted 53
minutes
• Operating room
loss of power. No
mention of other
hospital areas
• Ongoing
laparotomy
• Emergency
generators
worked for
approximately 3
minutes, then
failed
1993

• Outage lasted 45
minutes

D5 14-12-22 Page 113 of 117

Annex-XII
Hospital Emergency Experts and Resource Persons Consulted
Emergency Experts / Resource Persons
1. Prof. Dr. Shoaib Shafi, President, College of Physicians and Surgeons, Pakistan
2. Prof. Dr. Khalid Masood Gondal, VC KEMU Lahore
3. Prof. Dr. Ghulam Mustafa Arain, Director Academics, CPSP
4. Dr. Khawaja Junaid Mustafa, Director Clinical Risk Management, Shifa International
Hospital, Representative of Pakistan Society of Emergency Medicine
5. Dr. M. Tehsin, Medical Superintendent, Jinnah Hospital, Lahore
6. Syed Burhan Ali, Representative of Chairman Board of Management, Allama Iqbal
Medical College and Jinnah Hospital, Lahore
7. Dr. Mishkat Shaukat, AMS (Emergency Department), Jinnah Hospital, Lahore
8. Associate Professor Dr. Nasir Rana, Chairman Emergency Pediatrics, University of
Child Health Sciences (previously ICH&CH) Lahore
9. Dr. M. Amir Rafique, Director Emergency, Punjab Institute of Cardiology Lahore
10. Dr. Muhammad Azhar, Director Emergency, Bahria International Hospital, Lahore
11. Dr. Mujtaba Chaudhry, Consultant Internal Medicine, National Hospital Lahore
12. Dr. Imran Ahmad Moin-uddin, UOL /Saleem Memorial Trust Hospital, Lahore
13. Mr. Ali Hassan, Director Emergency, Shifa International Hospital, Islamabad
(coordinator, Pakistan Society of Emergency Medicine)
14. Dr. Shah Zaman, Deputy Director Emergency, Sir Ganga Ram Hospital, Lahore
15. Dr. M Bakht Yawar, Director Emergency, Mayo Hospital, Lahore
16. Dr. Ziman Amin, DMS Emergency Department, Mayo Hospital Lahore
17. Dr. Mishkat Shaukat , Deputy Medical Superintendent (A&E), Jinnah Hospital, Lahore
18. Dr. Hamza Waheed, Deputy Medical Superintendent (P&D), Jinnah Hospital, Lahore
19. Ms Sana Ali, Pharmacist / Representative, Director General Health Services Punjab
PHC Team:
1. Dr. Muhammad Saqib Aziz – Chief Executive Officer, PHC
2. Dr. Mushtaq Ahmed Salariya - Director Clinical Governance & Organizational
Standards
3. Dr. Muhammad Anwar Janjua- Director Licensing & Accreditation
4. Dr. Shamoon Massoud, Director Complaint
5. Dr. Qamar Salman- Additional Director Monitoring & Evaluation & Quality Assurance
6. Dr. Shahid Amin- Additional Director, Standards Development & Dissemination
7. Dr. Muhammad Farooq Adeel, Additional Director Enforcement
8. Dr. Imtiaz Ali - Deputy Director, Standards Development & Dissemination
9. Dr. Sana Hasan Deputy Director, Standards Development & Dissemination
 References and Bibliography
Assessment of the Paksitan Emergency Care System and Consensus Based Action Priorities, 14-15
November, 2017

Accident and Emergency Department Standard Operating Procedures 2019, Project Management
Unit, Primary & Secondary Healthcare Depatment, Lahore

APSF NewsLetter February 2016: Reports of Intraoeprative Power Failure

Basic Emergency Care; Approach to the Acutely Ill and injured by WHO & the Internationa;
Committee of the Red Cross (ICRC), 2018

Emergency Traiage Education Kit, Australian Government, Department of Health and Ageing,
Australian Colleg of Emergency Medicine.

Establishment f 1000 bedded General Hospital, Lahore (phase-I), IDAP

Emergency Department Rules and Regualtions, Torrance Memorial Medical Center, State of
Californea USA

Emergeny Department Design Guidelines, Australian College for Emergency medicine, October,
1998.

Healthcare Facilities and Power Outages Guide for state, local, tribal, tritorial and Private sector
Partners, August, 2019

Hospital Emergency Response Checklist , WHO, Europe 2011.

M. K. Dalwai, K. Tayler-Smith, M. Trelles, J-P. Jemmy, J. Maikéré, M. Twomey, M. Wakeel, M. Iqbal,

and R. Zachariah “Implementation of a triage score system in an emergency room in Timergara,
Pakistan” Public Health Action 2013, march 21; 3(1):43-45

Indian Health Facility Guidelines March 2014 based on Indian Public Health standards, 2007 (Revised
2012).

Ittefaq Hosptial Trust, Department of Emergency: (Infrastructure, Human Resource, logisitics &
spplies, SOPs)

Joint Commission International Survey Process Guide for Hospitals, 2020 Illinois, USA

Nurse Protocols for Registred Professional Nurses, 2014 Emergency Guidelines, Policies, Procedures
and Protocols, Georgia, USA

National Reference Manual on Planning and Infrastructure Standards; Ministry of Housing & Works,
Environment & Urban Affairs Division, 1986.

Power Safety Code for Licensees, June 2021, NEPRA

NHS England Emergency Preparedness, Resliience and Response Framework, November, 2015

“Planning for Power Outages: A Guide for Hosptials and Healthcare Facilities”[email protected]

“Patient Focussed Emergency Department”January 1998, Journal of Medicl Sciences, 1 (1)6-9 by Dr.
S.A Tabish, Sher-i-Kashmir Institute f medical Sciences. Srinagar.

The News Lahore, January 15, 2022 “Family protests patient’s death in hospital”

Khairulnisa Ajami; Triage; A Literature Review of Key Concepts; JPMA, Vol 62, No.5., May 2012),

D5 14-12-22 Page 115 of 117

 References and Bibliography
Khursheed, M., Fayyaz, J., Jamil, A. (2015). Setting up triage services in the Emergency Department:
Experience from a Tertiary Care Institute of Pakistan. A Journey Toward Excellence. Journal of Ayub
Medical College, 27(3), 737-740.
Minimum Service Delivery Standards, Punjab Healthcare Commission 2012

Need Assessment of Trauma Centres in Punjab, Punjab Economic Research Institue (PERI); 2018

Standard Hospital Emergency Management Guideline 2019, Government of the People’s Republic of
Bangladesh, DGHS Dhaka.

Standard Operating procedure (SOP) for Quality Improvement, Ministry of Health of Family Welfare,
Director Hospitals & Clinics, DgHS Dhaka, Bangladesh

Sarah Rominski, Sue Anne Bell, George Oduro, Patience Ampong, Rockfeller Oteng, Peter Donkor,
The Implementation of the South African Traiage Score (SATS) in an urban teaching hospital, Ghana:
African Journal of Emergency Medicine (2014)4, 71-75

Susan Baker, Brian O’Neill, Willaim Haddon & William B Long 1974: “The injury Severity Score: a
Method for describing patients with Multiple injuries and Evaluation Emergency Care” published in
Journal of Trauma, Vol 14., No.3 Washington DC, USA.

“Triage; a lierature review of key concepts”in JPMA (Vol 62, No.5, May, 2012) by Khairulnissa Ajani,
School of Nurisng, AKU Karachi

The Punjab Emergency Service Act, 2006

The Injured persons (Medical Aid) Act, 2004 (amendded 2012)

WHO Guidelines for Essentail Trauma Care, 2004

WHO Operational Support & Logisitics Disease Commodity Packages for Covid-19 v5, last updated on
21st July, 2021

W.J Henderson Centre for Patient Oriented Research (WJGCPOR) and Kingston Health Sciences
Centre (KHSC) & Reserch Institute Standard Operating Procedures, 2017.

Emergency Medical Services, Department of Health Punjab, October 2013

Working Paper for Provincial Devlopment Working Party, 20th January, 2022

Adonis Nasr (Editor), Flavio Saavedra Tomasich, Iwan Collaço, Phillipe Abreu, Nicholas
Namias, Antonio Marttos “The Trauma Golden Hour: A practical Guide” 1st ed, 2020
Abhilash KP, Sivanandan A. Early Management of Trauma : The Golden Hour. Curr Med Issues 2020;
18:36-9

Neal Wiggermann, Kathryn Smitt and Dee Kumpar “What Bed Size Does a Patient Need ? The
relationship between Body Mas index and Space Required to Turn in Bed Nurs Rs 2017 Nov;
66(6):483-489

Anderson H, Scantlebury A, Leggett H, Brant H, Salisbury C, Benger J, Adamson J. Factors influencing

streaming to General Practitioners in emergency departments: A qualitative study. Int J Nurs Stud.
2021 Aug;120:103980. doi: 10.1016/j.ijnurstu.2021.103980. Epub 2021 May 21. PMID: 34107355;
PMCID: PMC8299545.

Ana paula Santos de Jesus, Meiry Fernanda Pinto Okuno, Cassia Carolina Barbosa Teixeria Lopes
and Ruth Ester Assayag Batista “Manchester Triage Ssytem: Assessment in an Emergencgy
Hospital Service”Rev Bras Enferm.2021;74(3):e20201361.

D5 14-12-22 Page 116 of 117