Date

Name of the City

Name of Facility
Level of the facilitiy
Address of the facility
Catchment Population
Number Name of Assessor
1
2
3
Lists of Contacted People for
Interview and Discussion
Number Name of Interviwee
1
2
3

EMERGENCY UNIT LAYOUT AND SERVICE FOR ADVANCED LEVEL HOSPITAL (15%) CF (
Measurement Criteria Sub-measurment criteria
Does the facility provide emergency service for 24 hours a day
and 7 days a week?
Is the emergency unit led by a designated emergency director or
case team leader?
Is the ER clearly labeled and visible? (Red background with
White labels)
Is the emergency room situated at the ground floor of a
building?

Is the floor covering of the emergency unit should be a non-

slippery surface, impermeable to water, easy to clean; acoustic
properties that reduce sound transmission and shock absorption
to facilitate movement of beds.

Does the triage area have a clear vision to both the waiting
room and the ambulance entrance?

Are all doors through which patient pass of sufficient size to

accommodate a full hospital bed with attached intravenous
flasks and traction apparatus with ease?
Is ambulance parking area near to the Emergency Room?
Does the ambulance parking area have at least 2 ambulance
parking spots and is close to triage and resuscitation area?
Is there a walk-in entrance discrete from the ambulance
entrance?
Is there an air ambulance drop off area with easy access to the
emergency department?
Are there electrical sockets and hand washing facilities in the
emergency unit?
Is there an open waiting area for patients as well as
relatives/escorts which is clearly visible from the triage and
reception areas?
Is the waiting area located within an enclosed space with TV
and other recreational modalities?
Does the ED assign patient assistant (receptionist) at emergency
gate area to receive, support and direct patients?
1. Triage area
2. Resuscitation area
3. Procedure area
4. Examination area
Does the EU have a separate 5. Short stay area
6. Waiting area
7. Isolation area
8. Decontamination area
9. Dirty utility/disposal room.
Is there disaster equipment storage area with size depending on
the anticipated disaster and the facility’s role?

Is There an acute treatment area with short stay beds and color
coded zones depending on the acuity of patient condition (RED,
ORANGE, and YELLOW/GREEN ZONES)?

Is There dedicated work station with in the ED with office

furniture?
Does the emergency unit provide outreach and mentoring
service for basic emergency services at General hospitals?
OR and inpatient ward
Is there access to
Imaging center that has got MRI
Laboratory service
Pharmacy service
Operation theater
Radiology service
Blood product service
General surgery
Anesthesia
ICU service
 Trauma services
General medicine
Is there access to: Mental health services
Ophthalmology
ENT
Hematology
Gastroenterology
Nephrology
Radiology
Cardiology
Forensic medicine
Neurosurgery
Pediatric surgery
Infectious disease
Maxillofacial surgery
Dermatology
Pathology

Is there a patient decontamination area which is directly

accessible from the ambulance bay without entering any other
part of the emergency department? (It should have a flexible
water hose; floor drain and contaminated water trap. It should
have enough space for storage space of personal protective
equipment)?

Is there an isolation area for potentially infectious patients? (It

should have negative ventilation and should be easily accessible
from triage area to allow for the immediate isolation of
patients)?

Is there an ambulance decontamination area?

Are there staff facilities with male and female staff changing
area, locker, shower and toilet?

Is there a staff meeting room adjacent to the emergency

department for morning meetings and other clinical service
discussions?

Is there a central oxygen line in the emergency department?

(optional)
Total

MATERIAL RESOURCES FOR INTERMEDIATE LEVEL HOSPITAL EMERGENCY SERVICE (1

Measurement Criteria Sub-measurment criteria
 Mandatory materials (0.6)
Total number of Beds (40)
Wheelchair (10)
Stretcher (10)
Crash cart (4)
Hard board (2)
Generator (for the whole facility) (1)
Water reserve tank (for the whole hospital) (1)
Defibrillator (2)
Sphygmomanometer (per each station)
Cardiac monitor (10)
Suction machine (6)
Oxygen cylinder (18)
Portable oxygen cylinder (5)
Flow meter (23)
IV stand (PER PATIENT BED)
Thermo-meter (per each station)
Stethoscope (per each station)
1. LMA
2. Oral airway (small,
medium & large)
3. ETT (small, medium &
large) & Pediatrics)
4. Laryngoscope
Air way equipment for pediatric and adult 5. Stylet
6. Bugie

1. Nasal prong, catheter and

facemask (at least 20 each)
Breathing equipment
2. BVM (at least 5)
3. NIPPV (CPAP/BIPAP) (at
least 6)
Mechanical ventilator (non-portable) (per resuscitation bed)
Portable Mechanical ventilator (1)
Nebulizer (4)
Syringe with different sizes (10)
IV Cannula with different sizes (6)
Neck collar (2)
 Lumbar brace (2)
Crash cart Pelvic binder (2)
NS,RL & D5 (3 bags each)
NG tube and Urinary catheter and
urine bag (2 each)
Minor set (1)
OPA, NPA (2 each)
Tongue depressor (1 pack)
Torch light (1)
Suturing set (1)
Minor wound care set Dressing set (1)
Minor surgical set (1)
Instrument tray (Troly) (1 per each station)
Suction tip (15)
Hard board (2)
Cricothyrodotomy set (2)
Pericardiocentesis set (2)
ECG machine (1)
Portable X-ray (1)
Portable Ultrasound (1)
POP (4)
Pulse Oximeter (6)
Glucometer (2)
Weight scale (2)
Safety box for sharp object disposal (12 or 2 per each station)
Blood fridge (1)
Refrigerator (1)
Siren (1)

Desirable materials/equipment (0.3)

Portable ultrasound with ECHO/Vascular (1)

Perfuser (7)
Oxygen Concentrator (8)
Venturi airway mask (5)
Pediatric Intraosseous set (2)
Central lines (2)
Tracheostomy set (2)
Fluid warmer (1)
Fetal heart monitor (1)
Hand held Doppler machine (1)
Supra pubic catheter set (2)
Optional materials/equipment (0.1)
Traction kit (1)
Spirometer (1)
AED (1)
Fibrotic laryngoscopes (1)
Video laryngoscope (1)
Splinting (5)
Arterial lines (1)
Thoracotomy set (1)
Hoist (1)
Total
Human Resource (20%) CF (1.17)
Emergency Trained General Practitioners (7)
Emergency trained Health officer (2)

Clinical Nurse (emergency trained) / Emergency BSC nurse

(20)
Emergency masters nurse (3)
Emergency and Critical care specialist (4)
Pediatric emergency subspecialist (2)
Ambulance crew (4)
Guard (8)
Runner (6)
Porter (10)
Social Worker (4)
Clinical pharmacist (2)
Data clerk (2)
Phlebotomist (4)
Cleaner (16)
Biomedical Engineer/ Oxygen
Technicians (1 focal person at a time)
Traumatologist
Toxicologist
 Total

Lists of laboratory tests (25%) CF (3.52)

ER side lab (result received within than 1 hour) (cf 0.6)
CBC
Blood group and cross match
Urine analysis (Dipstick & microscopy)
PARASITOLOGY:
Stool microscopy
Blood film
RDT
RBS
Urine HCG
Result received within 4 hrs from main lab (cf 0.3)
Body fluid analysis
CSF analysis
Sputum AFB
C-reactive protein
CHEMISTRY (Serum K+, Na++, Ca++…
Liver and renal function tests)
Thyroid function test
Coagulation profile
Cardiac markers
Arterial blood gas analysis
Result received after 4 hrs from main lab (cf 0.1)
Culture
Toxicology screening (Optional)

Total

DRUGS AND SUPPLY (25%), CF (0.26)

Adenosine Injection,3mg/ml
Amiodarone Injection,50mg/ml
Digoxin Injection,0,1mg/ml, 0,25mg/ml
Metoprolol Injection,1mg/ml ,5mg/ml
Magnesium sulfate
Injection,2%,5%,10%,20%,50% in 20ml
Sodium Chloride 0.9% (Normal Saline),500ml,1000ml
Atropine sulfate injection,1mg/ml in 1 ml ampoule
Hydralazine Injection,20mg/ml in 1 ml ampoule
Labetalol injection,5mg/ml, 1000mg/20ml ml
Nitroglycerin sublingual powder ,0.4 mg /SL
Nimodipine
Sodium Nitroprusside powder Injection,50mg in ampoule
Adrenaline injection,0.1mg/ml
Dopamine injection, 40mg/ml
Nor-Adrenaline injection,1mg/ml
Furosemide injection10mg/ml

Acetylsalicylic acid (ASA) Tablet, 71mg ,75mg & 81mg

Diclofenac Injection,25mg/ml in 3 ml ampoule,75mg/ml

Tramadol Injection,50mg/ml in 2 ml ampoule,100mg/ml
Pethidine Injection,50mg/ml in 3 ml ampoule,100mg/ml
Morphine injection 1mg/ml
Diazepam Injection,10mg/2ml
Phenytoin Injection, (2) 50mg, po 100mg
Haloperidol injection,5mg/ml in 1 ml ampoule
Promethazine injection,25mg/ml ,25mg/2ml in 1ml&2m
CIMETIDINE Injection,200mg/ml
OMEPRAZOLE injection ,2mg/ml suspension
Dexamethasone Injection,4mg/ml ,25mg/ml,50mg/ml
Hydrocortisone Injection,50mg/ml (2)
Calcium Gluconate injection ,10mg in 10ml ampoule (2)
Potassium chloride Injection,150mg/ml in 10ml, ampoule (2)

Ringer’s Lactate (Hartmann’s Normal) Injectable solution ,1000ml

(3)
Dextrose injection, 5% in 1000ml, 40% in 20ml (2)
Oral rehydration salt powder (ORS) (5 sachet)
Aminophylline Injection ,250mg/10ml in 10ml & 20ml (2)
Salbutamol puff (2)
Ketamine (1)
Succinylcholine (1)
Thiopental (1)
Metoclopramide Drops,0.2mg/drop Injection,5mg/ ,50mg/2ml
ampoule

Sodium bicarbonate
Injection(concentrated),7.5%(40mEq/50ml)in ;8.4%(50mEq/50ml)

Dobutamine powder injection 250mg

Haloperidol injection,5mg/ml in 1 ml ampoule
Chlorpromazine hydrochloride Injection,25mg/ ,50mg/2ml

Hyoscine (scopolamine) butyl bromide

Drops,5mg/5ml Injection,20mg/ml
Lidocaine hydrochloride
Injection,5mg/ml,10mg/ml,20mg/ml
Procainamide hydrochloride
Injection,100mg/ml vial
propranolol hydrochloride Injection,1mg/ml
Verapamil Injection,2.5mg/ml
Clopidogrel Tablet ,75mg

Enoxaparin Injection 20mg/0.2ml,40mg/0.4ml,60mg/0.6ml,

80mg/0.8ml ,100mg/ml
Heparin (UFH)
Injection,1000U/ml,5000U/ml
Warfarin
Nitroglycerin powder ,0.4 mg/SL
Nitroglycerin sublingual, 0.4 mg/SL
Nitroglycerine injection 5mg/ml
Fosphenytoin
Phenobarbitone
Nimodipine injection,1mg/5ml
Esomeprazole
Hyoscine (scopolamine) hydro bromide
Injection,0.45mg/ml,0.6mg/ml in 1ml

Sodium chloride Injection,0.9% (Normal Saline),

1000m;235mg/ml,3% in 500ml
Colloid
T3
T4
PTU
Iodine + Potassium Iodide
(Lugol’s solution) solution ,5% + 10 %
Methylprednisolone Injection
(aqueous suspension),40mg/ml
Prednisolone Injection,10mg/ml

Insulin Regular, NPH

soluble/Neutral 9 Human, procaine& Bovine, Injection,
Glucagon
Ipratropium bromide Aerosol, 20mcg/meter inhalation
Etomidate
Propofol
Vancomycin injection, 1000mg/10ml
Azithromycin injection,500mg
Cefepime
Penicillin
Ciprofloxacin
Metronidazole
Acyclovir
Amoxicillin
Activated Charcoal Tablet,125mg,250mg, powder for reconstitution
15mg/120ml,25mg
Atropine Sulfate Injection,1mg/ml in 1 ml ampoule
Calcium Chloride Injection, 10%(100mg/ml), 13.6mEq
Protamine sulfate Injection,10mg/ml
Vitamin K Injection,10mg/ml in 1 ml ampoule
TAT Injection,1500IU/ml

Physostigmine Salicylate Injection, 1mg/ml in 1 ml and 2ml ampoule

Pralidoxime powder for injection, 1g/vial

Rabies Antiserum Equine Injection,200units in 5 ml
Snake Venom Antiserum Polyvalent Injection,10ml
Flumazenil
 Responsibility Mobile Email

Responsibility Mobile Email

VEL HOSPITAL (15%) CF (0.25)

Score Remark
MERGENCY SERVICE (15%) CF (0.37)
Score Remark
7)
(3.52)

.26)
Date
Name of the City
Name of Facility
Level of the facilitiy
Address of the facility
Catchment Population
Number Name of Assessor
1
2
3

Lists of Contacted People for

Interview and Discussion
Number Name of Interviwee
1
2
3

EMERGENCY UNIT LAYOUT AND SERVICE FOR INTERMEDIATE LEVEL HOSPITAL (15%) C
Measurement Criteria Sub-measurment criteria
Does the facility provide emergency service for
24 hours a day and 7 days a week?
Is the emergency unit led by a designated emergency
director or case team leader?
Is the ER clearly labeled and visible? (Red background
with White labels)
Is the emergency room situated at the ground floor of a
building?

Is the floor covering of the emergency unit should be a

non-slippery surface, impermeable to water, easy to
clean; acoustic properties that reduce sound transmission
and shock absorption to facilitate movement of beds.

Does the triage area have a clear vision to both the

waiting room and the ambulance entrance?
Are all doors through which patient pass of sufficient
size to accommodate a full hospital bed with attached
intravenous flasks and traction apparatus with ease?

Is ambulance parking area near to the Emergency Room?

Does the ambulance parking area have at least 2
ambulance parking spots and is close to triage and
resuscitation area?
Is there a walk-in entrance discrete from the ambulance
entrance?
Are there electrical sockets and hand washing facilities
in the emergency unit?
Is there an open waiting area for patients as well as
relatives/escorts which is clearly visible from the triage
and reception areas?
1. Triage area
2. Resuscitation area
3. Procedure area
4. Examination area
Does the EU have a separate 5. Short stay area
6. Waiting area
7. Isolation area
8. Decontamination area
9. Dirty utility/disposal room.
Is there disaster equipment storage area with size
depending on the anticipated disaster and the facility’s
role?
Is there an acute treatment area with short stay beds and
color coded zones depending on the acuity of patient
condition (RED, ORANGE, and YELLOW/GREEN
ZONES)?
Is there dedicated work station with in the ED with
office furniture?
Does the emergency unit provide outreach and
mentoring service for basic emergency services at
primary hospitals and health centers?
OR and inpatient ward
Imaging center
1. General surgery
2. Anesthesiology
3. Internal medicine
4. OB-GYN
5. Orthopedic surgery
Is there access to 6. Pediatrics
7. Radiology
8. Nephrology
9. Neurology
 10. Mental health
11. Otolaryngology
12. Dermatology
13. Maxillofacial surgery
Is there a patient decontamination area which is directly
accessible from the ambulance bay without entering any
other part of the emergency department? (It should have
a flexible water hose; floor drain and contaminated water
trap. It should have enough space for storage space of
personal protective equipment)?
Is there an ambulance decontamination area?

Are there staff facilities with male and female staff

changing area, locker, shower and toilet?

Is there a staff meeting room adjacent to the emergency

department for morning meetings and other clinical
service discussions?

Is there a central oxygen line in the emergency

department? (optional)
Total

MATERIAL RESOURCES FOR INTERMEDIATE LEVEL HOSPITAL EMERGENCY SERVICE (1

Measurement Criteria Sub-measurment criteria
Mandatory materials (0.6)
Total number of Beds (32)
Generator dedicated to ER (1) (for the whole facility)
Water reserve tank for the whole hospital (1)
Wheelchair (8)
Stretcher (8)
Crash cart (3)
Defibrillator (2)
Sphygmomanometer (per each station)
Cardiac monitor (8)
Suction machine (5)
Oxygen cylinder (14)
Portable oxygen cylinder (4)
Flow meter (18)
IV stand (PER PATIENT BED)
Thermo-meter (per each station)
Stethoscope (per each station)
 1. LMA
2. Oral airway (small,
medium & large)

Air way equipment for pediatric and adult 3. ETT (small, medium &
large) & Pediatrics)
4. Laryngoscope
5. Stylet
6. Bugie

1. Nasal prong, catheter and

facemask at least 20 each
Breathing equipment
2. BVM at least 5
3. NIPPV (CPAP/BIPAP) at
least 6
Mechanical ventilator (non-portable) (per resuscitation bed)
Portable Mechanical ventilator (1)
Nebulizer (3)
Syringe with different sizes (10)
IV Cannula with different sizes (6)
Neck collar (2)
Lumbar brace (2)
Pelvic binder (2)

Crash cart NS,RL & D5 (3 bags each)

NG tube and Urinary catheter and
urine bag (2 each)
Minor set (1)
OPA, NPA (2 each)
Tongue depressor (1 pack)
Torch light (1)
Suturing set (1)
Minor wound care set Dressing set (1)
Minor surgical set (1)
Instrument tray (Troly) (1 per each station)
Suction tip (12)
Hard board (2)
Cricothyrodotomy set (2)
Pericardiocentesis set (2)
ECG machine (1)
Portable X-ray (1)
POP (3)
Pulse Oximeter (5)
Glucometer (2)
Weight scale (2)
Safety box for sharp object disposal (12 or 2 per each station)
Blood fridge (1)
Refrigerator (1)
Siren (1)

Desirable materials/equipment (0.3)

Portable ultrasound with ECHO/Vascular (1)

Perfuser (6)
Oxygen Concentrator (6)
Venturi airway mask (4)
Pediatric Intraosseous set (2)
Central lines (2)
Tracheostomy set (2)
Fluid warmer (1)
Fetal heart monitor (1)
Hand held Doppler machine (1)
Supra pubic catheter set (2)
Optional materials/equipment (0.1)
AED (1)
Traction kit (1)
Fibrotic laryngoscopes (1)
Video laryngoscope (1)
Splinting (5)
Arterial lines (1)
Total
Human Resource for INTERMEDIATE LEVEL (20%) CF (1.42)
Emergency trained General Practitioners (5)
Emergency trained Health officer (2)
Clinical Nurse (emergency trained) / Emergency BSC
nurse (13)
Nurse to patient ratio: Red zone=1:1, Orange zone =1:2,
Yellow and Green zones =1:3
Emergency masters nurse (2)
Ambulance crew (3)
Guard (6)
Runner (5)
Porter (8)
Social Worker (3)
Clinical pharmacist (2)
Data clerk (2)
Phlebotomist (3)
Cleaner (13)
Biomedical Engineer/ Oxygen
Technicians (1 focal person at a time)
Total

Lists of laboratory tests for INTERMEDIATE LEVEL (25%) CF (3.52)

ER side lab (result received within than 1 hour) (cf
0.6)
CBC
Blood group and cross match
Urine analysis (Dipstick & microscopy)
PARASITOLOGY:
Stool microscopy
Blood film
RDT
RBS
Urine HCG
Result received within 4 hrs from main lab (cf 0.3)
Body fluid analysis
CSF analysis
Sputum AFB
C-reactive protein
CHEMISTRY (Serum K+, Na++, Ca++…
Liver and renal function tests)
Thyroid function test
Coagulation profile
Cardiac markers
Arterial blood gas analysis
Result received after 4 hrs from main lab (cf 0.1)
Culture
Toxicology screening (Optional)

Total

DRUGS AND SUPPLY INTERMEDIATE LEVEL (25%), CF (0.26)

Adenosine Injection,3mg/ml
Amiodarone Injection,50mg/ml (2 ampule)
Digoxin Injection,0,1mg/ml, 0,25mg/ml
Metoprolol Injection,1mg/ml ,5mg/ml
Magnesium sulfate
Injection,2%,5%,10%,20%,50% in 20ml
Sodium Chloride 0.9% (Normal Saline),500ml,1000ml
Atropine sulfate injection,1mg/ml in 1 ml ampoule

Hydralazine Injection,20mg/ml in 1 ml ampoule

Labetalol injection,5mg/ml, 1000mg/20ml ml

Nitroglycerin sublingual powder ,0.4 mg /SL

Nimodipine
Sodium Nitroprusside powder Injection,50mg in ampoule
Adrenaline injection,0.1mg/ml
Dopamine injection, 40mg/ml
Nor-Adrenaline injection,1mg/ml
Furosemide injection10mg/ml

Acetylsalicylic acid (ASA) Tablet, 71mg ,75mg & 81mg

Diclofenac Injection,25mg/ml in 3 ml ampoule,75mg/ml

Tramadol Injection,50mg/ml in 2 ml ampoule,100mg/ml
Pethidine Injection,50mg/ml in 3 ml ampoule,100mg/ml
Morphine injection 1mg/ml
Diazepam Injection,10mg/2ml
Phenytoin Injection, (2) 50mg, po 100mg
Haloperidol injection,5mg/ml in 1 ml ampoule
Promethazine injection,25mg/ml ,25mg/2ml in 1ml&2m
CIMETIDINE Injection,200mg/ml
OMEPRAZOLE injection ,2mg/ml suspension
Dexamethasone Injection,4mg/ml ,25mg/ml,50mg/ml
Hydrocortisone Injection,50mg/ml (2)
Calcium Gluconate injection ,10mg in 10ml ampoule (2)
Potassium chloride Injection,150mg/ml in 10ml, ampoule (2)
Ringer’s Lactate (Hartmann’s Normal) Injectable
solution ,1000ml (3)
Dextrose injection, 5% in 1000ml, 40% in 20ml (2)
Oral rehydration salt powder (ORS) (5 sachet)
Aminophylline Injection ,250mg/10ml in 10ml & 20ml (2)
Salbutamol puff (2)
Ketamine (1)
Succinylcholine (1)
Thiopental (1)
Metoclopramide Drops,0.2mg/drop Injection,5mg/
,50mg/2ml ampoule
Sodium bicarbonate
Injection(concentrated),7.5%(40mEq/50ml)in ;8.4%(50mEq/
50ml)
Dobutamine powder injection 250mg
Haloperidol injection,5mg/ml in 1 ml ampoule
Chlorpromazine hydrochloride Injection,25mg/ ,50mg/2ml

Hyoscine (scopolamine) butyl bromide

Drops,5mg/5ml Injection,20mg/ml
Lidocaine hydrochloride
Injection,5mg/ml,10mg/ml,20mg/ml
Procainamide hydrochloride
Injection,100mg/ml vial
propranolol hydrochloride Injection,1mg/ml
Verapamil Injection,2.5mg/ml
Clopidogrel Tablet ,75mg

Enoxaparin Injection 20mg/0.2ml,40mg/0.4ml,60mg/0.6ml,

80mg/0.8ml ,100mg/ml

Heparin (UFH)
Injection,1000U/ml,5000U/ml
Warfarin
Nitroglycerin powder ,0.4 mg/SL
Nitroglycerin sublingual, 0.4 mg/SL
Nitroglycerine injection 5mg/ml
Fosphenytoin
Phenobarbitone
Nimodipine injection,1mg/5ml
Esomeprazole
Hyoscine (scopolamine) hydro bromide
Injection,0.45mg/ml,0.6mg/ml in 1ml

Sodium chloride Injection,0.9% (Normal Saline),

1000m;235mg/ml,3% in 500ml
Colloid
T3
T4
PTU
Iodine + Potassium Iodide
(Lugol’s solution) solution ,5% + 10 %
Methylprednisolone
Injection (aqueous suspension),40mg/ml
Prednisolone Injection,10mg/ml

Insulin Regular, NPH

soluble/Neutral 9 Human, procaine& Bovine, Injection,
Glucagon
Ipratropium bromide Aerosol, 20mcg/meter inhalation
Etomidate
Propofol
Vancomycin injection, 1000mg/10ml
Azithromycin injection,500mg
Cefepime
Penicillin
Ciprofloxacin
Metronidazole
Acyclovir
Amoxicillin
Total
Grand Total
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DIATE LEVEL HOSPITAL (15%) CF (0.33)

Score Remark
TAL EMERGENCY SERVICE (15%) CF (0.39)
Score Remark
EVEL (20%) CF (1.42)
TE LEVEL (25%) CF (3.52)
EVEL (25%), CF (0.26)
Date
Name of the City
Name of Facility
Level of the facilitiy
Address of the facility
Catchment Population
Number
1
2
3

Name of Interviwee

EMERGENCY UNIT LAYOUT AND SERVICE FOR BASIC LEVEL (PRIMARY HOSPITAL) (15%) CF (0.44)

Measurement Criteria

Does the facility provide emergency service for 24 hours a day and 7 days a week?

Is the emergency unit led by a designated emergency director or case team leader?

Is there a 24 hours access to blood products?

Is there a 24 hours access to laboratory and pharmacy services with priority for emergency clients

Is the ER clearly labeled and visible? (Red background with White labels)

Is emergency service led by MSC/BSC nurse, health officer or physician trained in emergency and critical care?

Is the emergency room situated at the ground floor of a building?

Is the floor covering of the emergency unit should be a non-slippery surface, impermeable to water, easy to clean;
acoustic properties that reduce sound transmission and shock absorption to facilitate movement of beds.

Does the triage area have a clear vision to both the waiting room and the ambulance entrance?
Are all doors through which patient pass of sufficient size to accommodate a full hospital bed with attached
intravenous flasks and traction apparatus with ease?

Is ambulance parking area near to the Emergency Room?

Does the ambulance parking area have at least 2 ambulance parking spots and is close to triage and resuscitation
area?

Is there a walk-in entrance discrete from the ambulance entrance?

Are there electrical sockets and hand washing facilities in the emergency unit?
Is there an open waiting area for patients as well as relatives/escorts which is clearly visible from the triage and
reception areas?

Does the EU have a separate

Is there disaster response equipments storage area with size depending on the anticipated disaster and the facility’s
role?

Is There an acute treatment area with short stay beds and color coded zones depending on the acuity of patient
condition (RED, ORANGE, and YELLOW/GREEN ZONES)?

Is There dedicated work station with in the ED with office furniture?

Does the emergency unit provide outreach and mentoring service for basic emergency services at health centers?

Is there access to

Is there a mobile radiology area to house and charge mobile x-ray device?
Is there an ambulance decontamination area?
Are there staff facilities with male and female staff changing area, locker, shower and toilet?
Is there a staff meeting room adjacent to the emergency department for morning meetings and other clinical
service discussions?
Total

MATERIAL RESOURCES FOR BASIC LEVEL HOSPITAL (PRIMARY HOSPITAL) EMERGENCY SERVICE (1
Measurement Criteria
Mandatory materials (0.6)
Total number of Beds (22)
Stretcher (6)
Crash cart (2)
Generator dedicated to ER (1) (for the whole facility)
Defibrillator (1)
Sphygmomanometer (per each station)
Suction machine (3)
Oxygen cylinder (10)
Portable oxygen cylinder (3)
Flow meter (13)
IV stand (PER PATIENT BED)
Thermo-meter (per each station)
Stethoscope (per each station)
Traction kit

Air way equipment for pediatric and adult

Breathing equipment
Breathing equipment

Mechanical ventilator (non-portable) (per resuscitation bed)

Portable Mechanical ventilator (1)
Nebulizer (2)

Crash cart

Minor wound care set

Instrument tray (Troly) (1 per each station)

Suction tip (8)
Hard board (1)
Cricothyrodotomy set (1)
Pericardiocentesis set (2)
ECG machine (1)
Portable X-ray (1)
POP (2)
Pulse Oximeter (5)
Glucometer (1)
Weight scale (2)
Safety box for sharp object disposal (6 or 1 per each station)
Blood fridge (1)
Refrigerator (1)

Desirable materials/equipment (0.3)

Water reserve tank for the whole hospital (1)

Cardiac monitor (5)

Portable ultrasound with ECHO/Vascular (1)

Oxygen Concentrator (4)

Venturi airway mask (3)

Pediatric Intraosseous set (1)

Central lines (1)

Tracheostomy set (2)

Fluid warmer (1)

Fetal heart monitor (1)

Hand held Doppler machine (1)

Supra pubic catheter set (1)

Optional materials/equipment (0.1)

AED (1)
Fibrotic laryngoscopes (1)
Video laryngoscope (1)

Splinting (3)

Arterial lines (1)

Total
Human Resource (PRIMARY HOSPITAL) (20%) EMERGENCY SERVICE CF (1.42)
Emergency Trained General Practitioners (5)

Emergency trained Health officer (2)

Clinical Nurse (emergency trained) / Emergency BSC nurse (13)

Nurse to patient ratio: Red zone=1:1, Orange zone =1:2, Yellow and Green zones =1:3

Emergency masters nurse (2)

Ambulance crew (2)

Guard (5)
Runner (3)

Porter (6)

Social Worker (2)

Clinical pharmacist (1)

Data clerk (1)

Phlebotomist (2)
Cleaner (9)
Biomedical Engineer/ Oxygen
Technicians (1 focal person at a time)
Total

Lists of laboratory tests FOR BASIC LEVEL HOSPITAL (PRIMARY HOSPITAL) EMERGENCY SERVICE (2

ER side lab (result received within than 1 hour) (0.6)

CBC
Blood group and cross match

Urine analysis (Dipstick & microscopy)

CSF analysis
Sputum AFB
Pregnancy test
PARASITOLOGY: Stool microscopy
Blood film

Total

DRUGS AND SUPPLY (25%) FOR BASIC LEVEL HOSPITAL (PRIMARY HOSPITAL) EMERGENCY SERVIC
Adenosine Injection,3mg/ml
Amiodarone Injection,50mg/ml
Digoxin Injection,0,1mg/ml, 0,25mg/ml
Procainamide hydrochloride injection,100mg/ml vial
Magnesium sulfate Injection,2%,5%,10%,20%,50% in 20ml
propranolol hydrochloride injection,1mg/ml
Sodium Chloride 0.9% (Normal Saline),500ml,1000ml
Metoprolol injection, 1mg/ml, 5mg/ml
Sodium bicarbonate injection(concentrated),7.5%(40mEq/50ml) in ;8.4% (50mEq/50ml)
Dobutamine powder Injection 250mg
Adrenaline Injection, 0.1mg/ml
Atropine sulfate injection,1mg/ml in 1 ml ampoule
Dopamine Injection,40mg/ml
Hydralazine injection, 20mg/ml in 1 ml ampoule
Labetalol injection, 5mg/ml, 1000mg/20ml ml
Sodium Nitroprusside powder injection, 50mg in ampoule]
Nitroglycerin sublingual powder, 0.4 mg
Acetylsalicylic acid (ASA) Tablet, 71mg, 75mg & 81mg
Clopidogrel Tablet, 75mg
Heparin (UFH) Injection, 1000U/ml, 5000U/ml
Warfarin
Diclofenac injection,25mg/ml in 3 ml ampoule, 75mg/ml
Tramadol injection,50mg/ml in 2 ml ampoule, 100mg/ml
Pethidine injection, 50mg/ml in 3 ml ampoule, 100mg/ml
Morphine injection 1mg/ml
Diazepam injection, 10mg/2ml
Phenytoin injection, 50mg, po 100mg
Haloperidol injection, 5mg/ml in 1 ml ampoule
Nimodipine injection,1mg/5ml
Chlorpromazine hydrochloride injection,25mg/ ,50mg/2ml
Metoclopramide Drops,0.2mg/drop Injection,5mg/ ,50mg/2ml ampoule
Promethazine injection,25mg/ml ,25mg/2ml in 1ml&2ml
Cimetidine injection,200mg/ml
Omeprazole injection,2mg/ml suspension
Hyoscine bromide (scopolamine) butyl Drops,5mg/5ml Injection,20mg/ml
Hyoscine bromide (scopolamine) hydro njection,0.45mg/ml,0.6mg/ml in 1ml
Oral rehydration salt (ORS) powder
Ringer’s Lactate injectable solution ,1000ml
Calcium Gluconate injection ,10mg in 10ml ampoule
Potassium chloride injection,150mg/ml in 10ml, ampoule
PTU
(Lugol’s solution) solution, 5% + 10 %
Iodine + Potassium Iodide
Dexametasone injection,4mg/ml ,25mg/ml,50mg/ml
Hydrocortisone injection,50mg/ml
Dextrose injection,5% in 1000ml,40% in 20ml
Methylprednisolone injection (aqueous suspension),40mg/ml
Insulin Regular, NPH soluble/Neutral 9 Human, procaine& Bovine, Injection
Methylprednisolone injection (aqueous suspension),40mg/ml
Prednisolone injection,10mg/ml
Aminophylline injection ,250mg/10ml in 10ml & 20ml
Ipratropium bromide Aerosol, 20mcg/meter inhalation
Salbutamol puff
Ketamine
Calcium Chloride injection,10%(100mg/ml) ,13.6mEq
Succinylcholine
Thiopental
Rabies Antiserum Equine Injection,200 units in 5 ml
Activated Charcoal Tablet,125mg,250mg, powder for reconstitution 15mg/120ml,25mg
Snake Venom Antiserum Polyvalent Injection,10ml
Vitamin K injection,10mg/ml in 1 ml ampoule
Atropine Sulfate injection,1mg/ml in 1 ml ampoule
Flumazenil
TAT injection,1500IU/ml
Pralidoxime powder for injection ,1g/vial
Ceftriaxone injection,1000mg/10ml
Ceftazidime injection, 1000mg/10ml
Vancomycin injection, 1000mg/10ml
Cefepime
Penicillin
Ciprofloxacin
Metronidazole
Acyclovir
Clindamycin
Gentamycin
Chloramphenicol
Doxycycline
Anti TB
Name of Assessor Responsibility

Lists of Contacted People for

Interview and Discussion

Responsibility Mobile

Sub-measurment criteria Amaya Hospital

1
 1

0.75

1
1. Triage area 1

2. Resuscitation area
1
3. Procedure area 1
4. Examination area 1
5. Short stay area 1
6. Waiting area 1
7. Isolation area 1
8. Decontamination area 0

9. Dirty utility/disposal room.

1

OR and inpatient ward

1
Inpatient ward 1

0
 0
0
0
0

9.57

SERVICE (15%) CF (0.41)

Sub-measurment criteria Score

0.45
0.33
1
1
1
0.75
0.33
1
1
0.46
1
1
0.75
0
1. LMA 0
2. Oral airway (small, medium &
large) 1
3. ETT (small, medium & large) &
Pediatrics)
1

4. Laryngoscope
0
5. Stylet
0

6. Bugie
0

1. Nasal prong, catheter and

facemask at least 20 each
0.25
2. BVM at least 5 0
3. NIPPV (CPAP/BIPAP) at least 6
0
0
0
0

Syringe with different sizes (10)

1

IV Cannula with different sizes (6)

1

Neck collar (2)

1
Lumbar brace (2)
0

Pelvic binder (2)

0
NS,RL & D5 (3 bags each)
1

NG tube and Urinary catheter and

urine bag (2 each)
0.5
Minor set (1)
1
OPA, NPA (2 each)
1

Tongue depressor (1 pack)

1
Torch light (1) 0
Suturing set (1) 1

Dressing set (1)

1
Minor surgical set (1) 1
0
0
0
0
0
0
0
1
1
1
 1
1
0
0
0(16.692)

0.6

0.75

0
0

0 (0.705)

0
0

0 (0)
7.5
 0.2
0

0.1

0.4

0.67

0.17

0.5

0
0.4
1

6.3

SERVICE (25%) CF (3.52)

1
1
0
1
1
 1
21

NCY SERVICE, CF (0.26)

0
0
0
0
1

1
0
0
0
1
1
0
1
0
0
0
0
0
0
0
1
1
1
0
1
0
1
0
1

1
0
1
0
1
1
0
1
1
0
0
0
0
1
1
1

1
0

0
Mobile Email

Email

Tulu Bolo Hospital Inchini Hospital Kersa Arsi Robe Olenchit

Remark
 Seka
Chelanko Chekorsa Agaro Omo Neda
Date
Name of the City
Name of Facility
Level of the facilitiy
Address of the facility
Catchment Population
Number
1
2
3

Name of Interviwee

EMERGENCY UNIT LAYOUT AND SERVICE FO

Measurement Criteria

Does the facility provide emergency service for 24 hours a day and 7 days a week?
Is the emergency unit led by a designated emergency director or case team leader?
Is there a 24 hours access to blood products?
Is there a 24 hours access to laboratory and pharmacy services with priority for emergency clients
Is the ER clearly labeled and visible? (Red background with White labels)
Is emergency service led by MSC/BSC nurse, health officer or physician trained in emergency and critical care?
Is the emergency room situated at the ground floor of a building?
Is the floor covering of the emergency unit should be a non-slippery surface, impermeable to water, easy to clean;
acoustic properties that reduce sound transmission and shock absorption to facilitate movement of beds.
Does the triage area have a clear vision to both the waiting room and the ambulance entrance?

Are all doors through which patient pass of sufficient size to accommodate a full hospital bed with attached
intravenous flasks and traction apparatus with ease?
Is ambulance parking area near to the Emergency Room?
Does the ambulance parking area have at least 2 ambulance parking spots and is close to triage and resuscitation
area?
Is there a walk-in entrance discrete from the ambulance entrance?
Are there electrical sockets and hand washing facilities in the emergency unit?
Is there an open waiting area for patients as well as relatives/escorts which is clearly visible from the triage and
reception areas?

Does the EU have a separate

Is there disaster response equipments storage area with size depending on the anticipated disaster and the facility’s
role?
Is There an acute treatment area with short stay beds and color coded zones depending on the acuity of patient
condition (RED, ORANGE, and YELLOW/GREEN ZONES)?
Is There dedicated work station with in the ED with office furniture?

Does the emergency unit provide outreach and mentoring service for basic emergency services at health centers?

Is there access to

Is there a mobile radiology area to house and charge mobile x-ray device?

Is there an ambulance decontamination area?

Are there staff facilities with male and female staff changing area, locker, shower and toilet?

Is there a staff meeting room adjacent to the emergency department for morning meetings and other clinical
service discussions?
Total

MATERIAL RESOURCES FOR BASIC LEVEL HOSPITAL (

Measurement Criteria
Mandatory materials (0.6)
Total number of Beds (12)
Wheelchair (2)
Stretcher (2)
Crash cart (1)
Ground Ambulance (BLS) (1)
Generator dedicated to ER (1) (for the whole facility)
ER Water reserve tank (1)
Perfuser (2)
Sphygmomanometer (per each station)
Suction machine (2)
Oxygen cylinder (8)
Portable oxygen cylinder (3)
Flow meter (13)
IV stand (PER PATIENT BED)
Thermo-meter (per each station)
Stethoscope (per each station)
Traction kit

Air way equipment for pediatric and adult

Breathing equipment

Crash cart
 Crash cart

Minor wound care set

Instrument tray (Troly) (1 per each station)

Suction tip (4)
Hard board (1)
POP (2)
Pulse Oximeter (Per each station)
Glucometer (1)
Weight scale (2)
Safety box for sharp object disposal (6 or 1 per each station)
Refrigerator (1)

Desirable materials/equipment (0.3)

Cardiac monitor (5)

Oxygen Concentrator (4)

Venturi airway mask (3)

Tracheostomy set (2)

Fluid warmer (1)

Optional materials/equipment (0.1)

AED (1)
Fibrotic laryngoscopes (1)
Splinting (3)
Total
Human Resource (HEALTH CENTER)
 Emergency Trained General Practitioners (1)

Emergency trained Health officer (2)

Clinical Nurse (emergency trained) / Emergency BSC nurse (6)

Nurse to patient ratio: Red zone=1:1, Orange zone =1:2, Yellow and Green zones =1:3

Emergency masters nurse (1)

Ambulance crew (2)

Guard (2)
Runner (2)

Porter (1)

Social Worker (2)

Data clerk (1)

Phlebotomist (2)

Patient assistant (2)

Cleaner (6)
Total

Lists of laboratory tests FOR BASIC LEVEL HOSPITAL (P

ER side lab (result received within than 1 hour) (0.6)

CBC
Blood group and cross match

Urine analysis (Dipstick & microscopy)

CSF analysis
Sputum AFB
Pregnancy test
PARASITOLOGY: Stool microscopy
Blood film

Total

DRUGS AND SUPPLY FOR BASIC LEVEL HOSPITAL (H

Digoxin Injection,0,1mg/ml, 0,25mg/ml
Magnesium sulfate Injection,2%,5%,10%,20%,50% in 20ml
propranolol hydrochloride injection,1mg/ml
Sodium Chloride 0.9% (Normal Saline),500ml,1000ml
Sodium bicarbonate injection(concentrated),7.5%(40mEq/50ml) in ;8.4% (50mEq/50ml)
Adrenaline Injection, 0.1mg/ml
Atropine sulfate injection,1mg/ml in 1 ml ampoule
Hydralazine injection, 20mg/ml in 1 ml ampoule
Acetylsalicylic acid (ASA) Tablet, 71mg, 75mg & 81mg
Heparin (UFH) Injection, 1000U/ml, 5000U/ml
Diclofenac injection,25mg/ml in 3 ml ampoule, 75mg/ml
Tramadol injection,50mg/ml in 2 ml ampoule, 100mg/ml
Pethidine injection, 50mg/ml in 3 ml ampoule, 100mg/ml
Diazepam injection, 10mg/2ml
Chlorpromazine hydrochloride injection,25mg/ ,50mg/2ml
Metoclopramide Drops,0.2mg/drop Injection,5mg/ ,50mg/2ml ampoule

Cimetidine injection,200mg/ml
Oral rehydration salt (ORS) powder
Ringer’s Lactate injectable solution ,1000ml
Dexametasone injection,4mg/ml ,25mg/ml,50mg/ml
Hydrocortisone injection,50mg/ml
Dextrose injection,5% in 1000ml,40% in 20ml
Methylprednisolone injection (aqueous suspension),40mg/ml
Aminophylline injection ,250mg/10ml in 10ml & 20ml
Salbutamol puff
Ketamine
Rabies Antiserum Equine Injection,200 units in 5 ml
Activated Charcoal Tablet,125mg,250mg, powder for reconstitution 15mg/120ml,25mg
TAT injection,1500IU/ml
Pralidoxime powder for injection ,1g/vial
Ceftriaxone injection,1000mg/10ml
Ceftazidime injection, 1000mg/10ml
Vancomycin injection, 1000mg/10ml
Penicillin
Ciprofloxacin
Metronidazole
Clindamycin
Gentamycin
Chloramphenicol
Doxycycline
Anti TB
 Name of Assessor Responsibility

Lists of Contacted People for

Interview and Discussion

Responsibility Mobile

SERVICE FOR BASIC LEVEL (HEALTH CENTER) (15%) CF (0.44)

Sub-measurment criteria Score
 1. Triage area

2. Resuscitation area

3. Procedure area
4. Examination area
5. Short stay area
6. Waiting area
7. Isolation area

8. Decontamination area

9. Dirty utility/disposal room.

OR and inpatient ward

Inpatient ward

HOSPITAL (HEALTH CENTER) EMERGENCY SERVICE (15%) CF (0.49)

Sub-measurment criteria Score
 1. LMA
2. Oral airway (small,
medium & large)
3. ETT (small, medium &
large) & Pediatrics)
4. Laryngoscope
5. Stylet
6. Bugie

1. Nasal prong, catheter and

facemask at least 20 each

2. BVM at least 5
3. NIPPV (CPAP/BIPAP) at
least 6

Syringe with different sizes (10)

IV Cannula with different sizes (6)

Neck collar (2)

Lumbar brace (2)

Pelvic binder (2)

NS,RL & D5 (3 bags each)

 NG tube and Urinary catheter and
urine bag (2 each)

Minor set (1)

OPA, NPA (2 each)

Tongue depressor (1 pack)

Torch light (1)

Suturing set (1)

Dressing set (1)

Minor surgical set (1)

H CENTER) EMERGENCY SERVICE (20%), CF (1.81)

OSPITAL (PRIMARY HOSPITAL) EMERGENCY SERVICE (25%) CF (3.52)
OSPITAL (HEALTH CENTER) EMERGENCY SERVICE (25%), CF (0.26)
Mobile Email

Email

Remark
Remark