Pleasa return ta: | OOH Central Library MANUAL OF STANDARDS AND GUIDELINES ON THE MANAGEMENT OF THE HOSPITAL EMERGENCY DEPARTMENT eZ ~) DEPARTMENT OF HEALTHRepublic of the Philippines o Department of Health Jz] OFFICE OF THE SECRETARY MESSAGE Sustaining health care services in the Philippines is an uphill but necessary process ‘The challenges ahead, such as the high cost of health care services that requires spe ial tahnieal expertise, may prove to be prohibitive. Hence. our road map needs to be paved weith strategies, plans, structure, regulations, policies and legal mandates with which fo Carry out ou ideal future state in hospital management and operations. For this reason. the Sees ‘Center for Health Facility Development (NCHFD) produced a set_ of health/hospital facility manuals that serve as guide and standard reference for hospital management, service providers and support staff to inject quality in their day-to-day Gperations at various aspects of work and service delivery points in the hospital While our initiatives are focused on addressing the disparities between public and the private hospital facility performance as well as rural-urban inequities. we need to censure that the key dimensions of quality care are at the forefront of our core objectives We envision our approaches to be sustained by (1) informed and empowered individuals, families and communities; (2) competent and responsive health practitioners: {G) affective and eificient health care organizations: and (4) supportive health systems. All these through a sector-wide approach to health care, Let us all constantly engage in more functional partnerships with our health care delivery networks, and in mutually fulfilling relationships with our hospital personnel in Grder to wain more meaningful achievements that will make our hospital system a real force to improve the health of the Filipino people, SCOT: TES ‘Secretary of Health ic Son Lara Compound Rial Avense, Ste Cra 13 Mania « Trank Line 14-09-01 Direct Lin: 71-4801 Bee Sehaie, has-ttae © URL: https /aew.dohgou ph; em: oxriavoh.goshRepublic of the Philippines Department of Health OFFICE OF THE SECRETARY MESSAGE To operate successfully in today’s globally competitive environment, a health facility must consistently deliver high quality, cost effective care to its clients, improving RIK care quality and enhancing each patient's experience of care require attention not only on health system design but also on every process of patient care. ‘The goals and objectives stated at each carefully crafted Hospital Manual are reflective of the fundamental principles in the delivery of a continuum of quality are that is expected to operate efficiently and effectively Outstanding evidence-based medical care and management practices are bor out ofresoureectich as well as resource-challenged health systems. Most positive changes are schieved with the judicious and appropriate use of current capabilities of health facilities. Ina low-resource environment, quality care can be achieved ‘without compromising the life and safety of patients. ‘Thus, we enjoin every health facility worker from the top management to the frontline and support services to seriously study, discuss among themselves and implement this set of hospital facility/ospital manuals in the best way appropriate [0 their setting, always Keeping in mind human dignity--their own and their clients'~-in executing more effective, efficient and responsive health care and management systems. MARIQ‘C. VILLAVERDE,MD,MPH,MPM,CESO I indersecretary of Health Sanday 1 Baw Lazar Compounds Rial Avenue, St, Graz 1009 Mania «rank Line 743 8,0) iret Line 711252, Se area) sab. 1786 © URL: hispiverww.dah govsph: emul: asee@idub.zer. phREPUBLIC OF THE PHILIPPINES DEPARTMENT OF HEALTH NATIONAL CENTER FOR HEALTH FACILITY DEVELOPMENT bg 4, San Lazaro Compound, Real Avenue, Sto, Crs, Marula Fetgphune Now 742.8001 lovell 401-02. Telefax 742-8091 FOREWORD In line with the thrust of the Department of Health on Health Service Delivery and Good Governance under Fourmula One for Health (F1), the National Center for Health Facilities Development (NCHFD) formulates policies and develops standards for the establishment, development, management and operations of health facilities in the country. The NCHFD assumes the technical leadership and coordinates the health faciity development initiatives of government and its partners. Efforts to improve the health service delivery and determine the critical areas for continuing quality improvement that ensure patient-centered quality care have been our utmost priory Health workers and Health Facility/Hospital Administrators have been continuously confronted with a wide range of issues, new trends and technologies in various health care settings. The development of more relevant and responsive policies and guidelines for patient-centered quality care attunes our health systems to this dynamic environment. ‘The National Center for Health Facilities Development (NCHFD) proudly endorses a set of Manuals for health facilities/hospitals. These Manuals are outputs of Technical Working Groups composed of experts in various fields of health facility management and quality patient care. The Manuals considered Philippine settings while mainiaining Consistency with international standards. Each of the following individual manuals is best Used in conjunction with the other Manuals in the set +. Manual of Organization and Management of the Administrative and Finance Service for Hospitals 2. Hospital Property and Supply Management Manual 3. Hospital Nursing Service Administration Manual 4. Hospital Pharmacy Management Manual 5. Hospital Nutrition and Dietetics Service Management Manual 6. Manual for Medical Social Workers Fifth edition 7. Manual of Standards for Infection Control in Health Care Facilities 8. Quality Management Systems in Clinical Laboratories ©. Manual of Standards and Guidelines on the Management of the Hospital Emergency Department 10. Revised Organization and Staffing Standards for Government Hospitals The standards and guidelines recommended in this set of Manuals will assist the ‘Administrators and Clinical Practitioners achieve quality services through timely access, efficiency, effectiveness, safety and patient-centeredness in health facility/nospitals. The above-mentioned Manuals will serve as standard reference materials for DOH health facilties/hospitals to aid administrators and clinical practitioners in the management and operations of the various services that directly and indirectly contribute to patient safety and quality patient care. These Manuals are also recommended for use in the health facilities/hospitals of the Local Government Units, the military, the PNP, the private sector and the academe. CRISELDA G. ABESAMIS, MD, FPSP, CESO III Director IVPREFACE ‘The Manual of Standards and Guidelines on the Management of Hospital Emergency Department is intended for hospital administrators, doctors, nurses, paramedical and allied health staff. With the Emergency Department (ED) as the showcase window of the hospital, it is envisioned that this manual shall be a take off point towards a more comprehensive approach for the phased-in institutionalization of emergency medicine in hospital facilities in accordance with their service capability One of the major thrust of the Rationalization of the Health Care Facilities under Fourmula One for Health (F1) is to provide appropriate services for emergency response and acute care. This shall be seriously linked with the adequate provision of emergency equipment, supplies, drugs/medicines and an operational staff complement actos al levels of strategically located hospital facilities. Regardless of our readers’ roles, we hope this Manual helps them deliver the high quality care that their patients deserve and support them in their roles as health workers THE TECHNICAL CONTRIBUTORSxi ACKNOWLEDGEMENTS The Manual of Standards and Guidelines on the Management of Hospital Emergency Department was developed and prepared by the National Center for Health Facility Development in collaboration with the Health Emergency Management Staff (HEMS) of the DOH Hospitals and the active participation of personnel from the private hospitals. We sincerely appreciate the invaluable contribution of the members of Medical Action Group (MAG) of the Emergency Room Departments of UP-PGH, The Medical City and St. Luke's Medical Center. The Technical Working Group members directed and organized the preparation of this document from valuable inputs of Hospital Emergency Room personnel, as the main end-users. Our grateful acknowledgement is hereby extended to all the technical contributors who diligently prepare and critically reviewed the different sections of this publication. The painstaking efforts of the editors have evolved into a more structured and coherent final document harmonized with the goals and strategic thrusts of Fourmula One for Health (F1) under the leadership of the Secretary of Health, Dr. Francisco T. Duque IIL Technical Contributors Maximo Adan, Engineer National Center for Health Facility Development Visitacion Antonio, MD East Avenue Medical Center Ricardo Audan, MD Davao Medical Center James Babol, RN, MAN Amang Rodriguez Memorial Medical Center Romeo Bituin, MD Jose Fabella Medical Center Emmanuel Bueno, MD East Avenue Medical Center Jose Albert Capuno, M.D. Quirino Memorial Medical Center Cesario Castro, RN Quirino Memorial Medical Center Geraldine Constantino,RN San Lazaro Hospital Ma. Dolores Cruz, MD National Children’s Hospital Mary Jane Cruz, RN East Avenue Medical Center Aida Cuadra, RN Tondo Medical Center Melecio Dy, MD National Center for Health Facility Development Robert Enriquez, MD National Children’s Hospital Nancy Felipe, Assoc. Prof. Philippine Women’s University, QC Campus Faith Joan Mesa-Gaerlan, MD The Medical City /Manila Doctors Hospital Tomas Gahol, Architect National Center for Health Facility Developmentxii Emmanuel Gines, MD ‘Teodoro Herbosa, MD Sherjan Kalim, MD Consuelo Malaga, MD Zenaida Maningo, RN Ma, Teresa Mendoza, RN, MAN Peter Ng, MD, LLB, PhD Leo Olarte, MD, LLB Ronald Paguirigan, MD Vicente Sotto Memorial Medical Center Philippine General Hospital Cotabato Regional Medical Center Vicente Sotto Memorial Medical Center Vicente Sotto Memorial Medical Center National Center for Health Facility Development University of Santo Tomas National Children’s Hospital Philippine Health Insurance Corporation Rosalie P. Paje)MD, MPH,FPAFP National Center for Health Facility Development Mario Panay, MD Elmarie Pineda, MD Manuel Quirino, MD Enrico Reyes, MD Arnel Rivera, MD Naomi Ruth Saludar, MD Arvin Samson, MD Teresita Sanchez, MD, LLB Marjorie Suangco, Assoc. Prof. Charissa Faye Tabora, MD Florinda Tuvillo Ma. Theresa de Vera, MD Valenzuela General Hospital St. Luke's Medical Center Baguio General Hospital Jose Reyes Memorial Medical Center Health Emergency Management Service San Lazaro Hospital Philippine General Hospital Philippine Association of Women Lawyers Philippine Women's University, QC Campus Research Institute for Tropical Medicine National Center for Health Facility Development Bureau of Health Facilities and Services Zenaida Villaluna,RN,MAN EdD National Center for Health Facility DevelopmentABC ABG ACLS ACU AIDS AO APU BLS BP CNS car CSR DAMA DOA ECG ED EMT ENT ER OR ERC ERO FEIP HAMA HEMS HR icc IVF Jal MCI MFR MLC Mss NBC OPCEN opp OU PALS Qa RA ACRONYMS a Airway Breathing Circulation Arterial Blood Gas ‘Advanced Cardiac Life Support ‘Acute Care Unit Acute Immune Deficiency Syndrome Administrative Order ‘Acute Psychiatric Unit Basic Life Support Blood Pressure Central Nervous System Continuing Quality Improvement Central Supply Room Closed Thoracostomy Tube Discharged Against Medical Advice Dead on Arrival Electrocardiogram Emergency Department Emergency Medical Technician Ear, Nose and Throat Emergency Operating Room Emergency Room Complex Emergency Room Officer Field Epidemiology Training Program Glasgow Coma Scale Home Against Medical Advice Health Emergency Management Staff Heart Rate Infection Control Committee Intravenous Fluid Joint Commission International Mass Casualty Incidents Medical First Responder Medico-Legal Case Medical Social Service Nuclear, Biological and Chemical Operation Center Out Patient Department Observation Unit Pediatric Advanced Life Support Quality Assurance Republic Actxiv ROD RR SEROD SHO TPR WwcPU Resident on Duty Respiratory Rate Senior Resident on Duty Senior House Officer Temperature Pulse Respiration Triage Scale Ultraviolet Women and Child Protection UnitChapter TABLE OF CONTENTS ‘Messages Foreword Preface ‘Acknowledgements ‘Acronyms List of Figures List of Appendices List of ER Forms INTRODUCTION General Function Specific Functions Standards of Care in the Emergency Room EMERGENCY DEPARTMENT SERVICES ‘Acute Care Services ‘Trauma and General Surgery Medical and Toxicological Services Pediatric Services Obstetric and Gynecological Services Otorhinolaryngology - Head and Neck Services Opthalmology Medico-Legal Consultation Other Services ‘Ambulance Transport and Emergency Pre-Hospital Response Mass Casualty Incident Services Medico-Legal Consultations (for Government Hospitals) Ambulatory Care Service Ancillary Services ‘Animal Bite Service Women and Child Protection Unit (WCPU) Poison Control Unit Allied Medical Services xv Page iti vit ix xi xiii xx xxi xxii wOcwnannUNVa NN ° 10 10 10 10 au Wxvi Chapter 3 ORGANIZATION, DUTIES AND RESPONSIBILITIES General Guidelines in the Emergency Room Social Duties and Responsibilities of the ER and Its Staff Duties and Responsibilities of the Medical Staff Duties and Responsibilities of the Nursing Staff Duties and Responsibilities of the Security Guards Poison Control Unit of the Emergency Department Uniform PHYSICAL PLANT AND EQUIPMENT REQUIREMENTS Ambulance Bay Decontamination Area Triage Area Waiting Area Different Units in the Emergency Department Acute Care Unit Observation Unit Minor Operating Room Isolation Room Examination Room Counseling Room Supply Room or Stock Room Doctors’ Lounge Restrooms Ancillary Services Satellite Laboratory X-ray Room Satellite Pharmacy Allied Medical Services Women and Child Protection Unit (WCPU) Animal Bite Center Special Areas (Optional) Toxicology Room Poison Control Unit ‘MEDICINES AND SUPPLIES Minimum Basic ER Medicines Medication Standards Basic ER Equipment Basic ER Supplies Airway /Intubation Kit Closed Tube Thoracostomy Set Page 13 16 7 7 B 4 28 29 31 32 32 33 33 33 33 37 37 38 39 39 39 39 40 40 40 41 41 41 41 41 4 42 47 48 49 51 52 52 53Chapter 6 Cutdown Set Minor Surgical Set SYSTEMS AND PROCEDURES Policies and Standards General Procedures Triage in the Emergency Department Aims Key Points General Policies Allocation of Triage Category The Triage Scale: Descriptors for Categories Recognition of the Critically Ill Child Management of Aggressive/Combative Patients Aims Causes of Aggressive Behavior Managing Immediate Threat Verbal Strategies Pharmacological Restraint Assessment Process Physical Restraint Principles Indications Key Points Debriefing Informed Consent Observation Unit Laboratory and Ancillary Procedures Request for Laboratory, X-Ray and Other Ancillary Services Labelling Specimen Container/Slide Emergency Department Disposition of Patients Procedures for Disposition of Emergency Room- Trauma Department Discharged and Sent Home Discharge Against Medical Advice (DAMA) Referred or Transferred to Other Hospitals Referral System within the Hospital Disposition of the Cadaver Dead on Arrival (DOA) ER Death ‘Absconded xvii Page 53. 54 55 55 57 60 60 60 61 63 65 70 val 72 7 73 73 74 74 vey 75 7 78 79 79 80 80 81 82 82 82 84 85. 85, 88xviii Chapter 7 Admitted to Ward Admission Policies Procedures Treatment Billing Policies Medical Social Service Social Classification of ER Patients Health Information Management Records Management Procedures on the Release of Patient’s Information Mass Casualty Incident Management Incident Command System Organization Disaster Information Management Management of Nuclear, Biological, Chemical (NBC) Incident Standard Response Protocol for NBC Incident Strategies Needed by Hospital to Prepare and Respond to an NBC Incident Emergency Response to a Chemical Disaster Goals of an Emergency Responder at a Hazardous Materials Incident Hospital Management Guidelines for Protection of Persons in the ER Poison Control Unit Indication for Multiple Dose Activated Charcoal (MDAQ) MEDICO-LEGAL Cases Medico-Legal Policies and Standards Guidelines in Dealing with Medico-Legal Cases Procedures in Managing a Medico-Legal Case Disposition of Dismembered Body Part Health Information Management of Medico-Legal Cases Medico-Legal Reports Medico-Legal Certificates Chain of Custody Guidelines in Preservation of MLC Evidence Medico-Legal Aspects of Sexual Offences Medico-Legal Aspects of Poisoning Medico-Legal Aspects and Guidelines in Case of a Medical Mishap Page 88 90 90 90 92 93 93 95 95 98 99 100 100 100 102 104 106 107 107 108 109 109 113 4 115 116 117 17 118 118 119 119 120 122 123Chapter 8 Medical Negligence (Malpractice) Domestic Violence and Abuse of Women Child Abuse and Neglect ‘Medical Examination of Apprehended Persons in the ER CONTINUOUS QUALITY IMPROVEMENT AND PATIENT SAFETY PROGRAM ‘Quality Assessment and Improvement Standards Operations Plan for Patient Care Management and Performance Improvement Quality Assessment and Improvement Activities Infection Prevention Control Standard Routine and Specific Infection Control Precautions Facility Management Safety Staff Qualifications and Education Information Management Patient Safety References Glossary Appendi ces, xix Page 124 125 15 126 127 128 130 131 132 132 134 138. 143 145 147 151 152 155Xxx Figure Ce NVaae LIST OF FIGURES Organizational Structure of the Emergency Department (with Emergency Medicine Specialist Organizational Structure of the Emergency Department Floor Plan Model for Emergency Room Complex Floor Plan Model for Emergency Room for Level 2 Hospitals General Emergency Room (ER) Patient Flow Flowchart on Triage Flowchart on the Disposition of the Cadaver Algorithm for Ingestion of Poison Algorithm for Dermal Contamination/Inhalation of a Poison Page u 15 45 46 59 62 89 1 112—_ = 1 INTRODUCTION ‘The Emergency Department (ED) is a hospital department that provides initial treatment for patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and requires immediate attention. This department is often referred to as an Emergency Room (ER) or Emergency Ward (EW) in the United States, and Accident and Emergency Department (A&E) for most teaching hospitals and district general hospitals in the United Kingdom, In the Philippines, it is also called Emergency Room (ER) for Levels I and IT hospitals and Emergency Room Complex (ERC) for Levels III and IV hospitals. ‘The Emergency Rooms/Departments were developed during the 20 century in response to the increased need for rapid assessment and management of critical illnesses, While these departments provide initial treatment to patients with a broad spectrum of illnesses and injuries, most patients consider them as an important entry point for those without other means of access to medical care, Under the Department of Health Fourmula One for Health (F1) vision to provide quality health care for every Filipino, the Emergency Department/Emergency Room Service is tasked to fulfill its mission: To provide a comprehensive, immediate and quality medical and nursing care to the critically ill and injured, to save the life and limb of the patient, thus reducing mortality, morbidity and disability. In the Philippines, all government and private hospitals or clinics duly licensed to operate as such are hereby required to render immediate emergency medical assistance and provide facilities and medicines within its capabilities to patients in emergency cases who are in danger of dying and/or who may have suffered serious physical injuries (RA 6615, Section 1). Manual of Standards and Guidelines on the Management of the Hospital Emergency Department a &Ci i In line with this mandate, there has been a general consensus, among experts from the Philippine Society of Emergency Care Physicians and the Philippine College of Emergency Medicine, setting a maximum of four (4) hours standard waiting time for patients attended at the emergency room within which appropriate disposition shall have been established. GENERAL FUNCTION To provide quality emergency care services to patients attended in the Emergency Department. ‘SPECIFIC FUNCTIONS To provide emergency services, build the critical capacity of ED personnel and institutionalize standard system and procedure on emergency care Services © Complete assessment of all patients who seek help in the ED for a rational and accurate diagnosis of their medical problems. © Provision of immediate resuscitative measures to patients with life-and limb-threatening conditions © Referral of patients to appropriate levels of care after stabilization for cases beyond the limits of its capability © Acute care service delivery during mass casualty incidents and disasters © Coordination for appropriate and timely disposition of ED cases Promotion of patient's rights through informed consent © Counseling for cases that may require managed home care Provision of medico-legal services Capacity Building © Continuing professional education to all staff including paramedical staff handling emergency care services © Orientation and training on ED policy and procedures among ED personnel and student affiliates © Provision of competent, well-trained and committed staff for acute care services, 2 Mana of Standards ad Guieine n the Management ofthe Hospital Emergency Deparent @ Peaui aaa ea «Institutional Development © Provision of quality standards for emergency care «© provision of policies and guidelines on administrative procedures © Strengthening of the ED health information management © Provision of policies and procedures of an efficient Triage system Compliance to standards on physical plant and equipment © Provision of adequate supplies, medicines, and equipments © Implementation of a Continuing Quality Improvement (CQ) and Patient Safety Program Strengthening of a referral system/network ©. Institutionalizing patient-centered care © Development of a monitoring and evaluation system Conduct research and development STANDARDS OF CARE IN THE EMERGENCY DEPARTMENT “The Emergency Department is the show-window of a hospital facility providing ak hour service, seven (7) days a week. Adequate resources are made available for the provision of quality care to patients in an emergency situatfon, The care provided to each patient is carefully planned, written in the patient's record and Effectively carried out in a timely and responsive manner. Only qualified and competent personnel with training on basic and advanced cardiac life support (BLS and ACLS) systems are assigned at the ER Complex ‘The policies and procedures guide the care of ED patients to ensute that they receive quality care. Clinical Practice Guidelines and Clinical Pathways developed by the hospital and/or specialty societies are used to guide patient assessment and management. They can be reviewed and adapted on a regular avis after implementation to ensure its continued relevance for a pro-active quality improvement approach, Patients categorized as emergent, urgent, or non-urgent examined at the ED are identified through its established clinical assessment processes that may include diagnostic services to clearly define their appropriate disposition. Periodic cecexoment at appropriate intervals according to their condition, plan of care and sndividwal needs are performed and documented in the patient's record. Plan of ‘cate is modified relative to the changes in the patient's emerging condition 3 © sot Samant ots th Managant of the Hopital Emerge Drtmet2 it The hospital processes are designed to provide continuous Patient care services within the ED through inter-departmental referral or to appropriate levels of care through an established inter-hospital networking “and. referral system Institutionalized criteria or policies determine the appropriateness of transfer of Patients to other hospitals to meet their continuing needs, The disposition to discharge patients at the ED considers the need for support service and continuity of care with follow-up instructions that include diagnosis and interventions done; medications; pertinent medical advice, and date, time and service where to obtain follow-up care Physicians should explain all possible options of treatment and intervention. Patients and their families likewise, participate in decision-making as to the extent of care they choose. Thus, benefits are maximized, risks are minisniaet and potential complications are prevented. Mama ftaas and Guidlines te Manone te Hopi Enayecy Damen @2. EMERGENCY DEPARTMENT SERVICES The Emergency Department (ED) is an area of the hospital with special equipment and manned by specially-trained personnel that provides acute care and resuscitation. It is usually identified by a prominent signage with the word “EMERGENCY” in white text on a red background and with arrows to guide where patients should proceed. The services are intended for a broad spectrum of clinical cases, some of which are acute limb- or life-threatening conditions requiring immediate resuscitation and stabilization. The ED provides services 24 hours a day, 7 days a week (24/7). The typical Emergency Department has several functional areas that cater to yp ‘gency Dep: patients with illnesses and injuries of varying severity and type. * Acute Care Unit The ED has a major unit where acute care is provided and this area is called the Acute Care Unit (ACU). In the ACU, all patients that need critical care and stabilization are brought into the resuscitation area (so-called crash room), a key area of the Emergency Department, All initial stabilization of trauma and non- trauma cases is attended to in this area and where advanced cardiac life support and basic life support services are rendered. Diagnostic procedures rendered in the resuscitation area include EKG, portable X- rays (usually limited to the chest and pelvis), portable ultrasound and blood gas analysis or oxygen saturation determination through the use of pulse oximeter. Airway management (including nebulization and non- invasive ventilation) and management of cardiac rhythm disturbances and pulseless arrest with the use of defibrillators are likewise provided in this unit) & Manat of Standards and Guidelines onthe Management of the Hospital Emergency Department ©Ideally, an isolation room with negative pressure ventilation or, at least with a mechanism that provides ventilation rate of > 12 air changes per hour is provided for cases of infections with airborne or droplet transmission. A separate resuscitation area is usually dedicated for pediatrics pa nts, Very few ED have a dedicated obstetrics area since most pregnant patients are wheeled in directly into the labor room or delivery room, unless more urgent medical problems need to be addressed first. The ED also has minor units where patients without immediate life-threatening conditions are attended. Casting Room This area is for patients with fractures, dislocations and other conditions that require casting with or without traction. It shall be provided with an orthopedic bed. Trauma Unit This area is for patients requiring suturing for minor lacerations and those with ear, eye, nose and throat conditions. Fast Track Unit An area may be designated as fast track unit (or urgent care unit) where rapidly treatable conditions are brought in or where rapid screening must be done. Examples include the diarrhea fast track unit or the dengue express lane. Psychiatric Consultation Area An area may be designated for psychiatric consultation where patients with mental illnesses are examined 6——-> ee Ee © Minor Operating Room ‘A minor operating room is where minor surgical procedures like suturing, chest tube thoracostomy, debridement, vascular access, are attended Trauma patients are first assessed by the Trauma team composed of emergency physicians, surgeons, and anesthetists. Cases of multiple or major trauma of the chest, abdomen and emergency craniotomy for severe head injuries and cases with life- or limb-threatening surgical cases from major trauma, shall be directed to the Main Operating Room of the hospital. EMERGENCY DEPARTMENT (ED) SERVICES © Acute Care Services © Trauma and General Surgery = Road traffic accidents Gunshot wounds Burn and thermal injuries Spine injuries Severe abdominal pain Ingestion of caustic substance Blunt chest and abdominal injuries = Limb pain associated with discoloration of affected extremity = Category III Animal Bites © Medical and Toxicological Services Cardiac arrest = Heart attack Stroke Choking — Moderate to severe asthma attacks and difficulty of breathing, = Seizures / convulsions Drug / substance ingestion — Behavioural changes — Profuse non-traumatic bleeding Manual of Standards and Guidelines on the Management of the Hospital Emergency Departientee © Pediatric Services - High-grade fever ~ Moderate to severe difficulty of breathing (mild to severe) — Active seizure / convulsion — Lethargy or difficult to awaken — Frequent vomiting ~ Loose watery stools with increased! purging, ~_ Ingestion of foreign body ~ Poor feeding or inability to feed or drink Obstetric and Gynecological Services = Active labour ~ Profuse vaginal bleeding — Precipitous delivery = Abortion ~ Perineal mass/tumours Otorhinolaryngology - Head and Neck Surgery (ORL-HNS) ~ All patients with acute condition of ear, nose and throat. ° Ophthalmology ~ All patients with acute eye and peri-orbital conditions ° Medico-Legal Consultation for: — Acts of Social Violence ~ Injuries / Event ~ Vehicular Accidents = Mauling - Murder, ete. = Suicide — Rape Victims = Child Abuse ~ Other conditions requiring medico-legal examinations 8 Mana of Standards and Guidelines on the Managenet ofthe Hospital Emergency Department ® ee eeeEe) Other Services In addition to the prime function of the ED of providing acute care survices, the ED also provides varied services like medico-legal and emergency medical services coordination during disasters and mass casualty incidents, Since the ED is a 24/7 hospital department that provides acute critical care services, it has often, been prone to abuse brought about by an overburdened healthcare delivery system Some indi duals would seek ED consult for non-emergency cases because they could not go to a general practice clinic for consult. The ED should try its test to inform the community and to increase people's awareness of the vital function of the ED, which is provision of acute care, Doing so would Fesult in improved services because resources, both personnel and logistics, are better utilized. © Ambulance Transport and Emergency Pre-hospital response ‘Another service provided by the ED is pre-hospital care although most emergency medical services are sometimes outsourced to private entities. Pre-hospital care services include ambulance transport, emergency pre-hospital response and community outreach. © Mass Casualty Incident Services The ED also plays a crucial coordinating role during disaster situations, both external to the hospital and in the event of exceeding its surge capacity. The ED shall develop the hospital's emergency preparedness plan in collaboration with the other departments in the hospital and plan for its activation based on an alert system in place, This plan identifies the different functions and relationships of the ED to the local police and fire department, media, government, and non- governmental organizations during its activation. © Medico-Legal Consultations (for government hospitals) The ED also provides services for medical cases with legal implications. The emergency physician or the surgeon assigned has the mandate of conducting a thorough medical examination, complete and necurate documentation and reporting of medico-legal cases to the proper authorities. ®@ roo Stars ant nes ont Managene! of he Henpital Engeney eprint 9© Ambulatory Care Service Ambulatory care service is for non-critically ill patients who present themselves as non-urgent case in the ED, and can be given appropriate care and discharge instructions for home care and follow-up Ideally, they will receive treatment in the designated ambulatory care unit of the ER complex or in the out-patient department. © Ancillary Services Ancillary Services include a Satellite Laboratory, Pharmacy and Xray services. These areas are placed in the ED to facilitate faster turn around time of laboratory tests and ancillary procedures for patients needling emergent care. The laboratory, pharmacy and X-ray room shall be under the supervision and management of the pathologist, pharmacist and radiologist, respectively © Animal Bite Service In specialty hospitals with a unit known as “Animal Bite Center”, the ED shall cater to Category III animal bite cases where emergent management is needed. Categories I and I cases shall be triaged as non-urgent and referred to the OPD for management. Category II Animal Bites include ~ Injuries involving the Head and Neck, and Finger areas; ~ Deep, Lacerated wounds; - Multiple Bites; ~ Bites from stray, killed, sick animals and those which died within 10 days from the date of bite; and, ~ Patients from places highly endemic for rabies. © Women and Child Protection Unit (WCPU) The WCPU caters to women and children who are victims of violence and other cases as stipulated in RA 7610, This unit is designed to serve the ‘victims through gender sensitive, holistic, personalized and multidisciplinary approaches. Concerned specialties must be available 24/7 to attend to such cases and perform documentation and collection of evidences and specimens for examination. Hence, this unit is 10 Mano Standards and Guidelines onthe Management of th Hospital Emergency Doparonent &_ one mam TTT manned by a multi-disciplinary service management team from the pediatrics, obstetric/ gynecology, medical and surgical department and P per allied professional staff, e.g. psychologist and social worker. © Poison Control Unit ‘This unit shall be established in an institution duly designated by the National Poison Center. It shall be supervised and managed by a multidisciplinary team headed by a Clinical Toxicologist and staff trained in poison control management. Allied Medical Services Satellite Pharmacy. An ideal ED should have its own pharmacy that for essential emergency drugs included in the Philippine National Drug Formulary (PNDF). This saves time in obtaining medications without delay especially curing resuscitation attempts. This promotes vonvenient and ready access to emergency drugs without the necessity of leaving the ED premises, poetics! Racial Revel nome Ggeel pet ot Se Sele? Department. It subsumes the following functions and roles (but not limited to): _ provides assistance to patients based on a patient classification and a capability assessment tool _ Facilitates tracking of relatives of patients, as situation dictates ~ Coordinates with the Women and Child Protection Unit (WCPU), the Department of Social Welfare Development (DSWD) and the local police regarding cases of violence against women and child abuse. © Manat of Standard Guidlines on te Maagenent ofthe Hosptel Een Der utR : Moma of Sonar and Cid onthe Meagonet oft Hospital Emagen Domine @3 ORGANIZATION, DUTIES AND RESPONSIBILITIES The Emergency Department (ED), given its mandate of providing the best quality of care to the Filipino patient who needs emergency attention, has to be complemented by highly skilled staff with defined duties and responsibilities. Most Emergency Departments have a top-down organizational structure with the Chairperson at the helm of its operational management for the medical, nursing and administrative staff. Ideally, the Emergency Department is headed by an Emergency Medicine specialist as Chairperson (Figure 1). The medical officers /residents-in-training in Emergency Medicine shall be under his supervision. The residents from other clinical departments such as Surgery, Internal Medicine, Pediatrics, among others shall be designated as rotators in the Emergency Department. They shall be under the supervision of the Emergency Medicine Training Officer. Their training shall conform to all the standard requirements of their respective specialty societies, Current practice shows that where there is no Emergency Medicine specialist in the hospital, the Medical Center Chief shall designate one of its medical consultant staffs as Chairperson (Figure 2) of the Emergency Department. The training of residents is supervised by the respective clinical departments under their respective training officers. The ER Coordinator of the clinical departments shall be in close coordination with the Emergency Department Chairperson relative to its operation and management. The transition to the ideal future state of the Emergency Department is dependent on the availability of Emergency Medicine specialists in the country. 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Taste | ed : a cames 1 3 |[ soeuseus i : SRST] i ; sps03r PON Tauaedea, Caren 2 SIRAS A TRAATRAPY STS PA PAY Fes weRRD || sewup2209 a 4 é ame] | E i 2 t _[ rowumi005 sweat [Teeuwen aa i | & i | & TOGO eTEAURUPY ONO. TaSTATaG UORRRSOE APN PMO, oD a 2 SE 3 fiaIn both scenario, the Chairperson shall oversee the management of the nursing, administrative, ancillary, and allied medical operations of the Emergency Department. Under his leadership, he shall have administrative supervision of all the staff in the Emergency Department in close coordination with their respective clinical supervisors or Heads of Department or Sections under whom they have direct technical supervision and accountability. This includes the medical staff, nursing staff, and the staff from the ancillary and allied health services of the Emergency Department. GENERAL GUIDELINES IN THE EMERGENCY ROOM DOH Administrative Order No. FAE 007, s. 1998, Section 4, provides the general guidelines as follows: “The Emergency Room is considered the show-window of the hospital and as such reflects the management of the entire hospital. It should be the responsibility of the Chief of Hospital to ensure that enough manpower and equipment are available to ‘meet the emergency needs of every patient. Some reasons for transferring the patient, is primarily internal problems in the Emergency Room. As such, the following policies shall be followed: 4.1 All hospitals having departmentalized services should exercise some form of autonomy in the Emergency Room. Nurses and administrative staff should be permanently assigned to the Emergency Room so as not to disrupt the services and to provide continuous training skills and competencies in emergency care} residents and interns should have a fixed time frame of rotation e.g. 2-3 months and not pulled out anytime by different departments or units. In the same manner, emergency equipment should solely for ER use only. 4.2 Rotation in the Emergency Room should be primarily service-oriented. Hence seminars and training on Value Reorientation, Rights of Patients, Client Satisfaction, Art of Communication, etc. are suggested topics during orientation. 4.3 The Emergency Room shall be manned by no less than a second year resident up. If there will be a first year resident he/she not be a front-liner. 44 All residents manning the Emergency Room in addition to all health personnel should have formal briefing by the Head of the Emergency Room. 16 ‘Manual of Standards and Guidelines on the Management of the Hospital Emergency Department4.5 All medical personnel should have undergone Advanced Cardiac Life Support in addition to the Basic Life Support before being assigned to the Emergency Room. Likewise, all administrative personnel shall undergo Basic Life Support. 4.6 Respective departments have administrative supervision over those rotating in the Emergency Room however the Head of the Emergency Room shall have technical supervision over the said personnel.” SOCIAL DUTIES AND RESPONSIBILITIES OF THE ER AND ITS STAFF The Emergency Department shall have a mission-vision, with the patient at its core and which, shall be communicated to all the staff. Aligned with this mission-vision should be the following duties and responsibilities: * To render timely care to all patients with life- or limb-threatening situations; * To exercise the highest level of courtesy and ethical standards in the exercise of duties; * To empower the Filipino patient by making him a partner in his or her healthcare; « To support the community (government, local authorities, media, household) mitigate the effects of disasters during mass casualty incidents. DUTIES AND RESPONSIBILITIES OF THE MEDICAL STAFF * Chairperson of the Department The chairperson of the department is at least a diplomate of a duly recognized specialty/subspecialty society. He/she shall have the following duties and responsibilities: o Ensures that the professional care rendered to patients conforms to the highest quality of care standards possible. © Makes recommendations as to the qualifications of its member staff. @ Mua of Standard and Gilins onthe Managonet ofthe Hospital Emergency Dearest 7ation, Dut Recommends to the medical director/chief of hospital/medical center chief the essential drugs, supplies, instruments, and equipment for procurement. Formulates policies to standardize the daily operations of patient care Participate in inter- department meetings Conducts regular conferences, attended by all its members to address clinical, operational and organizational problems peculiar to the service. Activates the hospital’s emergency and incident command system (disaster management plan) during disaster situations and provide recommendation to the Hospital Director during the implementation of contingency plans. * Consultant Staff The consultant physicians of the Emergency Department should be fellows or diplomates of a duly recognized specialty /subspecialty society Consultant staff shall have the following duties and responsibilities: ° Assists the Chairman in the implementation of policies and guidelines of the Department. Attends regular department and inter-departmental hospital meetings Designates a Vice Chairperson and a Training Officer. The Vice Chairperson shall assist the Chairperson in coordinating matters and Policies within the department and within the hospital. The Training Officer shall ensure that the residents (and medical students) follow the prescribed training modules as part of their pre-qualification for graduation Assumes on-call status for 24 hours and provide supervision to the ER Officer and residents-on-duty especially when difficult and equivocal cases cannot be decided on by the residents in the Emergency Department. Supervises the training of the residents (or medical interns and clerks) and conducts through regular rounds and conferences for continuing medical education, 18 Manual of Standards and Guidelines on the Management of the Hospital Emergency Departmentene Senior House Officers (SHO) are Chief Residents from the different clinical departments who act as Officers-in-charge (OIC) after office hours. © Must be physically present in the hospital while on 24-hour duty unless directed otherwise by the Medical Director. © Shall assume administrative and clinical function after office hours, weekends, and holidays. Chief Resident The Chief Resident is the most senior resident usually on his 4! year of residency performing administrative function. Administrative training of Chief Residents is imperative in their residency program of training. The Chief Resident has the following duties and responsibilities: © Assists the Chairperson and Consultant Staff in the daily operations of the Emergency Department. ©. Performs pertinent administrative function for the department. Conducts regular rounds with the residents (and medical interns, clerks, and students). © Monitors the delivery of patient care in the emergency room. © Acts as liaison between the Department and the Hospital ‘Administration. Emergency Room Officer (ER Officer) ‘The ER Officer is the most senior clinical resident-on-duty of the Emergency Department, usually a 3°! year resident (and up) from the different clinical departments rotating in the ED. The ER Officer shall have the following duties and responsibilities: © Ensures timely disposition of all patients (admit, discharge, or transfer) to avoid or minimize congestion at the ED. © Goes on 24-hour duty and shall be physically present during his/her tour of duty. © Updates the consultant-on-duty of the status of the ED on a regular basis (and the Chairperson/Hospital Director in cases of mass casualty incidents). © Receives telephone referrals of patients for possible transfer from other hospitals/health facilities and documents said referrals (whether accepted or referted further) in a patient logbook © Manat of Standards and Guidlines nthe Management of the Hospital Emergency Department udee © Checks the attendance of the residents (and medical interns and clerks). © Checks the completeness of the ED register and patient charts, © Follows-up cases referred by the respective ED residents-on-duty for Proper disposition. © Follows-up inter-department referrals of the residenton-duty to facilitate the disposition of patients. ° Oversees the proper conduct of residents (and medical students) at the ED. All infractions/offences must be reported to the Head of the Department. © Ensures that the ER register is complete at the conclusion of duty with regards to: ~ signature of resident over a printed name and/or stamp + impression/diagnosis with appropriate management ~ accurate documentation of patients in accordance with the ER 24-Hour Report Form before admission © Supervises the operations of the ambulance with assistance from the Nursing Service. Physicians accompanying the patient for ambulance fransport shall come from the ward where the patient is admitted The ER Officer of the day shall facilitate the process, © Conducts regular disposition rounds with the residents-on-duty and the medical students. * Triage Officer ‘The Triage Officer is a second year (or higher) resident or a senior nurse or Faturse tained to perform triage. He/She shall have basic training in Basic Life Support and Advance Cardiac Life Support and, as may be appropriate, Pediatric Advance Life Support, The Triage Officer shall have the following duties and responsibilities: © Takes the vital signs/cardiopulmonary function and the chief complaint of the patient. © Performs a primary assessment of the patient and facilitates issuance of patient blotter and chart © Classifies the patient as either an emergent, urgent, or non-urgent case and directs the patient to the most appropriate service. ° Reports directly to the ER Officer any concern that may arise from the Triage Bay, 20 Manual of Sandarts nd Guidelines on the Managonent ofthe Hospital Emergency Department &© ER Residents Residents of Emergency Medicine or 2"¢ year residents per clinical department go on 24-hour duty as residents-on-duty (ROD). They are expected to be in the emergency room at all times during their tour of duty. The ER residents shall observe the highest standard of patient care and extend utmost courtesy to the patient and their relatives during management. All RODs shall observe and ensure a harmonious working relationship with each other and report to the ER Officer any concern or problem that may arise from patient management and disposition. The ROD shall observe proper decorum and wear the necessary badges and identification whilst at the ER. The ROD shall ensure completeness of patient records, charts, and all documentations. Specific duties and responsibilities of each ROD are as follows: Emergency Medicine Resident © Attends to all emergency patients, as directed by the Triage Officer, who need acute care stabilization © Institutes time-bound management and disposition. © Refers to the appropriate specialty service for further management and for possible admission of patients initially stabilized Surgery Resident © Attends to all surgical patients and, as part of the Trauma team, participate in initial resuscitation of all Trauma patients, The patient may be referred by the Triage Officer for management or by the Emergency Medicine, Medicine, Pediatric, or Obstetric residents for further management or co-management, as the need arises. © Receives referrals from other specialty services in the ER for surgical evaluation, Internal Medicine Resident © Attends to all medical patients seen at the ER (as may be directed by the Triage or the other specialty service in the ER). © Receives referrals from the Emergency Medicine or other specialty residents for medical evaluation @ Mana of tars an Guidlines onthe Managenet ofthe Hospital Emergency Deprtnent 21Pediatric Residents © Attends to all pediatric cases (whether with medical or surgical conditions). © Receives pediatric patient referrals from Emergency Medicine, Internal Medicine or Surgery for evaluation. Obstetric/Gynecology Residents © Attends to all patients seen at the ED (as may be directed by the Triage or the other specialty service in the ED) for obstetrical or gynecologic problems © Medical Interns and Clerks Interns or medical clerks may be rotated in the Emergency Room on 24 hours duty upon the discretion of the respective department heads. The medical interns (or medical clerks) shall have the following duties and responsibilities © Assists the ED residents during patient care and observe patient disposition. © Maintains proper decorum and wear badges and uniforms while on- duty at the ED. Observes utmost courtesy with the patients, the medical staff and the other ED staff. Interns should not treat and dispose patients without the direct supervision of residents or the ER Officer. At no time should the interns (or medical clerks) be allowed to cover for the ER Officer or the RODs in the latter's discharge of their duties and responsibilities, Man of Stands and Guidelines onthe Management th Hospital Energeny Department @ee eerie DUTIES AND RESPONSIBILITIES OF THE NURSING STAFF ‘The Emergency Department Nurses are organic employees of the hospital under the Nursing Service. All Nursing personnel in the Emergency Room shall be trained in: BLS, ACLS, PALS, EMT, MER. Mass casualty training and other related trainings on emergency procedures shall be provided to the response teams, They shall be positioned in the emergency department for easy dispatch Such teams shall not be rotated in other areas of the hospital. Nurses shall be permanently assigned to the Emergency Department so as not to disrupt the services. They shall be provided continuous training to further develop their skills and competencies in emergency care (Administrative Order FAE 007 s. August 10, 1998). «ED Clinical Supervisor is in charge of the Emergency Department nurses with supervisory function in behalf of the Chief Nurse, Asst. Chief Nurse and the Senior Nurse in the clinical area. The ED clinical supervisor shall have general supervision in the management of the nursing care service through mentoring and monitoring of the nursing staff and nursing school affiliates and performs the following regular staff function: © Assists in the development/ revision of pertinent policies, procedures and standards. ‘Analyzes and determines staffing needs of the nursing staff Participates in capacity building for the nursing staff, Determines the equipment and supplies needed for the clinical areas. ‘Assumes command responsibility for her staff and personnel. Checks the attendance of nursing personnel. Makes accurate investigation of all unusual/untoward incidents that occur during tour of duty. © Appraises her superior of the significant needs, problems and action taken during tour of duty. © Ensures the implementation of policies, procedures and standards. © Makes regular rounds and monitors work areas for cleanliness, safety and service delivery. © Manages resources on drugs and consumables, ©. Participates in the Quality Assurance Program of the Nursing Service as member of its Technical Working Group. o Evaluates the quality of nursing care provided based on the outcomes of the interventions ooo000 @ ana of Stoner and Gites onthe Management fh Hospital Emergency Deprtnent >PE ee 24 © Provides coaching and mentoring for the nursing staff. © Recommends personnel actions such as promotion, transfer, suspension and resignation. © Participates in meetings and conferences. Accomplishes and submits completed reports /projects/assignments. * ER Senior Nurse performs general supervision and overall management of the nursing care service through mentoring and monitoring of the nursing staff and nursing student affiliates and performs regular staff function as follows: © Assists in the development/revision of applicable policies, procedures and standards in the unit. Analyzes and determines staffing needs in the unit, Determines patient care needs in the unit Assists in appraisal of equipment and supplies and consumables. Assumes command responsibility for the nursing staff, Assumes full responsibility for patient care in the unit Delegates to subordinates/gives assignments. Ensures the implementation of policies, procedures and standards. Follows-up and mentors nursing personnel in the performance of their duties Inspects patient care areas for cleanliness, comfort and safety. © Conducts health education activities for the ED © Refers and coordinates patients/personnel/units needs and problems to hospital management © Acts as advocate for patients and staff. © Coordinates with other hospital department/services/units and other agencies. Carries out/transcribes doctor's order. Evaluates performance of personnel Recommends personnel actions such as disciplinary action and promotion, Conducts monthly inventory of properties, supplies and materials, Participates in nursing audit. Prepares and submits reports Ensures compliance to the Generics Act. Communicates with physician and other members of the health team regarding patient care. Communicates with the incoming shift on the status of patients. 00000000 ° ooo 00000 Manual of Standards and Guidelines on the Management of the Hospital Emergency Department* ER Renders direct nursing care, if necessary Accomplishes accurate and informative, legible unit records Keeps complete file of Emergency Room policies, administrative, circular, department memorandum/s Staff Nurse performs direct nursing care, services and assists physicians in diagnostic and therapeutic procedures in order to provide patient care. 00000000000000 oo00 ° Receives and endorses patients’ charts, equipments, medicines and supplies Obtains nursing history and performs physical assessment. Identifies physiological, emotional, psychological, spiritual needs of patients and provides support. Detects abnormalities from the assessment and results of diagnostic exam and report to the physician. Establishes nursing diagnosis. Prioritizes needs, problems of patients. Formulates Nursing Care Plan. Defines objective of nursing care Develops nursing care alternatives. Carries out plan of care. Refers patient's other needs and problems when necessary, ‘Administers prescribed medications and treatment, Provides health teaching to patients. Maintains a therapeutic environment. Carries out/transcribes doctor's order. Evaluates effects of nursing care. Revises plan of care when necessary. Records assessment, interventions and evaluation of nursing care Notifies immediate superiors of unusual, untoward, difficult situation/ conditions. Identifies and attends to emergency needs of patients and refer problems to nurse supervisor. Implements hospital regulations and policies Updates and completes record like chart, log book ete Prepares and submits monthly reports. ‘Assist the head nurse in guiding the nursing student affiliates during Related Learning Experience (RLE) duties. Participates in research studies. ® amu of Stands al Guidlines om he Managment ofthe Hotel Emergency Drtnet >* Nursing Attendants are the second line nursing care providers, responsible for hospital maintenance and provide assistance to patients, They are under the direct supervision of the nursing service. They often Provide the cleanliness and orderliness in the hospital, Perform direct patient care with supervision, Assist with admission/transfer/ discharge patients. Assist in the patient’s maintenance of personal hygiene. Perform simple nursing procedures as delegated, - Tepid Sponge Bath (TSB) - Bed Making ~ Oxygen gauge replacement - Perform simple enema as ordered > Take and report the vital signs, weight and height. - Ensure cleanliness of the patients linen - Perform post mortem care - Position patients comfortably ~__ Adjust bed side rails for patient's safety. Perform concurrent and terminal disinfection Provide a safe therapeutic environment. Serve/remove bedpans, urinals, emesis, basin as needed, Maintain patient's immediate environment clean and orderly. Do other assigned housekeeping duties. Assist in the preparation of patients for treatment, examination and surgery. Receive/Endorse and check equipments, linens, articles and supplies. © Collect and label specimen (urine, stool, sputum). Send specimens to the laboratory. © Assist physician with minor procedures and physical examination of patient, © Ensure the privacy of patients during procedures. Answer all calls from patients © Check and maintain equipment, instruments, linen and other ward supplies. Assist in the implementation of hospital regulations and policies © Attend and participate during regular and/or emergency meeting o000 oo0ecoo ° 26 ‘Manual of tends and Guidlines on he Management of the Hospital Energeney Depart @ean heen «Institutional Worker is a nursing support personnel who works under the nursing service departments with the following functions Transports patients to various wards and diagnostics areas, Brings cadaver to morgue Performs house keeping duties ‘Assists in the transfer of patients to ambulance ‘Assists the nurse, nursing attendant in performing simple nursing procedures 00000 DUTIES AND RESPONSIBILITIES OF SECURITY GUARDS Security Guards are service employees of the hospital. They are important personnel in ensuring the security and safety of the department. The security officers are to be permanently assigned at the Emergency Room-Trauma Department, Their duties and responsibilities are the following: © Documents all medico-legal patients in a permanent logbook which he maintains © Reports all medico-legal patients to the nearest police station not later than 24 hours after the alleged injury. © Secures the emergency treatment area and its personnel of looter and other bad elements © Controls the influx and egress of patient's visitor/companions (one companion per patient). © Conducts regular rounds in every all sections of the ED to: = Secure safety of the hospital staff ~ Strictly enforce one (1) patient-one (1) watcher The ER-Department is not a waiting area; all other person(s) shall be ordered out. 2 @ Molo Standards and idiot Managenent of te Hopital Emergency eprint 7nd POISON CONTROL UNIT OF THE EMERGENCY DEPARTMENT The Poison Control Unit is managed by a multidisciplinary team composed of health personnel with the appropriate training and experience in toxicology. The team consists of + MedicaY/Clinical toxicologist. A physician who has undergone fellowship training in clinical toxicology with the basic background in either of the following specialties: Emergency Medicine Family Medicine Neurology Occupational Medicine Pediatrics Psychiatry 200000 + Nurse who has a background in emergency care, intensive care and occupational/public health nursing or has attended short courses in clinical toxicology. * Poison information specialist is a pharmacist, nurse, physician appropriately trained to provide basic information on. poisoning, including patient management based on protocols prepared by the National Poison Control Information System (NPCIS). * Laboratory analyst has a background in chemistry, biochemistry and related sciences and has a practical analytical laboratory experience and had undergone training in analytical toxicology. * Administrative and support staff consists of individuals with background in computer science, management and finance, record keeping and related fields. * Consultants in specialized fields of epidemiology, psychiatry, intensive care, social work, ete. 28 Mama stv Cees he Mango of the Hepa Enzo Darin EB)ei ‘and Re ‘UNIFORM The hospital shall have a policy on the uniform/proper dress code of ED personnel to distinguish them from the rest of employees of the hospital. The distinction of the uniforms for the medical staff, medical interns, medical clerks, nursing staff, nursing attendants, institutional workers, and administrative staff is encouraged. The upper garment shall have an embroidered name, designation, unit/service/department where he/she belongs to, and seal/emblem of the hospital. This is to monitor the movement of individuals in the ED, especially unauthorized persons going to restricted / off-limit areas. © Maat of Stands nd itn th Management ofthe Hostal Emergecy Department 79ation, Duties and Responsibilites 30 ‘Manual of Standards and Guidelines on the Management of the Hospital Emergency DepartmentPhysical P fant and Equipment Requiren 4. PHYSICAL PLANT AND EQUIPMENT REQUIREMENTS ‘The Emergency Department (ED) has been called the “window” of the hospital where urgent consultations gain entry into the hospital. It is one of the special tare areas of a hospital like the Intensive Care Unit and Operating Room Complex. With its critical role in the hospital, the physical plant and facilities of this department is primarily designed to cater according to the patient load and the capability of the hospital staff to handle difficult cases. In setting up an ED, proximity to ancillary services and diagnostic areas like the main laboratory and fadiology departments and pharmacy, coupled with the need to have an easy access and unobstructed patient flow within the hospital is a primordial concer, Figures 3 and 4 present the floor plan models for Emergency Room Complex and Emergency Room for Level 2 hospitals, respectively (For details, please contact DOH National Center for Health Facility Development) In general, the entrance to the Emergency Department shall be strategically situated in a low-traffic, accessible area, free from obstructions, and away from the main pedestrian walkway. Entrances and exits are wellilluminated and marked with appropriate signages. An ambulance bay, a space in front of the emergency entrance, serves as a drop-off area for emergency patients brought in by an ambulance or by private vehicles, with properly labeled entrance and exit. To facilitate efficient flow of communication in the Emergency Department, communication equipments and/or devices have to be installed, such as a “red phone” which is a dedicated hotline that can always be accessed from outside the hospital. It has to be equipped with an efficient two-way intercommunication (intercom) device, which is a local phone for intra-hospital transactions and paging system. Manual of Standards and Guidelines on the Management ofthe Hospital Emergency Department aIn case of fire or power failure, emergency lighting fixtures have to be mounted to illuminate strategic areas. The ED should have its own power generator with @ smart switch that is triggered on during power outages and automatically switches off when the main power returns. Ambulance Bay The ambulance bay is a special receiving area, with a specially marked Pavement, exclusive for ambulances. It is a transient parking space where the ambulance must leave the area after disembarkation A triage area may also be placed in this bay. Patients who have been pre-triaged by the Emergency Medical Technician (EMT) in the ambulance and by the Physician who made coordination with the ER Officer before the patient transfer may proceed immediately inside the Acute Care Unit. Decontamination Area The decontamination area is the area of the ED where external decontamination of patients for toxicological management is performed before being directed to the Acute Care Unit. “In cases of nuclear, biological, and chemical incidents, exposed patients and/or personnel are also decontaminated in this area, The doors are uni-directional for entrance and exit. The exit door directly opens toward the Acute Care Unit, The Decontamination Bay should be at least equipped with the following: * High-pressure showers and/or retractable hoses with a water drain that does not connect with the main hospital sewage + Apron or water- and aerosol-proof suits * Mildly alkaline soap + Patient gown + Personnel protective equipment 32omen eeneean Triage Area ‘An Emergency Department should have a triage area with @ nearby patient waiting area, The triage area is the patient's first stop at the ED. The triage 208 Should have a triage desk where the Triage Officer and/or nurse, medical interns and clerks take their post. The triage bay shall have the following basic kit: + Digital Sphygmomanometer + Stethoscope + Digital Thermometer or thermoscan + Patient Consult Logbook «Triage Tags + Wheel chairs * Wheel-type stretchers or scoop stretchers + Personnel protective equipment (gowns, gloves, face shield) Waiting Area ‘This is the lounge for the triage area where patients await their turn to Be sect and examined by the triage officer. There are chairs for a patient and one () companion. The entrance of the ED opens into this area. DIFFERENT UNITS IN THE EMERGENCY DEPARTMENT ‘The Emergency Department (ED) has the following umits for emergency My namely: Acute Care Unit for adult and pediatric patients, Observation Unit, Minor, Operating Room, Isolation Room, Examination and Casting Room, Counseling Room, and Supply Room. © Acute Care Unit “There are two (2) Acute Care Units in ER namely: the Acute Care Unit for adult patients and Acute Care Unit for pediatric patients @ Manat of tedden Guidelines on the Manageient ofthe Hospital Emergency Department gPlaut and Equipn The Acute Care Unit for adults caters to adult medical and all trauma cases. © It should have separate cubicles (called a crash room) for examination, resuscitation, and acute care stabilization, © The cubicles may be separated by temporary compartments or drapes that ensure patient privacy during examination and intervention by the resiclent-on-duty. © The Wheel-type stretchers within each cubicle provide easy manueverability during patient transport and examination, The temporary partition and wheeled stretcher can also be adjusted with the aim of providing more space to the ED floor during mass casualty incidents. Areas in the Acute Care Unit © The crash room is where initial resuscitative measures are instituted. The beds in the crash room may be fixed beds or wheeled stretchers. It has also a Permanent E-cart, defibrillator, suction devices, mounted sphygmomanometer, high-pressure oxygen source via an oxygen tank oF piped in, and a door that can be closed during resuscitation © The nurses’ station should ideally be at the centre of the acute care unit to facilitate monitoring and mobility of the nurses as well as the medical staff. The nurses’ station must always be clutter-free © The pantry is where washing and rinsing of hands, equipment, and pared, Wound irrigation may be done, The pantry usually has taps (which may be knee-operated), wall-mounted soaps, and hand dryers, The ventilation of the acute care unit has to be one-way laminar airflow type that recycles air on a periodic basis. The patient assignment Per bed has to be clustered in such a way that all critical paticnts are srouped together so as to facilitate patient tracking. The disposition time of each patient in the acute care unit has to be closely monitored so as te prevent overcrowding the area. 34 ‘Mannal of Standards and Guideline on the Management of the Hospital Emergency Department =Equipment and Devices 20° ° 00000 9000000 ° ° “Advance airway kit (and surgical airway Kit) Biological refrigerator Cervical collars (ideally semi-rigid type) Clipboards for patient charts/blotters Cut down set Defibrillator with adult and pediatric paddles Electronic Monitoring devices (ideally one per patient bed) Emergency cart High-pressure oxygen supply Mechanical ventilators Minor surgical set Patient Referral and disposition logbooks Personnel protective equipment Public announcement system Puncture-proof sharp containers (located strategically in the crash room, pantry and patient areas) Stethoscopes and thermometers (thermoscans) Strategically located wash areas or hand sanitation areas Supplies and drugs (pls refer fo Chapter 5, Medicines and Supplies) Thoracostomy set Tracheostomy set ‘Trash can per patient bed Ultrasound machine (especially for focused abdominal sonography in trauma patients) Wall-mounted and mobile sphygmomanometers \Wall-mounted suction devices Weighing scale ‘The Pediatric Acute Care Unit caters to patients 0-18 years old, This unit has similar provisions and equipments with the ACU for adult patients. Its areas are also the same except for the obstetric examination room. Equipment and Devices for Basic Life Support (BLS) ° ES smal nnn cso esr el ee Dee 35 Ventilation and Airway Equipment Portable and fixed suction apparatus ~ Portable and fixed oxygen equipment~ Oxygen administration equipment Adequate length tubing, mask (adult, child and infant sizes), transparent, non-rebreathing Venturi and valveless; nasal cannulae (adult, child and infant sizes) ~ Bag-valve masks ~ Airways Nasopharyngeal, oropharyngeal (adult, child and infant sizes) © Monitoring and Defibrillation ~ Automatic external defibrillator is strongly recommended for systems that do not have immediate availability of an advanced life support service. © Immobilization Devices ~ Cervical collars Rigid for children ages 2 years or older, infant, child and adult sizes (small, medium, large and other available sizes) - Head © Weighing scale for neonates © Beds with radiant light * Observation Unit for observation. The OU may be lodged in the clinical areas for medicine, Pediatrics, surgery and obstetrics-gynecology. The OU should be in close Preuimily to the acute care unit. Patients are still monitored but to « lesser frequency. The stretcher beds in the OU may be fixed-type or wheeled-type. The OU also has a nurses’ station and pantry. The disposition time of patients at the OU has to be tracked and observed strictly so as to prevent overcrowding in the area. Within 4 hours, patients shall have a disposition Equipment and Devices © Advanced airway kit Defibrillator Electronic patient monitoring devices Emergency Cart Fire extinguisher ooo 8 36 Mowat of Sonar an Cdl onthe Manage ofthe Homa Enexeacy Dearie ©©. Patient disposition logbook o Suction devices + Minor Operating Room ‘The ED shall have its own operating room that will cater to patients who are in need of emergency minor surgical procedures. Asepsis in this area must be observed strictly. Equipment and Devices © Airway kit Defibrillator with intra-cardiac paddles Electronic tissue coagulation machine (Cautery) Fiberoptic bronchoscopic and endoscopic devices Fire extinguisher High-pressure oxygen source (pipe in) OR lights (lamp) OR table Oxygen (O2) tanks Suction devices Thoracotomy set ooe0000 °° «Isolation Room Patients suspected to have a highly communicable disease is brought to the isolation room from the triage. This area connects to the main ED through an ante-room where PPE’s can be accessed and standard precaution is strictly observed. ©. The ventilation of the isolation rooms must be isolated from the main ER ventilation, and ideally filtered by UV irradiation/HEPA before being let out into the atmosphere. © Awashing area or hand disinfection system has to be mounted in close proximity to the isolation rooms. nt ofthe Hospital Emergency Department >” & Manna of Stands and Guidelines onthe ManSome precautions when working in the Isolation Room © Exposing the isolation room to the main ED floor, for instance, frequent opening the door or failing to close the door, should be minimized unless so warranted by the patient's case. © Admittance of visitors and unauthorized personnel should likewise be limited. © The necessary signages like aerosol and droplet precaution and standard precautions should be posted conspicuously. © Regular wall scrubbing of the isolation rooms shall be performed after the patient is transferred out. Examination Room The Examination Room is where ENT and Ophthalmology patients are evaluated. Examination Rooms should have a casting area for Orthopedic cases, Equipment and Fixtures © 10 Nasal packs Diagnostic set (otoscope/ ophthalmoscope) Elastic bandages of different sizes Electric saw Eye gauze Eye shield Head set Immobilization devices (skin traction, plaster of Paris) Materials for rhinoscopy and Magill forceps Pantry for the casting area Patient Referral and disposition logbook Pinhole Slit lamp Snellen chart Splints Tongue depressors Traction devices e000000000000000 38 ‘Manual of Standards and Guidelines on the Management of the Hospital Emergency Departmentee : wie © Counseling Room Relatives of patients must be brought in this room where privacy is ensured In this area, the ER Officer or the ROD talks with the relatives when securihg a informed consent, updates patent's condition and counsels in case th patient deteriorates or eventually dies. This room shall not be used as waiting for patient's relatives. + Supply Room or Stock Room ‘The Supply Room or Stock Room is where the devices and other consumables sre stoped and where the buffer stocks are placed. ‘The Charge Nurse should regularly update the inventory of the stocks per shift, and make the necessary requisition before his/her shift ends. Access to the supply room should be reuiricted to authorized personnel only. All supplies should be properly Iabeled and locked. Keys should be properly endorsed to Nurse on Duty (NOD) every shift Adjacent to these units includes Doctors’ Lounge and restrooms for patients. * Doctors’ Lounge ‘The Doctors’ Lounge acts as the “call room” for physicians and medical interns and clerks. It should have provisions for resting like sofa and beds, for studying and research like an internet connection and a study table, and for relieving, personal necessities such as a comfort room. © Restrooms Restrooms shall be provided for patients. This shall conform to guidelines for accessibility of disabled persons. Male and female comfort rooms shall be provided. Manual of Standart and Guidelines onthe Management of the Hospital Emergeney DepartmentPhysical Plant and Equipment Requiresnes ANCILLARY SERVICES Ancillary services which include a satellite laboratory and X-ray room shall be placed in the ED, when the main laboratory or radiology department is inconveniently inaccessible. + Satellite Laboratory The satellite laboratory shall receive all specimens from Patients at the ED. The equipments installed here are intended for “STAT” laboratory tests. The laboratory shall have at least the following tests: for determination of Arterial Blood Gases (ABG), determination of Hemoglobin/Hematocrit (Hgb/Het) or Complete Blood Count (CBC), urinalysis, serum electrolytes (sodium and Potassium), and point of care (POC) testing for Troponin I, Troponin T and Pregnancy test, among others Equipments and Devices Arterial blood gases analyzer Centrifuge Hemoglobin/ Hematocrit analyzer or automated Hematology analyzer Microscope Point of care (POC) testing kits © Serum electrolyte analyzer © Urine dipsticks ecco © X-ray Room The design of the X-ray room shall conform to the requirements for the Geeatuction of facilities equipped with radiation emitting machines, ‘The door shall be large enough to accommodate stretcher. The X-ray film shall be developed in the main radiology department. Equipment and Devices © Negatoscope © Portable X-ray machine 40 Maul of Standants and Guidelines on the Management ofthe Hospital Emergency DepartnentSatellite Pharmacy A Satellite Pharmacy is a storage area for emergency medicines. A pharmacist or pharmacy aide shall take charge of this unit which is under the Central Pharmacy of the hospital. Equipments and Devices © Cabinets © Cash register ALLIED MEDICAL SERVICES ‘The ED shall have provisions for special units, namely: Women and Children Protection Unit (WCPU) and Animal Bite Center for designated facilities. Women and Children Protection Unit (WCPU) This unit shall be located near the Emergency Department. It shall have an examination room equipped with examination bed, lithotomy examination table, rape kits, and speculum. Animal Bite Center It is a special area for facilities specifically designated for animal bites Otherwise, the institution shall cater to “animal bite” patients under the care of Trauma and General Surgery service SPECIAL AREAS (OPTIONAL) Toxicology Room ‘The Toxicology Room is where rapid bedside tests or toxicology screens are done to ascertain the identity of an unknown substance that a patient may have ingested. This room may be merged with the satellite laboratory to minimize space. 41Physical Plant and Equipment Requirements Equipment and Devices © Alcohol lamp © Biological refrigerator (with a separate freezer) © Ceramic diffusion tray ° Chemical reagents (activated charcoal, sodium sulfate, etc.) ©. Fire extinguisher © Fume Hood © Petri dish © Reference books and materials © Tap water and sink (With drainage not connected to the main hospital sewage) Test tube and test tube rack * Poison Control Unit A Poison Control Unit can be established if the institution is designated by the National Poison Control Center as a Regional/ Area Poison Control Center. Clinical toxicology service unit Minimal Requirements Optimum Requirements Availability of methods, equipment | Full facilities for prolonged life and areas for resuscitation, support systems decontamination and initial management of poisoning cases __| Equipment for decontamination and elimination of poisons Protocols for treatment of common acute poisoning cases, Protocols for assessment and management of poisoning cases Availability of antidotes and supportive medications for Availability of an analytical common poisoning cases laboratory with appropriate equipment for qualitative and Bedside laboratory tests quantitative biological and toxicological assays Availability of patient transport systems 2 Marlo Stonarts and Cuideins on the Momgonet of te Hospital Emegeney Departmen ®-_—_————orr ‘al Plant and Equipment Requirements Minimal Requirements Optimum Requirements | Emergency plan for disasters and major chemical accidents Established systems for poisoning data collection and analysis for toxicovigilance assessment and prevention Psychiatric rehabilitation and social assistance services Reporting of cases to Toxicology Unit of their respective hospital for statistical data ———— Poison information service unit «5 Suitable room for working area with basic furniture (desks, tables, chairs, etc,), lockable filing cabinets and bookshelves © Computer facilities Communication facilities (telephone, fax machine, answering, machine, recorder) «Databases of commercial products, chemical products and other poisons «o Library, consisting of books in toxicology, toxicology journals, poisoning protocols Analytical toxicology service unit «© Basic equipment includes fume hood, analytical balances, ordinary and refrigerated centrifuges, vortex mixer, water bath, fridge, freezers, hotplate, pH meter © Analytical equipment e.g. UV-visible spectrophotometcr © Reference materials, reagents and consumables, reference works © Manat of tana and Guidelines om th Manageent of he Hopital Emergency Department aGece Ee eT Minimum Devices Required Asepto syringe Foley catheters Gloves (surgical, gauntlet) IV catheters (G 24 to G 18) IV tubes with venoset/soluset Kidney basin KY jelly Laryngoscope with blades & extra bulbs Low-reading thermometer Nasogastric tubes (Fr. 16 for adults, Fr. 10-12 for children) Oropharyngeal tubes Oxygen with nasal catheter & venturi masks Suction apparatus with suction bottles Laboratory Equipment Analytical balance (max 20 g, min 10 g) (Heitler Toledo) Centrifuge (6-placer) Electric burner Freezer Fume hood Hot plate pH meter Refrigerated centrifuge (Hettich) Refrigerator Spectrophotomer v-530 (UV-visible spec) (Jasco) Top loading balance (Heitler Toledo) Vortex mixer Water bath Mama of tavdarts and Gites on te Management of he Hospital Emergency Deprinene @ ae ae er& amat of Standards and Guielns onthe Mangement te Hospital Emergency Departnent ©ms 46 = Manual of Standards and Guidelines onthe Managemen ofthe Hospital Emergency Department @5 MEDICINE AND SUPPLIES The operation of the Emergency Department depends on a large extent on the capability of the hospital in terms of skilled manpower and on the availability of medical supplies and functional equipment. In line with the Department of Health's goals of ensuring that every Filipino receives the best possible quality care in emergency situations, this chapter presents a list of basic medical supplies and equipment that are essential in the Emergency Department Hospitals have been categorized according to bed capacity and case mix with the types of services that it renders and the capacity to provide the standard equipment and supplies for that category. A Level 1 hospital facility caters to patients coming from the local community and should be able to address the endemic diseases and the most common illnesses prevailing in that community. The scenario will be different for a Level 2, 3 and 4 health hospital facilities, relative to its service capability. The standard equipment and supplies requirement are based on licensing and accreditation. Inherent to all emergency care services regardless of the level of service capability of the hospital is the capacity to provide initial stabilization with the provision for basic, essential, functional equipment and life-saving drugs. Basic equipment and essential drugs used to manage Airway, Breathing and Circulation (ABCs) is the lifeline of acute critical care. Essential drugs as listed in the National Drug Formulary (PNDF) used in emergency care are located in the emergency cart (E-cart). Preventive maintenance of basic equipment on a periodic basis ensures minimal disruption of ED operations due to non- functional equipment. ® Manu of tenards and Guidelines onthe Manogemeto th Hospital Emergency Department $7During mass casualty incidents and disaster situations, a mechanism shall be in place for emergency procurement of medicines, supplies and equipment in a contingency plan to address surge capacity with the unexpected influx of patients, Listed below are examples of the basic drugs that shall be available in the E-cart at any given time at an optimal level and dates of expiration checked judiciously Requisition and replenishment of supplies and drugs shall be done on a regular basis and as frequently as the need arises MINIMUM Basic ER MEDICINES (E-CART AND PNDE DRUGS) B-adrenergic agonists like Salbutamol 2 mg/ml (20 pieces) 5 Caloric agent (D50 W 50 mL/vial) (10 pieces) Activated charcoal sachet (20 pieces) Amiodarone 150 mg/ampoule (10 pieces) Anti-rabies vaccines (active) (5 pieces) Anti-rabies vaccines (passive) (5 pieces) Anti-tetanus serum (either the horse-anti-serum based or the human anti serum) (40 pieces) Anti-venins* (for centres with high incidence of poisonous animal bites) Aspirin USP grade (325 mg/ tablet) (20 pieces) Atropine 1 mg/mL ampoule (15 pieces) Benzodiazepine (Diazepam 10 mg/2 ml ampule and/or Midazolam) (10 pieces) Calcium (usually calcium gluconate 10 mg/ampoule) (10 pieces) D5 0.3 NaCI 500 mL /bottle (10 pieces) DSLR 1 L/bottle (10 pieces) D5.NM 500 mL/bottle (10 pieces) D5 NSS 1 L/bottle (10 pieces) DSW 250 mL/bottle (10 pieces) Dexamethasone Digoxin 0.5 mg/ampoule (10 pieces) Diphenhydramine 50 mg/ampoule (10 pieces) Dobutamine 250 mg/ 20 ml vial (10 pieces) Dopamine 200 mg/ vial (10 pieces) Epinephrine 1 mg/mL ampoules (30 pieces) Furosemide 20 mg/2 ml ampoule (20 pieces) 48 Manual of Standards and Guidelines onthe Managment ofthe Hospital Emergency Dopartnent @Haloperidol 50 mg/ampoule (10 pieces) Hydrocortisone 250 mg/vial (10 pieces) Hyoscine N-butyl-bromide 20 mg/vial (5 pieces) Lidocaine 5% solution/ vial - 19/50 mil (20 pieces) Magnesium sulphate 1 g/ampoule (10 pieces) Mannitol 20% solution (500 mL/ vial) (10 pieces) Mefenamic acid 500 mg/tablet (10 pieces) Meperidine 100 mg/vial (5 pieces) Methylprednisolone 4 mg/tablet (10 pieces) Metoclopramide 10 mg/ampoule (5 pieces) Morphine sulphate 10 mg/ampoule (10 pieces) Nitroglycerin spray or Isosorbide di-nitrate 5 mg/tablet/ amp (10 pieces) Noradrenaline 2 mg/ampoule (5 pieces) Oral rehydration salt preparation (10 pieces) Paracetamol 300 mg/ampoule (10 pieces) Phenobarbital IV or tablet preparation (15 pieces) Phenytoin 300 mg/capsule or IV preparation (15 pieces) Plain LRS 1 L/bottle (10 pieces) Plain NSS 1 L/bottle (10 pieces) Potassium chloride 40 mEq/vial (15 pieces) Pyridoxine 1 gram/ampoule (10 pieces) Sodium bicarbonate 50 mEq/ampoule (10 pieces) Succinylcholine 200 mg/ vial (5 pieces) Terbutaline 0.5 mg/ampoule (10 pieces) Tetanus toxoid 0.5 mL/ vial (20 pieces) © Thiamine (usually in parenteral Vitamin B complex preparation) (10 pieces) * Tramadol 50 mg/capsule (10 pieces) * Verapamil 5 mg/2 mL ampoule (10 pieces) MEDICATION STANDARDS © Medicines are administered in a timely, safe, appropriate and controlled manner, * Only qualified personnel order, prescribe, prepare, dispense, and administer the medicines. © Moria of Stondanis and Guidelines onthe Management ofthe Hospital Emergency DepartmentNeen + Prescriptions or orders are verified and patients are identified before medications are administered. * Administrations of medications are properly documented as to the time, signature of person who administered it, and amount of drug in the patient's chart, * Medications are checked against the original prescription and administered as prescribed. + Telephone orders are countersigned by the ordering physician not later than the standards set by the organization. « Adverse events identified are to be recorded in the patient's record and reported accordingly * Medications are properly stored and accessible only to authorized person, + Expiry dates are checked periodically. + Regulated drugs are stored in a cabinet of substantial construction for which only authorized staff has access. * Medications shall be securely labeled and stored in a clean environment in accordance with the manufacturer’s instructions relative to temperature, light and humidity specifications * A refrigerator for medications that require storage at low temperature shall be available in the satellite pharmacy. * Medications shall be inspected and those with visible contamination, cracks or leaks are discarded. 0 Man of Standards and Guidelines on the Managenent ofthe Hospital Emergency Departnent @Basic ER EQUIPMENT «Airway adjuncts (oropharyngeal and nasopharyngeal airways) Airway/Intubation kit Biomedical refrigerator for storage of biologicals and other heat-sensitive drugs Calculator e.g. for dose computation Cardiac board Cardiac/EKG leads Cervical collars of different sizes Defibrillator (with cardiac monitor and/or pacemaker functions) Diagnostic (ophthalmoscope/otoscope) set Different sets of bins (to include a puncture-proof sharp container) Fire extinguishers Floor lamps (drop light and gooseneck) Foot stools IV stands (poles) Mayo table and tray Nebulisation Oxygen tank Penlights or flashlights Portable suction device (suction catheters included) Pulmonary Function Test (PFT) or Peak Expiratory Flow Rate (PEFR) tube Pulse oximeter Random blood sugar meter (Gluco-meter) Sphygmomanometer Spine board with straps Splinting / immobilization devices Stethoscope Stretchers and gurneys (Wheel-type and the fixed-type stretchers) Thermometers Ultrasound machine with a set of probes (for obstetric, trauma abdominal, and chest sonography) Water-proof aprons © Weighing scale + X-ray reading lamp ® Maral of tandards and Guidelines onthe Managenent ofthe Hospital Emergency DepartmentBasic ER SUPPLIES * Alcohol disinfectant + Armsling (or sling and swathe bandages) + Aseptic bulb syringe * Elastic bandages of different sizes Gloves (examination and sterile gloves) Hydrogen peroxide solution Nasal cannula Nasogastric tube Oxygen tubing Povidone iodine wound and cleaning solutions * Protective face shield or mask * Standard face mask * Sterile gauze * Sutures © Syringes + Urethral cathether * Urine collection bag Each resuscitation bay (crash room) of the acute care unit shall have an airway set and E-cart, suction devices, a defibrillator, intravenous lines and fluids, and an oxygen tank. Ideally, one or two gurneys or stretchers are dedicated for resuscitation purposes, The acute care unit shall have an EKG machine and a portable X-ray for chest and pelvic X-rays at the least. Ultrasound machines have become valuable nowadays, especially in its role on focused abdominal sonography in trauma, obstetric sonography, and preliminary 2D echocardiography. Airway/intubation kit © Bag-valve-mask device (adult, child, infant sets) + ET tube (different sizes) * Laryngoscope (adult and paediatric sets) + Surgical airway 52 Manual of Standards and Guidelines on the Management of the Hospital Emergency Department+ Tracheostomy set* © Curved Mayo scissors, 8 inches Kelly forceps curve, 6 inches Knife handle with blades Metzenbaum scissors, 8 inches Mosquito forceps curve Needle holder, 8 inches Skin retractors Straight mayo scissors Tissue forceps with teeth Tissue forceps without teeth eo0ceco00 00 Closed Tube Thoracostomy Set * Curved Mayo scissors, 8 inches + Kelly forceps curved, 6 inches + Knife handle with blade + Metal tray cover 8 X 12 inches Mosquito forceps curved * Needle holder, 8 inches + Metzenbaum scissors, 8 inches «Skin retractors * Straight Mayo scissors * Tissue forceps with teeth * Tissue forceps without teeth Cutdown set* * Curved Mayo scissors, 8 inches + Kelly forceps curve, 6 inches Knife handle with blades Metal tray cover, 8 X 12 inches Metzenbaum, 8 inches Mosquito forceps curve Needle holder, 8 inches Skin retractors Straight Mayo scissors Tissue forceps with teeth + Tissue forceps without teeth & Manat of tandris and Guidlines onthe Management ofthe Hospital Emergency Department 95Minor Surgical Set © Curved Mayo scissors, 8 inches * Kelly forceps curve, 6 inches + Knife handle with blades * Metal tray cover, 8 X 12 inches * Metzenbaum scissors, 8 inches © Mosquito forceps curve * Needle holder, 8 inches «Skin retractors * Straight mayo scissors «Tissue forceps with teeth * Tissue forceps without teeth NOTE: Items with asterisks (*) are optional. f Manual Standards and Guidelineson the Menagnent of th Hospital Emergency Deparimet @ae 6 SYSTEMS AND PROCEDURES A typical emergency department has several functional areas, each specialized for patients with particular illnesses and injuries. In the triage area, patients are seen by a triage physician or nurse who conducts a preliminary evaluation including vital signs, chief complaint and cursory survey, before endorsing the patient to the appropriate clinical area of the Emergency Department. Patients with apparent life-threatening conditions may bypass triage and be routed directly to the resuscitation area. ' POLICIES AND STANDARDS + All patients coming in for consultation and treatment should be entered into the ER Register provided for in every department. + Patients brought to the ER by transport or by ambulance must be immediately examined and treated inside the ER facility. * ONLY ONE (1) RELATIVE OR COMPANION per patient is allowed and bags and other bulky things should be deposited in a baggage counter. ‘ «Vital signs for adult and pediatric patients are to be taken and recorded. Pediatric patients must be weighed by the nursing attendant. «After medical assessment and necessary emergency measures has been instituted, the ER Officer determines the patient's, disposition not more than four (4 Jhours after patient's entry to the ED. © Informed consent for treatment must be obtained by the health professional responsible for the care of the patient. Manual of Standards and Guidelines on the Management of the Hospital Emergency Department 5Ca a The patient's medical/health records shall be treated with utmost confidentiality and all efforts made to ensure its completeness. Firearms and other deadly weapons ARE NOT ALLOWED to be brought inside ED premises and MUST be deposited at the security compound for safe-keeping. In emergency cases, patient's rights are protected by: © RA 6615 “An Act requiring all government and private hospitals and clinics to extend medical assistance in emergency cases” which states that “all government and private hospitals and clinics are hereby required to render immediately medical assistance and to provide facilities and medicine within its capabilities”; and © RA 8344, “An Act penalizing the refusal of hospitals and medical clinics to administer appropriate initial medical treatment and support in emergency or serious cases, amending for the purpose Batas Pambansa Bilang 702, otherwise known as ‘an act prohibiting the demand of deposits or advance payments for the confinement or treatment of patients in hospitals and ‘medical clinics in certain cases.’” It states that “in emergency or serious cases, it shall be unlawful for any proprietor, president, director, manager or any other officer, and/or medical practitioner or employee of a hospital or medical clinic to request, solicit, demand or accept any deposit or any other form of advance payment as a prerequisite for confinement or medical treatment of a patient in such hospital or medical clinic or to refuse to administer medical treatment and support as dictated by g00d practice of medicine to prevent death or permanent disability provided, that by reason of inadequacy of the medical capabilities of the hospital or medical clinic, the attending physician may transfer the patient to a facility where the appropriate care can be given, after the patient or his next of kin consents to said transfer and after the receiving hospital or medical clinic agrees to the transfer: provided, however, that when the patient is unconscious, incapable of giving consent and/or unaccompanied, the physician can transfer the patient even without his consent: provided, further, that such transfer shall be done only after necessary emergency treatment and support have been administered to stabilize the patient and after it 56 Manat of Standards and Guidlines on the Management ofthe Hospital Emergency Department ©wre eS ree EE has been established that such transfer entails less risks than the patient's continued confinement: provided, furthermore, that no hospital or clinic, after being informed of the medical indications for such transfer, shall refuse to receive the patient nor demand from the patient or his next of kin any deposit or advance payment: provided, finally, that strict compliance with the foregoing procedure on transfer shall not be construed as a refusal made punishable by this Act." GENERAL PROCEDURES & Entry to the Emergency Department (ED) Introduce yourself as the doctor or nurse in-charge [Ask the complaints and take the necessary information including the general data, Do initial cursory examinations. Explain to the patient and/or relative the physical examination (PE) to be performed, Comfort the patient and give emergency measures, ‘» Clinical Assessment Explain the initial impression/s. If diagnostic procedure is required, explain its importance. A consent form should be secured for invasive diagnostic intervention. Prepare interdepartmental referral if necessary. Indicate remarks if the patient is either for admission, discharge or transfer. & Maat of Standards and Guidlines nthe Management of the Hospital Emergency Departnent /ES * Disposition * If the patient is for discharge, a medical discharge slip must be issued containing the discharge diagnosis, home medication, date of follow- uP and instructions on diet, what to avoid and what to expect Instructions are to be given on how to take the medications and inferm the patient of the possible side effects of the medications, * Ifthe patient is for admission, explain the plan of management * Hf invasive procedure is contemplated, explain the procedure as to its risk-benefit based on evidence-based medicine so that the patient can render an informed consent. Secure the consent from the patient and/or relatives that the procedure to be performed is; well. understood, + If the patient is to be transferred/referred to other institutions, the reason for the transfer should be explained to the patient or his relatives and the necessary consent for the transfer secured Discharged Against Medical Advise (DAMA) patients should sign a waiver, Figure 5 shows General Emergency Room (ER) Patient Flow. 58 Manual Standart and Guideline onthe Managenent of the Hospital Emegeney Doaronent @ i MleSTART Envy toER) Proceed to Triage Area, a Perform TRIAGE PROCEDURES Gee Figure 6, Flowchart on Triage SS Clinical Departments (Pediatrics, Medicine, Surgens, OB-Gyne, ENT, Opthalmology) ¥ Immediate care and work-up atthe ‘respective Clinical Departments eS EE Disposition by Clinical Departments Yes 7 For No} ‘Admission? Tbsuee Admission Orders and ‘Admission Slip Lr Patient and/or relatives, proceed to Admitting Section for ward assignment ‘Determine disposition of patients if «Discharged (patients beated and sent horre) 1 Discharged Against Medical Advice (DAMA) «Referred (or transferred to other hoepitals) ERDewth ‘¢ Dead on amival (DOA) t TER Nurse accompantes patient to ward Absconded y [Rout andyorpuiens inte proceeds Sag tka tr appeoresie nto «Ganon peyment of harper ee Patient and/or patient's relatives presents to official receipt (OR to ER clerk ——22_2__————— END —— Release patient (Exit to ER) Figure 5. General Emergency Room (ER) Patient Flow Manual of Standards and Guidelines on the Management of the Hospital Emergency Department oecae ‘TRIAGE IN THE EMERGENCY DEPARTMENT The triage is an essential function in Emergency Department (ED) because it is the point of entry into the hospital where patients are initially assessed. In this case, the degree of urgency is used as basis in sorting out patients needing acute care or ambulatory. Urgency refers to the time where critical intervention is needed by the patient. It is based on the severity of illness of the patient, eg Patients triaged to lower severity categories may be safe to wait for assessment and treatment but may still require hospital admission. Aims + To ensure that patients are assessed and treated in the order of their clinical urgency. * To ensure that treatment is rendered appropriately and timely + To direct the patient to the most appropriate clinical area for treatment, + To gather vital information that facilitates categorization of patients based on set criteria + To manage congestion in emergency treatment clinical areas. Key points + The Triage area must be immediately accessible and clearly identifiable by signage. Its design should allow for patient examination with privacy. * Strategies to protect the triage staff should be in place, * The same standards for triage categorization should apply to Emergency Department (ED) setting. It should be remembered however, that a symptom reported by an adult may be less significant than the same symptom found in a child and may render a child’s urgency greater. 60 Manual of Standards and Guidelines on the Management ofthe Hospital Emergency Department oneone Victims of trauma should be allocated a triage category according to their objective clinical situations. This includes consideration of high-risk history as well as brief physical assessment (general appearance with or without physiological observations). Patient with mental health or behavioral problems should be referred immediately to Acute Psychiatric Unit (APU). General Policies Triage guidelines should be formulated and communicated to ER staff. The health facility should formulate procedures, protocols and resources/ training to ensure proper patient triaging, All Emergency Departments should have a policy on managing suspected child abuse cases The designated triage officer may either be a physician or a nurse trained in triaging. Instead of full registration before patient placement in a room, the minimum demographic information needed to initiate a chart can be obtained initially, followed by complete registration at the bedside while evaluation and management are ongoing. Figure 6 presents the flowchart on triage procedures. & Manual of Standards and Guidelines onthe Management ofthe Hospital Emergency Department ©‘Upon entry to the Emergency Room (ER) ‘e Assess petientin 2 minutes « Register patientin the Tage logbook and ER Form with the following date: 9 Name of patient (Sumarre, First Name, Middle Name) © Chiefcamplant/s © Age © Date and Time of Consult 1 “Meaoure vital igne (RR, PR, BP, Temperature snd mental status t ‘Determire cliricel urgency based on 3-point ‘Triage Seale t ‘Wait for further Refer toOPD sseesernent and/or observation Emergent ‘Document details of the tage asoesementin the ae ‘Triage Form, Notify doctor at the respective XD Clinical Depertrents Figure 6. Flowchart on Triage 62 Man of tondands nd Gdelines onthe Management of the Hosptal Emergency Department @Allocation of Triage Category PROCEDURE On arrival assess the patient | Balance the need for speed against the need to be thorough. Measure vital signs at triage if required to estimate urgency, and if time perm Determine the clinical urgency of the | patient. | | | Multiple patients seen must be sorted and categorized in 3 point Triage scale. Notify doctor on call of patient's aval and TS category as required. Allocate a Triage Scale (TS) code in response to the question: ‘This patient should wait for medical assessment and treatment no longer than 5 | aninutes.! Categorized patient must be directed ADDITIONAL INFORMATION | Upon arrival of patients to the Emergency Department, all should be triaged by a doctor or nurse specifically trained on triage and with clinical expertise on a wide range of emergency conditions ‘The triage assessment should generally take no more than two to five (2-5) minutes ‘The triage assessment is not necessarily | intended to make a diagnosis, although this may sometimes be possible. | In determining the degree of urgency, the problem, general appearance and | physiological observations of the patient should be assessed together. | Categorizing is done after registration is filled up to the administering clerk. Indicate urgency of doctor's attendance. ] ‘The Triage Scale (TS) is a scale for rating | dlinical urgency so that the patients are seen ina timely manner, and whose case are commensurate with the clinical urgency needed ED Record attached with TS form must be | to the service department for treatment | presented to the receiving nurse for as soon as possible. atment in a timely manner. appropri Manual of Standards and Guidtelines om the Management of the Hospital Emergency Department ce| PROCEDURE | Take any patient identified as TS. Category 1 (Emergent). The patient needs an appropriate assessment by the receiving nurse. Category 2 (Urgent). The patient should wait for further assessment and wait until Category 1 patients initial urgent treatment is served Category 3 (Non-Urgent). The patient | should be advised to proceed to Out | Patient Department (OPD) for proper | treatment if during working hours. | Meet any immediate care needs. As appropriate, initiate appropriate investigations, e.g. X-rays, laboratory work ups, etc. or initial management Document details of the triage assessment as follows: + Date and time of assessment | + Name, Age, Sex and Civil Status of the patient | # Chief problem(s) + Limited, relevant history « Initial triage category allocated * Vital signs, first aid or treatment measures initiated. _ managemi _ ADDITIONAL INFORMATION A more complete nursing assessment should be done by the treatment nurse receiving the patient. Decongesting Triage Area must be observed, treatment nurses receiving patient must serve patient accordingly to TS category. OPD nurse must perform further assessment and possible re-triaging and bring patient to service department for diagnostics and treatment. Standing orders may apply. Waiting time is reduced and patient satisfaction is increase where nursing staff follow protocols ad order tests and/or Use a 3-point TS form appropriately, properly filed up and attached to patient ER Record any disposition or outcome to patient must be recorded at ER Register for documentation and recording purposes. 64 Manual of tarde and Guidelines onthe Management of he Hospital Emergency DepartentLE _ PROCEDURE ADDITIONAL INFORMATION | Ensure continuous reassessment of | Both the initial triage and any subsequent | patients who remains waiting. categorizations should be recorded and the | | reason for the re-triage should be | * Regularly check any changes in | documented. | patient's condition while waiting | contribute | | for treatment; * Take note of any additional relevant information that becomes available that may contribute to patient's urgency. The Triage Scale: Descriptors for Categories The clinical descriptors listed in each category are based on available research data where possible, as well as expert consensus (Australian Triage Scale) However, the list is not intended to be exhaustive nor absolute and must be regarded as indicative only. Absolute physiological measurements should not be taken as the sole criterion for allocation to a TS category. Trained physician or nurse should exercise their judgment and where there is doubt, err on the side of caution (so-called over-triage). Key Points on Triage Scale + The most urgent clinical feature identified determines the Triage Scale category, + Once a high-risk feature identified, a response commensurate with the urgency of that feature should be initiated. * TS Category 1 - Emergent Cases An emergent case is defined as any insult to the patient's airway, breathing, and circulation that warrants immediate intervention within 10 minutes, otherwise, death and morbidity will ensue. The vital signs of the patient are often unstable (tachypneic, tachycardiac, hypotensive, with labored breathing) or the patient is not fully awake @ Manat Stars and Guidelines on te Monagenent ofthe Hospital Emergency Department ©It exists when a patient has a life- or limb-threatening condition that includes compromising insults into the airway, breathing, and circulation. Minimum. treatment for emergent cases requires initial stabilization of the ABCs, depending on the capability of the health facility. ‘+ Immediate simultaneous assessment and treatment within 10 minutes + Immediately Life-Threatening Condition The condition is serious enough or deteriorating so rapidly that there is potential of threat to life, or organ system failure if not treated within 10 minutes of arrival at the ED. Conditions that are threats to life (or imminent risk of deterioration) require immediate aggressive intervention «Important time-critical treatment The potential for time-critical treatment (e.g. thrombolysis, antidote) to make a significant effect on clinical outcome depends on treatment commencing within a few minutes of the patient's arrival in the ED. + Very severe pain Humane practice mandates the relief of very severe pain or distress within ten (10) minutes. + Clinical Descriptors (indicative only) co Immediate risk to airway - severe stridor or drooling with distress, impending arrest Respiratory rate < 10/minutes Severe to extreme respiratory distress Respiratory Arrest Circulatory compromise - Clammy or mottled skin, poor perfusion = Heart rate of less than 50 or more than 150 beats/minute (adult) - Hypotension with homodynamic effects, BP <80 systolic (Adult) or severely shocked child and infants = Severe blood loss = Chest pain of likely cardiac nature © Cardiac Arrest © Drowsy, decreased responsiveness from any cause with Glasgow Coma Scale (GCS) of less than 13 © Unresponsive or responsive to pain only (GCS < 9) oo00 Manual of Standards and Guidelines on the Managemerit of the Hospital Emergency Department© Very severe pain - any cause © Ongoing/Prolonged seizures © Acute hemiparesis/dysphasia © Fever with signs of lethargy (any age) © Acid or alkali splash to eye - requiring irrigation © Major multi trauma (requiring rapid organized team response) © Severe localized trauma (requiring rapid organized team response) © Severe localized trauma - major fracture, amputation High-risk history: Non-modifiable risks such as too young or too old and co-morbidities Significant sedative or other toxic ingestion Drug overdose and unresponsiveness or hypoventilation Significant/ dangerous envenomation Severe pain suggesting pulmonary embolism, abdominal aortic aneurysm or ectopic pregnancy © Behavioral/ Psychiatric - Aggressive with immediate threat of dangerous violence to self or others = Requires or has required restraint - Severe agitation or aggression e000 + TS Category 2 - Urgent Cases An urgent case is defined as any case involving insult to the airway, breathing, and circulation but that intervention is given within two (2) hours before death and/or morbidity ensues. The vital signs may be stable but frequent re-assessment is warranted since the patient's status may change abruptly for worse condition. «Assessment and treatment start within 30 minutes to 60 minutes + Potential Life-Threatening and serious The patient’s condition may deteriorate, or adverse outcome may result, if assessment and treatment is not commenced within one (1) hour of arrival in ED. The patient's condition may progress to life- or limb- threatening, or may lead to significant morbidity, if assessment and treatment do not commenced within thirty (30) minutes of upon arrival. Manual of Standars and Guidelines on the Management ofthe Hospital Emergency Department ©”Syste is and Procedures Situational Urgency There is potential for adverse outcome if time-critical treatment is not commenced within thirty (30) minutes to one hour or humane practice mandates the relief of severe discomfort or distress within thirty minutes. Significant Complexity or Severity Likely to require complex work-up and consultation and/or impatient management or humane practice mandates the relief of discomfort or distress within one hour. Clinical Descriptors (indicative only) ooo e000 ooco Severe hypertension Mild to moderately severe blood loss - any cause Mild to moderate shortness of breath, Foreign body aspiration SAO2 90 - 95% Seizure (now alert) Any fever if immunosuppressed ex. Oncology patient, steroid Rx Persistent vomiting or diarrhea with some signs of dehydration Difficulty of swallowing, no respiratory distress Eye inflammation or foreign body - normal vision Mild to moderate head injury with short loss of consciousness - now alert Moderately severe pain - any cause - requiring analgesia with some risks features Chest pain likely non - cardiac and mild to moderate severity, no respiratory distress Abdominal pain without high risk features - moderate severe or patient age > 65 years old Mild to moderate limb injury - sprained ankle, deformity, crush, severe laceration requiring investigation or intervention with mild to moderate pain, normal vital signs Limb - altered sensation, acutely absent pulse, swollen “hot” joints. Tight cast, no neurovascular impairment Trauma high - risk history with no other high-risk features Stable neonate and child at risks 8 ‘Manual of Standards and Guidelines on the Management of the Hospital Emergency Department© Behavioral/ Psychiatric: - Semi urgent mental problem - Under observations with impending behavioral distress - Acutely psychotic or thought disordered + Situational crisis, deliberate harm - Agitated, withdrawn, potentially aggressive “TS Category 3 - Assessment and treatment start within 120 minutes A non-urgent or ambulatory case is a case where there is no threat to the airway, breathing, and circulation. The patient is in no immediate risk of death or morbidity. © Less Urgent The patient's condition is chronic or minor enough that symptoms or clinical outcome will not be significantly affected if assessment and treatment are delayed up to two (2) hours from arrival. + Clinico-administrative problems Results review, medical certificates, prescriptions only * Clinical Descriptors (indicative only) © Minimal pain with no high risk features Low-risk history and now asymptomatic Minor symptoms of existing stable illness Minor wounds - small abrasions, minor lacerations (not requiring sutures) Scheduled revisit ex, Wound review, complex dressing Immunization only Behavioral/ Psychiatric: - Known patient with chronic symptoms, e.g. Hypochondriacs - Pseudo Psychosomatic Syndrome Reaction Manual of Standards and Guidelines on the Management of the Hospital Emergency Department ©?Recognition of the Critically-Il Child Serious illness in a child may not be recognized. This is because children: + Are poor historians «May manifest non-specific symptoms + May be uncooperative during examination + May not show significant indicators ~ but rather may present as subtle signs «May be presumed to have age specific diseases Markers of serious illness in infants under 6 months ] ‘THREE POINT ean HIGH RISK MEDIUM RISK | TRIAGE SYSTEM _ | | Feeding <1/2 normal ¥y-2/3 normal Fluid intake <1/2 | Le oe normal 4 ‘Arousal (CNS) | Often drowsy Occasionally Activity decreased | Decreased activity | drowsy | | Convulsion | | | | | Weak cry - nee | Breathing | Apnea or Cyanosis | Breathing difficulty | Chest wall recession (in | | | drawing) —__|_ drawing) __ | Circulation Skin pale and hot _ | Skin pale | Paleness (sudden po | | onset, but persistent) _ Fluid output | Green vomit | Vomit >5 vomits in | | | <4wet 24 hours | | nappies/day | Lessurine than | | =—s jusuall= = | Feces Bloody stool Loose Bowel more | than usual i Manual of Standards and Guidelines on the Management of the Hospital Emergency DepartmentSa Ee Useful signs ~ Alertness drowsiness hypotonic on examination + Breathing moderate/ severe recession cyanosis wheeze «Circulation pallor signs of dehydration «Temperature > 38.5 C «Signs of dehydration + Tender abdomen Specific signs © Respiratory grunt, crepitations, stridor, apnoea tachypnea > 80 + Abdominal mass, hernia, distension «CNS weak cry, abnormal posture + Skin cold periphery, mottling, bruise, rash + Pulse >200 and Urine output < 4 wet diapers MANAGEMENT OF AGGRESSIVE/COMBATIVE PATIENTS Triage is the first point of public contact with the Emergency Department where patients with the whole spectrum of acute illness, injury, mental health problems ea challenging behavior may present. Aggressive people presenting to the Emergency Department are usually patients or the relatives or friends of patients. Aggression is said to occur where a person is verbally oF physically eesed, threatened, assaulted or injured and can arise directly or indirectly as @ consequence of the actions of another person. Aims * Maintain a safe work environment «Establish and maintain a positive client focus © Minimize the risk of escalation of aggression Causes of Aggressive Behavior If the mentioned factors are present it may provoke or magnify aggressive behavior and create a risk of harm for triage nurse and other reception staff. * Pain + Fearand stress «Influence of drugs and/or alcohol @ Mua of Standards an Guelines on the Manage ofthe Hospital Emergency Department a+ Mental instability * History of Aggression + Invitation and frustration + Asense of loss of control + Perceived prejudice Relatives/friends can become quite anxious and upset when they see ‘their’ renee ip Pain OF not being attended to by medical staff frequently enough. Usually this anger is expressed verbally Managing Immediate Threat * While some acutely-clisturbed patients may require an immediate clinical intervention, other individuals who enter an emergency department and ose an immediate threat to staff (for example, brandishing a dangerous AeaPon, verbal assaults, etc.) should not receive a clinical response until the safety of staff can be secured. * Where the safety of staff and/or other patients is under threat, the staff and (other ED) patient safety should take priority over clinical assessment and treatment. The staff should obtain immediate intervention from security staff and/or any concerned so as to protect themselves * Once the situation is established, a clinical response can take place as (and if) required, and triage should then reflect clinical and situational urgency. Verbal Strategies * While not effective with all patients, verbal diffusion can be as effective as pharmacologic restraint, Encourage patients and relatives that due care would be rendered * Offer food and drink to encourage cooperation if patient agitated if not contra-indicated with the presented clinical symptoms + Enforce behavior 'ts and explain the consequences of the person's unacceptable 72 Manual of Standards and Guidelines on the Management ofthe Hospital Emergency Departnent iPharmacological Restraint * More humane than physical restraint and most effective for severe aggression + No one medication is appropriate for every situation + Regular monitoring of patient will be required following sedation to detect adverse side effects. Assessment Process + Alert security staff or any concerned as required to provide assistance during the assessment, * It should be decided whether those who accompany the patient have establishing or destabilizing influence. People who appear to provoke the patient should be requested by the security staff to leave the premises, + Staff who sense feelings of danger, however vague, should discontinue the assessment and seek assistance. So called ‘gut feelings’ should not be ignored + Ifa ‘dangerous’ person leaves the Emergency Department alert security staff or any concerned immediately. Do not attempt to chase the person ___ADDITIONAL INFORMATION —___ __PROCEDURE | | Do not assess people in confined or _ Lessens the client's feeling of being trapped | | fsolated areas. Ensure that there is and to create any easy escape route if | ‘easy access to the door, _ __| necessary _ 7 | | | | Consider One other person should be sufficient so as_ | ‘« Whether the person's anger is not to create an atmosphere of “them” and | manageable or out of control “us”. This may cause further anxiety. | present (e.g. nurse, security officer, etc.) | | | © The need for another person to be | | |_+ Any previous history of violence __ @ ‘Manual of Stands and Guidelines onthe Management ofthe Hospital Emergency Department 73PROCEDURE ADDITIONAL INFORMATION Establish the circumstances of Patient's old notes may provide additional presentation from: | information. « Referring person/letter + Other staff | * Patient * Patient's family/friends | | Use a confident reassuring approach | by staff without added stimuli. Use a soft modulated tone of voice _| It is difficult for angry people to maintain when speaking to the person their anger when faced with calm, controlled people, Do not respond to verbal aggression _ Rarely will a person's anger be directed at | with verbal aggression. Ifa person’s the staff member. It is more likely they are anger is specifically directed to you _ angry about a situation or event and you 1en hand over to another person. are targeted for ventilation and relief. If the person is rational, acknowledge | For instance, “you seem very angry about their anger. | this... I'm wondering what's causing this anger.” By engaging the client in thoughtful * Be aware of your own body discussion, he/she may mirror your sitting language. position and general demeanor. * Minimize direct eye contact. * Attempt to relax the person by appearing calm, | | a J Physical Restraint Principles + Physical restraint and emergency sedation should only be used when other reasonable methods of calming the patient down are unsuccessful. If a patient who is acting out does not need acute medical or psychiatric care, he/she should be discharged from the hospital rather than restrained. 74 Manual of Standards and Guidelines onthe Management ofthe Hospital Emergency Department &ar ee) + When restraint is required a coordinated team approach is essential, with roles clearly defined and swift action taken. + Unless contraindicated, sedation upon physician’s order should usually accompany physical restraint. Indications Aggressive and combative behavior in a patient who requires urgent medical or psychiatric care, which is: + Compromising the provision of urgent medical treatment (physical or psychiatric); * Placing the patient at risk of self-harm; or «Placing staff at risk Contra-indications to physical restraint and emergency sedation + Safe containment possible via alternative means + Inadequate personnel, setting and equipment. + Situation judged as too dangerous e.g, patient has a weapon. + Known adverse reaction to drugs usually used (e.g. neuroleptic malignant syndrome) Key points If the staff thinks they will not be able to safely restrain the patient or manage the threat, then the security staff should be called. __ ADDITIONAL INFORMATION PROCEDURE _ _ | Explain the procedure to the parents/relatives, if possible. Establish roles, including defining This is usually the attending doctor. _person in charge. | Manual of Standards and Guidelines on the Management of the Hospital Emergency Department >| PROCEDURE ADDITIONAL INFORMATION | Assemble all available staff. | | Assign roles before approaching the | patient. Draw up drugs upon physician's order. | Drugs will vary bets | Secure the patient quickly and calmly. | __ Hold the patient supine, with hands and feet restrained to the stretcher _with consent of the relative. - IE - =| Once sedated, monitor O2 saturation | continuously. Consider need to transfer patient to _| Patients who have been sedated may not be specialty facility transferred into police custody. | observe conscious state, respirations, | If sedation other than their normal | pulse, BP, and temperature as medication has been administered, a staff determined by the condition of the must accompany the patient being | | patient. ___| transferred to another health care facility. | | Complication of emergency sedation Extra pyramidal reactions (dystonia) may include: occur with major tranquillizers, particularly # Anaphylactic reactions when medication wears off. These are « Respiratory depression treated with repeated small doses of ___ hypotension, tachycardia. a * Cardiovascular symptoms such as | diazepam. | | | Follow up In cases patients are referred to Acute | Following restraint the patient must Psychiatric unit at OPD. have a complete medical and mental health assessment by the physician to guide subsequent management. Consider the need for on-going | physical restraint Consider the need for on-going | | sedation, ‘Manual of Standards and Guidelines on the Management of the Hospital Emergency Department[ PROCEDURE ADDITIONAL INFORMATION _ Document fully in the patient's unit record: | The indication for chemical and | physical restraint. | « the patient's responses to sedation * on-going observations |_¢ Stan for ture management __| Debriefing The need to restrain an aggressive patient is fortunately a rare event, but can be extremely distressing when the staff is involved. A formal debriefing session should be arranged, ideally chaired by an objective facilitator who was not involved in the restraint process. INFORMED CONSENT An informed consent refers to the voluntary agreement of a person to undergo or be subjected to a procedure based on full information, whether such permission is written, conveyed verbally, or expressed indirectly All patients of legal age (18 years old and above) with sound mind and consciousness, treated at the Emergency Room, shall give an informed consent forall interventions. The informed consent for children brought at the ED should be obtained from the parents (or guardians) if the child is less than 18 years old, In emergent cases, the doctrine of implied consent applies to all resuscitative interventions, unless revoked by patient's nearest of kin. Procedure «The ER Nurse on Duty explains the need for the informed consent in a language understandable to the patient. «Obtains the signature of the patient, and © Witnesses all signatures given by patient's companion. ® Mana Standart and Guilin onthe Mangement ofthe Hospital Emergency Dywriment 7Person Who May Execute a Informed Consent for Incapacitated Patients, 18 years old and above (as adopted from Republic Act 7170, Section 4) Any of the following persons, in the order of preference, in the absence of actual notice of contrary intentions by the patient or actual notice of opposition by a member of the immediate family of the patient, may give consent for any purpose: * Spouse; + Son or daughter of legal age; + Either parent; + Brother or sister of legal age; or + Guardian. OBSERVATION UNIT * The observation unit, also known as the minor unit, is where urgent cases without immediate life threats are sent for further observation. * Patients are allowed four (4) hours in the Observation Room. After that Period they are admitted, discharged, or transferred to other hospitals. + In cases of pediatric patients admitted for rehydration purposes, they maybe allowed to stay for four (4 Jhours. LABORATORY AND ANCILLARY PROCEDURES: All Emergency Department patients requiring laboratory and ancillary Procedures which are crucial and necessary for immediate decision-making and treatment, shall be done immediately on “STAT” basis without requiring, prior Payment. Admissible patients must be admitted immediately, Routine laboratory tests and X-Ray procedures already requested at the ER but were not carried out, shall be done in the Ward. 78 Manual of Standards and Guidelines onthe Managenent of th Hospital Energeny Department &Eocene > Request for Laboratory, X-Ray and Other Ancillary Services at the Emergency Room Considering the emergent or urgent need to institute proper and immediate care or treatment of ER patients, the laboratory and other ancillary services shall not ask for payment or deposit prior to the performance of the requested procedure. The tests shall be performed but charged and to be paid prior to discharge. For patients who have no capability to pay, should go to the Medical Social Service for classification and must issue a promissory note prior to discharge in accordance to R.A. 9439 (An Act prohibiting the detention of patients in hospitals and medical clinics on the grounds of nonpayment of hospital bills or medical expenses). The procedure shall follow the hospital policy on this matter. Pursuant to RA 8344 (An “Act prohibiting the demand of deposit or advance payment for the confinement or treatment of patients in Hospitals and medical clinics in certain cases”), laboratory procedures not necessary in the urgent or emergency needs, can be deferred and done while the patient is in the Ward/or sent Home, not necessitating delay or prolong stay at the ER. The ER resident makes judicious use of the laboratories that are needed to aid in his management of the emergency case Laboratory and ancillary tests may be categorized as: + Routine. Tests are done during the usual running time with the releasing, of results within 24 hours. This is done on samples in which the result is not emergently needed. + STAT. Tests are done on patient samples, where there is real life- threatening condition. The turn around time of releasing the official result shall not be more than 2 hours. STAT test requests are given the highest priority by the laboratory for processing, analysis and reporting. It shall be the responsibility of the hospital administration to establish a list of “STAT” laboratory tests as recommended by the ER Department and approved by the Laboratory Department. This is to avoid abuses made on the “STAT” laboratory tests because there are many physicians ordering routine laboratory tests and label them as “STAT”. ‘Manual of Standards and Guidelines on the Management of the Hospital Emergency Department “iLabeling Specimen Container/Slide Labels (at least five) should be used whenever possible. The label should be permanently affixed to the specimen container. Based on the Guidelines for Collection of Specimens for Laboratory Testing (World Health Organization, March 2003), it should contain: + patient name + unique identification number * specimen type and date and place of collection * name or initials of specimen collector. Request Forms for Laboratory Tests shall contain a stamp of the name and signature in addition to the above data X-ray requests labeled as “STAT” shall have the approval of the Radiology department personnel. EMERGENCY DEPARTMENT DISPOSITION OF PATIENTS The final disposition of patients shall be recorded as: + Discharged and sent home + Discharged Against Medical Advice (DAMA) + Referred or transferred to other hospitals + ER Death + Absconded + Admitted to ward Procedures for the Disposition of Emergency Room-Trauma Department * Patients for discharge by the resident are advised regarding prescription, treatment and OPD follow-up if necessary. CSR supplies, medicines and procedures done to the patient maybe charged accordingly if patient can afford to pay. However, if not, they are referred to the Social Services for proper evaluation, 30 Mama of Santerds and Gittins on the Management ofthe Hospital Emergency Department 3)* All transfers should be properly networked with the admitting hospital accompanied with properly filled-up forms in triplicate with acknowledgement form duly signed by the receiving hospital. (All laboratory results, x-ray plates, etc. and abstract should go with the patient and properly endorsed and acknowledged (Refer to DOH ‘Administrative Order No. FAE 007, S. 1998). Patients transferred to the other hospitals are given a referral slip and required to sign a release of responsibility. Likewise, patients who refuse admission, procedure of treatment or medication should sign a release of responsibility with the resident and nurse as witness. + Communicable disease are advised transfer to end referral hospitals (e.g. San Lazaro Hospital) by ambulance, unless they desire to go their own after being required to sign a release of responsibility. ‘Absolute contra- Reverse Isolation - (Depends indication for admission | Diseases for Isolation | upon discretion of attending, physician) Diptheria Tetanus ‘AIDS Small pox Mumps Postpartum and post abortal Poliomyelitis Scabies sepsis Rabies Measles Premature and Newborn Psychiatric cases, violent | Meningitis infants PTB active, open cavity | Meningo-coccal infections | Leukemia Bubonic Plaque Gonorrhea Hypo-or-a-gamma- Chicken pox Chaneroid globulinemia Meningococeemia Syphillis Certain post surgical Gas gangrene conditions Infectious hepatitis, Patients treated with a large precomatose, comatose doses of radiation, steroids Pertussis, or various immuno- Cholera suppresive agents ‘Typhoid Severe burns (follow Burn Unit Hfever Policy) Discharged and Sent Home A patient discharged from the ED shall be given a discharge note to be accomplished by the attending physician. The note shall contain the following, information: name of patient, age, date examined, take home medications with the proper instructions, diagnosis, results of laboratory examination, date of follow-up visit and the name of the attending physician. S Manat of Standard and Guidelines on the Management ofthe Hospital Emergency Department ©+ Discharge Against Medical Advice (DAMA) + Refusal of admission and other treatments to be given to patients usually requires a form for release of responsibility. This should be signed by the patient himself. If the patient is a minor, the nearest of kin may sign. Proper and clear explanation of consequences that may arise after refusal of medical management must be made. + After signing the waiver form, the patient should leave the hospital premise at once. + The person who signed the waiver must be the one to remove all the contraptions connected to the patients. * All supplies and medicine used by the DAMA patient shall be replaced or charged. * DAMA cases are not allowed to use the ambulance for conduction, Referred or transferred to other hospitals + AILER consults need to be documented and hence, charted prior to any disposition by the ER resident. + All emergent cases require initial stabilization of ABCs prior to referral or transfer. + When referring emergent and urgent cases, the referring institution accomplishes an inter-hospital referral form and coordinates the transfer/referral via telephone, radio, or reliable real-time communication available with the receiving hospital for proper networking. * All coordinated and networked referrals shall be conducted by the referring health facility using an ambulance or EMS system. Hospitals without ambulance/EMS transport shall make the necessary arrangement with their local government for assistance in patient transport 82 ‘Manual of Standards and Guidelines on the Management of the Hospital Emergency Department«Referrals of emergent and urgent cases for transfer to other hospitals shall be accomplished by the attending resident physician and noted by the Senior Resident on Duty, A waiver for release of responsibility shall be signed by the patient or the patient's relatives prior to the transfer of the patient. A clinical summary specifying the clinical evaluation and interventions done to include medication dosage, time administered and condition prior to transfer shall be accomplished and attached to the inter- hospital referral form. The patient's vital signs and condition prior to the transfer shall be recorded in the ED record data sheet + All networked referrals shall not be refused by the receiving hospital once properly coordinated. + Referrals of ambulatory and non-urgent cases require only the written inter-hospital referral form + All referral notes shall be written legibly and duly signed by the physician answering the referral. The original copy shall be attached to the chart. + Patients suspected to have highly communicable diseases shall be referred immediately to the Infection Control Committee (ICC) after initial stabilization of ABCs and if deemed for transfer, the ICC shall make the necessary coordination with the receiving facility. Referral System within the Hospital * The triage form which serves as the ER “STAT” referral sheet shall be properly accomplished and the referral promptly answered by the appropriate service within thirty (30) minutes for urgent cases and within ten (10) minutes for emergent referrals. «Referrals not answered within the designated period shall be referred to the ER Officer on Duty for appropriate action. «Referrals shall be made at the residents’ level. In cases of conflict or issues regarding patient disposition, department consultant on call shall be consulted to decide on the case. In case the issue remains unresolved, the matter is then elevated to higher hospital authority. @ Manat of Stands and Guidelines onthe Managment ofthe Hospital Emergency Department °3* Previous patients re-admitted to the ED for the same complaint or problem shall be referred and admitted to the previous service that last managed the patient. + Patients with emergent and urgent conditions referred for admission from the OPD shall be examined at the ER prior to hospital admission for initial stabilization. * Elective and non-urgent cases from the OPD that are for admission shall be admitted directly into the floor or wards. The ER will not serve as holding area for such elective and non-urgent cases when these cannot be accommodated at the ward or floor. DISPOSITION OF THE CADAVER Death is the irreversible cessation of circulatory and respiratory functions or the irreversible cessation of all functions of the entire brain, including the brain stem. A person shalll be medically and legally dead if either: + In the opinion of the attending physician, based on the acceptable standards of medical practice, there is an absence of natural respiratory and cardiac functions and, attempts at resuscitation would not be successful in restoring those functions. In this case, death shall be deemed to have occurred at the time these functions ceased; or + In the opinion of the consulting physician, concurred in by the attending physician, that on the basis of acceptable standards of medical practice, there is an irreversible cessation of all brain functions; and considering the absence of such functions, further attempts at resuscitation or continued supportive maintenance would not be successful in restoring such natural functions. In this case, death shall be deemed to have occurred at the time when these conditions first appeared. The death of the person shall be determined in accordance with the acceptable standards of medical practice and shall be diagnosed separately by the attending physician and another consulting physician, both of whom must be appropriately qualified and suitably experienced in the care of such patients. The death shall be recorded in the patient's medical record (Republic Act 7170-Sec 2). a Manual of Standards and Guidelines nthe Management ofthe Hospital Emereney Department &ae “Dead on Arrival (DOA) Patients brought to Emergency Room without cardio-pulmonary and brain functions, This will include patients who did not respond to initial resuscitation, Resuscitation is no longer done to patients with signs of Rigor Mortis, Livor Mortis, Algor Mortis and Decapitation and advance state of decomposition. +» ER Death ER Death refers to death of patient who is not yet admitted occurring at the ER. These include patients who arrived at the ER with no detectable vital signs (BP, HR, and RR) but revived by initial resuscitative measures, but eventually died, regardless of the time of stay. Postmortem care shall be done by the ER nursing personnel. Death of an admitted patient at the ER and while on transport This is a death of an admitted patient who is not yet accepted or reached the assigned ward. For such cases, the mortality shall be counted to the census of the admitting Ward. + Admitted patient who died at the ER In this case, the death certificate shall be accomplished by the ER Officer. Postmortem care shall be done by the ER nursing personnel «Admitted patient who died while on transport When the patient dies on transport, the patient shall be brought and resuscitated in the nearest unit which has an E-cart. The physician who pronounced the death of the patient shall accomplish the death certificate. The postmortem care shall be done by the nursing personnel in that unit Case Study. A patient is admitted to the 3*! floor but while on transport, the patient coded arrested at the 2" floor, the patient shall be resuscitated in the nearest unit with E-cart at that floor. Even though, the personnel who attended the patient are not from the admitting ward, the census shall still be counted to the admitting ward. ‘Masnual of Standards and Guidelines on the Management of the Hospital Emergency Department ceReporting ER Death Death certificate shall be accomplished by the ER Officer, if there is a definite diagnosis. Otherwise, it shall be issued by the city/municipal health officer, or NBI or police crime laboratory in a medico-legal case after the conduct of an autopsy. The death shall be reported to the local health officer within 48 hours after death and the death certificate shall be forwarded to the local civil registrar concerned within 30 days after death for registration (Section 4, Chapter XXI- IRR, P.D. 856 of the Sanitation Code of the Philippines). Role of ER Staff in case of ER Death + ER Officer and ER Nurses must complete the patient medical chart. + ER Officer must issue a death certificate if the diagnosis is certain; otherwise, mandatory autopsy is necessary before a death certificate is issued + ER Nurse facilitates billing, post mortem care, and transfer of the cadaver to the morgue. Role of the ER Physician in case of ER Death In case of a death of a patient, the following are the responsibilities of the ER Officer or Attending Physician: + Refer all ER deaths for autopsy to the physician (referred to as the Prosector), Pathology department, hospital's medico-legal officer, ot Provincial/City/ Municipal Health Officer, who will do the autopsy, + Send a formal referral to the prosector regarding the reason for the autopsy. * Must write on the chart/medical record of the decedent the indication for the autopsy 36 Maral of Standards and Guidlines on the Management ofthe Hospital Emergency Departnent ®+ Provide a clinical abstract, which must include the circumstances surrounding the demise, and laboratory and ancillary test results including X-ray plates. * Must clearly inform the relatives of the decedent on the need for the autopsy. «Shall not give any detail on the procedure of the autopsy ~ which is the responsibility of the prosector. «If the relatives do not give informed consent or have outright refusal on the conduct of the autopsy, the ER Officer or attending physician must indicate in the chart the reasons and consequences, + The nearest of kin sign must sigm a waiver for refusing the conduct of the autopsy. A waiver form may be adapted and revised by the institution + For mass casualty incident, proper documentation of identification of the cadaver is deemed necessary. Death due to Dangerous/Communicable/Infectious Diseases shall be properly disposed of with the following advises: + The remains shall be buried within 12 hours after death. «The remains shall not be taken to any place of public assembly. © Only the adult members of the family of the deceased shall be permitted to attend the funeral. The remains shall be placed in a durable, air tight and sealed casket. + No permit shall be granted for the transfer of such remains. Figure 7 shows the flowchart on the disposition of cadavers. Saline sl @ Manual Standards nd Guidlines onthe Management ofthe Hospital Emergency Department °7© Absconded A patient who leaves the ED/hospital premises without permission from or notification to the attending ER physician or the nurse-in-charge after diligent efforts have been made to track the patient shall be considered absconded. Patient documentation and tracking should be done diligently and if, in spite of this, the patient still leaves without due notification, the ER staff has the responsibility to report the said incident to the nursing supervisor or the senior house officer for incident reporting and investigation. * Admitted to Ward Patients, who have been in the ER for four (4) hours, needed further work-up, and needed close medical attention, shall be admitted to the ward. The ER Officer shall issue an admitting order slip and directs the relatives of the Patient to go to the Admitting Section. Once admitted, the nurse in-charge of the patient shall endorse the patient to the nurse on duty at the receiving ward. 38 Manat Standard Gudetineson the Mangement of th Hospital Emergency Department ®wr = 1 daa Yer Tafonnad const = a > Suartanntraenous tine > train Chet Xray + tach the otient to acardiac montor sana + Obtainon ANGand give supplemental oxygen fk + Senco for CBC. ghson, lecobyts, LF PT No sain vial igs are Mfthreting enor prose Consiserthe ure of emerge Consider adminiseaton othe lowing hdaied therapies for ceaues gant * Hypertonic dextose psychomtorapftion. crac shyt, a evers met bc atromaies + amine Naloxone [of Fetorm a rapa physical amma, t [cana spectictndome be erio® fireatthe intone org) Consider sn docetamirtian forderma cantmination ther La] + creaina toroagh istry + Reassest and complete the physical examination > Send bod: ectrottspucne, CBC ABC, on ologi amination a neat done 1 * Ottainan ECG noted dene [consider gusrc emptying + Eness Cras tube + Neatalaing agents eg wits (orcaust) Adut=-#~ 12 pe0 ingsous nt THO Ciguatera ee) ort Teak [Gosider revonon oF tninabeorp Actiatedcharcad ‘Adult -200 gin 250ml HO Pediat g/kg add EO PP] + caarie=Nasox Palla d= Ada © NaHCO, 154 or mix Adult 15 gin 100ml LO Pein ins in TLHK0 de do ga Pedia-250 mp/Kgas 0% tnclavage (ore g FePS, ‘salstion ove ‘Whole towelirgnon~ Polyetytene gee Adal-3 73, oe weak set Adait-T gga Pedia 20 mg/g 68 urine pH = $3 + Farced duress -Mareitol ‘Adal 1 al wth 10 min (1D) then 75-100 ce 681 4D) Pedia 375 ng wan 1D mie (0D) then25.-500/ Keg st (04D) att + Dae rhemopertision Fore ray Evaluate for ICU admission continued ener social services ness prirtulscharge as ndsted agra Pro oare ene gen department management paychnbi satn and Figure 8. Algorithm for lngestion of Poison J) Mamal of Standards and Guidelines onthe Management of the Hospital Emergency Department 111Tate patient ving ici of reting? yes No [Geainconrl ofthe airway veistion and onygen™ Tose and abe the cerca spine inde on whe abzing the ceria spine ava the int oa cardiac mono, ina Crain an ABGand give supplemental oxygen fot stray one Sent toc for COC uc, letlyes, LETS TT Shue lod for otharstadies |» Ortaina Chet Xray [Goier the wre of mgt oniderdminsiton of efalowing inated herpes or steers aes payctomoteragistion cardiac [A] Auster Pefore pid pysal eamnaion yatta, severe me re ps atormalites stoner [Cana spec todome te iden ve 4 xe Yanna thorough Story 4 Resuan and ample the physi amination > Send blog: ctrl, glee, CBC, ABG toxiolgs amiaton, Ssundkted/not done + Chiainan EG ot aendy dane 1 Gin ieustenraton mmgalialine sap eg Pela cary (ante Sen sae ahldte made tonerlior an acd wth abuse rice vers. ef gree or cream shoul be avoid or contaminate jes ria with ee owing HBO for ois (i) {lange forall ul seem ophhaiolops q ado eapy (anu Alga of Pasig or dsags) Antidotes be gem ander the saperson ofa Texcalogst 1 Trane or ISU aimioon, conned emerges depatnen manage Peaurapchsrie stay and sce services neds pir to shang, a rested (eer Posen Conte Center. Figure 9, Algorithm for Dermal Contaminatiow/Inhalation of a Poison 112 ‘Manual of Standards and Guidelines on the Management of the Hospital Emergency Department7 MEDICO-LEGAL CASES A medico-legal case (MLC) is any case of injury or ailment where the physician after history taking and clinical examination, considers that investigation by lawful authorities is warranted to ascertain justice and fix responsibility regarding the said injury or ailment according to the law. It is a medical case with legal implication or a legal case requiring medical expertise. Accordingly, a medico-legal report is one, which is prepared for the purpose of litigation — imminent or prospective. The responsibility to label any case as an MLC tests solely with the attending physician, The following cases should be considered as medico-legal and as such the medical officer is “duty-bound” to report such cases to the police. Reporting of injuries shall conform to the coding system of the International Classification of Diseases, 10 edition (ICD-10). * All forms of injuries - physical, thermal, chemical, and electrical where the circumstances suggest commission of an offence by somebody. Example of which include but not limited to: Vehicular accidents Unnatural accidents or disasters due to force majeur Industrial accidents © Mauling © Fire arm or Gunshot Injuries Burns Assault and battery, including domestic violence, child abuse, and sexual assault/ offences © Suspected self-inflicted injuries or attempted suicide * Cases of suspected or evident criminal abortion, poisoning or intoxication. * Cases referred from court/police/NBI or patients under police custody or otherwise for age estimation. ‘Manual of Standards and Guidelines on the Management of the Hospital Emergency Department 123Cases of undiagnosed coma/unconsciousness + Cases brought dead with improper/inconsistent medical history creating suspicion of an offence. Examples of which include: © Dead on arrival © Unnatural death © Death due to animal bite © Unreasonable death in ER/OR o ER deaths Deaths within 24 hours of hospitalization without diagnosis © Any other case not falling under the above categories but has legal implications. MEDICO-LEGAL POLICIES AND STANDARDS «In attending to emergencies, the first priority is to save the life of the patient. The ER team shall ensure that everything possible is done to resuscitate and provide immediate and timely medical care. All legal formalities stand suspended until this is achieved, * The medical officer on duty shall inform the nearest concerned police station regarding the admission, discharge or death of the said patient without any unnecessary delay. + A medico-legal register shall be maintained by the health facility and all medico-legal cases shall be entered in this register, including the time, date, place, nature of injury and the physician in charge of the case. «A valid consent from the patient or the legal guardian is mandatory for examination. To be valid, the consent must be freely given, informed, competent and specific to the procedure to be performed. A person arrested and accused in a criminal offence may however, be medically examined without his consent on the request of a police officer or on the orders of a court, if there are sufficient grounds to believe that such examination will provide evidence of the commission of the offence. 114 anual of Sond an Gittins on the Management ofthe Hostal Emergency Dparinent @ee All information relative to the patient shall be treated with utmost confidentiality. Medico-legal reports shall be treated as strictly confidential and should not be issued directly to the patient All relevant specimens shall be collected, properly labeled and sealed. Guidelines in Dealing with Medico-Legal Cases In emergencies, resuscitation and stabilization of the patient is carried out promptly. Consent for treatment is implied. MLC documentation is completed later. Triage, prompt treatment, and safe transfer of a patient from one facility to another should be carried out. No delay in treatment is acceptable Cases of trauma will be labeled as MLC’s if there is violence, unreasonable injuries/death, or suspicions of illegality. Date, Time, Place, and Mechanism of Injury are indicated in the Medical Record for Trauma cases Record in the diagram (see Appendix 1) all external and internal injuries, meticulously. Severity of injuries should be established after appropriate diagnostic procedures or work-up. Samples and specimens collected for MLC will be properly sealed, labeled and handed to authorities, The attending physician is legally bound to report to the police all MLC. In case of discharge/transfer/death in the hospital, the police should be informed Stable patient may be transferred to another health facility, if further management is warranted. Manual of Standards and Guidelines on the Management of the Hospital Emergency Department 219i el Procedures in Managing a Medico-Legal Case A medico-legal case shall be entered in the ER register as soon as the physician suspects foul play or deems it necessary to inform the police, at any time during admission without unnecessary delay (Presidential Decree 169). A case is also registered as a medicolegal case even if it is brought several days after the incident, ‘A valid consent shall be obtained from the patient or the legal guardian for medical procedures, laboratory procedures, etc, To be valid the consent must be competent, freely given, informed, and specific to the procedure being performed, In medico-legal cases, an informed consent includes information that: © The examination to be conducted would be a medico-legal one and would culminate in the preparation of a medico-legal injury report. « Allrelevant investigations needed for the said purpose would be done. «The findings of the report may go against the patient if they do not tally with the history given A person arrested as accused in a criminal offence may, however, be medically examined without his consent on the request of a police officer or on the orders of the court if there are sufficient grounds to believe that such examination will provide evidence of the commission of the offence provided that: «the person should have been arrested on charge of committing an offence punishable under law; © there are reasonable grounds for believing that an examination of his person will afford evidence as to the commission of an offence, and + the written requisition for medico-legal examination is from a law officer. In civil cases, however, no examination should be done without the consent of the person to be medically examined. 116 "Manual of Standards and Guidelines on the Management of the Hospital Emergency DepartmentDisposition of Dismembered Body Part All dismembered body parts, which are non-viable for attachment, brought in the ED shall be forwarded to the Surgical Pathology section of the laboratory for gross and microscopic examination and documentation for future reference if the case has medico-legal implication. The surgical pathology report shall serve as the certificate of dismembered body part which is issued and duly signed by the pathologist. The certificate shall bear the name of the owner if the dismembered body part is claimed by the owner through identification of an identifying mark of malformation. This “Certificate of Dismembered Body Part” is issued instead of the practice of issuing a death certificate for the dismembered body part for burial or proper disposal If the ownership is uncertain, the body part shall be stored in the surgical pathology for a certain period for further studies; thereafter, it is released for proper disposal. The certificate shall not bear any name of person. Further documentation such as taking photographs, radiologic studies, and samples for possible DNA testing shall be done. HEALTH INFORMATION MANAGEMENT OF MEDICO-LEGAL CASES Documents of medico-legal cases are treated with utmost confidentiality and should be stored under safe custody to avoid tampering In civil cases, a physician cannot examine a patient without his/her consent. Although the physician has the responsibility of reporting such cases to law enforcement agencies and city/municipal health officer, the consent is required for the release of any advice, treatment, or information which the physician may have acquired in attending the patient to avoid blackening of the patient’s reputation Medical records must be thorough, complete and should document the date, time, place, and mechanism of the injury. @ Manual of Standards and Guldelines on the Managenent ofthe Hospital Emergency Deparment 117Medico-Legal Reports All Medico-Legal cases should be managed and disposed of by the physician of the respective department concerned. Medico-legal reporting procedure is as follows: In the column “Nature and Cause", location, date, time and nature of the incident should be completed by the ER officer. * Time of admission at the Emergency Department should be noted. * The Emergency Department notifies the Guard-on-Duty, who in turn notifies the police station. Medico-legal cases that occur within area of jurisdiction should be reported to the local police department and those that happened outside the local police’s area of responsibility should be reported to the NBI + ER Death should be taken to the morgue with necessary forms and tags accomplished + AIL ER deaths and Dead on Arrival (DOA) cases are considered medico- legal, Autopsy should be done by the hospital autopsy service or turned- over to the police- or NBL-accredited funeral parlors for autopsy to their respective crime laboratories or medico-legal officers. Medico-Legal Certificates Medico-Legal Certificates are legal documents to be presented in court, quasi- judicial bodies, investigative agencies, as documentary evidence to prove the truth of the physical injuries sustained by the victim. It must be executed by the hospital medico-legal officer/consultant, immediately for police/ prosecutors investigation or inquest. All requests for medical and medico-legal certificates shall be referred to the Health Information Management (HIM), formerly medical/health records, or medico-legal officer if there is available one. No ER Officer shall issue a medico- legal certificate at the ED. 118 2 esCHAIN OF CusToDy Chain of custody is a systematic documentation of transfer of evidence to another person/office. The physical evidences like bullets, removed/recovered from the patient by the ER personnel, shall be responsible of documenting the detailed description of the object/s, location where it was removed/recovered, position/ direction of how the object was positioned in the body of the patient, and date/time when it was recovered. ‘These physical evidences shall be labeled accordingly with name of patient, type of object, date/time it was removed, name of responsible ED personnel, and unique number/code. The object shall be placed in a tamper-proof container and properly sealed, The seal shall be signed by he responsible ED personnel ‘The standardized form on chain of custody shall be used as proof of transfer and receipt of the physical evidences. The chain of custody shall also apply to the personal belongings/ effects of patients without companion. The hospital shall have a written policy on who shall be the custodian of such physical evidences and personal belongings/effects, GUIDELINES IN PRESERVATION OF MLC EVIDENCES + Allrelevant evidences will be identified, sealed and labeled properly. Loss or destruction of evidence is punishable. + In physical injury cases, the following articles should be preserved in sealed envelopes: © Clothing worn by the patient showing evidence of injury such as tears, bullet holes, cuts, blood stains, etc. © Each piece of evidence will be encircled and numbered with matching description in the MLC report and case sheet © Bullets recovered from a body should be identified by etching a mark on the bottom before preservation. “Manual of Standards and Guidelines on the Management of the Hospital Emergency Department ne)© The chain of custody of the MLC evidences must be properly recorded. * In cases of Burns and Carbon Monoxide poisoning, the following should be preserved in sealed containers: © Articles soiled with inflammable substances like burnt pieces of clothing, scalp hair etc. © Blood (and not serum) for carbon-monoxide levels. + In sexual offences, the following articles should be preserved in sealed envelopes: © Clothing worn by the patient and showing evidence of blood stains or seminal stains, stains of mud, tears/cuts ete. © Vaginal swab preferably from posterior fornix / anal swab. MEDICO-LEGAL ASPECTS OF SEXUAL OFFENCES * Victims of alleged Sexual offences like rape may be brought to the ER + The examination may be carried out at a centre for MLC work with forensic experts. The examination is preferably done by a lady physician or Gynecologist Guidelines in attending to victims of sexual crimes * The date, time, place when affront was committed and the date, time and place of exam are written in the case sheet. * Consent of the victim must be obtained before starting the examination. * Case sheet is properly captioned, noting personal particulars, physical findings in the exam, along with date and time of reporting + The alleged victim will be admitted if the medical condition is serious. 120 Manual of Standards and Guidelines on the Management of the Hospital Emergency Department at+ Case is reported to the proper authorities. * Care is taken to preserve the confidentiality of the victim from others not related with the case. «The steps of examination and their purpose should be explained to the victim in a language she understands. «The examination is to be carried out in the presence of a female attendant. + Torn clothings will be preserved and all injuries present will be recorded. + If the clothes are the same as those worn during the occurrence of alleged sexual offence, they should be carefully examined for the presence of blood, seminal stains, mud etc. + If there are foreign hairs, fibers, debris under the nails etc, they must be carefully preserved and sent to experts for possible DNA examination, Specimens should include vaginal swab, preferably from the posterior fornix. + Special precautions in case of sexual offences. © The date and time of E.R. arrival of the victim is written, both in the ! case sheet and the MLC Register. The duplicate copy of case sheet and MLC Report shall be preserved for future reference, Where the accused in a case of sexual offence in police custody is brought for medical examination, consent is not required. © All injuries shall be recorded in cases of alleged victims of sodomy. Care must be taken to preserve the vaginal/anal swab for forensic examination Maat of tatards and Guidelines onthe Management ofthe Hospital Emergency Deparment 121Medic re 122 MEDICO-LEGAL ASPECTS OF POISONING * Poison may be defined as any substance which when absorbed into the body or by local action on the tissues injures health or destroys life. * Administration of any substance with the intention of causing injury or death is punishable. * In suspected poisoning the following articles will be preserved and forwarded for forensic examination: © Gastric lavage/ gastric contents/vomitus and soiled clothing, blood, urine © Other relevant body fluid depending on the poison ingested. Guidelines for Cases of Poisoning + When poisoning is suspected, every attempt must be made to save the patient's life. * Case sheet shall be properly captioned, noting personal particulars, along with date and time of reporting, + A careful history is to be elicited including relationship of food or medicine taken and the toxic manifestations. All signs and symptoms are to be noted + The vomitus, urine, feces, stomach wash, sample of food or medicine, should be examined. + Any suspicious bottle or utensil seen near the victim, the clothes and bed clothes used by the victim are preserved for chemical analysis, * It is advisable to take second opinion and advice of a senior colleague in all matters regarding diagnosis and treatment. ‘Manual of Starts and Guidelines onthe Management th Hospital Emergency Departnent ®ea | + If there is any indication of danger to the general public, for example, food poisoning from a hotel, the public health authorities must be notified at ‘once so that suitable remedial measures are taken. «+ Precautions to be taken in cases of poisoning co Emergency medical treatment will be administered. © Poison Control Center shall be consulted. © Medical certification and cause of death will be issued stating that ‘cause of death to be ascertained after chemical analysis’ © Samples of MLC, will be preserved and handed over to the police for forensic examination © A receipt shall be obtained from the police for all samples that are handed over for forensic examination. MEDICO-LEGAL ASPECTS AND GUIDELINES IN CASE OF A MEDICAL MISHAP + The patients and their relatives expect a kind and compassionate attitude from doctor. A scientifically sound approach, good behavior and care of a reasonable standard usually protects from professional complaints. «Immediately, explain to the patient relatives the actual procedure and what had happened during the time of the procedure. «There are occasions when something fortuitous happens following a diagnostic or therapeutic procedure. In such situation, physician takes the following steps: © Complete the patient's record and recheck the written notes. © Show genuine concern about the unfortunate incident. Answer all the queries of patient, & relatives. Doctors, who are open-minded and communicative, are much less likely to face complaints. & Momualoy Standart ond Guidelines th Management ofthe Hone! Emaeney Deparment 17>Cea © The doctor may contact other doctors, Forensic Medicine experts and professional protection bodies to seek advice. MEDICAL NEGLIGENCE (MALPRACTICE) Medical negligence, is the “lack of reasonable care and skill or training on the part of a doctor in the treatment of a patient whereby the health, life and limb of a patient is damaged”, The term “damage” means mental or functional injury to the patient, while “damages” are assessed in terms of money by the court on the basis of loss of concurrent and future earnings, costs and reduction in qualities of life. The following are to be established to the satisfaction of the court: * The doctor owed him a duty to conform to a particular standard of professional conduct. * The doctor breached that duty. * The patient suffered actual damage. * The doctor's conduct is the proximate cause of the damage. Reckless Imprudence The negligence is so great as to go beyond a matter of mere compensation; not only the doctor has made the wrong diagnosis and treatment, but has shown gross ignorance, gross carelessness or gross neglect for life and safety of the Patient. The doctor may be prosecuted in a criminal court for having caused injury or death, under the following conditions. + Injecting anesthetic in fatal dosage or in wrong tissues, transfusing wrong blood or medicine. + Amputation of wrong finger, operation on wrong limb, removal of wrong organ etc. iad ‘Manual of Standards and Guidelines onthe Managemen of the Hospital Emergency Deparonent @* Operation on wrong patient or on the wrong side. + The principle of “res ipsa loquitur” shall apply to cases where instruments or sponges are left inside the part of body operated. + Leaving tourniquet too long resulting in gangrene. + Applying too tight plaster or splints, which may cause gangrene or paralysi * Performing a criminal abortion. DOMESTIC VIOLENCE AND ABUSE OF WOMEN Domestic violence is a leading cause of injury to women. It is a pattern of physical assaults, threats, & coercive behavior used to maintain control over a Partner. Behaviors can include ongoing verbal, emotional, sexual, physical, psychological, and economic abuse, and typically get worse over time. Such behavior may result in death, serious injury, isolation and emotional damage for the victims. The doctor should remain vigilant about such incidences. CHILD ABUSE AND NEGLECT Instances of child abuse and neglect are on the rise, Be vigilant in clinical practice to detect these cases. Child Abuse may be defined as the “physical and psychological effects produced by deliberate repetitive physical or sexual abuse of a child”. Physicians have a duty to recognize and report suspected abuse and neglect to the police and other government agencies Physicians need to work together with statutory agencies in cases of child abuse and neglect. Role of a physician includes recognition, diagnosis and treatment of injuries, care and monitoring of children following suspected abuse. It also includes prevention of abuse by counseling, training, supervision, and education of the community to heighten awareness about the problem. Manual of Standards and Guidelines on the Management of the Hospital Emergency Department 129Child and Youth Welfare Code Article 166, Report of Maltreated or Abused Child of Presidential Decree 603 states that: “All hospitals, clinics, and other institutions as well as private physicians providing treatment shall, within 48 hours from knowledge of the case, report in writing to the city or provincial fiscal or to the local council for the protection of children or to the nearest unit of the dept. of social welfare any case of maltreated or abused child, or exploitation of an employed child contrary to the provisions of labor laws, it shall be the duty of the council for the protection of children as the unit of dept of social welfare to whom such a report is made to forward the same to the provincial or city fiscal. Violation of this provision shall subject the hospital, clinic, institution or physician who fails to make such report to a fine of not more than two thousand pesos. MEDICAL EXAMINATIONS OF APPREHENDED PERSONS IN THE ED During counter insurgency operations, a government doctor may be called upon to medically examine and render a physical fitness certificate before and after interrogation or handing over of an apprehended person to the police or on release. Medical examination prior to prison commitment of arrested persons must be detailed, taking more focus on external injuries. 126 anual of tna and Guidelines onthe Management ofthe Hospital Emergency Deartnent ®ene 8 CONTINUOUS QUALITY IMPROVEMENT AND PATIENT SAFETY PROGRAM Continuous Quality Improvement Program (CQD) is a strategic approach to providing the best health care possible. It is a preventive strategy that uses Constant innovation to improve work process and systems by reducing time consuming, low value activities. COL is a process of continuous improvement of a system by gathering data or performance evaluation and using multi-disciplinary team to analyze the system, Collect measurement, and propose change. The four main principles are customer focus, the identification of the key processes to improve quality, the use of tools ‘and statistics, and the involvement of all people in problem solving. This can be achieved by specifically linking customer service and Continuous Quality Improvement (CQl) in emergency care services. This CQI effort and customer service development will allow the emergency service department to: + Improve direct patient satisfaction. + Complete the implementation of a five-step customer satisfaction process, * Handle an emergency or crisis environment with a friendly customer service philosophy. + Ensure responsiveness to a dynamic environment in the event of a crisis atmosphere. Manat of Standards and Guidelines on the Management of the Hospital Emergency Department aoeee CQL is a more comprehensive approach to quality. Based on a structure-process- Outcome framework, it inludes producer-provider and product-service aspects as well as the client perspective (needs, rights, preferences). Quality assurance is a process with the objective of improving outcomes of all health care in terms of health, functional ability and the well being and satisfaction of health care users, It considers the structures and inputs required and assist in analyzing and re- engineering service delivery processes and measuring outcome. The main purpose is to foster an environment in which everyone is involved, supports quality, is alert to problems of performance and opportunities for improvements and is prepared to take responsibility for setting in motion the needed changes to improve care. This approach is related to competence with standards and can be applied to facilities, program, systems and sectors, Continuous monitoring, analysis, and improvement in the clinical and managerial processes must be well organized and have clear leadership to achieve maximum benefit. QUALITY ASSESSMENT AND IMPROVEMENT STANDARDS The Emergency Department should have a Quality Improvement Plan which is designed to integrate hospital activities to improve its organizational Performance with a particular focus on performance ~ what is done (efficacy, appropriateness) and how well it is done (availability, timeliness, effectiveness, continuity, safety, efficiency, respect and caring). Since most clinical and managerial quality issues are interrelated, efforts to improve processes addressing these concerns must be guided by an overall framework for quality management and improvement activities in the organization (JCI Standards for Hospitals ~ First Edition) The Emergency Department should follow a framework of standards suitable to the institution and should be based on Philippine Health Insurance Corporation's (PhilHealth) Benchbook Standards on Performance Improvement of Health Services. This outlines and defines the core standards that all hospitals must meet to be accredited. 128 ‘Manual of Standards and Guidelines on the Management ofthe Hospital Emergency DepartmentThe Emergency Department shall follow a framework that will: develop greater leadership support train and involve more staff in monitoring and improvement activities set clearer priorities for what to monitor and what to improve base decisions on indicator data, and make improvements based on benchmarks with other organizations, locally and possibly internationally. The scope of the CQI Program includes both clinical and administrative services and shall involve the following personnel: The Medical Staff Other Professional Staff: Nursing, Midwives, Nursing Aide Ancillary Medical Staff: Pharmacy, Laboratory, X-Ray ete. Allied Health Professional Staff: Medical Social Worker, Medical Records Administrative Staff: Admitting Section, Billing, Security Hospital Committees on CQ includes : Ethics, Infection Control, Medical Records, Pharmacy and Therapeutics, Research, Utilization’ Review, Nursing and Medical Audit, Risk Management Other sources of CQI information may be obtained from the following but are not limited to: Medical records Risk Analysis (incidents, etc.) Statements of concer (patient, employee and visitor) Patient surveys Employee surveys co co00 © Mana of Standards and Guidelines nth Management ofthe Hospital Emereney Department 129ontinuou OPERATIONS «The Medical Director, Administrator, Medical Staff, Chief Nurse/ED Nurse supervisor set expectations, develop plans, and implement procedures to assess and improve the quality of the organization’ governance, management, clinical and support processes «The Emergency Department has a written plan for assessing and improving quality that describes the objectives, organization, scope, and mechanisms for overseeing the effectiveness of monitoring, evaluation, and improvement activities. «When the Emergency Department of the hospital, in its care of patients, requires the services outside of is capability and requires further referral, the monitoring and evaluation process examines the appropriateness of hospital's use of such services and the degree to which the services aid in its care of patients. «The following quality assessment and improvement activities are performed: © Infection control © Utilization review © Morbidity and Mortality Review © Life Safety review of accidents, injuries, patient safety, and safety hazards. = Relevant results from the quality assessment activities are used primarily to study and improve processes that affect patient care outcomes; and when relevant to the performance of an individual, are used as a component of the evaluation of individual capabilities, « There is a planned, systematic, and ongoing process for monitoring, evaluating, and improving the quality of care and of key governance, managerial, and support activities, © Each of the quality and assessment and improvement activities are performed appropriately and effectively. 130 anual of Standards and Guidelines on the Management of the Hospital Emergency Department© Necessary information is communicated among departments/ services and/or professional disciplines when opportunities to improve patient care or problems involve more than one department/service and/or professional discipline © Information from departments/services and the findings of discrete quality assessment and improvement activities is used to detect trends, Patterns, opportunities to improve, or potential problems that affect more than one department/service and /or professional discipline © There are operational linkages between the risk management functions related to the clinical aspects of patient care and safety and quality assessment and improvement function. © Existing information from risk management activities that may be useful in identifying opportunities to improve the quality of patient care and/or resolve clinical problems are linked to the quality assessment and improvement function. ©. The status of identified opportunities or problems is tracked to assure improvement or resolution. ©. The objectives, scope, organization, and effectiveness of the activities toassess and improve quality are evaluated annually and revised as necessary. PLAN FOR PATIENT CARE MANAGEMENT AND PERFORMANCE IMPROVEMENT The following medical staff quality assessment and improvement activities are performed: * Assessment and improvement of the quality of patient care and the clinical performance of individuals with clinical privileges through © Participation by members of each department/service in intra- and/or interdepartmental/service monitoring and evaluation of care; periodic review of the care; and communication of findings, conclusions, recommendations, and actions to members of the department/service @ Mama of Standards and Guidelines onthe Management of te Hoxptst Emagen Deparment 131© Medical record review function; © Evaluation and improvement in the use of the medications; © Pharmacy and therapeutics function «Indicators ate identified to monitor the quality of important aspects of care. ‘The indicators are related to the quality of care and may include clinical criteria (sometimes called "clinical standards," "practice guidelines," oF “practice parameters"). These indicators are objective, measurable, and based on current knowledge and clinical experience. + When an important opportunity to improve, or a problem in, the quality of care is identified Action is taken to improve the care or to correct the problem and The effectiveness of the action taken is assessed through continued monitoring of care. «The findings, conclusions, recommendations, actions taken, and results of the action taken are documented and reported through established channels. QUALITY ASSESSMENT AND IMPROVEMENT ACTIVITIES 4 Infection Prevention Control ‘The goal of an organization's infection surveillance, prevention and contro) program is to identify and reduce the risks of acquiring and transmitting Infections among, patients, staff, doctors, students and other individuals who may be exposed to a potentially infectious environment 2 ana StandaasandGnelineson the Managenent of th Hospital Emergeney Deartnet ©, t ema General Standard Activities The department designs and implements a coordinated program to reduce the risks of nosocomial infections in patients and health care workers, All patient, staff and waiting areas are included in the infection control program, The department establishes the focus of the nosocomial infection prevention and reduction program. Gloves, masks, soap and disinfectants are available and used correctly when required. Cultures are routinely obtained from designated sites in the department associated with significant infection risk, A designated individual or group monitors and coordinates infection control activities in the department, Coordination of infection control activities involves medicine, nursing and others as appropriate to the department. The infection control program is based on current scientific knowledge, accepted practice guidelines, and applicable law and regulation The information management systems support the infection control program. The department provides education on infection control practices to staff, doctors, patients, and, as appropriate, family and other caregivers The department identifies the procedures and processes associated with the risk of infection and implements strategies to reduce infection risk. @ Moma of tna al Gaeineon te Management of th Hospital Emergency Department #33one Standard Routine and Specific Infection Control Precautions + Hand hygiene before and after contact with every patient is among the most important means of preventing the spread of infection. © Points to remember when performing hand hygiene. © When hands are visibly dirty or contaminated with proteinaceous material, they should be washed with soap and water. ©. If hands are not visibly soiled or contaminated, an alcohol based hand product for routine decontamination of hands should be used. o Ensure hands are dry before starting any activity. * Personal Protective Equipment (PPE) © ROUTINELY ASSESS THE RISK of exposure to body substances or contaminated surfaces BEFORE any anticipated health-care activity. Select PPE based on the assessment of risk, Have appropriate PPE available which comprises gloves, gowns, eye protection and medical masks. General PPE Guidelines Hand hygiene should always be performed despite PPE use. Remove and replace if necessary any damaged or broken pieces of reusable PPE as soon as you become aware that they are not in full working order. © Remove all PPE as soon as possible after completing the care and avoid contaminating: — The environment outside the isolation room, = Any other patient or worker; and - Yourself © Discard all items of PPE carefully and perform hand hygiene immediately afterwards. 134 “Manual of Standards and Guidelines on the Management of the Hospital Emergency Department ieErer Respiratory hygiene/cough etiquette All patients, visitors and health care workers should be encouraged to adhere to cough etiquette and respiratory hygiene at all times to contain respiratory secretions. © Cover the mouth and nose when coughing/sneezing, © Use tissues, handkerchiefs, cloth masks or medical masks if available, as source control to contain respiratory secretions, and dispose of them into the waste containers; © Use a medical mask on a coughing/sneezing person when tolerated and appropriate; and © Perform hand hygiene, General needle stick and sharp object guidelines © Health care workers should be properly oriented on the use and disposal of sharps. © Use of aseptic technique to avoid contamination of sterile injection equipment. © Never administer medications from a syringe to multiple patients, even if the needle is changed. © Needles, cannula and syringes are single use items; it should not be reused for another patient. © Never recap used needles. © Never direct the point of a needle towards any part of the body except prior to injection, © Do not remove used needles from disposable syringes by hand, and do not bend or break, Always use forceps in removing needle from syringes and picking sharp debris. © Dispose of syringes, needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers, which should be located as close as practical to the area in which the items were used. © In case of an incident of needle stick injury, Institutional policy should apply with regards to reporting, documentation, protocol management to the individual which is injured. According to the standards of Infection Control Procedures. ® Manat of Standards and Guidelines nth Managenentf the Hospital Emereney Department 135Ree + Essential points for cleaning and disinfecting equipment ° Clean and disinfect all respiratory equipment between uses. Thoroughly clean respiratory and reusable equipment prior to disinfection. Health-care workers must use PPE for cleaning and disinfection of respiratory equipment. Keep clean and disinfected items dry and in individual packages. * Key issues about cleaning and disinfection oo ° ‘The environment used by the patient MUST be regularly cleared. Cleaning should use proper techniques to avoid aerosolization of dust. Only surfaces that enter in contact with the patient's skin/mucosa and surfaces frequently touched by health-care workers require disinfection after cleaning, Health-care workers MUST use PPE for cleaning and disinfection of respiratory equipment and hand hygiene must be performed after PPE removal © Managing Linen and waste Handle linen and waste with care ‘Transport soiled linen and waste in closed containers or bags. Ensure safe handling and final treatment of waste, by classifying the waste (this is of utmost importance) and using the containers or bags specified according to its classification. Health-care workers must use adequate PPE whenever handling soiled linen and waste. Handle used textiles and fabrics with minimum agitation to avoid contamination of air, surfaces and persons. If laundry chutes are used, ensure that they are properly designed, maintained and used in a manner to minimize dispersion of aerosols from contaminated laundry. 136 anual of Standards and Guidlines on the Managemen of the Hospital Emergency Department @| Ain * Droplet precautions guidelines Wear a medical mask when within a 1 meter range of the patient. Put the patient in a single room or in a room that contains only other patients with the same diagnosis, or with similar risk factors, and ensure that every patient is separated by at least one meter. © Ensure that the transportation of a patient to areas outside of the designated rooms is kept to a minimum. © Perform hand hygiene immediately after removing any item of PPE. © Contact Precautions © Use clean, unsterilized gloves and a disposable or re-usable gown whenever you have direct contact with a patient. © Remove safely the gloves and gown immediately following any contact with a patient. Perform hand hygiene immediately after removing any item of PPE. © Dedicate specific equipment for use with a single patient and ALWAYS clean and disinfect shared equipment between patient uses. © Avoid touching your face, eyes or mouth with either gloved or un- gloved hands as these may be contaminated. © Place patients in a single occupancy room whenever possible or alternately with other patients with the same diagnosis. © Airborne Precaution Guidelines © Use a particulate respirator whenever entering and providing care within the patient isolation facilities ensuring that the seal of the respirator is checked before every use. © Place the patient in an airborne precaution room which has >/= 12 Air Cycle per Hour (ACH) plus control of airflow direction. o Limit the movement of the patient and ensure that the patient wears a medical mask outside their room. © Perform hand hygiene immediately after removing any item of PPE Manual of Standards and Guidelines on the Management ofthe Hospital Emergency Department 177 + Effective natural ventilation guidelines © Keep doors and windows open unto well ventilated corridors with open doors. © Ensure the surrounding areas, including the corridors, are well ventilated to warrant rapid dilution of air coming from the patient room. If the corridor is not well ventilated, the room door should be kept closed. An exhaust fan can be added to increase the air circulation out of the open windows. © Locate patient beds close to the exterior walls and open windows. (Epidemic-prone and pandemic-prone acute respiratory diseases, WHO) * Facility Management and Safety The hospital works to provide a safe, functional, and supportive facility for patients, families, and staff. To attain this goal, the physical facility, medical and other equipment, and people must be effectively managed. In particular, management must strive to: * Reduce and control hazards and risks + Prevent accidents and injuries, and * Maintain safe conditions Effective management includes planning, education and monitoring, + The leaders plan the space, equipment and resources needed to safely and effectively support the clinical services provided, + All staff is educated about the facility, how to reduce risks, and how to monitor and report situations that pose risk. + Performance criteria are used to monitor important systems and identify needed improvements. Planning should consider the following seven areas, when appropriate to the facility and activities of the organization: 138 Man of Standards and Gudelnes on the Management ofthe Hospital Emergency Department @et i ee an We font in hi eee eee ad + Safety - buildings, grounds, equipment, and systems do not pose hazards to the occupants. + Security - property and occupants are protected from harm and loss + Management of Hazardous materials - handling, storage, and use of radioactive and other materials are controlled and hazardous waste is safely disposed. + Emergency Preparedness Plan ~ response to epidemics, disasters and emergencies is planned and effective. «Fire safety - property and occupants are protected from fire and smoke and conduct fire drills + Preventive Maintenance of Medical equipment - equipment is selected, maintained and used in a manner to reduce risks. + Management of Utility systems - electrical, water, and other utility systems are maintained to minimize the risks of operating failures. Standards + The organization complies with relevant laws, regulations, and facility inspection requirements. The organization plans and budgets for upgrading or replacing key systems, buildings or components. + The organization plans and implements a program to manage the physical environment. ‘The organization inspects patient care buildings for fire safety and has a plan to reduce evident risks and provide a safe physical facility for patients, families and staff. + The organization plans and implements a program to ensure that all occupants are safe from fire, smoke, or other emergencies in the facility. & Manat of Sanda and Gaels on he Management te Hospital Emergency Deparment 19°The plan includes prevention, early detection, suppression, abatement, and safe exit from the facility in response to fires and non-fire emergencies. The organization regularly tests its fire and smoke safety plan, including any devices related to early detection and suppression, and documents the results. The organization develops and implements a no smoking policy of staff and patients. The organization has emergency processes to protect facility occupants in the event of water or electrical system disruption, contamination, or failure, The organization tests its emergency water and electrical systems on a regular basis appropriate to the system and documents the results. The organization develops a plan to respond to likely community emergencies, epidemics, emerging infectious diseases and natural or other disasters, The organization has tested its response to emergencies, epidemics, and disasters. The organization has access to any medical supplies, communication equipment, and other materials to support its response to emergencies, epidemics, and disasters. The organization has a plan for the inventory, handling, storage, and use of hazardous materials and the control and disposal of hazardous materials and waste. One or more qualified individuals oversee the planning and implementation of the program to provide a safe and effective physical facility. Manual of Standards and Guidelines on the Management of the Hospital Emergency Department Pe ee eerey ie + The organization plans and implements a program for inspecting, testing, and maintaining medical equipment and documenting the results, The organization collects monitoring data for the medical equipment management program. These data are used to plan the organization's long-term needs for upgrading or replacing equipment * Potable and electrical power are available 24 hours a day, seven days a week, through regular or alternate sources, to meet essential patient care needs. + Electrical, water, waste, ventilation, medical gas, and other key systems are regularly inspected, maintained, and when appropriate, improved. Designated individuals or authorities monitor water quality regularly. + The organization educates and trains all staff members about their roles in providing a safe and effective patient care facility. Staff members are trained and knowledgeable about their roles in the organization's plans for fire safety, security, hazardous materials, and emergencies. Staff is trained to operate and maintain medical equipment and utility systems. The organization periodically tests staff knowledge through demonstration, drills, and other suitable methods. This testing is then documented Safe Work Environment Establish policies and procedures for routine and targeted cleaning of environmental surface as indicated by the level of patient contact and degree of soiling, & Mama of tnd nd Guidelines onthe Management of he Hospital Emergency Department 141Continuous Qui ieee a + Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient (side rails, over bed table) and frequently touched surfaces in the patient care environment such as door knobs, surfaces in the toilet on or more frequent schedule compared to that for other surfaces (horizontal surfaces in waiting rooms). * Review the efficiency of in-use disinfectants when evidence of continuing transmission of an infections agent (rota virus and difficile novo virus) may indicate resistance to the in-use product and change to a more effective disinfectant as indicated. «Include multi use electronic equipment in policies and procedures for preventing contamination and for cleaning and disinfectant, especially those items that are used by the patients, those used during delivery of patient care, and mobile deliveries that are moved in and out of patient rooms frequently + Include the potential for transmission of infectious agents in patient placement decisions. Place patients who pose a risk for transmission to others (uncontained secretions or wound drainage; infants with suspected viral respiratory or gastrointestinal infections) in a single patient room when available. Patients Transport + Limit transport and movement of patients outside the emergency room to medically necessary purposes. «If transport or movement in any healthcare setting is necessary, instruct patient to wear a mask and follow respiratory hygiene/cough etiquette, © Infection control measures shall be observed by staff handling transport of patients 12 staal of Stondads and Guidelines on the Managenet ofthe Hospital Emergency Departnet @ty Inpro Fire Safety + There should be an institutionalized fire safety plan. * Fire evacuation plan is posted. + Fire exits are well identified and lighted strategically located and kept open * Fire extinguishers should be visible and accessible. * Fire extinguisher must be checked periodically * Hospital staff must be oriented on how to operate fire extinguishers * Physical plant/building should be checked regularly such as electrical wirings and presence of fire hazardous materials. A “NO SMOKING? signage is posted in strategic areas Continues training and information dissemination to all hospital staff. Never operate electrical equipment with wet hands Do not attempt to use an equipment which is unfamiliar with its operation. * Be sure that the electrical equipment is plugged into the proper type of outlet. + Staff Qualifications and Education An emergency department needs an appropriate variety of skilled, qualified People to fulfill its mission and meet patient needs. The administrative and clinical leaclers must work together to identify the number and types of staff needed based on the recommendations from the department and section heads. Evaluating and appointing staff to the Emergency Department are best accomplished through a coordinated, efficient and uniform process. It is Particularly important to document the skills, knowledge and previous Work experience of the staff who will be assigned in the Emergency Department because they will be involved in the clinical care processes in a critical area, The staff should also be provided opportunities to learn and advance personally and professionally. Manual of Standards and Guidelines on the Management of the Hospital Emergency Department 143ee eee Pee Standards «The desired education, skills, knowledge, and other requirements of all staff members shall be defined. (Nurses must have BLS and IV ‘Therapy Trainings as a minimum requirements) Each staff member's responsibilities are defined in a current job description. + The Department develops and implements processes for recruiting, evaluating, and appointing staff as well as other procedures identified by the department. There should be NO NEWLY HIRED nurse assigned at Emergency Department, a nurse with at least one (1) year experience from other units/wards can be rotated or transferred to Emergency Department. «The Department uses a defined process to ensure that staff knowledge and skills are consistent with patient needs. Fach staff member's ability to carry out the responsibilities in his or her job description is evaluated at appointment to the department and then regularly thereafter. «A staffing plan for the department, developed collaboratively by the clinical and managerial leaders, identifies the number, types, and desired qualifications of the staff. The staffing plan is reviewed on an ongoing basis and updated as necessary, «All staff members are oriented on their specific job responsibilities at appointment to the department. Orientations are done before their actual duties «Each staff member receives continuous ongoing in-service education and training to maintain or advance his or her skills and knowledge. 144 ‘Manual of Standards and Guidelines on the Management of the Hospital Emergency DepartmentWnt Me hoe eee rr Staff members who provide patient care and other staff identified by the department are annually trained in basic or advanced cardiac life support. Data on staff education needs are the basis for the department's ongoing education program. The department provides facilities and time for staff education and training, Staff is given the opportunity to participate in advanced education, research and other educational experiences to acquire new skills and knowledge and to support job advancements. + Information Management Providing patient care is a complex endeavor that is highly dependent on information. To provide, coordinate, and integrate services, health care organizations rely on information about the science of care, individual patients, care provided, results of care, and their own performance. Every organization seeks to obtain, manage, and use information to improve patient outcomes and individual and overall organization performance. Although computerization and other technologies improve efficiency, the principles of good information management apply to all methods, whether paper based or electronic. Standards © The department plans and implements processes to meet the information needs of all those who provide clinical services, those who manage the department, and those outside the organization who require data and information from the organization. + The department initiates and maintains a clinical record for every patient assessed or treated. Manual of Standards and Guidelines on the Management of the Hospital Emergency Department aoas The clinical record contains sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results of treatment, and promote continuity of care among health care providers. The clinical record of every patient receiving emergency care includes the time of arrival, the conclusions at termination of treatment, the patient's condition at discharge, and follow-up care instructions. As part of its performance improvement activities, the department regularly assesses patient clinical record content and the completeness of patient clinical records, Health care providers have access to the information in a patient's clinical record each time the patient is seen for a new or continuing care episode. * Aggregate data and information support patient care, organization management, and the quality management program. * The plan includes how the confidentiality, security, and integrity of data and information will be maintained. + The plan defines the levels of security Organization policy identifies those authorized to make entries in the patient clinical record and determines the record’s content and format. Only authorized providers make entries in the patient clinical record. Every patient clinical record entry identifies its author and when the entry was made in the record. * The organization has a policy on the retention time of records, data, and information + The plan is implemented and supported by sufficient staff and other resources 146 ‘Manual of Standards and Guidelines on the Management of the Hospital Emergency Department+ The organization uses standardized diagnosis codes, procedure codes, symbols and definitions * The data and information needs of those in and outside the organization are met on a timely basis in a format that meets user expectations and_ with the desired frequency. + Appropriate clinical and managerial staff participates in selecting, integrating, and using information management technology «Staff members have access to the level of information related to their needs and job responsibilities. * Records and information are protected from loss, destruction, tampering and unauthorized access or use. © Clinical and managerial information is integrated to support the organization's governance and leadership © Decision makers and other appropriate staff members are educated and trained in the principles of information and management. + Patient Safety Patient safety is a critical component of health care quality. As health care organizations continually strive to improve, there is a growing recognition of the importance of establishing a culture of safety. Achieving a culture of safety requires an understanding of the values, beliefs, and norms about what is important to a hospital and what attitudes and behaviors related to patient safety are expected and appropriate. ‘As a general rule, physicians and other health care providers must always be aware of patient risks, their prevention and management. Patient safety goals set by the Joint Commission on Accreditation of Healthcare Organizations (ICAHO) are general standards that must be observed to avert adverse events. ® nme Starts and Cdl on he Monagenet of th Honpita Emergency Deparment 47eres | The following are Standard Operating Procedures and Guidelines for Patient Safety: Improve the accuracy of patient identification. © Use at least two patient identifiers when providing care, treatment or services. Improve the effectiveness of communication among caregivers. © For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and "read- back" the complete order or test result. Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization, Measure, assess and, if appropriate, take action to improve the timeliness of reporting, and the timeliness of receipt by the responsible licensed caregiver, of critical test results and values. Improve the safety of using medications. ° Standardize and limit the number of drug concentrations used by the organization. © Identify and, at a minimum, annually review a list of look: alike/sound-alike drugs used by the organization, and take action to prevent errors involving the interchange of these drugs. © Label all medications, medication containers (for example, syringes, medicine cups, basins), or other solutions on and off the sterile field Reduce the risk of health care-associated infections. © Comply with current hand hygiene guidelines. 148 ‘Momalof Standards and Guidelines on the Management of the Hospital Emergency Department, \ Accurately and completely reconcile medications across the continuum of care. © There is a process for comparing the patient's current medications with those ordered for the patient while under the care of the organization. © A complete list of the patient's medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization. The complete list of medications is also provided to the patient on discharge from the facility. Reduce the risk of patient harm resulting from falls. © Implement a fall reduction program including an evaluation of the effectiveness of the program. Encourage patients’ active involvement in their own care as a patient safety strategy. ©. Define and communicate the means for patients and their families to report concerns about safety and encourage them to do so. The organization identifies safety risks inherent in its patient population, © The organization identifies patients at risk for suicide. (Applicable to psychiatric hospitals and patients being treated for emotional or behavioral disorders in general hospitals.) @ Marat of Standards and Guideineson the Management ofthe Hospital Emergeney Department 149Continuous Quality Improvement and Patient Safety Program All hospital emergency departments must address these Patient Safety Goals: * Identify safety risks inherent in your patient population. + Develop a mechanism for patients and/or families to report safety concerns. Suggested Actio brochures, ete. Verbally communicate, room/waiting room signage, * Improve medication safety by providing patients with a complete list of their (known) medications Suggested Action: A routine search for drug interactions whenever meds are prescribed. Place on chart, give patient a copy. * Identify patients at risk for suicide. Suggested Action: Make sure you have a good Policy for the patient's time in the ED and note "Suicide Precautions" on any inpatient orders written in the ED - for appropriate patients, 150 ‘Manual of Standards and Guidelines onthe Management of the Hospital Emergency Department @151 REFERENCES Australasian College of Emergency Medicine. 2000. Guidelines for Implementation of the ‘Australasian Triage Scale in Emergency Departments. Carlton Vic: Australasian College of Emergency Medicine. ‘Australasian College of Emergency Medicine. 2000, The Australian Triage Scale. Carlton Vic “Australasian College of Emergency Medicine. Australian College of Emergency Medicine. 2000. The Australian Triage Scale. Carlton Vic. Publisher. Benchbook on Performance Improvement of Health Services. 2004. Philippine Health Insurance Corporation, Quality Assurance Research and Policy Development Group Government of NSW. Clinical Information Access Program. 2003. Management of Aggressive People in A & F. Hewson P, Poulakis Z. Jarman F. Kerr J. McMaster D. Goodge J. Silk G. 2000. Clinical markers of serious illness in young infants: a multicentre follow-up study. Journal of Paediatrics & Child Health. 3653: 221-5. Kuhn W, 1999, Violence in the emergency department. Managing aggressive patients in a high- stress environment. Postgraduate Medicine. 105:1: 143-8, 154 (Review). Lee KM. Wong TW. Chan R. Lau CC. Fu YK. Fung KH, 1996, Accuracy and efficiency of X-ray requests initiated by triage nurses in an accident and emergency department. Accident & Emergency Nursing.. 4179-81 (Level II3). Royal Perth Hospital. Division of Critical Care, 2003. Zero tolerance to patient and visitor initiated workplace aggression at Royal Perth Hospital Emergency Department. Perth: Royal Perth Hospital Sinn K, n.d. Recognition of the Critically Ill Child. Canberra: The Canberra Hospital, ‘Tambimuttu J. Hawley R. Marshall A. 2002, Nurse-initiated »-ray of isolated limb fractures in the emergency department: research outcomes and future directions. Australian Critical Care. 153: 119-2. (Review). World Health Organization (WHO) Regional Office to the Western Pacific, “People at the Center ‘of Care Initiative,” International Symposium on “People-Centered Health Case: Reorienting Health Systems in the 21* Century”, The Tokyo International Forum, 25 November 2007.152 GLOSSARY Algor mortis (Latin algor meaning “coolness”; mortis meaning “of death”) is the reduction in body temperature following death, This is generally a steady decline until matching ambient temperature, although external factors can have a significant influence. Decomposition refers to the process by which tissues of dead organisms break down into simpler forms of matter. Emergency is a condition or state of patient wherein based on the objective findings of a prudent medical officer on duty for the day there is immediate danger and where delay in initial support and treatment cause loss of life or cause permanent disability to the patient. Emergency Treatment and Support is any medical or surgical measures within the capability of the hospital or medical clinic that is administered by qualified health care professionals to prevent the death or permanent disability of patient Hospital is a facility devoted primarily to the diagnosis, treatment and care of individuals suffering from illnesses, disease, injury or deformity, or in need of Obstetrical or other medical and nursing care. It shall also be constructed as any institution, building or place where there are facilities and personnel for the continued and prolonged care of patients. Livor mortis or postmortem lividity or hypostasis (Latin livor meaning, “bluish color mortis meaning “of death’), one of the signs of death, is a settling of the blood in the lower (dependent) portion of the body, causing a purplish red discoloration of the skin: when the heart is no longer agitating the blood, heavy red blood cells sink through the serum by action of gravity. This discoloration does not occur in the areas of the body that are in contact with the ground or another object, as the capillaries are compressed. Pallor mortis (Latin “for paleness of death”) is a postmortem paleness which happens in those with light skin almost instantly (in the 15-120 minutes after the death) because of a lack of capillary circulation throughout the body. The blood sinks down into the lower parts of the body creating the livor mortis, Rigor mortis is one of the recognizable signs of death (Latin mors, mortis) that is caused by a chemical change in the muscles after death, causing the limbs of the conpse to become stiff (Latin rigor) and difficult to move or manipulate ‘ i 4 '153 Stabilize is the provision of necessary care until such time the patient may be discharged or transferred to another health care facility. STAT (Latin word statim meaning “immediately”) is the transfer to another hospital or clinic with a reasonable probability that no physical deteriorate or would result from or occur during such discharge or transfer._ eg ee APPENDICESOg157 Appendix A REPUBLIC AcT 6615 -— AN ACT REQUIRING GOVERNMENT AND PRIVATE HOSPITALS AND CLINICS TO EXTEND MEDICAL ASSISTANCE IN EMERGENCY CASES. SECTION 1. "All government and private hospitals or clinic duly licensed to operate as such are hereby required to render immediate emergency medical assistance and to Provide facilities and medicine within its capabilities to patients in emergency cases who are in danger of dying and/or who may have suffered serious physical injuries SECTION 2. |The expenses and losses of earnings incurred by a private hospital of clinic for medicines, facilities and services beyond first aid extended to emergency cases as required herein, and not to exceed fifty thousand pesos per year, shall be deductible expenses and losses for income tax purposes which may be carried over for a period of five years, any provision of law or regulation to the contrary notwithstanding SECTION 3. Any hospital director, administrator, officer-in-charge or physician in the hospital, medical center or clinic, who shall refuse or fail without good cause to render the appropriate assistance pursuant to the requirements of section one after said case had been brought to his attention, or any nurse, midwife or medical attendant who shall refuse to extend the appropriate assistance, subject to existing rules, or neglect to notify or call a physician shall be punished by imprisonment of one month and one day to one year and one day, and a fine of three hundred pesos to one thousand pesos, without Prejudice to the provisions of Republic Act Numbered Twenty-three hundred eighty- two in the case of physicians. In the case of Government hospitals, the imposition of the penalty upon the person or Persons guilty of the violations shall be without prejudice to the administrative action that might be proper. In the case of private hospitals, aside from the imposition of penalty upon the person or persons guilty of the violations, the license of the hospital to operate shall, whenever justified, be suspended or revoked. SECTION 4. Subject to the approval of the Secretary of Health, the Bureau of Medical Services shall promulgate the necessary rules and regulations to carry out the provisions of this Act. SECTION 5. Any law or laws or parts thereof inconsistent with the provisions of this Act is hereby repealed SECTION 6. This Act shall take effect upon its approval Approved: October 23, 1972Appendix B DOH ADMINISTRATIVE ORDER NO. FAE 007 8. 1998 ADMINISTRATIVE ORDER No. _fELOF 5. 1998 I. ust 10, 1998, ¥ sted 7” SUBJECT: | POLICIES AND GUIDELINES ON THE TRANSFER AND REFERAL OF PATIENTS BETWEEN DOH METRO MANILA HOSPITALS RATIONALE: Government hospitals are not supposed to refuse patients. However, there are instances when a particular patients cannot be handled in such hospital because it has no capability, it is fully occupied, it has no equipment necessary for its ‘management and many other reasons that would be for the better treatment of the patient. But transferring patients entails a lot of administrative procedures, It has been noted that in some cases transferring patients from one hospital to another result to complications and to the detriment of the patients. To address these concerns, these guidelines are issued to ensure that proper procedures are followed in transferring emergency room patients as well as in referrals of admitted patients. DEFINITION OF TERMS: 2.1 Emergency Room Patients - are patients being evaluated and managed in the emergency room but are not yet admitted. 2.2 Inpatients - are admitted patients in the wards or private rooms 23. Capability of Hospitals - refers to the ability of the hospitals to manage cases based on their type of hospital, accreditation of departments, subspecialities, manpower, equipment, etc.M, 159 APPLICABILITY/COVERAGE: 31 These regulations and procedures shall have general applications in all Department of Health hospitals located in Metro Manila; in the event that there will be additional hospitals to be placed under the Department of Health they shall be automatically be covered under these regulations. 52° Local government hospitals who wish to follow this procedure may coordinate with the Undersecretary of the OHF. GENERAL GUIDELINES IN THE EMERGENCY ROOM: The Emergency Room is considered the show-window of the hospital and as such reflects the management of the entire hospital. It should be the responsibility of the Chief of Hospital to ensure that enough manpower and equipment are available to meet the emergency needs of every patient, Some Feasons for transferring the patient is primarily internal problems in the Emergency Room. As such the following policies shall be followed: 41 All hospitals having departmentalized services should exercise some form of autonomy in the Emergency Room. Nurses and administrative staff should be permanently assigned to the Emergency Room so as not to disrupt the services and to provide continuous training skills and competencies in emergency care; residents and interns should have a fixed time ame of rotation eg, 23 months and not pulled out anytime by the different departments or units. In the same manner, emergency equipment should be solely for ER use only. 42° Rotation in the Emergency Room should be primarily service oriented Hence seminars and training on Value Reorientation, Rights of Patients, Client Satisfaction, Art of Communication, etc. are suggested topics during, orientation. 43° The Emergency Room shall be manned by no less than a second year resident up. If ever there will be a first year resident, he/she should not be a front-liner.160 44 45 46 ‘All residents manning the Emergency Room in addition to all health personnel should have formal briefing by the Head of the Emergency Room All medical personnel should have undergone Advanced Cardiac Life Support in addition to the Basic Life Support before being assigned to the Emergency Room. Likewise, all administrative personnel shall undergo Basic Life Support. Respective departments have administrative supervision over those rotating in the Emergency Room however the Head of the Emergency Room shall have technical supervision over the said personnel Guidelines in Transferring Emergency Room Patients 51 52 53 54 55 ‘Attending physician in consultation with the senior resident of the Emergency Room or the senior resident of the service makes the decision in transferring the patient based on the capability limitation of the hospital. Only the senior resident or Head of the Emergency Room Department should inform the patient or relative as to the reason for transferring the patient and have them sign on the space provided in the Hospital Referral Form #1. (no nurse, no first year resident should be authorized to inform the patient or relative) ‘Attending physician should fill up all the necessary papers for transfer and brief the Senior House Officer or Head of Department. (See attached Hospital Referral Form #1). Senior House Officer/Head of Emergency Room should make the call to the Senior House Officer/Head of Emergency Room of the receiving hospital. Receiving hospital should be chosen based on capability of the hospital. The telephone lines should be used in discussing the patient and not the radio communication located in the Emergency Room of all hospitals. (This is reserved for emergency and disaster calls). ‘Transport the patient by an ambulance and properly accompanied by a resident with the official referral slip and laboratory and x-ray results if available. Acknowledgment form should be filled up and kept by the transferring hospital. (ee attached Hospital Form #2).VI. 56 57 58 161 In case there is no hospital to receive the patient and the only reason for referral is no vacancy and not capability, the patient should be observed for not more than six hours after which there should be final disposition, that is, to admit the patient. In the meantime, the patient should be properly monitored, managed and corresponding chart should be issued. The transfer could be done in both ways, that is, tertiary hospitals could also transfer patients to secondary hospitals to decongest the hospitals and/or make available beds for tertiary cases that will come or be transferred. Monthly reports should be submitted by all hospitals to the Office for Health Facilities every first week of the succeeding month, Guidelines for Inter-Hospital Referral or Request Procedures: 61 62 63 64 65 66 67 The service senior resident or the service consultant will recommend procedures needed by an Inpatient Fill up Hospital Referral Form #3 to be signed by the Head of Department or Designate, and approved by Hospital Director or Designate. Social service of referring hospital should assess and classify the financial status of the patient, and at the same time source out and make funds available. The Social Service should have an updated list of all hospitals and corresponding available procedures including their rates, The Attending Physician should coordinate with the hospital about the schedule and preparation of the patient. ‘Conduct patient by an ambulance with a resident. Receiving hospital to fill up the acknowledgement report (lower portion of Hospital Referral Form #3). Monthly reports should be sent by all hospitals to the Office of Health Facilities on the first week of the succeeding month,162 vu. vin. Guidelines for Transferring Inpatients: 7.1 The Attending Physician or the Service Consultant recommends transferring of patients already admitted in the hospitals. 72 Prepare Form No. #4 to be signed by the Attending Physician and approved by the Department Head. 7.3 Social Service should fill up the Patient's Classification and Justification. 74 Attending Physician should coordinate with the receiving hospital about the necessity of transferring the patient and the schedule of the transfer. 7.5 Transfer patient by an ambulance with a resident. 7.6 Referring hospital to fill up the acknowledgment receipt at the bottom page of Hospital Referral Form #4 and receiving hospital to sign. Detach this portion to be kept by referring hospital. 7.7 Monthly reports should be submitted to the Office for Health Facilities. TRANSFERRING OF PATIENTS DURING DISASTERS AND EMERGENCIES: In times of disasters, emergencies or any mobilization of the Department of Health in anticipation of mass casualties the rules and procedures will be unsuitable in Emergency Referrals described above. In such cases the following procedures will be followed: 8.1 All General Hospitals are designated as receiving hospitals to accept Victims of disasters; they have the option to transfer patients even within their capability to decongest their emergency rooms and for them to prepare for victims that will be brought in. 8.2 All other hospitals should accept cases being transferred even without the proper calls as required. In these cases, they will be informed through the radio communication via the Operation Center of the Department of Health Central Office. 83. The announcement and the termination of the disaster will be announced by the Operation Center of the Department of Health. Once it is lifted, everything will revert back to the usual procedures described above.x. 163 IMPLEMENTING MECHANISM: “FUNCTIONS AND RESPONSIBILITIES” These regulations shall be administered by the following: 94 9.2 94 95 The Office for Health Facilities through the Undersecretary shall evaluate and propose policy changes to the Secretary. The STOP DEATH Program through the Program Manager shall monitor the compliance of the procedures and report to the Undersecretary of the Office for Health Facilities, The Operation Center of the Department of Health through the Disaster Management Unit shall monitor radio referrals and report to. the Undersecretary of the Office for Health Facilities. The Medical Director/Chief of Hospitals, through the Chief of Clinics shall administer these regulations and submit monthly reports to the Undersecretary of the OHF. The Head of the Emergency Room of the hospitals shall directly oversee the implementation of these procedures at the hospital level; he shall report to the Director through the Chief of Clinics, EFFECTIVITY CLAUSE This Administrative Order shall take effect on September 1, 1998, PE AQUINO ESTRELI M. QL, Seeriany OFF Cy164 Appendix C REPUBLIC ACT 8344 jae eee AN ACT PROHIBITING THE DEMAND OF DEPOSITS OR ADVANCE PAYMENTS FOR THE CONFINEMENT OR TREATMENT OF PATIENTS IN HOSPITALS AND MEDICAL CLINICS IN CERTAIN CASES Republic of the Philippines Congress of the Philippines ‘Metro Manila Tenth Congress Second Regular Session Begun and held in Metro Manila, on Monday the twenty-second day of July, nineteen hundred and ninety-six. Republic Act No. 8344 AN ACT PENALIZING THE REFUSAL OF HOSPITALS AND MEDICAL CLINICS TO ADMINISTER APPROPRIATE INITIAL MEDICAL TREATMENT AND SUPPORT IN EMERGENCY OR SERIOUS CASES, AMENDING FOR THE PURPOSE BATAS PAMBANSA BILANG 702, OTHERWISE KNOWN AS "AN ACT PROHIBITING THE DEMAND OF DEPOSITS OR ADVANCE PAYMENTS FOR’ THE CONFINEMENT OR TREATMENT OF PATIENTS IN HOSPITALS AND MEDICAL CLINICS IN CERTAIN CASES, Be it enacted by the Senate and the House of the Representatives of the Philippines in the Congress assembled: SECTION 1, Section 1 of Batas Pambansa Bilang 702 is hereby amended to read as follows. "SECTION 1. In emergency or serious cases, it shall be unlawful for any proprietor, president, director, manager or any other officer, and/or medical practitioner of Employee or a hospital or medical clinic to request, solicit, demand or accept any deposit of any other form of advance payment as a prerequisite for confinement or medical treatment of a patient in such hospital or medical clinic or to refuse to administer medical treatment and support as dictated by good practice of medicine to prevent death or permanent disability: Provided, That by reason of inadequacy of the medical capabilities of the hospital or medical clinic, the attending physician may transfer the pationt to a facility where the appropriate care can be given, after the patient or his next Be kin consents to said transfer and after the receiving hospital or medical clinic agrees to the transfer: Provided, however, That when the patient is unconscious, incapable of giving consent and/or unaccompanied, the physician can transfer the patient even erthoat his consent: Provided, further, That such transfer shall be done only after necessary emergency treatment and support have been administered to stabilize the patient and after it has been established that such transfer entails less risks than the patient's continued confinement: Provided, furthermore, That no hospital or clinic, after being informed of the medical indications for such transfer, shall refuse to receive the patient nor demand from the patient ot his next of kin any deposit or advance payment:165 Provided, finally, That strict compliance with the foregoing procedure or transfer shall not be construed as a refusal made punishable by this Act.” SECTION 2. Section 2 of Batas Pambansa Bilang 702 is hereby deleted and in place thereof, new sections 2, 3, and 4 are added, to read as follows: "SEC. 2. For purposes of this Act, the following definitions shall govern: (a) 'Emergency' - a condition or state of a Patient wherein based on the objective findings of a prudent medical officer on duty for the day there is imeediate, danger and where delay in initial support and treatment may cause loss of life ot eneve Permanent disability to the patient. (b) ‘Serious case’ - refers to a condition of a patient characterized by gravity or danger wherein based on the objective findings of a prudent medical officer on duty for the day when left unattended to, may cause loss of life or cause permanent disability to the patient. (©) ‘Confinement’ - a state of being admitted in a hospital or medical clinic for medical observation, diagnosis, testing, and treatment consistent with the capability and available facilities of the hospital or clinic. (@) Hospital’ - a facility devoted primarily to the diagnosis, treatment and care of individuals suffering from illness, disease, injury or deformity, or in need of obstetrical or other medical and nursing care. It shall also be construed se any institution, building or place where there are facilities and personnel for the. continued and prolonged care of patients, (©) Emergency treatment and support! - any medical or surgical measure within the capability of the hospital or mecical clinic that is administered by qualified health care professionals to prevent the death or permanent disability of a patient. {0 "Medical clinic’ - a place in which patients can avail of medical consultation or treatment on an outpatient basis. (g) Permanent disability’ - a condition of physical disability as defined under Article oC and Article 195-B and C of Presidential Decree No. 442, as amended, othervins known as the Labor Code of the Philippines. "(h) ‘Stabilize’ - the provision of secth ay care until such time that the patient may be discharged or transferred to another hospital or clinic with a reasonable probability that no physical deterionauic would result from or occur during such discharged or transfer, SEC. 3. After the hospital or medical clinic mentioned above shall have administered medical treatment and support, it may cause the transfer of the patient to an appropriate hospital consistent with the needs of the patient, preferably to a Sovernment hospital, specially in the case of poor or indigent patients.166 SEC. 4. Any official, medical practitioner or employee of the hospital or medical clinic who vielates the provisions of this Act shall, upon conviction by final judgment, be punished by imprisonment of not less than six (6) months and one (1) day but not Pere than two (2) years and four (4) months, or a fine of not less than Twenty thousand pesos (P20,000.00), but not more than One hundred thousand pesos (100,000.00) or both, at the discretion of he court: Provided, however, That if such Violation was committed pursuant to an established policy of the hospital or clinic oF upon instruction of its management, the director or officer of such hospital or clinic responsible for the formulation and implementation of such policy shall, upon Conviction by final judgment, suffer imprisonment of four (4) to six (6) years, ot a fine Sf not less than One hundred thousand pesos (P100,000.00), but not more than Five hundred thousand pesos (P300,000.00) or both, at the discretion of the court.” SECTION 3. Section 3 of Batas Pambansa Bilang 702 is hereby repealed. SECTION 4. Section 4 of Batas Pambansa Bilang 702 shall become Section 5 thereof and. shall be amended to read as follows: 'SEC. 5. The Department of Health shall promulgate the necessary rules and regulations to carry out he provisions of this Act.” SEC. 5 This Act shall take effect fifteen (13) day after its publication in two (2) national newspapers of general circulation. Approved: ERNESTO M. MACEDA. President of the Senate JOSE DE VENECIA, JR. Speaker of the House of Representative ‘This Act which is a consolidation of House Bill NO. 26 and Senate Bill No. 1817 was finally passed by the House of Representatives and the Senate on June 5, 1997. LORENZO E. LEYNES, JR. Secretary of the Senate ROBERTO P. NAZARENO Secretary General House of Representative Approved: FIDEL V. RAMOS President of the Philippines167 Appendix D REPUBLIC ACT 9349 [H. No. 68] —-_- AN ACT PROHIBITING THE DETENTION OF PATIENTS IN HOSPITALS AND MEDICAL CLINICS ON GROUNDS OF NON-PAYMENT OF Hosrrrat BILLS OR MEDICAL EXPENSES Be it enacted by the Senate and House of Representatives of the Philippines in Congress assembled: Section 1, It shall be unlawful for any hospital or medical Clinic in the country to detain or to otherwise cause, directly or indirectly, the detention of patients who have fully or Partially recovered or have been adequately attended to or who may have died, for reasons of nonpayment in part or in full of hospital bills or medical expenses Section 2, Patients who have fully or partially recovered and who already wish to leave the hospital or medical clinic but are financially incapable to settle, in part or in full, their hospitalization expenses, including professional fees and medicines, shall be allowed to leave the hospital or medical clinic, with a right to demand the issuance of the corresponding medical certificate and other pertinent papers required for the release of the patient from the hospital or medical clinic upon the execution of a promissory note covering the unpaid obligation. The promissory note shall be secured by either a mortgage or by a guarantee of a co-maker, who will be jointly and severally liable with the patient for the unpaid obligation. In the case of a deceased patient, the corresponding death certificate and other documents required for interment and other Purposes shall be released to any of his surviving relatives requesting for the same Provided, however, That patients who stayed in private rooms shall not be covered by this Act. Section 3. Any officer or employee of the hospital or medical clinic responsible for releasing patients, who violates the provisions of this Act shall be punished by a fine of not less than Twenty thousand pesos (P20,000.00), but not more than Fifty thousand pesos (P50,000.00), or imprisonment of not less than one month, but not more than six months, or both such fine and imprisonment, at the discretion of the proper court. Section 4. The Departinent of Health shall promulgate the necessary rules and regulations to carry out the provisions of this Act Section 5. If any provision of this Act is declared void and unconstitutional the remaining, provisions hereof not affected thereby shall remain in full force and effect Section 6. All laws, decrees, orders, rules and regulations or part thereof inconsistent with this Act are hereby repealed or amended accordingly168 Section 7. This Act shall take effect fifteen (15) days after its publication in two national newspapers of general circulation. Approved: (Sgd.) MANNY VILLAR President of the Senate (Sgd.) JOSE DE VENECIA, JR. Speaker of the House of Representatives This Act which originated in the House of Representatives was finally passed by the House of Representatives and the Senate on June 7, 2005 and February 19, 2007, respectively. (Sgd.) OSCAR G. YABES Secretary of the Senate (Sgd.) ROBERTO P. NAZARENO Secretary General House of Representatives Approved: April 27, 2007 (Sgd.) GLORIA MACAPAGAL-ARROYO President of the Philippines169 Appendix E ADMINISTRATIVE ORDER NO. 2008-0001 Hs IMPLEMENTING RULES AND REGULATIONS OF REPUBLIC ACT No, 9439 Republic of the Philippines Department of Health Office of the Secretary ADMINISTRATIVE ORDER NO. 2008 - 0001 January 7, 2008 SUBJECT: Implementing Rules and Regulations of Republic Act No. 9439, otherwise known as "An Act Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds of Nonpayment of Hospital Bills or Medical Expenses" Rationale The passage of Republic Act (R.A.) No, 9439, otherwise known as "An Act Prohibiting the Detention of Patients in Hospitals and Medical Clinics on Grounds of Nonpayment of Hospital Bills or Medical Expenses", addresses the problem involving some hospitals and medical clinics that refuse to discharge patients due to the latter's inability to pay their hospital bills or medical expenses by encouraging them to employ appropriate Payment schemes. It also emphasizes the responsibility of patients to honor their obligation with the hospital or medical clinic to pay their bills. Section 4 of R. A. No. 9439 authorizes the Department of Health (DOH) to promulgate the necessary rules and regulations. TI. Objective This Administrative Order sets the implementing rules and regulations to carry out the provisions of R. A. No. 9439, otherwise known as "An Act Prohibiting the Detention of Patients in Hospitals -and Medical Clinics on Grounds of Nonpayment of Hospital Bills or Medical Expenses". IIL. Scope This Administrative Order applies to patients admitted in government and private hospitals and medical clinics, except those who stay in private rooms IV. Definition of Terms For purposes of R. A. No, 9439 and its implementing rules and regulations, the following definitions are provided:170 ‘A. Co-Maker - a person, natural or juridical, who binds himself jointly and severally to pay the unpaid hospital bills or medical expenses/hospitalization expenses of the patient, B. Complaint - a swom written statement of ultimate facts, filed by the patient, charging the official or employee of the hospital or medical clinic with any violation of RA No 9439 and its implementing rules and regulations. C. Detention - an act of restraining a person from leaving the hospital premises for nonpayment of hospital bills or medical expenses in part or in full. D. Guarantee - an expressed assurance by the co-maker to the hospital or medical clinic that certain facts or conditions are true and/or will happen. The hospital or medical clinic is permitted to rely on that assurance and seek appropriate action if it is not true and/or followed. E, Hospital - a health facility for the diagnosis, treatment and other forms of health care of individuals suffering from deformity, disease, illness or injury, or in need of surgical, obstetrical, medical or nursing care. It is an institution where there are installed bassinets or beds for 24-hour use or longer by patients in the management of deformities, diseases, injuries, abnormal physical and mental conditions, and maternity cases. F. Hospital Bills or Medical Expenses/ Hospitalization Expenses - costs of diagnosis, treatment and other forms of health care of patients, which include, but not limited to, doctor's fees, amount owing for clinical and ancillary services rendered, charges for room, meals, medical supplies, drugs and medicines, and payments for use of equipment. G. Medical Clinic - a health facility that satisfies the above definition of a hospital but uses the phrase "medical clinic’ in its business name. H. Mortgage - a method of using real property (land) or personal property (other physical possessions) as security for the payment of a debt. 1. Officer or Employee of a hospital or medical clinic - a person acting in behalf of a hospital or medical clinic responsible for releasing patients in accordance with written policies and procedures of the hospital or medical clinic. J. Patient - for the purposes of R. A. No. 9439 and these implementing rules and regulations, a person who is already admitted and availed of health care services in a hospital or medical clinic. K. Private Room - a single occupancy room or a ward type room divided by either a permanent or semi-permanent partition (except curtains) not to exceed 4 patients per room who are admitted for diagnosis, treatment and other forms of health care maintenanceTR 171 L. Promissory Note - an unconditional promise in writing made by the patient and/or his/ her next of kin to the hospital or medical clinic, engaging to pay on demand, or at a fixed or determinable future time, a sum certain in money to order or to bearer, V. Policies and Guidelines A. General Policies 1. Patients, except those who stay in private rooms, who are partially or fully recovered and who wish to leave the hospital or medical clinic but are incapable to pay, in part or in full, their hospital bills or medical expenses/ hospitalization expenses shall be allowed to leave the hospital or medical clinic and shall be issued the corresponding medical certificate and other pertinent documents for their release from the hospital or medical clinic upon execution of a promissory note covering the unpaid obligations. The promissory note shall be secured by either a mortgage, or a guarantee of a co-maker who shall be jointly and severally liable for the unpaid obligations. 2. In the case of a deceased patient, any of his/ her surviving relatives shall be issued the corresponding death certificate and other pertinent documents for interment purpose only. For other purposes, such documents shall be issued only upon execution of a promissory note covering the unpaid obligations by any of the surviving relatives. The promissory note shall be secured by either a mortgage, or a guarantee of a co-maker who shall be jointly and severaily liable for the unpaid obligations. In the event the documents will be needed for purposes of getting the benefits from the Social Security System. Government Service Insurance System, Philippine Health Insurance Corporation, insurance policies or pre-need plans, the hospital may require the execution of an assignment of proceeds up to the extent of the hospital bills or medical expenses/ hospitalization expenses. 3. Inthe case of a deceased patient, any of his/ her surviving relatives who refuse to execute a promissory note shall be allowed to claim the cadaver and can demand the issuance of death certificate and other pertinent documents for interment purposes. Documents for other purposes shall be released only after execution of a promissory note. 4. Any hospital or medical clinic detaining or causing, directly or indirectly, the detention of patient for reason of nonpayment, in part or in full, of hospital bills or medical expenses/ hospitalization expenses shall be held accountable for such unlawful act. Detention occurs when all of the following are present a) The patient who is partially or fully recovered has expressed his/ her intention to leave the hospital or medical clinic, or the attending physician has issued a discharge order;172 b) The patient is not confined in a private room and is financially incapable to settle in part or in full the corresponding hospital bills or medical expenses/ hospitalization expenses; ©) Patient has executed a promissory note covering the unpaid hospital bills or ‘medical expenses/ hospitalization expenses; and d) The officer or employee of the hospital or medical clinic responsible for releasing the patient has restrained him from leaving the hospital premises. 5. In the case of a deceased patient, any hospital or medical clinic refusing to release the cadaver for reason of nonpayment, in part or in full, of hospital bills or medical expenses/ hospitalization expenses shall be held accountable for such unlawful act. Detention occurs when all of the following are present: a) The medical officer has made the pronouncement of death; b) Any of the surviving relatives is incapable to pay the corresponding hospital bills or medical expenses/ hospitalization expenses; ©) Any of the surviving relatives has executed a promissory note covering the ‘unpaid hospital bills or medical expenses/hospitalization expenses; and 4) The officer or employee of the hospital or medical clinic responsible for releasing the deceased patient has refused to release the cadaver and/ or relevant documents. B. Specific Guidelines: 1, Classification, Admission and Discharge of Patients ‘To minimize, if not prevent, incidence of patients being unable to pay, and hospitals or medical clinics detaining patients for reason of nonpayment of hospital bills or medical expenses/ hospitalization expenses, patients and hospitals or medical clinics alike may institute and observe the following: a) ‘Government hospitals or medical clinics shall classify patients in terms of their capacity to pay according to the guidelines set by the DOH in Administrative Order No. 51-A s. 2000: Implementing Guidelines on Classification of Patients and on Availment of Medical Social Services in Government Hospitals, dated October 12, 2001. b) Private hospitals or medical clinics shall have written policies and procedures to classify patients in terms of their capacity to pay. For this purpose, private hospitals or medical clinics may refer to AO No. 51-A s. 2000.173 ©) The DOH, government and private hospitals or medical clinics shall, as far as Practicable, assist patients in looking for financial assistance from government and non-government sources to settle the unpaid hospital bills or medical expenses/ hospitalization expenses. Toward this end, the DOH shall work closely with financial institutions like, but not limited to, Philippine Health Insurance Corporation, Philippine Charity Sweepstakes Otfice, Philippine Amusement and Gaming Corporation, Local Government Units, as tvell 8,Congress, to provide funds for this purpose. 4) All hospitals of medical clinics shall establish billing and collection procedures subject to current accounting and auditing rules and regulations. ©) All hospitals or medical clinics shall have written policies and procedures for admitting and releasing patients, including identifying the officer/s or employee/s responsible for releasing patients. 2. Execution of Promissory Note a) Except those who stay in private rooms, patients who are partially ot fully recovered and who wish to leave the hospital or medical clinic but are incapable to ay’ in part or in full, their hospital bills or medical expenses/hospitalization expenses are obliged to execute a promissory note secured by either a mortgage, or a guarantee of a co-maker. b) In the case of a deceased patient, any of his surviving relatives is obliged to execute a promissory note secured by either a mortgage, or a guarantee of a co. maker, ©) Hospitals or medical clinics shall have written policies and procedures for execution of promissory notes secured by either a mortgage, or a guarantee of a co- maker. 3. Penalty Any officer or employee of a hospital or medical clinic responsible for releasing Patients who has been found to commit any violation of R.A. No. 9439 and ite implementing rules and regulations shall be punished by either a fine of not ese than Twenty Thousand Pesos (P20,000) but not mote than Fifty Thousand Pesos (P50,000), or imprisonment of not less than One (1) Month but not more than Six (6) months, or both such fine and imprisonment, at the discretion of the proper court. VI. Repealing/Separability Clause Provisions from previous issuances that are inconsistent or contrary to the provisions of this Order are hereby rescinded and modified accordingly.174 If any provision of this Order is declared unauthorized or rendered invalid by any court of law or competent authority, those provisions not affected thereby shall remain valid and effective. R. A. No, 9439 repeals or amends the pertinent provisions of the Revised Penal Code, particularly Articles 267, 268 and 270, decrees, orders, rules and regulations inconsistent with the same, in so far as the same involves hospitals or medical clinics, medical practitioners, and their staff and employees. VIL. Effectivity This Order shall take effect fifteen (15) days after publication in a newspaper of general circulation. (Signed)FRANCISCO T. DUQUE, III, M.D. M.Sc. ‘Secretary of Health175 Appendix F ADMINISTRATIVE ORDER NO. 51-A s. 2000 Repunie of he Prigginat ment of Heat ‘OFFICE OF THE SECRETARY 12 Ocsober 2001 ADMINISTRATIVE ORDER No. I-A +. 2000 SUBJECT: Implementing Guidelines on Classification of Patients and on Availment of Medical Social Services in Government Hospitals I. POLICY BASIS AND RATIONALE: The Department of Health is mandated by R.A. No. 747 of 1954, An Act to Regulate fees to be charged Against Patients in Government and Charity Clinics Classifying Patients ‘according to their Financiul Condition, to set the necessary rules and regulations for the due execution of the provisions of this Act: This policy issuance is one of the responses of the DOH to the need for people- centered hospitals that are responsive to the demands of the present socio-economic situation in which most Filipinos find themselves. Based on the latest statistical data gathered from all regions, the National Statistics and Coordinating, Board (NSCB), has described the poverty situation as follows: In 2000: (a) The Poverty Incidence [proportion of families to the total number of families) stood at 34.2%; (0) The Magnitude of Poor Families [number of families whose annual per capita ‘income falls below the annual per capita poverty threshold] was 5,215,989; (©) The Per Capita Poverty Thresholds [annual per capita income required... to satisfy essential nutritional requirements (2,000 calories) and other basic needs} ranged from P10,868 for Region VIII to P18,001 for NCR and averaged P13,916 for the whole Philippines; and176 Addressing the poverty situation by means of providing accessible and affordable health care services, especially public hospital services, constitutes the main rational for this Order, I PURPOSE OF THIS ORDER ‘This Administrative Order aims to: 1. Update and improve existing policies on availment of medical social services and mode of payment for hospital services rendered in government hospitals to indigent patients, especially those who qualify for and avail of Medical Social Services. 2. Set realistic guidelines for evaluating and classifying patients, specially those who are legitimately indigent or have limited capacity to pay their hospital bills; and 3, Enable the Medical Social Service Units of government hospitals nationwide to (a) classify hospital patients; (b) use criteria that are objective and reasonable, simplified and “implementable”, but subject to controls and limitations; and (©) help make health resources available to the periphery. III. COVERAGE SCOPE: This Administrative Order covers all government hospitals, National, Local and those ran by other government agencies. IV. GENERAL GUIDELINES A. Criteria for Classification of patients ‘The criteria for the classification of patients seeking Medical Social Service assistance in hospitals shall be based on the following: 1. The latest Per Capita Poverty Threshold (PCPT), by Region, as determined by the proper government authority, specifically the National Statistics and Coordinating Board (NSCB); 2. Regional location of the hospital or health facility; 3. Income or paying capacity of the patient or in cases where the patient is a minor or a dependent, the income or paying capacity of his/her parents, immediate relatives, or guardian as the case may be;7 4. Level of social functioning of the patient 5. Modifiers’ arising from specific situations or circumstances; 6. Hospital room or ward where the patient is confined or treated; 7. Costs or bill of expenses charged for hospital services rendered. B. Categories of Patients On the basis of their income or paying capacity, patients shall be classified as follows: 1. Class A - Pay A patient admitted to a hospital suite, private room, or semi-private room as a pay patient; A patient who may or may not be a qualified Philippine Health Insurance Corp. (PHIC or Phil health), beneficiary and who shall pay in full all fees/charges for hospital and professional services, including any excess amount that is not reimbursable by Phil health, if any. 2. Class B - Pay Ward A patient admitted to a Pay Ward (3 beds or more); A patient who can and shall pay in full all fees/charges for professional and hospital services rendered at the Pay Ward level, including expenses in excess of amounts payable by Phil health, if any. 3. Class C - Ward A patient or family who are the “working poor”, those with fulltime work but their income is not sufficient to meet their treatment expenses in full. A patient admitted to a ward; A patient with or without Phil health benefits who (a) cannot pay in full the excess of hospital expenses chargeable to Phil health; or (b) has monthly income per capita that falls under Sub-Class C-1, C-2, or C3 as. affected by the modifying circumstances (modifiers) described herein. To determine how much a patient shall pay as his/her actual share of hospital expense incurred, Class C patients shall be further categorized as. follows178 Patients whose monthly income per capita is above the 180% but ‘not more that 220% of the latest PCPT for the region in which the hospital is located. Example: A patient who is confined in a hospital located in the National Capital Region (NCR) should at least have a monthly income per capita of P2,700.00 but not more than P3,300.18 in order to be categorized as a Class C-1 patient. [The 2000 PCPT for the National Capital Region is P1,500.08 monthly} Class C2 Patients whose income is above the 140%, but not more than 180% marked up of the latest PCPT for the region in which the hospital is located. Example: A Class C-2 patient confined in a Region IV hospital should have a total monthly income per capita of more than P1,785.81 but less than P2,296.04. [The 2000 PCPT for Region IV is P1,272.58 monthly per capital. Class C-3 Patients whose monthly per capita income is equal to but not more than the 140% marked up of the latest PCPT for the region where the hospital is located. Example: A Class C-3 patient admitted to a Region V hospital should have a monthly per capita equal to P1,084.42 but not more than P1,518.19 [Region V's 1997 PCPT = 1,084 monthly] 4. Class D - Full Social Service A patient or family who cannot provide for the basic food and non-food requirements, which is called the poverty threshold. Their income is below the latest PCPT of the region in which the hospital is located. Patients covered by Republic Acts, special laws, Executive Orders, local ordinances, or other national policy instruments that issued because of specific circumstances or situations of the target groups or sectors of socie179 C. MODIFYING CIRCUMSTANCES ‘The Patient's capacity to pay shall be further evaluated on the basis of these modifiers: 1. Modifiers related to personal circumstances: 1.1 Patients in crises situations; 1.2. Patients who are differently-abled or have physical/mental disabilities or limitations; 1.3 Patients who have no known family, relatives or guardians; 14 Patients who are orphans, “senior citizens”, war veterans, or widows with no concrete source of financial support. 2. Modifiers related to Community Situations Patients coming from “squatter” areas or urban slums; Patients dislocated from their homes or communities as a result of disasters or calamities caused by nature, by accidents, or by human failures or intentions, Examples of such situations include inclement weather and violent climate disturbances, typhoons, floods, droughts, fires and wars or armed conflict, among others, and Patients belonging to economically disadvantaged or marginalized ethnic groups or indigenous cultural communities (ICs). 3. Modifiers related to Nature of Illness/Disease Patients with chronic diseases needing long-term and costly treatment, e.g, chronic kidney disease, chronic lung ailments, and cancer; Patients with acute or chronic diseases for which no curative medicines are currently available or diseases known to require hospital service, drugs of health care equipment that are expensive or beyond their means. Examples of such diseases include HIV/AIDS, cancer, etc. D. Modes of Cost-Sharing Given patients capacity to pay and the modi cost-sharing arrangement shall be applied: ‘ing circumstances, the following180 PATIENT HOSPITAL SHARE PATIENT'S SHARE CATEGORY ClassD | Full - The hospital shail provide | The patient shall not pay for free room and boards, professional | hospital charges incurred. services, linen and ancillary services, and available medicines. Class C3 Partial - The hospital staff shall | The patient shall share any provide free room and board, linen, | affordable amount for and professional services. Subsidize | medicines provided and more than 50% on the available | ancillary services rendered. medicines and ancillary services. ‘Class G2 _| Partial - The hospital shall provide | The patient shall pay 50% of free room and board, linen, and | the charges for medicines professional services. Subsidize 50% | given and ancillary services of the available medicines and | rendered. ancillary services. ‘Glass C3 _| Partial ~ The hospital shall provide | The patient shall pay 75% of free room and board, linen, and | hospital charges __for professional services. Subsidize 25% | medicines given, ancillary of the available medicines and | services rendered, and other, ancillary services if any. V. SPECIFIC PROCEDURES: 1. The patient walks in or is brought or referred to the OPD or Emergency Unit. 2. The physician-on-duty conducts and evaluation: 2.1 Can patient be treated in the hospital based on the hospital's facilities and competence; 22 Cannot be treated in the hospital. 3. It if can be treated, the patient is referred to the hospital's Medical Social Service for evaluation: 3.1 Purpose of evaluation: a) assess financial capacity of patient and family, and b) determine level of social functioning of patient.181 3.2. How to evaluate on the basis of criteria: fa) Assess the Patient and family’s financial capacity through Intake Interview suing the MSS Form No. 1 (as attached in this order) for short term treatment, and for long term treatment, validated by the following requirements: Certificate of Employment, Income Tax Return or Certification of Exemption, Certification from Assessor's Office, and or/Treasurer’s Office, Barangay Certificate and DSWD's Social Case Study Report if the patient resides outside the hospital's catchments area or a Home Visit Report if within the hospital's catchments area. b) Assess the level of functioning, which is the ability of people to perform the tasks of daily life and to engage in mutual relationships with other people in ways that are gratifying to themselves and to other and meet the needs of an organized community using the Person-in-Environment as organizing construct. The Medical Social Worker shall describe the patient's problem complex, its severity and duration, in the following areas: + Problems in Social Functioning (Familial Roles, Interpersonal Roles, Occupational Roles, and Special life situation Roles) i + Problems in Environment (Economic/Basic Needs System, {Food /nutrition, shelter, employment, economic resources, transportation, discrimination}, Education and Training, Health, Safety and Social Services System {Health/ Mental Health, Safety, Access to social Services, Discrimination), Voluntary Association System (Religious, Community Groups}, Affectional Support System + Problems in Mental Health (Current mental disorder or } condition that is relevant to the understanding of the patient's problem) + Problem on Physical Health (Current physical disorder or condition that potentially relevant to the understanding of the patient's problem) ©) Getting the aggregate monthly income of the household and dividing it with the number of household members determine the monthly income per capita. d) The Poverty Threshold shall be used as the baseline for determining indigency or for classifying patients according to their capacity to pay.182 ©) For purposes of the Order and for the year 2001 and thereafter, the latest Poverty Thresholds by region (2000) provided by NEDA or NSCB shall apply until such time that the PCPT’s are revised and updated. 1) Patient/Relative shall sign the Intake Survey Sheet after the initial interview to certify that the informations he/she disclosed are true, 8) Patients who are covered by the “modifiers” listed in this Order shall be evaluated by the Medical Social Service to determine their financial capacity to contribute to their hospitals expenses. Based on the findings, the Medical Social Service shall determine the mode of cost sharing to be applied to them 4. The Medical Social Worker shall inform the patient about his/her classification and the patient's financial contribution (if any) corresponding to the patient’s class (Class A, B, C-1, C-2, C-3 or D) 41 If financially needy, a) The MSW issues pre-numbered MSS cards renewable each year. ») Upon admission, the patient may be accommodated as belonging to any of the categories, if warranted by further financial or social evaluation, the patient may be moved to a category below or above the initial category. ) Changes in the classification shall primarily be based on the changes in patient’s income, while the patient’s share shall be adjusted based on the modifiers. d) Whenever necessary or appropriate, the patient or his/her accompanying family relatives or guardian shall be motivated not to depend totally on “social services” for the payment of hospital charges, instead find other resources to ensure maximization of ‘medicinal assistance and continuing treatment. ©) Pay patients who are to be transferred to the service ward shall avail of the discount only after the reclassification of the Medical Social Worker. Service patients who shall transfer to a pay ward shall have to be reevaluated as to his capacity to pay treatment expenses in the pay ward. If he was found to have withhold vital information that lead to his wrong classification, he shall pay all services and accommodation since the start of his/her admission. On the other hand, if his citcumstances changed unexpectedly orVi. 183 due to an unexpected benefactor, he can still avail of the discounts on his accounts for his stay in the service ward, 4) Paymentin-kind schemes that are the non-cash payment in exchange for the hospital goods and services can be implemented as an alternative mode of recovering cost of hospitalization, and in encouraging patient's participation in his/her treatment expenses, 4.2 If financially not needy a) If the patient is found not eligible for MSS assistance he/she shall be informed by the Medical Social Worker about the estimated cost of his/her treatment or hospitalization, 5. The Medical Social Worker shall provide the patient and family the appropriate clinical intervention according to their level of social functioning no matter what classification they have, 6. The Medical Social Worker still reserves the right to client participation and that his/her basic function to assess, evaluate and orient patient regarding their Primary responsibility of meeting their health needs will be compromised, 7. For monitoring purposes, the hospital shall submit quarterly reports on the availment of medical social services to the DOH National Center for Health Facility Development (NCHFD). Responsibilities of implementing units or persons 1. The National Center for Health Facility Development (NCHFD) 11 Shall monitor compliance with the guidelines on availment of Medical Social Service by government hospitals and make appropriate recommendations as may be needed. 1.2 Shall coordinate or facilitate the implementation of this Order. 1.3. Consolidate and analyze submitted reports, 2. Hospital 21 Requires the Medical Social Service Unit to formulate additional implementing guidelines to cover the unique needs of the hospital. 2.2 Approves the additional Implementing Guidelines.184 23 24 Requires the Medical Social Worker to submit monthly report on the classified patients. In health facilities where a Medical Social Service unit or person is not available, officially designates the proper unit or person who shall do Classification of patients in coordination with the Local Social Welfare Office. 3. The Medical Social Service Unit 34 32 33 ‘The Medical Social Service of the hospital concerned shall evaluate and classify patients secking admission or treatment in hospitals to determine his/her eligibility for medical social services in accordance with the guideline prescribed in this Order. Submits an annual psychosocial profile of patients served. Documents social issues and concerns in relation to the implementation of these guidelines. 4 Local Governments Units 4a 42 Monitor compliance with the guidelines on availment of Medical Social Service by government; hospitals under its management and make the appropriate recommendation as may be needed. “Approves the additional Implementing Guidelines needed to address the unique needs of their locality. 5. The Medical Social Workers League 51 ‘The League shall coordinate or consult with NCHFD and the DOH Medical Social Work Adviser on matters that connected with or may arise from this Administrative Order. VII. Repealing Clause Department Order No. 435-B s. 1990 dated October 22, 1990 is repealed by this Order, Provisions of other administrative issuances inconsistent with this ‘Administrative Order are also repeated, superseded or modified accordingly.——-a VIIL Effectivity ‘This Administrative Order shall take effect upon approval. Lond f' MANUEL M. DAVRIT, ‘Secretary of Health Hise.186 (Name of Hospital) (Address) MEDICAL SOCIAL SERVICE INTAKE SURVEY SHEET. Date Admitted; Diagnosis Classification: Ao 60 Gad po cu oo Name: (Last) (Given) City Address: CS.0S OM OW OD OSep pcr enn as ees EEE Date Referred: MSS No. Date Discharged: Ward/Rm, No. Age: Sex:_ Hosp. Noz_ (Mil) Provincial Address: Religion: nia Income: Employer: —_lT RELATIONSHIP | OCCUPATION | INCOME HOUSEHOLD AGE] _GviL MEMBERS STATUS, Other Source of Income: Total Monthly Income: OO MONTHLY FAMILY EXPENDITURE House and Lot Transportation: Light Clothing: Water: Insurance Premium Fuel Real Estate Food eee Houschelp: See Education: Medical Expenditure: Recreation: Others: a ‘Total Monthly Expenditure = Persons to be notified in case of emergency: Address Tel. No. TT Problem presented at intake: MSS FORM NO. 1 Medical Social Worker Papago187 Appendix G Rerustic ACT 7170 ee AN ACT AUTHORIZING THE LEGACY OR DONATION OF ALL OR PART OF A HUMAN BODY "AFTER DEATH FOR SPECIFIED PURPOSES Section 1. Title. - This Act shall be known as the "Organ Donation Act of 1991" Section 2. Definition of Terms. - As used in this Act the following terms shall mean: {@) "Organ Bank Storage Facility" - facility licensed, accredited or approved under the law for storage of human bodies or parts thereof. (b) "Decedent" - a deceased individual, and includes a still-born infant or fetus. (© "Testator’ - an individual who makes a legacy ofall or part of his body. (@ "Donor an individual authorized under this Act to donate all or part of the body ofa decedent lawphilYalf (6) "Hospital ~a hospital licensed, accredited or approval under the law, and includes, a hospital operated by the Government. (0 "Part" - includes transplantable organs, tissues, eyes, bones, arteries, blood, other fluids and other portions of the human body. (g) "Person’ - an individual, corporation, estate, trust, partnership, association, the Government or any of its subdivisions, agencies or instrumentalities, including government-owned or -controlled corporations; or any other legal entity. (h) "Physician’ or ‘Surgeon -a physician or surgeon licensed or authorized to practice medicine under the laws of the Republic of the Philippines. {i "Immediate Family" of the decedent - the persons enumerated in Section 4(a) of this Act. {j) "Death" - the irreversible cessation of circulatory and respiratory functions or the Greversible cessation of all functions of the entire brain, including the brain stem. A person shall be medically and legally dead if either: {Q) Inthe opinion of the attending physician, based on the acceptable standards of medical practice, there is an absence of natural respiratory and cardiac functions and, attempts at resuscitation would not be successful in restoring those functions. In this case, death shall be deemed to have occurred at the time these functions ceased; or188 ©) In the opinion of the consulting physician, concurred in by the attending physician, that on the basis of acceptable standards of medical practice, there is at irreversible cessation of all brain functions; and considering the absence of such functions, further attempts at resuscitation or continued supportive maintenance Would not be successful in resorting such natural functions. In this case, death shall be deemed to have occurred at the time when these conditions first appeared. ‘he death of the person shall be determined in accordance with the acceptable standards of medical practice and shall be diagnosed separately by the attending physician and patient's medical record, Section 3 Person Who May Execute A Legacy. - Any individual, atleast eighteen (18) years of age and of sound mind, may give by way of legacy, to take effect after his death olive Part of his body for any purpose specified in Section 6 hereof Section 4. Person Who May Execute a Donation. = (@) Any of the following, person, in the order of property stated hereunder, in the absence of actual notice of contrary intentions by the decedent or actual motice wf cpposition by a member of the immediate family of the decedent, may donate all or any part of the decedent's body for any purpose specified in Section 6 hereof: (1) Spouse; (2) Son or daughter of legal age; (3) Either parent; (4) Brother or sister of legal age; or (6) Guardian over the person of the decedent at the time of his death, (b) The persons authorized by sub-section (a) of this Section may make the donation after or immediately before death. Section 5. Examination of Human Body or Part Thereof. A legacy of donation of all or part of a human body authorizes any examination necessary to assure medical acceptability of the legacy or donation for the purpose(s) intended. For purposes of this Act, an autopsy shall be conducted on the cadaver of accident, {{auma, or other medico-legal cases immediately after the pronouncement of death, 6 determine qualified and healthy human organs for transplantation and/or’ in furtherance of medical science. Bection 6. Persons Who May Become Legatees or Donees. - The following. persons may become legatees or donees of human bodies or parts thereof for any of the purposes stated hereunder:189 (@) Any hospital, physician or surgeon - For medical or dental education, research, advancement of medical or dental science, therapy or transplantation; ©) Any accredited medical or dental school, college or university - For education, research, advancement of medical or dental science, or therapy; (9 Any organ bank storage facility - For medical or dental education, research, therapy, or transplantation; and (4) Any specified individual - For therapy or transplantation needed by him, Section 7. Duty of Hospitals. - A hospital authorized to receive organ donations or to conduct transplantation shall train qualified personnel and their staff to handle the task of introducing the organ donation program in a humane and delicate manner to the relatives of the donor-decedent enumerated in Section 4 hereof, The hospital shall accomplish the necessary form or document as proof of compliance with the above requirement. Section 8. Manner of Executing a Legacy. - (2) Legacy of all or part of the human body under Section 3 hereof may be made by will. The legacy becomes effective upon the death of the testator without waiting for testamentary purposes, the legacy, to the extent that it was executed in good faith, is nevertheless valid and effective, (b) A legacy of all or part of the human body under Section 3 hereof may also be made im any document other than a will. The legacy becomes effective upon death of the {stator and shall be respected by and binding upon his executor or administrator, heirs, assigns, successors-in-interest and all members of the family. The document, which may be a card or any paper designed to be carried on a person, must be signed by the testator in the presence of two witnesses who must sign the document in his Presence. If the testator cannot sign, the document may be signed for him at his discretion and in his presence, in the presence of two witnesses who must, likewise, sign the document in the presence of the testator. Delivery of the document of legacy during the testator's lifetime is not necessary to make the legacy valid. () The legacy may be made to a specified legatee or without specifying a legate. If the legacy is made to a specified legatee who is not available at the time and place of the testators death, the attending physician or surgeon, in the absence of any expressed indication that the testator desired otherwise, may accept the legacy as legate. If the legacy does not specify a legatee, the legacy may be accepted by the attending Physician or surgeon as legatee upon or following the testator's death. The physicion who becomes a legatee under this subsection shall not participate in the procedures for removing or transplanting a part or parts of the body of the decedent.190 (@) The testator may designate in his will, card or other document, the surgeon oF physician who will carry out the appropriate procedures. In the absence of a Uesignation, or if the designee is not available, the legatee or other persons authorized to accept the legacy may authorize any surgeon or physician for the purpose. Section 9. Manner of Executing a Donation. - Any donation by a person authorized under subsection (a) of Section 4 hereof shall be sufficient if it complies with the formalities of a donation of a movable property. In the absence of any of the persons specified under Section 4 hereof and in the absence of any document of organ donation, the physician in charge of the patient, the head of the hospital or a designated officer of the hospital who has custody of the body of the deceased classified as accident, trauma, or other medico-legal cases, may authorize in a public document the removal from such body for the purpose of transplantation of the Organ to the body of a living person: Provided, That the physician, head of hospital or officer designated by the hospital for this purpose has exerted reasonable efforts, within forty-eight (#8) hours, to locate the nearest relative listed in Section 4 hereof or guardian of the decedent at the time of death. Inall donations, the death of a person from whose body an organ will be removed after his death for the purpose of transplantation to a living, person, shall be diagnosed separately and certified by two (2) qualified physicians neither of whom should be: (@) A member of the team of medical practitioners who will effect the removal of the organ from the body; nor (0) The physician attending to the receipt of the organ to be removed; nor (@) The head of hospital or the designated officer authorizing the removal of the organ Section 10. Person(s) Authorized 10 Remove Transplantable Organs. - Only authorized medical practitioners in a hospital shall remove and/or transplant any organ which is authorized to be removed and/or transplanted pursuant to Section 5 hereof. Section 11. Delivery of Document of Legacy or Donation. - If the legacy or donation is made toa specified legatee or donee, the will, card or other document, or an executed copy thereof, may be delivered by the testator or donor, or is authorized representative, to the legate or donee to expedite the appropriate procedures immediately after death. The will, card or other document, or an executed copy thereof, may be deposited in any hospital or organ bank storage facility that accepts it for safekeeping or for facilitation or procedures after death. On the request of any interested party upon or after the testator's Geath, the person in possession shall produce the document of legacy or donation for verification. Section 12. Amendment or Revocation of Legacy or Donation. - a) If he will, card or other document, or an executed copy thereof, has been delivered to a specific legatee or donee, the testator or donor may amend or revoke the legacy or donation either by191 (1) The execution and delivery to the legatee or donee of a signed statement to that effect; or (2) An oral statement to that effect made in the presence of two other persons and communicated to the legatee or donee; or (3) A statement to that effect during a terminal illness or injury addressed to an attending physician and communicated to the legatee or donee; or (4) A signed card or document to that effect found on the person or effects of the testator or donor. (b) Any will, card or other document, or an executed copy thereof, which has not been delivered to the legatee or donee may be revoked by the testator or donor in the manner provided in subsection (a) of this Section or by destruction, cancellation or mutilation of the document and all executed copies thereof. Any legacy made by a will may also be amended or revoked in the manner provided for amendment or revocation of wills, or as provided in subsection (a) of this Section. Section 13. Rights and Duties After Death. - a) The legate or donee may accept or reject the legacy or donation as the case may be. If the legacy of donation is of a part of the body, the legatee or donee, upon the death of the testator and prior to embalming, shall effect the removal of the part, avoiding unnecessary mutilation. After removal of the part, custody of the remainder of the body vests in the surviving spouse, next of kin or other persons under obligation to dispose of the body of the decedent. (b) Any person who acts in good faith in accordance with the terms of this Act shall not be liable for damages in any civil action or subject to prosecution in any criminal proceeding of this Act. Section 14. International Sharing of Human Organs or Tissues, - Sharing of human organs or tissues shall be made only through exchange programs duly approved by the Department of Health: Provided, That foreign organ or tissue bank storage facilities and similar establishments grant reciprocal rights to their Philippine counterparts to draw organs or tissues at any time. Section 15. Information Drive. - In order that the public will obtain the maximum benefits from this Act, the Department of Health, in cooperation with institutions, such as the National Kidney Institute, civic and non-government health organizations and other health related agencies, involved in the donation and transplantation of human organs, shall undertake a public information program. The Secretary of Health shall endeavor to persuade all health professionals, both government and private, to make an appeal for human organ donation.192 Section 16. Rules and Regulations, - The Secretary of Health, after consultation with all health professionals, both government and private, and non-government health organizations shall promulgate such rules and regulations as may be necessary or proper to implement this Act. Section 17. Repealing Clause. - All laws, decrees, ordinances, rules and regulations, executive or administrative orders, and other presidential issuance inconsistent with this Act, are hereby repealed, amended or modified accordingly. Section 18. Separability Clause, - The provisions of this Act are hereby deemed separable. If any provision hereof should be declared invalid or unconstitutional, the remaining provisions shall remain in full force and effect. Section 19, Effectivity. - This Act shall take effect after fifteen (15) days following its publication in the Official Gazette or at least two (2) newspapers of general circulation. Approved: January 7, 1992193 AMENDMENT TO REPUBLIC ACT NO. 7170 - ORGAN DONATION ACT OF 1991 February 20, 1995 AN ACT'TO ADVANCE CORNEAL TRANSPLANTATION IN THE PHILIPPINES, AMENDING FOR THE PURPOSE REPUBLIC ACT NUMBERED SEVEN THOUSAND ONE HUNDRED AND. SEVENTY (R.A. NO. 7170), OTHERWISE KNOWN AS THE ORGAN DONATION ACT OF 1991 Sec. 1. Section 9 of Republic Act No. 7170 is hereby amended to read as follows: "Sec. 9. Manner of Executing a Donation. - Any donation by a person authorized under subsection (a) of Section 4 hereof shall be sufficient if it complies with the formalities of a donation of a movable property. "In the absence of any persons specified under Section 4 hereof and in the absence of any document of organ donation, the physician in charge of the patient, the head of the hospital or a designated officer of the hospital who has custody of the body of the deceased classified as accident, trauma, or other medico-legal cases, may authorize in a public document the removal from such body for the purpose of transplantation of the organ to the body of a living person: Provided, That the physician, head of the hospital or officer designated by the hospital for this purpose has exerted reasonable efforts, within forty-eight (48) hours, to locate the nearest relative listed in Section 4 hereof or guardian of the decedent at the time of death: Provided, however, That the said physician, head or designated officer of the hospital, or the medico-legal officer of any government agency which has custody of such body may authorize the removal of the cornea or corneas of the decedent within twelve (12) hours after death and upon the request of qualified legates or donees for the sole purpose of transplantation: Provided, That such removal of the cornea or corneas will not interfere with any subsequent investigation or alter the post-mortem facial appearance of the decedent by such means as placing eye caps after the said cornea or corneas have been removed, “In all donations, the death of a person from whose body an organ will be removed after his death for the purpose of transplantation to a living person, shall be diagnosed separately and certified by two (2) qualified physicians neither of whom shall be: “(a) A member of the team of medical practitioners who will effect the removal of the organ from the body; nor "(b) The physician attending to recipient of the organ to be removed; nor ) The head of hospital or the designated officer authorizing the removal of the organ."194 See. 2. Section 10 of Republic Act No. 7170 is also amended to read as follows: "Sec. 10. Person(s) Authorized to Remove and Transplant Organs and Tissues. - Only authorized medical practitioners in a hospital shall remove and/or transplant any organ which is authorized to be removed and/or transplanted pursuant to Section 5 hereof: Provided, however, That the removal of corneal tissues shall be performed only by ophthalmic surgeons and ophthalmic technicians trained in the methodology of such procedure and duly certified by the accredited National Association of Ophthalmologists.” Sec. 3. The implementing rules and regulations of Republic Act No. 7170 shall be amended accordingly by the Secretary of Health, in consultation with professional health groups and non-government health organizations, to make it consistent with the provisions of this Act. Sec. 4. The provisions of this Act are hereby declared separable, and in the event any such provisions is declared unconstitutional, the other provisions not affected thereby shall remain in force and effect. Sec. 5. All other laws, decrees, executive orders, administrative orders, rules and regulations or parts thereof which are inconsistent with the provisions of this Act are hereby repealed, amended or modified accordingly. Sec. 6. This Act shall take effect upon its approval Approved: February 20, 1995195 Appendix GUIDELINES FOR MEDICAL EVALUATION OF TORTURE AND ILL-TREATMENT ee Eitective Investigation and Documentation of Torture ant GUIDELINES FOR MEDICAL EVALUATION OF TORTURE & ILL-TREATMENT { sulstatial postion ofthese guidelines have heen ited from the Istanbul Protocol Maral on the other Cruel, Inhuman or Degracling Treatment dr Punishment. Professional Training Seies No.8, page 70-71, United Nations, New York and Geneva p01). These modified guidelines ace the result ofa series of workshops on Recognizing, Desumenting nd Reporting Cases of Torture conducted by the Medical Action Group (MAG) and the PRPPIne ‘Commission on Hunan Rights among health professionals and jail personnel 1 m™. (CASE INFORMATION, Die of exam _____Bvaum requested by (name position)__ ase or report Nos. __Daation of evaluation: _ _ hours, minutes Subjects given name: ‘Birth: __ date: _Blith Place: __ Subjects tamily/niddle nase 1 Gender: male __ temsle__ Reason for exas Subjects ID Nos liniian’s name’ Informed consent: __yes / __ no If no informed consent, wl abject accompanied by (name/position): Peizons prevent during exam (naune' postion} Sabject cesteained dusing exam: __yes / __no; I “yes”, howiwhy? tor ID Nox: Medical report transferred to (namepo Tranoter date _Transier tne’ Medical evaluation investigation conducted ssithout restriction (fr subjects in estody) — yes / — ne Provide details of any restrictions: BACKGROUND INFORMATION General information: ___ occupation status _ education Past medical history Review of prior medical evaluations of tortuce and iltreatment: Paychosoctal history pre-arrest: ALLEGATIONS OF TORTURE, PHYSICAL INJURY & ILL-TREATMENT 1. Summury of detention and abuse 1S. Chteumstances of arrest and detention 4 Iatal and subsaquent places of detention cheronology tanzpestation and detention conditions) 4k. Nowtative account of ill-treatment or torture (in each place of detention) 5. Review of toyture methods196 IV. PHYSICAL SYMPTOMS AND DISABILITIES 1, Acute symptoms andl disabilities 2 Chuonic symptoms and disabilities PHYSICAL EXAMINATION 1. General appearance 2 Sin 3. Face and Hend 4. Eyes, ears, nose and throat Oral cavity and teeth Chest ancl Absdomen (including vital signs) Genito-usinary system & Anal Region 9. Musculoskeletal system, 10. Central and peripheral nervous system IV. PSYCHOLOGICAL HISTORY/EXAMINATION 1, Methods of assessment 2 Curent psychological complaints 3. Post-tostusre history 4 Pre-tosture history 3. Post paychologicalpeychiatric history 6 Substance use and abuse history ‘Mental status examination $ Assessment of soci functioning chological testing 10. Newopsychtogical testing VILPHOTOGRAPHS VULDIAGNOSTIC TEST RESULTS IX. CONSULTATIO? X. INTERPRETATION OF FINDINGS 1. Physical evidence 2. Poychological evidence Xl. CONCLUSIONS AND RECOMMENDATIONS NISTATEMENT OF RESTRICTIONS ON THE MEDICAL EVALUATIONANVESTIGATION197 Appendix I OF TorTURE ANATOMICAL DRAWINGS FOR THE DOCUMENTATION AND ILL-TREATMENT vray anny aes SIN wonsa180d any YoRsaLNWan¥H 4 Aa08 TnED | | veyAND SKELETAL ANATOMY, SUPERIORVIEW. INFERIOR VIEW OF NECK Case No, Date203204 nA en RESTORATION A MSKNG TEETH ARTHEAD-TO-TOE PHYSICAL EXAM Carefully draw any injuries, scars, deformities or irregularities onthe diagrams below and at let. Shape, size, and precise location are important s0 be as accurate as possible, ‘Was woods lamp used? OY ON Floresence noted? oY on (Please mark on graph) REFERENCES wont roc Mans ote eve nestgaton and Dicreren a tae te rc aman nein eter or Phen ceo igh) Commision Human ahs, Utd tons How ons en 200% Pts Conec Univesity a Ete, Uo Kao, 2000. 205206 Appendix J SAMPLE PATIENT SATISFACTION SURVEY we PATIENT SATISFACTION SURVEY This survey is about your overall treatment at the specified hospital, It asks for your opinion about the services that you received at the Emergency Department Your grswers are important and will help the hospital to improve its services to patients. To complete the survey please follow the instructions by either placing an “X” in the appropriate box or writing in your answers as required. REMEMBER, THE SURVEY IS COMPLETELY CONFIDENTIAL, No information that ‘will identify you will be given to anyone at the hospital What was the nature of your visit to the hospital? Q Surgical Q Medical O Pediatrics O Obstetrics & Gynecology O Others On your visit to this hospital, were you admitted? Q Yes 1 No Were you satisfied with each of the following aspects of your experience inthe hospital? DOES gxcettent | very | Goon | FAIR | Poor | NoT | NOT oop SURE | APPLY Warring TIME Waiting time - not having, to wait too long a alalaj/ajfaja when you arrived before being attended to Length of time between a enrages pe eae tceve |e when you were initially attended to and the hospital was able to admit you ‘The time you had to wait a a/ajajafaja for bed207 DOES mesurnt | very | coon | Fair | poor | nor | ROE coop sure | arrty_| CUSTOMER SERVICE Attitude of Sait ‘Admission Staif o Qo Totoayays Medical Staff [=] a Q Q Qa Q Q Nursing Staff a Qo Toroyoata Others, pls specify a ayo y;oaroayeats The way the hospital a ayo y;ay;ayata routine & procedures were explained to you Hoserrat Factrries Well maintained and a ay;oy;ayeyrats clean Conducivetoheatth cate |G Q}a/fafa}lala needs Facilites and equipments |g Q9}a};ajajlalg are functioning properly CoNsutTATION AND MANAGEMENT Doctors The way the doctor/s a aya ;oayfoayatya explained your illness and treatment to you How well the purpose of |G Q9}/afafalala treatment was explained to you and its possible side effects and/or complications Opportunity to ask a Q)/a/fafalala questions about your treatment Your confidence in the a Q/alajalala doctor/s in charge of you ‘Nierses Responsiveness of nurses | aya ;arayeaya to your needs Length of time the Q Q Q lia ere ec Q nursing staff took to respond to your need J208 DOES exerunr | very |GooD | FAIR | POOR | NOT. | ROT Goop. SURE | APPLY ‘The way the nurses a a\/ajajajo)9 explained your treatment toyou DISCHARGE INSTRUCTIONS Were you given written information about how (0 manage your condition at home? O Yes Q No Does not apply Were you told what to do if you had a problem or needed help regarding your condition? OYes No Does not apply Was a follow-up appointment scheduled for you to see a doctor © to the OPD clinic? OYes Q No O Does not apply What is your overall satisfaction rate of your hospital experience? O Very Satisfied OQ. Fairly satisfied Not too satisfied OD Not satisfied at all Q Notsure Comments/Suggestions, if any: Thank you for completing this survey:209 TO_NT SG PAT oN wonsodsia [amy ysoweradg | ssou8eia seppy | vas | atiy | wong soawen for weal ava | 9 Appendix K Various ER Fors WAISIDIY WOO ONIN210 & EMERGENCY TREATMENT RECORD ‘anne of Hopital Adres I TRIAGE RECORD PATIENT INFORMATION [Name (last Given Naaaiey hae = ONG Oa [aeottiah asa Rete ode of evar on ORSEH Ose Ambulance Patent Guardian aor Walkin Parent oss OPaeMo A Prvate vehicle Family {2 Concerned tisen Hospital Pate exon Fnend owes [TAL siaNs; TR [7 r Wage [cuter COMPLAINT lHisTORY OF PRESENT TEENESS REVIEW OF SYSTEMS [ona lee ler lev REP Fever Redness congestion forest pin bow fen ting ferstans Psipations cough Weskowss [sured vison [sre oat Jortopnes puta INausce Loe of vison oorsenes peda era emopayes psetopia fearache leo lwteesng lear dechange lor lor Neuro cg [sa [atdomnal pain loyrana bssascne feck pain ass vomiting Frequency [sectour [ck pain [sweting Iconsipaion INoctaa fines ip pa ones discharge era vagina charge instead gait [snoutder pain ercast masses Hematchena [vapinaecding fsiure ont pin Heratmesie Ppsvcar lores ‘ALL SYSTEMS REVIEWED pessoas Negative [Depression Altotber syste ne fatscinaon| Incomplete duet: fee Loa of Conscousess / Intbated/ Exposure to Toxic Chemicals Notsteeping ‘MEDICAL HISTORY [PAST MEDICATAURGICAL [MEDICATIONS fancy ocr None Nove Jsmoker_ppaX yee frre lrrs tc bev diner [oats fosters ns drag a hypertension Hypertension astina sth Jatercies lcartise fcaraiac cu Admsion ncer R Finnge Oc [pe rime211 I EMERGENCY ASSESSMENT AND DISPOSITION PHYSICAT EXAMINATION DIAGNOSTICS acs Tihood ELECE ace A Usinalys RES BUN Crea Na K C1 Ca Mg P Jarrgrany tet [RRA Ochs Cain OP ric acid LDH Chal TG LDL HDL a vane cscs GALT AST alk phos a Fecalsis [et Sem —Cranad Jura Tare Ja rine srr Dstt asses frais Cervical fap reno Whole acres CO NM CPE Tot ‘0 Jcontast —Astomen fier biomes lat 1 T a Transvagiul THERAPEUTICS (oa Tawa sro et [Medications Team sae RADIOGRAPS REFERRALS: Teme Reason fr Reed Tessie by NURSES NOTES, [pare rise fa212 [a Tresed and decharped rime | 2.Absconded [iscarge Digan [Masietone os DISPOSITION TD Fome Again Mee ACE OER Dest [Dead on Arrival (OOA) [Discharge Pane pal aaa To Tranaer of hospital ‘Ambulance Private ATTENDING RNSCIAN213, (FO Republic of the Philippines 3 ; Department of Health Fi XS ao (Name of Hospital) (Address) CONSENT FORM I HEREBY AUTHORIZE member of the Medical Staff of the (Name of Hospital) toactas Q my Attending Physician / Q Attending Physician of ___ Name of Patient ‘0 perform diagnostic and treatment procedures as may be deemed necessary in the ‘management of the patient. The Attending Physician will not be held responsible for any untoward complications resulting in death, provided he has not been negligent and has expressed utmost professional diligence in patient care. ee PAHINTULOT PARA SA PAGGAMOT PINAHIHINTULUTAN KO ang sinunan sa pangkat ng mga Manggamot ng (Pangalan ng Hospital nna naatasang gumamot Osa akin CD sa pasyenteng si (Pangalan ng Pasyente} na gawin ang kaukulang lunas maging ag-oopera kung nararapat at lahat ng paraang pagsusuri at paggnmot sa inaakalang nakabubuti St may sakit. Hind! ko binibigyang sala ang nasabing gumamot na doctor sa akin Kungmagkaroon ng. kumplikasyon o hindi inansahang_pangyayari nang hindi sa kanyang Kapabayaan at ginawa ang lahat para sa pasyenteng ito bilang ismg manggagamot. ee eereerenecseeee ne EEAEOAE Signature of Patient Date Lagda ng Pasyente Petsa ee eee nee IT Signature of Relative Date Lagda ng Kamag-anak Petsa24 Republic of the Philippines Department of Health (Name of Hospital) (Address) INTERDEPARTMENTAL REFERRAL SLIP To Department From Department Chief Resident Chief Resident. Reason for Referral: a aes Date/Time Referral Slip was sent: Weg ef Peltents EMERGENCY (1 NOT AN EMERGENCY Q CP.CLEARANCE ER Qa warp Q opp O CLINICAL ABSTRACT ee Signature of Referring Dept. Chief Resident Date/Time Referral Slip was received: Plan/Comments of Referral DepartmentRepublic of the Philippines Department of Health (Name of Hospital) (Address) INTER-AGENCY REFERRAL SLIP Date: Health Record No. To: Address: (Hospital, Center, Agency) Request for: Name of Patient: Age: Sex:__ Status: Address: Working Diagnosis: Management: a Reason for Referral: Requesting Physician: Approved by: Consultant/Senior House Officer Patient's Classification: Note: Please accomplish in triplicate form 1. Medical Records File a Agency Referral to Medical Social Worker: 3. Patient Justification: Hospital opp Hospital No. 1 Endorsement Respectfully returned to the Chief with its information Re-Patient Sex EEE of ACTION TAKEN: a COMMENTS AND RECOMMENDATION: OO $$ Attending Physician & Designation Address216 Republic of the Philippines DATE: Department of Health TO: (Name of Hospital) Reason for Referral (Address) ER TRANSFER RECORD. “Type of conduction: ‘Age Sex First Name First Name Middle Name ‘ADDRESS: (CHIEF COMPLAINT: VITAL SIGNS: History of Present Illness: Tnitial Physical and Neurologic examination: ‘Working Diagnosis: Pertinent Diagnostics: Therapeutics: ‘Course in the ER: completely. Patient advised admission but patient/ relatives opted to be transferred to ‘Consequences explained Patient/ Relative's Signature over Printed Name Physician’ Signature over Printed Name217 Republic of the Philippines ‘Department of Health (Name of Hospital) (Address) OPD FOLLOW-UP SLIP DATE/TIME BLOTTER DATE: NO. DEPARTMENT NAME AGE____ HRNo. DIAGNOSIS: TREATMENT DONE: RECOMMENDATION: Scheduled Appointment at OPD: Resident Physician218 RELEASE FROM RESPONSIBILITY Reet eee Time am/pm NAME: ROOM NO.: HRNO.: ADDRESS: ATTENDING PHYSICIAN: This is to certify that I, the undersigned, release the (Name of Hospital) and/or the attending physician from responsibility and liability for any consequence, directly or indirectly due to (check any of the following): 1 Discharge against advice of the attending physician QO Refusal of medication, treatment or diagnostic procedure OQ Refusal of admission in the hospital Q. Taking of photograph for publication Q2 Research studies performed with consent OQ others, please specify if reason is not mentioned above eee Witness Patient’s Kin or Guardian Witness Relationship to Patient State circumstances briefly: tt es Sane eee219 Republica he Pity Deptt of Heth em a ‘ie cunicaL coven test FRTENTSNANE = me TARO ROOM BED/ SERVICE PERN ANENT AOD ERO] Sx oS on or [as up ose aw aN aN. aC GIRTTFIAGE | NATONAUTT REGION JoccUPATION PLOVER type o Bases) DRESS SEERTONENO RTHRS ANE ADRES TELEPFONENG OTHERS Waa Name DOES ELEFHONENO SroosE NANT RDO HaERTONENG SCARE TOTAL OF ENON TOON pare ADMITTING CORR ORITONG RSA SPE OF ADMISSION EES oY ENT caFORWER OPO RRS TCECLASSRIGNNON OA Os Be HCY GOB SS SEER TS HOSPITALIZATION PUAN HEALTH INSURANCE FA [company /ndustal nae), [NAME ss OSS Dependent Sess _ Gass Depenr DATA FNSHED WY OORESSOF FOREN SEEATON TOPATIONT RDNIESION DIAGNOSE RNCIFALDIGNOSS ToSCOEE THER DINGNOSS RNP OPERATION PROCEDURE TER OPERATION / PROCEDURES) RCCIDENT/ NURS FOSONING CODES RCE OFOCCURRENCE RESTS apaayiana— [aremena Jone [aruupsy aes |shous [ano Suaaprves [estou220 Republic of the Philippines Department of Health (Name of Hospital) (Address) ADMITTING HISTORY SURNAME: AGE: HR No: GIVEN NAME: SEX: Ward: ‘CHIEF COMPLAINT PRESENT ILLNESS HISTORY ADMITTING IMPRESSION Admitting Physician Signature over Printed Namean a ai an ae atte 221 Republic of the Philippines Department of Health (Name of Hospital) (Address) DOCTOR'S ORDERS SURNAME: AGE: HR No: GIVEN NAMI Ward: DATE | TIME PROGRESS NOTES DOCTOR'S ORDER‘SURNAME: GIVEN NAME: Republic of the Philippines Department of Health (Name of Hospital) (Address) NURSES NOTES AGE: HRNo, SEX: Ward: DATE/TIME FOCUS DATA, ACTION, RESPONSERepublic of the Philippines Department of Health (Name of Hospital) (Address) NURSES NOTES AND TREATMENT RECORD, 223 DATE / TIME SIGNATURE224 Republic of the Philippines Department of Health (Name of Hospital) (Address) CLINICAL LABORATORY REPORT SURNAME: AGE: HR No: GIVEN NAME: SEX: Ward: 15 4 13 12 11 10 09 08 06 05 03 02 (ATTACHED FIRST LABORATORY RESULT ON THIS LINE)Republic of the Philippines Department of Health (Name of Hospital) (Address) INTRAVENOUS FLUID SHEET 225 SURNAME: AGE: HRNo: GIVEN NAME: SEX: Ward: ———__ —— DATE | SHIFT | BOT. |” KIND OF VOL. ] GTTS. | TIME] REMARK NURSE No. SOLUTION sTD226 Republic ofthe Philippines ‘Department of Health Name of Hospital Address ‘TEMPERATURE RECORD ‘Admission No. Bed No. Doctor Year Month Name of Patient [Bayete [Day of Disease or aays weight lurveName 227 Republic ofthe Philippines Department of Health, ‘Name of Hospital Address ‘THERAPEUTIC SHEET Age Hosp. No. Bed Medication, Dose and Frequency DATE and SIGNATURE ‘Note and Administration HoUuR|Republic of the Philippines Department of Health (Name of Hospital) (Address) OBSTETRICAL ABSTRACT ‘SURNAME: AGE HRNo. GIVEN NAME, SEX: Ward Date Admitied: Date Discharged: FINAL DIAGNOSIS CHIEF COMPLAINT ADMITTING DIAGNOSIS ATTENDING PHYSICIAN ‘Signature Over Printed Name Date Accomplished BRIEF CLINICAL HISTORY: LMP: Epc: | aoc: | [_>———_—_—_ ~—— ‘ABORT PERTINENT PE Bp. cR ‘Temperature GENERALSURVEY —-HEENT — Chest/lungs FY Heart a | Neurological examination Abdomen ana | Extremities229 ‘Course in the Ward: (include medications) Laboratory Findings: (inclading EKG, X-ray and Other diagnostic procedures) Medication: Disposition: (indicate home medication, special instruction and follow-up)230 Republic of the Philippines Department of Health, ‘Name of Hospital “Address MEDICO-LEGAL REPORT DA’ mpm PATIENT ADDRESS AGE SEX ‘CIVIL STATUS DATE OF INCIDENT PLACE OF INCIDENT NATURE OF ACCIDENT BLOTTER PAGE NUMBER NAME & ADDRESS OF NEAREST KIN; NAME & ADDRESS OF PERSON WHO BROUGHT THE PATIENT DATE/TIME OF TREATMENT NATURE OF TREATMENT DIAGNOSIS PROGNOSIS DISPOSITION ER RESIDENT N.B. IF STAB CASE, INDICATE TYPE OF WEAPON (to be accomplished with four (4) copies)231 Republic of the Philippines ‘Department of Health (Name of Hospital) (Address) MEDICO-LEGAL SLIP HR No. Date NAME; Age Sex Date Treated: Diagnosis: i Duration Disposition Resident232 Republic of the Philippines Department of Health Name of Hospital Address CADAVER'S TAG NAME: WARD: _ BED NO. DATE: — ‘TIME OF DEATH PRONOUNCED BY — SERVICE: DR. PERSON TOBE NOTIFIED: ADDRESS: OO PACKED BY: — LINEN USED: — OO