Malaysian Hospital Accreditation Standards 4th Edition January 2013

SERVICE STANDARD 8 Emergency Services

PREAMBLE

All hospitals shall provide Emergency Services by setting up an Emergency Services Department that handles
emergency cases who require immediate examination and treatment. These services shall be provided on a
24-hour basis. The Facility shall identify the scope of Emergency Services to be provided. Where the services
are not available, there is a policy regarding referral to a facility equipped with such services to render
optimum care to the patient, e.g. 3rd and 4th degree burns.

TOPIC 8.1: ORGANISATION AND MANAGEMENT

STANDARD 8.1.1

The Emergency Services shall provide optimum care for patients in a safe, appropriate, efficient, effective,
responsive and caring manner and shall be organised, directed and coordinated with other services in the
Facility according to the goals and objectives of the Facility and to meet the needs of the patient population
being served.

CRITERIA FOR COMPLIANCE:

8.1.1.1 There are documented purposes which may be termed Vision and Mission statements, goals,
objectives and values that suit the scope of the Emergency Services. When compiling the
purposes, consideration shall be given to the following:

a) They are what the services want to achieve.

b) The scope of Emergency Services.

c) The goals of the service are achieved by the objectives as stated.

d) The goals and objectives are consistent with professional standards, guidelines and
relevant legislation.

e) Statements are monitored, reviewed and revised as required accordingly.

8.1.1.2 There is an organisation chart which:

a) provides a clear representation of the structure, function and reporting relationships

between the Head and the staff of the Emergency Services;

b) is accessible to all staff;

c) includes off-site services if applicable;

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d) is revised when there is a major change in any one of the following:

 organisation;
 functions;
 reporting relationships;
 goals and objectives;
 staffing patterns.

8.1.1.3 There are written and dated specific job descriptions for all categories of staff that include:

a) qualifications, training, experience and certification required for the position;

b) lines of authority;

c) accountability, functions, and responsibilities;

d) review when required and when there is a major change in any one of the following:

 nature and scope of work;

 duties and responsibilities;
 general and specific accountabilities;
 qualifications required and privileges granted;
 staffing patterns;
 Statutory Regulations.

8.1.1.4 Regular staff meetings which include medical practitioners are held to discuss issues and matters
pertaining to the operations of the Emergency Services. Minutes are kept and accessible to
relevant staff.

8.1.1.5 Personnel records on training, staff development, leave and others are maintained for every staff.

8.1.1.6 The Head of the Emergency Services is involved in the planning, management, and justification
of the budget and resource utilisation of the services.

8.1.1.7 The Head of the Emergency Services is involved in the appointment and/OR assignment of the
staff.

8.1.1.8 The Head of the Emergency Services shall ensure that the staff of Emergency Services complete
incident reports which are discussed by the department with learning objectives and forwarded to
the Person In Charge (PIC) of the Facility.

8.1.1.9 Incidents reported have had Root Cause Analysis done and action taken to prevent recurrence.

8.1.1.10 Appropriate statistics and records shall be maintained in relation to the provision of Emergency
Services and used for managing the services and patient care purposes.

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STANDARD 8.1.2: CONTINUITY OF CARE

Where the Facility does not have the facilities or medical skills to render optimum care to the patient,
arrangements shall be made for transfer to another facility or appropriate treatment centre after performing
basic resuscitation or stabilisation.

CRITERIA FOR COMPLIANCE:

8.1.2.1 When arranging for patient to be transferred to a receiving facility, communication between the
facilities is established, if necessary, ensure that appropriately qualified staff accompanies the
patient. All the relevant clinical details need to be documented and communicated to the
accompanying staff and the team receiving the patient.

8.1.2.2 Close working and formal arrangements shall exist with:

a) other departments of the Facility;

b) the ambulance service and other appropriate transport services;

c) other local healthcare agencies operating within the Facility’s catchment area;

d) non-clinical functions of the Emergency Services i.e. reception and clerical services.

8.1.2.3 The Emergency Services shall play a key role in operations of emergency and disaster plans,
e.g. internal or external disaster including plan for a quick response when cardiac arrest occurs
within the Facility, e.g. Code Blue Team.

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TOPIC 8.2: HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

STANDARD 8.2.1

The Emergency Services shall be under the supervision of a registered medical practitioner with training and
experience in emergency medicine. It shall be staffed with appropriately qualified and licensed personnel to
achieve its objectives.

CRITERIA FOR COMPLIANCE:

8.2.1.1 The direction of the Emergency Services by the Head shall be provided by a registered medical
practitioner and the staffing shall be by individuals qualified by education, training, experience
and certification to meet the demands of the various positions and to achieve the objectives of
the services.

8.2.1.2 The authority, responsibilities and accountabilities of the Head of Emergency Services are clearly
delineated and documented in a letter of appointment.

8.2.1.3 Sufficient numbers of personnel and support staff with appropriate qualifications are employed to
enable the services to meet the documented purposes.

8.2.1.4 There is a structured orientation programme where new staff including medical practitioners are
briefed on their services, operational policies and relevant aspects of the Facility to prepare them
for their roles and responsibilities.

8.2.1.5 Staff including medical practitioners receive written evaluation of their performances at the
completion of the probationary period and annually thereafter, or as defined by the Facility.

8.2.1.6 There is evidence of a staff development plan which provides the knowledge and skills required
for staff to maintain competency in their current positions as the demands of the positions evolve.

8.2.1.7 There are continuing education activities for staff including medical practitioners to pursue
professional interests and to prepare for current and future changes in practice. There is
evidence that staff education and development needs have been appraised and identified.

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TOPIC 8.3: POLICIES AND PROCEDURES

STANDARD 8.3.1

A reliable and consistent triage system shall be established and used to assess all patients on arrival.

CRITERIA FOR COMPLIANCE:

8.3.1.1 Triage shall be performed by a medical practitioner or a trained paramedical staff to assess and
direct the patient to the appropriate zoning area taking into account the degree of urgency and
clinical condition of the patient.

8.3.1.2 The zoning areas shall be well demarcated and appropriate to the degree of urgency and clinical
condition of the patient.

STANDARD 8.3.2

Documented policies and procedures shall reflect current knowledge and evidence based practices for the
services; and they are consistent with the objectives of the services and relevant regulations and statutory
requirements.

CRITERIA FOR COMPLIANCE:

8.3.2.1 There are written policies and procedures for the Emergency Services and they are consistent
with the overall policies of the Facility.

8.3.2.2 Policies and procedures are developed in collaboration with staff, medical practitioners,
Management and where required with other external service providers and with reference to
relevant sources involved.

8.3.2.3 Policies and procedures are dated, authorised, signed and reviewed at least once every three
years and revised as required.

8.3.2.4 New and revised policies and procedures are communicated to all staff.

8.3.2.5 There is evidence of compliance with policies and procedures.

8.3.2.6 Copies of policies and procedures, relevant Acts, Regulations, By-Laws and statutory
requirements are accessible to staff.

8.3.2.7 A working relationship exists with police and other relevant governmental and non-governmental
agencies.

8.3.2.8 All patients shall be correctly identified on arrival at the Emergency Services. Identification is best
achieved by a facility registration system and utilisation of the Health Information Management
System (HIMS) Services.

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8.3.2.9 Where staff provide direct care to patients, documentation is made in the patient’s medical record
that care has been given. Where appropriate, response to care is recorded by the care provider;
signed, dated and designation documented.

8.3.2.10 Seriously ill patients shall have appropriate monitoring, observation, and documentation of these
activities at all times. There is a policy stating which patients must be admitted and which
patients can be observed in the emergency room and for how long before patient must be
admitted, e.g. patients requiring ventilation support, severe burns must be admitted.

Notes/Explanations

Monitoring shall continue during transfer to other areas of the Facility or other facilities and the
patient shall be accompanied by an escort capable of dealing with complications. In some cases,
the escort shall be a medical practitioner or a trained nurse.

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TOPIC 8.4: FACILITIES AND EQUIPMENT

STANDARD 8.4.1

Appropriate facilities and lifesaving equipment are available to enable the Emergency Services to meet its
goals and objectives to provide safe, effective and efficient emergency care.

CRITERIA FOR COMPLIANCE:

8.4.1.1 The Emergency Department shall be clearly and visibly sign posted and easily accessible with
facility design that facilitates the care process.

8.4.1.2 There is adequate and proper utilisation of space and equipment to enable staff to carry out their
professional and administrative functions.

8.4.1.3 There is documented evidence that equipment complies with relevant standards, e.g. those set
by SIRIM Berhad (Standards and Industrial Research Institute of Malaysia) and current statutory
requirements.

8.4.1.4 There is evidence that the facility has a comprehensive maintenance programme such as
predictive maintenance, planned preventive maintenance and calibration activities, to ensure the
facilities and equipment are in good working order.

8.4.1.5 Where specialised equipment is used, there is evidence that only staff who are qualified and
privileged by the Facility operate such equipment.

8.4.1.6 The Emergency Services are equipped with the minimum requirements in terms of equipment
and medications. Additional equipment may be required to meet the goals and objectives of the
Emergency Services and the Facility depending on the level and scope of Emergency Services.
Minimum requirements are:

a) Equipment and other functionalities:

i) Airway Adjuncts, Endotracheal Intubation Equipment and End-tidal CO2

detectors, Oxygen Delivery Equipment, Alternative Airway Devices
ii) Breathing (Ventilation) Support Equipment and Respiratory Care including
ventilator, nebuliser devices and suction apparatus
iii) Vascular Access Devices and Circulatory Support including Intravenous
Administration Sets, Fluids and Infusion Pumps
iv) Defibrillator and Emergency Cardiac Care Equipment including 12 Lead ECG
machine and Transcutaneous pacing depending on the level of care provided.
v) Patient Body Thermal Control Equipment
vi) Fluid Warmers, Storage for Blood products and Special Emergency Drugs
vii) Limb, Neck and Spine Immobilization and Protection Equipment
viii) Patient Vital Parameters Monitor including Blood Pressure, Pulse Rate,
Respiratory Rate, Pulse oxymetery, Cardiac Monitoring and temperature.
ix) Wounds, Soft tissue and Burns Care Sets

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x) Point of Care or Bedside (Rapid) Diagnostic Tests or Support including blood

sugar analyser.
xi) Bedside Imaging Devices or Support
xii) Paediatric Emergency Care Equipment and Length Based Chart/Tape for
equipment sizing and emergency drug dosing
xiii) Obstetric Delivery Equipment
xiv) Emergency Patient Care Beds
xv) Emergency Carts, Organizer/Storage Systems for Equipment and Drugs, IV
Poles and Emergency Drug Labels
xvi) Patient Transfer Equipment and Safety Restraining Devices
xvii) Personal Protective Equipment (PPE)
xviii) Antiseptics and Disposables.
xix) Decontamination Services for Patient and Equipment

b) Medications in formulations or form that reflect current standards as indicated by the

International Liaison Committee on Resuscitation (ILCOR), American Heart Association’s
Emergency Cardiac Care Committee (Core ACLS drugs), and other accepted emergency
and resuscitative care best practices, deemed necessary for it to optimally meet goals
and objectives of the Emergency Services and the Facility:

i) Oxygen
ii) Antianginal – at least Sublingual Glyceryl Trinitrate (GTN)
iii) Antiarrythmics
 Adenosine
 Amiodarone
 Digoxin
 Lidocaine
iv) Antihypertensives
 ACE inhibitors
 Beta Blockers
 Calcium Channel blockers
v) Antidotes
 Activated charcoal
 Flumazenil
 Naloxone
vi) Antiepileptic
 Diazepam
 Phenytoin
vii) Antihistamines
 Chlopheniramine
viii) Antiplatelets
 Aspirin
 Clopidogrel
ix) Atropine
x) Bronchodilators, Theophylline (aminophylline) and nebuliser preparations

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xi) Corticosteroids
 Hydrocortisone, dexamethasone
xii) Inotropic drugs
 Dobutamine
 Dopamine
 Adrenaline
 Noradrenaline
xiii) Fibrinolytic or thrombolytic agents
xiv) Furosemide
xv) Glucose 20%
xvi) Insulin
xvii) Heparin: unfractionated (UFH) or low molecular weight (LMWH)
xviii) Intravenous Solutions: crystalloids including Saline, Dextrose containing
Solution, Hartmanns, Paediatric solutions, colloid including Mannitol.
xix) Drugs to facilitate intubation: Induction agent
 Thiopentone
 Ketamine
 Midazolam

xx) Drugs to facilitate intubation: Muscle Relaxant

 Suxamethonium
 Rocuronium

xxi) Drugs to facilitate intubation: Direct Reversal for Rocuronium

 Sugammadex

xxii) Magnesium Sulphate

xxiii) Calcium Chloride
xxiv) Opioids
 Morphine
 Fentanyl
xxv) Analgesics
 NSAID
 COX-2 inhibitors
xxvi) Sodium Bicarbonate

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TOPIC 8.5: SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

STANDARD 8.5.1

The Head of the Emergency Services shall ensure the provision of high quality performance with staff
involvement in the ongoing safety and quality improvement activities of the Services.

CRITERIA FOR COMPLIANCE:

8.5.1.1 There is evidence that the Head of the Service has in a written document assigned
responsibilities to appropriate individuals/committees for safety and quality improvement
activities within the services.

8.5.1.2 There are planned and systematic safety and quality improvement activities that monitor and
evaluate the performance of the services including a plan for action and follow up to ensure that
the action taken is effective in continually improving the quality of care. Innovation is advocated.

8.5.1.3 There are safety and quality improvement activities in place which support the Facility’s safety
and quality improvement activities including tracking and trending of specific performance
indicators not limited to but at least two (2) of the following:

a) i) waiting time relative to Triage Category: Malaysian Triage Category (MTC) Red seen
immediately (100%)
ii) waiting time relative to Triage Category: Malaysian Triage Category (MTC) Yellow seen
within 30 minutes (≥80%)
iii) waiting time relative to Triage Category: Malaysian Triage Category (MTC) Green seen
within 90 minutes (> 70%)

b) unplanned return of patient seen at Emergency Department within 24 hours for a similar
complaint

c) percentage of patients seen at Emergency Department hospitalised.

Notes/Explanations

Reports are available on indicators include tracking and trending for specific performance
indicators carried out.

8.5.1.4 Feedback on results of safety and quality improvement activities are regularly communicated to
the staff.

8.5.1.5 Appropriate documentation of safety and quality improvement activities is kept and confidentiality
of staff and patients is preserved.

8.5.1.6 There are safety and quality improvement activities that address staff safety.

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