CSSD Layout

CSSD Layout

Entry Level COP8

COP 8: Documented procedures guide the care of patients undergoing surgical procedures.

a)   The surgeon does assessment and provisional diagnosis is documented prior to the surgery. For patients having specific health issues like diabetes, hypertension, renal disease, etc. are advised to take fitness certificate from their treating doctor who needs to be specialist.

b)  Informed consent is obtained by the surgeon prior to the procedure. _______Hospital maintains a list of consent forms that are frequently used in the set up. The updated list is available with the Hospital Administrator.

c)    _______Hospital has following SOP for prevention of adverse events like wrong side/eye, wrong patient and wrong surgery besides other likely errors.

SOP to prevent Adverse Events during Surgery
Sr. No.	Process Flow	Responsibly
1	It is verified from the patient that he has stopped the medicines as per the advice of the doctor.	Treating Doctor
2	The surgery site is marked with micropore tape, area was cleaned.	Nurse Asst./ OT incharge
3	Pre-operative check list is filled in.
4	OT nurse while receiving the patient verifies from the patient his/her name and type of surgery that is planned.
5	Doctor asks the patient his/her name and the chief complaint or the type of surgery that is going to be performed.	Doctor
6	Before starting the surgery/ induction of anesthesia, TIME OUT done, the OT Nurse loudly announces the name of the patient, the type of surgery, and Implant availability.	Nurse Asst.
7	If any discrepancy at any point of time arises, the surgery is withheld until the discrepancy is resolved.	Treating Doctor

d)  _______Hospital ensures that qualified persons are permitted to perform the procedures that they are entitled to perform. The hospital maintains a list of Consultants along with their qualifications certificates and Medical Council Registration No. The up to date list is available with the Hospital Administrator.

e)      Post-operative notes are prepared by the surgeon who includes procedure performed, post-operative diagnosis, plan of care and status of the patient. Post-operative plan of care includes

a.    Medications

b.   Care of the area

c.    Do’s & Don’ts during initial period

d.   Infection control practices to be observed at home

e.    Observations for any complications

f)       The operation theater is adequately equipped and monitored for infection control practices. The list of equipment is available with the Hospital Administrator. Following Infection Control practices are observed.

a.    The staff is trained on OT cleaning, fumigation and other precautions to be observed.

b.  The OT is normally closed after fumigation and only opened during surgeries.

c.    All the instruments used are autoclaved

d.   All articles used in OT are sterilized.

e.    Sterilized drapes are used for the patients.

f.     Staff wears sterile clothes and OT footwear.

g.    All surgical staff is vaccinated against Hepatitis B.

h.   Staff having wounds or cuts should be excluded from the OT team

i.     Reusable instrument are immersed in a tray.

j.  Before entering OT all the occupants change to OT clothes, does surgical hand wash and change to OT footwear before entering.

Entry Level COP7

COP 7: Documented procedures guide the administration of anaesthesia.

a.    The procedure for Administration of Anaesthesia is: In order to achieve patient safety, the Anaesthetist is responsible for determine the procedure for administration of anaesthesia.

b.   Pre-anaesthetic evaluation of the patient: A pre-anaesthesia evaluation allows for the development of an anaesthesia plan that considers all conditions and diseases of the patient that may influence the safe outcome of the anaesthesia.

c.    Prescribing of anaesthesia plan: The anaesthesiologist is responsible for prescribing an anaesthesia plan aimed at safety of each patient. The anaesthesiologist discusses with the patient (when appropriate), the anaesthesia risks, benefits and alternatives.

d.   Pre Anaesthesia evaluation: An Anaesthesiologist shall be responsible for determining the medical status of the patient and developing a plan of anaesthesia care. The Anaesthesiologist is responsible for: Reviewing the available medical record; Interviewing and performing a focused examination of the patient to discuss the medical history, including previous anaesthetic experiences and medical therapy; Assess those aspects of the patient’s physical condition that might affect decisions regarding pre-operative risk and management; Prescribing and reviewing of available tests and consultations as necessary for administration of anaesthesia care; Prescribing appropriate pre-operative medications.

e.    Anaesthetist obtains consent from the patient after briefing him/her about the advantages, disadvantages the risk involved.

f.     Intra Procedural Monitoring: Immediate review prior to initiation of anaesthetic procedures: Patient re-evaluation; Check of equipment, drugs and gas supply; Monitoring of the patient (e.g., recording of vital signs); Amounts of drugs and agents used, and times of administration; The type and amounts of intravenous fluids used, and times of administration; The technique(s) used; Unusual events during the administration of anaesthesia; The status of the patient at the conclusion of anaesthesia.

g.    Post-surgery the anaesthetist determines whether the patient can be sent out of OT or needs enhanced level of care. Suitable record in the patient file is made.

Entry Level COP6

COP 6: Documented procedures guide the care of pediatric patients as per the scope of services.

1.   The hospital has defined and displayed the services it can provide for pediatrics by competent medical staff trained in paediatrics.

2.   All clinical staff working in the pediatric department shall receive special training in the care of the new born and pediatrics.

3.   Care of neonatal patients shall be provided in accordance to IAP / WHO guidelines. Pediatric and Neonatal patient’s assessments shall include detailed nutritional growth, psychosocial and immunization assessment.

4.   Parents / Guardians shall be educated at the time of admission that protection and security of pediatric patients rest with the parents / guardians who stay with the patient. Security of Neonates shall rest with the NICU staff as long as they remain in the NICU and with the ICU in Charge for Pediatric patients during their stay at that unit.

5.   Children’s family members are educated about the importance of breast feeding, weaning, rooming-in, nutrition, immunization, and safe parenting and this shall be documented in the medical record of the patient.

Clinical Staff at pediatrics department shall ensure that they maintain pediatric assessment, diagnosis and treatment skills (as appropriate) in accordance with their training.

Staff shall manage pediatric patient appropriate to their skills, training and scope of practice. If the management of pain for a particular paediatric patient is beyond them, they should promptly consider seeking advice or the attendance of a clinician with more advanced skills.

General Instructions: Recognition of the seriously ill or injured child involves the identification of a number of key signs affecting the child’s airway, breathing, circulatory or neurological systems. If these signs are present, the child must be regarded as critical. Then the staff will follow the assessment, diagnosis and treatment regimens as per procedures:

1)     Medical Emergencies in Children

2)     High Risk New born babies

3)     Trauma Emergencies in Children

4)     Anaphylaxis and Allergic reactions in Children

5)     Asthma in Children

6)     Convulsions in Children

7)     Hyperbilirubinemia & Glycaemia Emergencies in Children

8)     Overdose and Poisoning in Children

9)     Child Basic/advanced Life Support

10)  New born Life Support

11)  Foreign Body Airway Obstruction

12)  Dealing with the Death of Children including sudden infant death syndrome

Management of Pain in Children:

1)   Analgesia shall be normally introduced in an incremental way, considering timeliness, effectiveness and potential adverse events.

2)   Pain management should always include the non-pharmacological methods of treatment as a starting point and may be administered by all attending staff.

3)   However it may be apparent from the assessment that a stronger analgesia is necessary from the outset and, therefore the appropriately trained staff would need to administer it.

4)   Non pharmacological methods include psychological, dressings and splintage. (Necessary restraints without any harm).

5)   Pharmacological methods include topical analgesia, oral analgesia, and inhalational analgesia, parenteral and enteral analgesia. These methods are administered by appropriately trained staff.

Entry Level COP5

COP 5: Documented procedures guide the care of Obstetrical patients as per the scope of services provided by the hospital.

Gynecologist shall train medical officers and staff nurses in care of obstetric cases. The assessment of obstetric cases shall include maternal nutrition, immunizations and education. High risk obstetrical care shall be provided to required cases by Gynecologist and Trained Medical Officers and nurses.

Definition and Display of obstetrical cases:

1)         The hospital has defined and displayed the services it can provide for high risk obstetrics cases.

2)         High risk obstetric cases includes emergencies like Shock, PIH (pregnancy induced hypertension), Fetal distress, PET (pre eclamptic toxemia), APH (ante partum hemorrhage), PPH (post-partum hemorrhage), Meconium aspiration, Ectopic pregnancy, Eclampsia, Inevitable abortion, Amniotic embolism etc.

Assessment for Maternal Nutrition:

Diagnosis	Assessment criteria	Diet prescribed
Elderly primi / Grand Multi	30 yrs, screen for down’s syndrome, PIH more, GDM	Normal diet / Diabetic diet
Habitual/Missed Abortion/ Threatened Labour	Previous history of habitual / missed abortion and threatened labor	Normal diet
PIH or eclampsia	PIH	Salt restricted diet
Anaemia	History, weakness, breathlessness, fatigue, pallor, puffiness of face, haemogram, stool examination, urine examination	Normal diet
Cardiac problems and DVT (Deep venous thrombosis) with or without Respiratory Distress.	History of breathlessness, fever, palpitation, on prophylaxis, confirmation by ECHO DVT – clinical suspicion, color Doppler confirmation	Low salt diet
Previous LSCS. (Lower segment caesarian section)	Patient History	Normal diet
GDM (Gestational diabetic mellitus)	Family history of diabetes, previous history still born, pre mature labor, congenital anomalies	Diabetic diet
Preterm labor with or without PROM. (Premature rupture of membrane).	Pain, rashes on examination, cervical or not dilation, NST	Normal diet

Initial Assessment of patient: All patients attending the obstetrics and gynecology OPD after obtaining a detailed History undergoes routine obstetric gynecology examination which includes: General examination for pallor icterus; Thyroid swelling; Pedaloedema followed by examination of breasts, abdomen. This is followed by speculum examination and pervaginal examination.

List of High Risk Obstetric cases cared for: All kind of High Risk Obstetric cases like pregnancy complicated by: Hypertension /PIH; Diabetes/ GDM; Cardiac diseases complicating pregnancy; Renal Diseases with pregnancy; Respiratory problems with pregnancy; Age of mother; Liver disorders, Infections disease.

In a high risk pregnancy the fetus or neonate is at increased risk of morbidity or mortality before or after delivery.

Some of the risk factors for high risk pregnancy are hypertension, diabetes, sexually transmitted diseases, pyelonephritis, acute surgical problems, genital tract abnormalities, high or low maternal age, High maternal obesity, Exposure to teratogens (smoking, drugs, etc), prior still birth, prior pre term delivery, Hydramnios, Multiple pregnancy, prior birth injury and maternal nutrition.

Risk assessment is a part of prenatal care in this hospital. Risk is also assessed during or shortly after labor and at any time these events may modify the risk status.

High risk obstetrics care is provided by competent senior gynecologist assisted by assistants and an experienced Neonatologist. Hospital is well equipped and manned by competent doctors, nurses and para-medical staff to deal with any type of high risk cases.

High risk obstetrics patient’s assessments shall include maternal nutrition. Maternal nutritional deficiencies are identified and the dietician shall be consulted. The dietitian counsels the patient about her dietary needs and the importance of a healthy diet in the long term health of the mother and child. Dietary changes and diet substitutes, special care to be given for correction of maternal anemia are advised.

The hospital has a well-equipped NICU with Baby ventilators, warmers, incubators, phototherapy machines, facilities for continuous monitoring and exchange transfusion etc. and it is manned by a well-qualified and trained Neonatologist and a group of trained nurses.

Entry Level COP4

COP 4: Documented procedures guide the care of patients as per the scope of services provided by the hospital in intensive care and high dependency units.

• Intensive care admission and / or discharge shall be decided by treating doctor. Each patient shall be under the care of a nurse, always maintaining the patient to nurse ratio of 2:1. Intensive care areas shall follow infection control practices as per procedure. (Ref: Infection control manual). Intensive care units shall follow the quality assurance program.
• Visitors shall not be allowed in high dependency areas, except in special situations wherein restricted entry of one or two close relatives shall be permitted during visiting hours only.
• As and when there is a shortage of beds, patients those who are normal will be shifted to the wards and priority will be given to the emergency patients.
• One empty bed shall be kept reserved for all the time for receiving emergency patients who need ICU admission.
• Quality assurance system is implemented and followed in ICU’s.

Patients needed emergency care is shifted to Intensive Care Unit depending up on the cases.

Admission Criteria in ICU: Admission criteria are used to select patients who are likely to benefit from care in ICUs. Patients who meet any of the following criteria shall be admitted to the ICUs at the request of the consultant. While we make every effort to strictly adhere to admission criteria, we accommodate requests from consultants who clinically feel that a patient would benefit from close monitoring in the critical care unit even through not strictly meeting the criteria stated below:

Respiratory:

• Acute respiratory failure (PaO2 < 60 mm Hg).
• Respiratory rate > 30 breaths/minute and <8 breath/mt.
• Patients requiring ventilator support (invasive or non-invasive).
• Pulmonary emboli with hemodynamic instability.
• Massive Haemoptysis
• Post-operative patients requiring hemodynamic monitoring, ventilator support or extensive nursing care.
• Patients with surgical abdomen requiring preoperative fluid and/or electrolyte resuscitation.
• Polytrauma with significant injury to thoracic / abdominal organs requiring surgical intervention.

Renal:

• Patient who has acute renal failure with accompanying respiratory or hemodynamic components require close monitoring & respiratory/ hemodynamic support.
• Significant acidosis or alkalosis.
• Hypo or hyper kalemia with dysarhythmias or muscular weakness.
• Hypo or hyper natremia with seizures, altered mental status.
• Severe hyper calcemia with altered mental status, requiring close neurological monitoring.
• Hypo or hyper magnesemia with hemodynamic compromise or dysarrhythmias or muscular weakness

Drug Ingestion and overdose:

• Drug ingestion with significantly altered mental status & inadequate airway protection / hemodynamic instability.
• Seizures following drug ingestion

Endocrine:

Diabetic ketoacidosis complicated by hemodynamic instability, altered mental status, respiratory insufficiency, or severe acidosis.

Thyroid storm or myxedema coma with hemodynamic instability. Other endocrine problems such as adrenal crisis with hemodynamic instability

Miscellaneous:

• Environmental injuries (lighting, near drowning, hyperthermia or hypothermia).
• Any other clinical conditions requiring ICU level nursing care
• Suicidal gestures including partial hanging, drug overdoses and other self-inflicted injuries.

Discharge Criteria:

1)   Written discharge order by the attending physician.

2)   Substantial resolution of the problems responsible for admission.

3)   Anticipation of prolonged medical stability.

4)   Elimination of need for mechanical ventilation/ airway protection.

The admission of a patient to these units shall be done by the RMO who in turn shall inform the specialists / doctors who are trained to handle emergency care in Intensive Care Units.

The specialist shall give written instructions to trained nursing staff for the management and treatment of a particular patient in such units.

Each patient shall be under the care of a nurse, always maintaining the patient to nurse ratio of 2:1 / as advised by ICU doctor in-charge.

Emergency medicines with resuscitative equipments shall always be kept ready for use. (Ref: Checklist for emergency medicines and equipments).

Specialized life support equipments like, ventilators, defibrillators, infusion pumps, Central oxygen supply and suction, etc., are readily available.

The staff on duty is trained to handle and use this highly technical equipment properly and at the right time.

All staff shall be trained periodically on how to handle critical care equipments so as to minimize break down and loss.

Staff in charge of these units shall check that these equipment's are kept in proper working condition at all times.

Bio medical engineer shall also take care of the maintenance and calibration of equipment's of the intensive care units.

This shall be reviewed by the head nurse of the intensive care units.

In the event of a large number of patients arriving to these units which exceed the capacity of the established beds, the nursing superintendent shall be contacted and she shall arrange for extra beds to be placed in the areas and provide more staff to meet the demand.

Sterility of these units shall be strictly maintained.

Restricted entry of attendants, only one or two close relatives shall be permitted during visiting hours only. Whenever such visitors are allowed inside, measures shall be taken to maintain the sterility of the area. Foot wear shall not be allowed, and they shall wear only the foot wears provided for exclusive use inside the area. Cap, masks, shoe covers are also to be worn by the visitor/relative.

Transfer of the patients to the normal ward or the patient’s home is done after the treating doctor gives specific orders for the same.

Proper instructions on further treatment, advice on preventive aspects and follow up are given to the patient / attendee by the doctor or senior staff nurse.

In order to maintain the quality of care in these departments, the recipients of these services are interviewed from time to time and their satisfaction in the treatment provided is assessed.

When a patient is discharged, details about the investigation, treatment given, condition on discharge, advice on discharge, medications, diet, exercise, follow up, when and how to seek care in case of emergency and details visit schedule shall be written in the discharge card duly named, signed, dated and time by the treating doctor.

A copy of all reports shall be given to the patient along with the discharge summary.

Infectious cases need isolation.

Handling shortage of beds:

1)            In case of bed shortages, this information is given to the Chief Medical Officer immediately.

2)            All stable patients will be transferred out to other wards with their or the attend consent and the same will be intimated to the patient attendant.

3)            On arrival the patient /attendant will be informed about the non-availability of beds, if the patient is stable he will be transferred to other hospital of patient choices.

4)            In case of minor injury or unstable will be stabilized and transferred with the help of hospital ambulance to a hospital of patient choice.

5)            At the time of transfer, transfer protocol is followed.

Quality Assurance Program in ICU:

S.No	Quality objective	Performance indicator	Responsibility	Measurement criteria
				Criteria	Frequency
1.	Service Quality	Staff availability - doctors ,nurses and support staff nurses patient ratio 2:1	ICU incharge staff	Duty Roster / Attendance Record	Monthly
		Bed Availability and turnaround time for making bed	ICU incharge staff	Ward census book ,front office	Monthly
		Reporting time of investigations	ICU incharge staff	HMS / investigations register	Monthly
		Medication administration (route, dose and frequency)	ICU incharge staff	Drug chart	Once in two months
		Coordination between staff in ICU	ICU incharge staff	Feedback form	Monthly
2.	Hospital Infection Control	Infection rates	Hospital infection control committee	UTI, Intra vascular device related infection, Respiratory tract infections, surgical site infections , VAP	Monthly