A

Guide Book
for

H o s pi t a l
Adm i ns t r a t o r s

1
 Index

C H A P T E R - I ........................................................................................................................... 3
HOSPITAL ADMINISTRATION AS A SPECIALITY................................................... 3
C H A P T E R - II .......................................................................................................................... 9
MANAGEMENT OF THE HOSPITAL SERVICES...................................................... 9
JOB DESCRIPTION: .................................................................................................... 11
CHAPTER 3.1 .............................................................................................................................. 33
OUT PATIENT SERVICES .......................................................................................... 33
CHAPTER 3.2 .............................................................................................................................. 49
IN PATIENT SERVICES ............................................................................................. 49
CHAPTER 3.3 .............................................................................................................................. 59
INTENSIVE CARE SERVICES ................................................................................... 59
CHAPTER 3.4 .............................................................................................................................. 78
ACCIDENT AND EMERGENCY SERVICES ............................................................ 78
CHAPTER 3.5 .............................................................................................................................. 97
OPERATION THEATRES............................................................................................ 97
CHAPTER - IV ........................................................................................................................... 114
NURSING AND WARD MANAGEMENT ................................................................. 114
CHAPTER V ............................................................................................................................... 122
LABORATORY SERVICES ....................................................................................... 122
RADIOLOGY SERVICES........................................................................................... 136
BLOOD BANK SERVICES......................................................................................... 145
C.S.S.D. ........................................................................................................................ 192
LINEN AND LAUNDRY SERVICES ......................................................................... 200
DIETARY SERVICES ................................................................................................. 215
MORTUARY SERVICES............................................................................................ 217
HOUSEKEEPING........................................................................................................ 231
CHAPTER VI.............................................................................................................................. 241
COMMUNICATION SYSTEM IN HOSPITAL .......................................................... 241
CHAPTER VII............................................................................................................................. 247
RECORD MANAGEMENT IN A HOSPITAL ........................................................... 247
CHAPTER VIII............................................................................................................................ 261
USE OF COMPUTER IN HOSPITALS..................................................................... 261

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 CHAPTER-I

HOSPITAL ADMINISTRATION AS A SPECIALITY

INTRODUCTION
As we step into the new century, the population of India has surpassed 1000 million mark. Half of the
population is likely to be below 20 years of age and approximately one fourth will be above 60 years.
Resurgence of some old dreaded epidemics like TB, Plague and mounting threat from newer one like AIDS,
Cancer and stress related diseases and conditions arising out of man made disasters have necessitated
hospital services of today to be more responsive to social and economic needs at shortest possible time, both
qualitatively and quantitatively. Added to this, the breaking down of old traditional system of joint family,
increasing number of working couple has led to the demand of more hospital beds for therapeutic and nursing
care for old and sick particularly for terminal care, institutional deliveries in the nursing homes or hospitals
rather than at home in family environment and so on.
Experience has shown that the workload in an Indian hospital doubles every 8 to 10 years particularly in terms
of OPD attendance, emergency case load indoor admissions, surgeries and diagnostic investigations. But
while analysing the growth of hospital facilities in major metropolitan cities, there has been only a marginal
increase in the number of beds vis a vis population during the last few decades. As per statistics available we
have one hospital bed per 1412 population. The goal of bed population ratio in our country of one bed per
thousand population by the year 2000 as projected in the National Health Plan, seems to be still a distant
dream. The overcrowding and over stretching of services therefore has increasingly resulted in the poor
patient care outcome, particularly in government sector hospitals.
Out of total 13692 odd hospitals in the country, about one-third hospitals are in the rural areas and two third
are located in the urban areas. The government owns about two third of all such hospitals comprising around
35 percent of country’s total bed component. Although private sector owns only one third of hospitals but the
number of beds in private sector constitute just above sixty percent of total hospital beds available in the
country.
Hospitals all over the world account for a significant proportion of health care expenditure regardless of health
status of the population or income levels of the country. Largest share (60-80 %) of health resources goes
to hospitals. So many of the efforts to control health resources in the developed world are normally focussed
on hospitals.
The review of health sector in our country particularly the government sector suggest that the significant
expenditure on hospitals involve a great waste of resources because of the technical and managerial
inefficiency within the hospital system. Hospitals independent of its profit or non-profit status, is in principle
subject to the same economic rules, which are valid for any industrial set up. The rule of effectiveness,
efficiency and quality form the framework for industry and health care sector alike. So the hospital
administration needs to be radically strengthened to respond to two different issues of hospital management,
cost containment on one hand and patient satisfaction and improving patient care on the other hand. The
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concept of professionalisation, development of specialized skills and leadership in Hospital Administration has
to be re-emphasized so as to rationalize the resource utilization and maximize outcome in health sector.
In our country, particularly in Government Sector, doctors who have attained the position by virtue of the
service seniority or a specialist from a most demanding clinical discipline manage most of the hospitals. On
the other hand a trained (professional) administrator with multidisciplinary training and knowledge base has
shown that he can ensure the economic use of resources, standardize hospital and equipment design, prevent
and control overuse of expensive drugs and collect the data for evaluation of performances in a similar line to
that of a corporate production or service unit.

Development of Hospital Administration as a specialty

The coordination and management of hospital activities has increasingly called for specialized skill for which
the profession of hospital administration has emerged. This is in recognition of the fact that to direct and
manage a hospital, it is necessary to have special knowledge, develop specific skills and establish certain
time-tested strategies.
The emergence of hospital administration as a medical sub- specialty and the genesis of the professional
hospital administrator can be traced back to the days when management science from business and industry
made inroads into the social sector and service industry. Rockefeller Foundation and Dr. Michael David did
pioneering work in this area in the early 1920s and 1930s. The Health Survey and Planning Committee in India
popularly known as “Bhore Committee” had also the foresight of visualizing hospital administration as a
specialty, and the subsequent health committees constituted by Govt. of India have re-iterated the need of
hospitals being administered by professionally qualified hospital administrators.
Taking a cue from that, All India Institute of Medical Sciences started the Pioneer postgraduate (PG) course in
hospital administration in year 1966, as part of its commitment to research, patient care and development of
medical education. The PG course leading to Masters in Hospital Administration is the first of its kind in the
field and has been adopted in many more medical and professional institutes in the country. Such medical
post graduate course has since been recognized by Medical Council of India as a special stream of medical
specialty. The National Board of Examination for various medical specialties is also conducting examination
and awards the degree of Diplomatein Health and Hospital Administration. Subsequently, a number of other
non- medical professional institutions also started similar programs to meet the market demand of such
trained manpower. However, it is seen that there is no uniformity of the training curriculum and no formal
system of coordination amongst such institutions other than the Medical Council of India recognized medical
institutions.
In order to equip the practicing hospital administrators with the knowledge and skill of hospital administration,
a large number of in service training program for senior and middle level managers are frequently organized
by public sector undertakings, Training division of Department of Personnel, Govt. of India, Director General of
Health Services and various State Governments. Similar, programs are sponsored by International Hospital
Federation, World Health Organization, Indian Hospital Association, Academy of Hospital Administration and
other professional bodies.
Globalization of the economy has resulted in sweeping changes in the health scenario. Particularly the
emergence of tertiary cares corporate hospital, resulting in a greater challenge to the hospital administrators of
the twenty first century. This has resulted into a need for reassessment of all such education program in the
field of Hospital Administration so as to identify thrust area of development and make the training program
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more meaningful, need based and market oriented. A National workshop on Curriculum Development was
held in the year 1997 at Manipal, India, and also in Nizam’s Institute of Medical Sciences, Hyderabad during
June, 99 has recommended some changes in the existing syllabus of the post graduate course of Hospital
Administration with focus on topics like capital financing, marketing techniques, management information
system, business laws and regulations, companies Act management, import procedures, custom duty
exemption procedures and so on. It was also stressed upon that in order to make such training programs.
Community Health oriented, more emphasis is to be given on public health related issues like AIDS Cancer
and Diabetics Control Program, alternative system of medicine; quality and legal aspects of hospitals. Topics
on risk management, organization and administration of super specialty services were also suggested to be
incorporated to the syllabus.
It is also recommended that for adequate skill development to the trainee meeting the real life situations in
hospital management, an organized apprenticeship program needs to be organized or rotation training on the
lines of internship program in medical curriculum. Such an approach would go a long way in sensitizing the
students doing the courses in the major challenges of hospital administrators today. For post graduate
residents in the medical stream emphasis should be given more on communication skills and marketing of
hospital services and areas of Hospital Financial Management, this has been acutely felt while evaluating such
hospital managers trained in the field from the existing training program. In the absence of a regulatory
authority or a professional body for all the post graduate programs in non-medical stream of hospital
administration programs, like ACTE or any professional body like Medical Council of India led to the absence
of any standards and lack of uniformity in curriculum has been identified during evaluation of such courses.
So in order to give a credential to all such courses as well as to maintain a standard concrete steps have to be
taken by the concerned human resource development authorities. The number of seats in the various courses
offered in such courses are also found to a pittance, compared to the number of jobs available in the market
(both public and private sector); it is strongly felt that the course curriculum should be dovetailed into the
existing problem areas and more such courses should be started for middle and senior level administrators of
the hospitals in our country.
Hospital and primary health care: Today it has been established beyond doubt that the goal of Health for all
by 2000 AD has become a distant dream with the present health care strategy. So it is becoming an absolute
necessity in collaborating of hospital services with the primary health care program. The array of programs
under the ambit of primary health care programs will need the support of hospitals for health promotion and
preventive action, as well as for treatment and rehabilitation. It has to take charge of those patients who need
specialized care and has to refer back those who do not need this to the periphery in a sort of referral system
which should function both ways. Without adequate technical and financial inputs from the hospitals - primary
health care as a strategy cannot succeed.
Hospitals and Primary Health Centers (PHC) are complimentary to each other and PHC cannot exist in
absence of referral support of hospitals. Hospital managers of tomorrow will have to be aware of socio
economic conditions and health problems of the community.
Technological revolution and Hospitals: The present century has witnessed a technological revolution and
the hospitals of all size and dimension have been involved and influenced tremendously in terms of cost and
manpower requirement. The present day hospitals are technology intensive organisations. Some of the salient
technological innovations being advances in telemedicine, sharing of patient information database, use of
laparoscopic methods of surgery, stereotactic surgical methods using “Gamma Knife and X knife”? advance

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in Molecular Biology and Genetic engineering, diagnostics like CAT Scan, MRI and PET, use of newer
generation of antibiotics. So much so that the computer software magnate Bill Gates has also stated
emphatically that if the present century belonged to computer technology, the next century will belong to
“health care technology” and “sky will be the limit”.
Hospital managers of tomorrow will have to be well versed with these technologies - various brands and
options available in the diagnostic and therapeutic equipment, their selection, procurement, utilisation,
maintenance, cost benefit and cost effectiveness analysis and so on.
Medical profession and Consumer Protection Act : In India, with the recent judgement of the Hon’ble
Supreme Court by bringing those Govt. and private hospitals, which are charging for the services within the
ambit of the Consumer Protection Act, the accountability of the hospitals have increased. The more aware
and literate consumer has increasingly demanding more from the hospitals and the hospitals have to be
responsive to it. The negative side of this, of course, is the doctors practising “defensive medicine” which is
bound to increase the cost of medical care for the community. Hospital managers have also added the
responsibility of protecting the clients from the malpractices of health care functionaries and also protecting
the latter from unnecessary litigations.
Rising costs and hospitals : As a consequence of all these factors and also due to inflation and overall
increase of price rise there has been a tremendous increase in the cost of health care. Not only is the
establishment of a hospital a costly affair but also the maintenance and cost of patient care is increasing
manifold. The time is fast approaching when the Govt. alone cannot afford the medical bills of all its citizens
hence the Insurance companies and third party payment systems have been recognised to be saviour and
such multi national insurance companies are knocking at our doors. In fact in this era of funding limits and
resource crunch, the government has given the go-ahead to proposals which allow charging from patients
especially in super specialty and tertiary care government centres. Hospital Managers of tomorrow will have
to take part in the process of cost containment on one hand and resource mobilisation on the other hand.
Quality of care in hospitals : With the modern world obsessed with quality, the hospitals have not been left
behind. Hospitals are forever striving to provide quality services in order to carve out a niche for themselves in
the market driven world, and some private hospitals have started quality control departments/units to monitor
quality services. ISO certification of hospital and hospital services are some of the new phenomena being
witnessed presently. The recently introduced Citizens Charters in some hospitals is a pointer in the same
direction. Increase in super and sub-specialisation results in “team” approach, thus necessitating co-
ordination amongst a group of professionals. Setting up of accreditation schemes is the call of the day.
Hospital managers will have to be trained in quality assurance techniques, organising quality circles, medical
audit and may be reengineering of Hospital Management in the professional line.
Privatisation of health care and rise of corporate hospitals While reviewing the proceedings of the
Central Council of Health Ministers meeting held in 1996 the Minister of Health gave a clear indication call for
the private and voluntary sector to step in and assume responsibility for the tertiary level of health care in
hospitals. Going hand in hand with the resource crunch and the rising costs, there has been the rise of the
corporate hospitals so much so that the (World Health Report) WHR-2000 mentions that in our country about
5.9% of GNP is being spent on health of which the private sector alone spends 4.6%. These corporate
hospitals with their five star rates and sound marketing strategies have created a considerable number of
devoted clients and have usurped the pre-eminent position of government run hospitals. The rise in the
corporate hospitals is also pre-dominantly due to opportunities provided to them by virtue of huge demand

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supply gap in terms of quality services as perceived by the consumer of health care. The objectives of the
private hospitals are not same as that of the government hospitals. Unlike government hospitals, making a
profit is one of their prime objectives. The hospital managers of tomorrow will therefore require training in
organising and managing such private hospitals also, in fulfilling their objectives, in understanding the
relationship with the owners, trustees and also with the consultants and the medical professionals.
Market approach in Health : It has been established beyond doubt that the present day need is the
revamping of older system of “free” medical care for all and a new approach is needed which should match
the needs and demands of the users. In other words there has to be a shift from seller’s market to `buyer’s
market approach in order to meet the present challenge. It has to be self sustaining through its own funds and
should be capable of updating and adapting itself continuously to the realities. The hospital managers will
have to be well versed with the modern marketing techniques in order to sustain the organisation in the
competetive market.
In the words of Werner G. Fack “the hospital managers of tomorrow needs a qualified academic education on
different levels (for example, a bachelor, Master and Doctor’s degree). The necessary professional
knowledge of a junior hospital manager includes all kinds of economic sciences, applicable to hospitals, such
as statistics and economics; management methods and techniques of organisation; personal management
and development; finance management; controlling; clinical information system, marketing, product
diversification, quality management; risk management; health care policy; health care economics and
planning, communication, information and conflict management, administrative systems; cost containment in
health care system; management of health care and hospital care; environment conservation; sociology,
health law, social insurance ,low costing and pricing of health care and hospitals; logistics emergency
management, human relations, human resource technology; cooperation and fusion of health care and
hospital care; technical management and so on.
Each hospital manager of tomorrow needs continuous work related education, with sufficient qualifications
and expertise Manager with thorough knowledge of medicine, nursing, general and medical techniques i.e.
interdisciplinary qualified manager will be the winner. Hospital administration as a specialty has
therefore established its own position with the established body of knowledge and job specific skill in the
modern scientific society.

Job Opportunities for Hospital Managers

With the growth of corporate style of health care system and services there is a significantly expanded market
and demand for health services managers, administrators and executives. As per James N. Heuerman, Vice
President of an executive placement firm in San Franscisco, the real action for health managers in 90’s will be
in outpatient services, insurance firms, consulting firms and association and long term and ambulatory care
facilities etc. Similarly, Michael D. Cover, Managing partner of an international executive search firm in
Chicago predicted 500-1000% increase in opportunities in non-traditional setting by the year 2000 along with a
contraction in management jobs at traditional acute care hospitals because of down sizing and consolidations.
Accordingly hospital managers of tomorrow will have to be trained to visualise the future possibilities and to
act accordingly.
The salaries of top health managers in the developed country are competitive with those of industrial and
financial executives and there is growing need for people with specialties in areas such as finance, marketing,
operations, quality assurance and research.
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The above is equally true in our country also, although in India and other developing countries, the situation is
yet to establish such scope in a firm footing but nevertheless, it has tremendous scope if hospital managers
are trained according to the needs of the day. The following chapters will deal with few important basics for
the operational efficiency of a hospital and are described as procedural guidelines.

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 C H A P T E R - II

MANAGEMENT OF THE HOSPITAL SERVICES

The very reason for the existence of hospitals is to care for the sick and injured and at the same time, it has to
facilitate many other functions like the training and education of the physicians, nurses, nursing aides,
dieticians, social workers, physical therapists and other personnel who are involved in many activities related
to health care of the community. One of the important function of the hospital is also to organise the
prevention of disease and the promotion of health. Likewise the research in clinical medicine and nursing is
also dependent on a functionally efficient hospital. At the same time, when the hospital is to render to the
community a high quality of clinical service including the support function on a broad scale; competent
personnel, good facilities and effective organisation are the basic necessity.
The person incharge of the hospital management function has to oversee the management on behalf of the
governing council or the trustee or the owner of the hospital. If it is a Government hospital on behalf of the
Ministry of Health be it a State or Central government organisation, the manager is expected to be
accountable to the public for its efficiency and quality of the service. The manager on behalf of the
management has to maintain the hospital premises and equipment in best possible status and to procure and
buy goods for all time need and also has to deal with the press and with patient’s relations and other members
of the public. The most important function is to oversee that the patients in the hospital receive the best
medical care which can be provided within the resources available at his disposal.
The hospital organisation has to have its functional head who is normally designated as the Medical Director,
Medical Superintendent or the Chief Executive, depending on the ownership of the hospital. The Chief
Executive is expected to have under him who functions as the departmental managers and form a very
heterogeneous group. They include, at one end of the scale managers of the medical and nursing units,
individual clinical consultants, chiefs of surgical and medical teams, ward sisters and sister in charge of
theatres and outpatients department. There are also departmental manager in the paramedical support
services areas, like X-ray and imaging, pathology, Pharmacy, Physiotherapy, Medico-social work and so on.
At the other end of the scale comes heads of “Hotel” service departments, like domestic or house keeping
services, catering officers, laundry managers, Business Managers or Finance people, building supervisors
and the rest. The job of each such functionaries is more managerial. They also have to have more
supervisory training but what all these people have in common and makes them managers, is that each one of
them uses resources and each one of them exercises control over a recognisable functional unit. The
managers or sub-managers or unit head conducts the unit’s affairs in consultation with other managers and
even without reference of overall management except on matters of general policy.
The basic service of Hospital Management revolves round the concept of Professional Clinical Care. The
primary concern of clinical care of the patients are of the physician or that of the Surgeon, who are in
possession of the professional permit within the frame work of scientific medical practice.
Nursing Service: The Matron or the Chief Nursing Officer or the Nursing Superintendent is the head of the
Nursing Services of the Hospital and her main function is to see that all the patients who attend the hospital
receive good nursing care, she or he has also to ensure co-operation with the doctors engaged in the hospital
and to ensure that every consideration is given for the general well being of the patients during the process of

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medical care and recovery of the patient. The Chief Nursing Officer is also responsible for the recruitment and
training of nurses and for their health and welfare. The nursing management has also to ensure that the
hospital wards are scrupulously cleaned and maintained. Other important functions of nursing management is
provisioning and supplies of medicine and other material required in the patient care areas and are
standardized depending on the type of the hospital and patient care need.
These entire different group of people be they the doctor, the nurse or the visiting patient or their relation and
see the hospital in their own perspective. To the patient the hospital is a place where he is expected to get
treatment for relief of pain and suffering. The domestic and catering staff of the hospital is to provide hotel type
of services for house keeping and also provision of meals to the sick patient. The engineering and
maintenance staff has a place where the building, plant and fixtures are kept clean and to ensure all the
drainage, sewerage and water supply are maintained in a proper working condition. To all these people the
hospital is a place of employment and for the professionals like the Resident doctors, nurses or the
technologists it may be a Institute or place of learning and practice their vocation. For the Medical Director or
the Chief Executive the Hospital is an organization with a specific objective and goal to be achieved within a
framework of rules and regulation. When a doctor or a nurse in the hospital organization or any other
functionary is negligent towards the patient or his assigned responsibility the hospital authority is legally liable
for their negligence. Similarly omission or commission on the part of the other staff, resulting in quality of care
of the patient is to be attributed to the hospital authority in the eyes of Law. The Medical Director or the Chief
Executive is therefore the authority accountable for all these matters. So it is expected that the Medical
Director or the Head of the Institution have to take all decisions concerning the hospital functioning. His job is,
to plan, to organize, to motivate and control and this is termed as basic managerial function. Coordination of
all the activities in the hospital is the added dimension of his responsibilities. All Managers at the departments
and the sub-departments level are to exert the management function under the overall control of the Medical
Director or the Chief Executive of the Hospital. In our health service set up such a Chief Executive is
commonly designated as Medical Superintendent.
Thus the manager or the Medical Superintendent is to see that every employee in the hospital is responsible
for the assigned job to him and is also accountable for the same. It also means, he is answerable to his
supervisor or manager for doing the job that has been assigned to him. Maximum possible delegation of
power to the departmental manager should always be the aim of the Medical Director or the Medical
Superintendent. The notion of this delegation links to the accountability in the hospital service. It is however to
be kept in mind in all situations, that responsibility should never be delegated without delegation of
commensurate authority to match it. The standard financial control and accounting technique are to be
maintained at all the level of hospital management. It is essential to estimate that all the expenditure are
subjected to the maximum possible accuracy and budgetary approval, and at the same time step are to be
taken to monitor the actual rate of spending so as to identify the variation from the expected rate.
Budgetary control is a standard way of checking the fund disbursement and expenditure as the financial year
progresses and maintain the hospital services within the available resources. Internal audit for such purpose is
a recognized tool in organization like hospital. The function of the internal auditor is to plug the wastage and to
identify the deviation of financial rule by the hospital authority. The internal auditor should be responsible to
the chief executive or the medical superintendent as the case may be and he should not be involved in the
hospital expenditure and accounting of the hospital finance. In our country cost control in the hospital services

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has not been started as an organized activity, but as a modern approach to hospital management it has
become one of the primary function of the hospital manager in the developing economy.
In order to enumerate the authority and responsibility of the hospital functionaries it is necessary to a have a
clear cut organization set up with proper job descriptions and job specifications at all levels of hospital worker
for each type of hospitals. This is the starting point for any hospital administrator, worth the name to be
successful in his job. One of the basic approaches for a successful hospital administrator is to develop an
organization manual for the hospital concerned.
Organization Manual: Organization manual in a hospital aims to describe the structure of the hospital
organization and the various job or position, which are to be listed only by the title on the charts. Usually this
includes the organizational charts as well and other indoor position related information that may be helpful for
any of the members of the organization to know about the overall objective of the hospital, the policies and
working principle in the organization. This manual also should include the various guidelines and methods to
be applied for conducting the job and achieving the goal of the hospital.
A workable hospital manual provides many important advantages. While preparing such a manual the
corporate objective or the institutional objective and the work necessary to attain these should be made amply
clear for all those who go through it. Such a step will always be a safeguard against duplication of duties and
responsibilities avoiding a possible point of conflict. A manual may also be used to acquaint the members of a
complex organization like hospital, with the way in which the different positions or the jobs interact with each
other and it also becomes helpful tool for the members of the staff to know his position in the organization.
Lastly a properly prepared manual lets each person know the extent of his decision-making powers and thus
allows the staff to proceed with more confidence in his job. Such a manual may also have some negative
aspects, like if there is a too detailed job description that may lead to strict compartmentalization of each job
and eventually it may be self-defeating. Some of the manuals if very voluminous and poorly written, it may
confuse the people rather than enlightening them.
Most of these contradictions can be overcome when the job descriptions are broad enough to permit the
exercise of ingenuity and flexibility and at times some change can be incorporated as and when a job
incumbent changes. Some organizations use the manual as a guide rather than as a manual.

JOB DESCRIPTION:

Each worker in an organization is expected to know which tasks he or she is responsible for. But often there
are parts of a job, which are not clear. Details of tasks vary from place to place. These are occasions when no
one knows who should do odd things that do not fit into one “station” or another.
If no one is given official responsibility for these tasks, no one does them. Job descriptions prevent those
gaps, and they also prevent overlaps, that is, two people both doing the same task. Job descriptions are tools,
which help the manager to organize the details of the work, and which help everybody else to feel absolutely
clear about what the others expect of them.
Job descriptions should not be the bulk of the hospital manual. To prevent the manual from becoming too
unwieldy, generally there should be “cut off” point below which the jobs are not to be described. However, in
the hospital situation it is seen that hospital administrator desires that job descriptions of all the job be made

11
so as to make effective supervision at all levels and at the same time it can be an useful document in case of
disputes with unions over assignment of job.
Each job description should begin with a basic objective or mission of the job. Then the major duties should
be enlisted which are to be performed by the incumbent in order to accomplish the mission. These are to be
enumerated either in the order of their importance or in the order of the amount of time that will be spent on
them.
For each responsibility the nature of accompanying authority must be listed as and when it is applicable. The
nature of the authority in each area may be described whenever it is practicable in terms of decision-making
powers:
These may be like clear indication of whether the incumbent has:
i. Complete freedom to make decision
ii. Complete freedom to make decisions but with the obligation to report the Decision made
within a given time limit
iii. Authority to make decision only with prior consultation and approval.
Preparation of the hospital manual should be rested on one person, although it may be the contribution of a
number of personnel of the organization that is involved in the Hospital Management.
Job description should normally indicate the title of the job, relation to other staff, working hours, contents of
the job, and special job instructions.
The manual should preferably be in loose-leaf form so that revisions as and when required could be made
reviewed and revised accordingly once a year or once a quarter or whenever a major change is effected in the
hospital. If there is any major policy change or structured change in the organization there should also be
immediate change in these manual in the form of new job descriptions or position whose responsibilities and
authority have been changed. So a loose-leaf manual will be handy for deleting the obsolete material and
incorporate new pages.
Availability of the manual should always be ensured to all unit heads and departments for overall coordination.
It is also to be seen that each one of the workers, whose jobs are included in the manual, should have a copy
of the manual for his or her understanding and compliance
The following are few model job descriptions of some important functionaries in a general Indian hospital.

MODEL JOB DESCRIPTIONS:

DUTIES AND RESPONSIBILITIES OF OFFICERS OF HOSPITAL ADMINISTRATION
The duties of the Medical Superintendent, Deputy Medical Supdt., Asstt. Medical Supdt., Administrative
Officer, Welfare Officer, Nursing Supdt. and Dietician are as follows :

MEDICAL SUPERINTENDENT OR CHIEF OF THE HOSPITAL SERVICES

1. Planning, medical supervision and coordination
2. Medical consultation/operations/ward work (for the clinicians who continue patient care activities)
3. Teaching (not exceeding three hours a week to be arranged preferably in one or two sessions)
4. Financial and administrative functions - administrative work which should be performed specifically by
the chief of the Hospital, under the rules and cannot be delegated to lower levels, the matters of

12
 general principles and policy in hospital administration, sanction of all kinds of leave to gazetted staff;
appeals of Class-C and Class-D staff against decisions at lower levels (appropriate authority).
5. Appointment and discipline authority for class-D staff

ADDITIONAL MEDICAL SUPERINTENDENT OR DY. MEDICAL SUPDT

One or two depending on the size of the hospital
1. Day to day routine medical administration of the hospital subject to the control and general supervison
of the Medical Supdt.
2. Administrator incharge of
a) Emergency Deptt.
b) Out patient Deptt.
c) Inpatient Deptt.
3. Medical examination (overall in charge of medical examination cell)
4. Hospital infection control services
5. Sanction of free treatment of indigent patients and routine administrative matters like public relation
6. Matters concerning treatment of patients, enquiries and their complaints and related parliamentary
questions
7. Medical records for medico-legal cases and court summons relating to them.
8. Matters relating to residents doctors and nurses hostel
9. Supervise the “Asstt. Medical Supdt.” on their functioning of support service areas.
10. Call duty after office hours
11. Any other duty that may be specified by the Medical Supdt. from time to time.
12. Transport - Controlling, maintenance and repair of staff cars, station wagons, load carrying vehicles
and other vehicles of the hospital - Detailing of ambulance staff cars, station wagons and load carrying
vehicles.

MEDICAL OFFICER/ASSISTANT MEDICAL SUPERINTENDENT

1. Sanitation
2. Medical stores responsibilities
3. Surprise stock verification of stores and cash
4. Transport and ambulance fund
5. Support service areas like blood bank, laboratory, Dietary, Central Sterile Supply, Hospital sanitation,
Medical social work, linen and laundry service.
6. Security and fire fighting
7. Maintenance of plant and equipment
8. Communication
9. Call duty after office hours
10. Any other duty that may be specified by the Medical Supdt.from time to time.
11. Maintenance of hospital buildings and liaison with CPWD

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MANAGER (Admn. & Pers.) (Administrative officer in a govt. set up)
1. Incharge of logistics and establishment
2. Maintenance of personnel files of all employees
3. In charge of time keeping machine and leave records of all employees
4. Issuing of show cause notices on their disciplinary processes against class-II and class-III and IV
employees
5. Member of enquiry committees, when required
6. In charge of advertisement for fresh appointments
7. Assisting Dy. Medical Supdt. and CEO in planning and development of the hospital and image building
by organising various neighbourhood camps, participating in government health programmes,
empanelling Public Sector Undertakings and other organisations
8. In charge and coordinater of all legal matters
9. Survey and operational research work
10. Fixation of pay of Class-III and IV staff and sanctioning their leave
11. In charge of vigilance

FINANCE MANAGER (Finance Advisor, Finance and Accounts Officer, depending on the size of the hospital.
The position may be at a senior level in a large hospital. To be assisted by middle level officer with clear cut
division of different Finance functions)
1. Maintenance of daily collection and expenditure account
2. Authorised signatory for financial transactions of the hospital
3. Drawing and disbursing authority for pay and allowance of the hospital employees
4. Detail scrutiny of purchases, salary bills and passing of contingent bills
5. Maintenance of all financial accounts
6. Preparation of cash flow statement and profit and loss statement every month for the CEO
7. Work hand in hand with the company secretary for increasing the value of the hospital in the share
market
8. Pursuing and collection from debtors
9. Payment to vendors in time
10. Payment of salary, gratuity, advances when approved in time
11. Technical advice in costing
12. Conducting internal/external audit in consultation with the CEO
13. Joint custodian of cash along with accounts officer

DUTIES AND RESPONSIBILITIES OF MEDICAL STAFF

HEADS OF DEPARTMENTS
The Heads of Departments are to be responsible for the proper and efficient functioning of their respective
departments, keeping in view the over-all requirements of the institution and specific needs of hospital
services. For the purpose they are authorised :
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1. To deploy and utilize staff and equipments etc., and to delegate functions in any manner as and when
they consider necessary in the best interest of the institution and functioning of the constituent units. In
this matter, they are expected to keep close liasion with the Medical Supdt. In all major matters prior
consultation/concurrence of the Medical Supdt. should be obtained.
2. To sanction casual and restricted leave of the non- gazetted staff working in their departments in
accordance with the existing rules and order for which they will keep proper record.
3. Departmental correspondence as well as leave applications of the staff (excluding casual leave) and
including their own casual leave applications will continue to be submitted to the Medical Supdt.
While sanctioning casual leave and submitting other leave applications/proposals in respect of the
staff and their own, it will be ensured that satisfactory alternative arrangements have been made and
these will be recorded on the applications. In case satisfactory internal arrangements are not possible,
the leave applications/proposals should however be submitted with specific recommendations/
suggestions. Mere forwarding of applications/proposals will be presumed as NO OBJECTION to the
acceptance of the proposal/request etc.
The Heads of Department will, in addition, perform duties as assigned by the Medical Supdt. from time to time.

HEADS OF UNITS
1. The heads of units will be responsible for the medical care and attention of all patients admitted to
their units (indoor, emergency wards, etc.) and coordinate with Additional Medical Supdt. for smooth
functioning of the clinical and patient care areas in their charge.
2. The heads of units must see all patients as soon as possible after admission. For serious cases, the
heads of the units must ensure immediate consultation/examination as considered necessary and the
same should be properly recorded.
3. During the stay of patients in the wards, the heads of units should exercise continuous personal
attention to all seriously ill cases as also to other cases and should be available for consultation in
cases of need in respect of patients in their units.
4. No patient should ordinarily be discharged from the hospital except on instruction from head of the
unit.
5. It would be the special responsibility of the head of the unit to ensure that the case sheets of
the patients are maintained properly and is chronological order and a true and faithful record of
various events in connection with his treatment, referrals and progress in the hospital is kept.
Completion of all medical records of the patients under his/her treatment.
6. Patients should be placed on the “seriously ill list” or “Dangerously ill list” as the case may be by the
Head of the unit, and such list should be sent to the enquiry (Central Admission Registry) daily. In all
these cases heads of units must explain to the relatives about patients’ condition.
7. The head of the unit should ensure consultation with his colleagues in case of need. The consultant
requested would similarly record his observations in the case sheets. Urgent consultation should be
so mentioned and consultations arranged without delay.
8. In case of surgical operations adequate operation notes regarding the surgical approach used,
findings at the operation and operative procedure done, and post-operative orders should be written.

15
9. The heads of the units will be responsible for the proper maintenance and up-keep of the ward in his
area and also ensure submission of timely indents of the various articles required for the treatment of
the patients in the ward. The head of the units under guidance from the head of the department of the
speciality should lay down definite procedure to be adopted in case of emergencies and also ensure
that the staff working under him has been thoroughly drilled in the techniques to be followed.

GENERAL DUTY OFFICERS

1. The Junior Medical Officer of the unit wll work in collaboration with the Senior Resident of the unit and
supervise the day-to-day work of house surgeon and interns.
2. He will accompany the physician/surgeon incharge for ward rounds.
3. On the day when physician/surgeon incharge is not available for ward rounds, the Junior Medical
Officer will take rounds of his own ward. It would be his sole responsibility to contact the
physician/surgeon and discuss about the serious cases in the ward and if necessary to show these
cases to the physician/surgeon.
4. He will scruitinise the clinical documents completed by the house staff and make corrections where
necessary.
5. The senior-most GDMO will allocate night duties by rotation to house staff in consultation with the
respective registrars/senior resident of different units and will ensure that the respective staff is
available for duty. The duty roster will be hung up in the duty rooms on the board indicating the name
and unit. The next on duty will be shown in the same list. In case the duty officer is not available for
urgent reasons, the next on duty will act for him.
6. On day of admission he will be available in the afternoon and evening till relieved by the
Registrar/Senior Resident by 1900 hours. He will ensure that all patients have received attention and
necessary discharges from Accident and Emergency Department have been affected. He will report to
the physician/surgeon in charge by phone whenever available.
7. He will also attend to referred cases till the evening. Thereafter, registrar will take the responsibility of
referred case.

REGISTRARS (WHEREVER APPLICABLE) /SR. RESIDENTS:

He is responsible for clinical care of the patient as well as local ward administrationl.
1. Sanitation and cleanliness of wards: The Registrar/ Sr. Resident, will take a sanitary round with the
ward staff before he starts his professional work and ensure cleanliness of the ward. He will cooperate
with the ward staff to maintain discipline in the ward.
2. The Registrar/Sr. Resident will be directly responsible for supervision of patient care in his unit with
the assistance of junior residents or house-surgeons.
3. He will be contacted by the Junior Resident on duty in case of emergency, if he thinks necessary, he
should consult the physician/surgeon in charge of the unit or G.D.O. when available.
4. He will go through all the case notes written by house surgeon and will make corrections where
necessary
5. Besides taking round in the wards during day time, he will daily take round late in the evening with the
house-surgeon on call.

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6. On admission days, he will attend to cases referred for medical opinion from other wards. If
necessary, he may contact the physician/surgeon in charge for necessary advice.
7. In case of death, it is his responsibility to scrutinize that case documentation is complete in every
respect and will write a brief summary of the case, before it is sent to the Medical Records Section.
8. He will maintain a book to indicate the patients in his care who would need attention after the night
rounds and he will apprise the duty house staff of such cases.
9. He will maintain a register to indicate that the relatives of seriously ill patients are informed through the
central registration office of the hospital. This is also applicable in case of patients absconding from
the ward and also in case of death.
10. When house surgeon are not available, he will carry out all the duties of a house surgeon.
11. Registrars/Sr. Residents will certify death.

HOUSE SURGEON
1. He will take advice from Registrar or Sr. Resident for guidance and efficient execution of professional
care of his patient.
2. In OPD house staff will refer the case to the Registrar/ Senior Resident or the G.D.O. with a short
history and physical findings of the case written on the OPD card.
3. House staff is primarily responsible for the case allotted to him. Besides, he would have a general idea
of all the cases in the ward. As soon as a case is admitted, patient will be examined by the house
surgeon who will complete the case sheet in all details. He will then show the case to the
Registrar/Senior Resident or G.D.O. He will see that all necessary investigations are done in time, and
entered in the case sheet.
4. In case of acutely ill patients, it is his responsibility to show the case immediately to the
Registrar/Senior Resident or G.D.O. for advice.
5. He will enter the daily follow up of the case in case sheet. In case of seriously ill patients the progress
of the case will be recorded every time the patient is examined.
6. On admission days one house physician will be physically present on duty in Accident and Emergency
Deptt. during OPD timing for attending to cases admitted there. After the OPD closes, two house
surgeons will be present on duty throughout the day in Accident and Emergency Deptt. In the night
one house surgeon will be on duty in Accident and Emergency Deptt.
7. On other days the house surgeon, junior resident on duty should be present in the doctors duty room.
8. On Sundays and Gazetted holidays all house surgeons junior residents will come for rounds in the
forenoon. In the afternoon and thereafter only one house surgeon junior resident will be on call duty.
9. Night emergency duty in ward (from 2100 to 0800 next day) - House surgeons from each unit/sub-unit
will be on emergency duty in the night for the respective units in addition to one resident staying in
Accident and Emergency Deptt. The senior resident on night call will apprise himself by direct contact
with the Registrar/Resident about cases that would need special attention.
10. Laboratory and X-ray registration - Requisite forms for laboratory and X-ray registration should be
filled in the previous evening with full clinical notes for routine cases. In emergency it should be done
immediately. The requests for investigation should be collected in time to be useful.

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POST-GRADUATE STUDENTS (RESIDENTS):
1. They will attend the OPD on the scheduled OPD days of the unit to which they are attached.
2. They will go through and examine all the cases admitted in their respective units and attach a review
of the case on a separate sheet of paper. They will go through the recent medical literature available
on all aspects of the case and add it to the review of the case. During ward rounds they will discuss
the case with the physician/surgeon.
3. They will attend the clinical meetings and present cases for the same.
4. For all purposes they will work in collaboration with the Registrar/Senior Resident.
5. They will not certify “death” and will not discharge a medico-legal case without the permission of the
ward in charge. under the technical guidance of senior resident or the Registrar. Clinical duties and
assignment of the patient care duties will be organised as per the teaching schedule of the
department. For all practical purpose they will be responsible for patient management to the
consultant or faculty in charge of the case through his senior resident.

INTERNS
1. They will work in collaboration with the house surgeon/ junior resident.
2. They will attend OPD on the admission days of the unit to which they are attached.
3. In the wards they will be allotted beds. They will examine the patients on the beds under them and
complete their case sheets.
4. They will work in the clinical side-room and do routine blood, urine, stool and sputum examination of
the cases under their care.
5. They will be on emergency duty in Accident and Emergency Department according to the duty roster
prepared by the Department.
6. They will attend special clinics, run by their units on the respective days.
7. Interns will neither prescribe treatment nor certify deaths.

MISCELLANEOUS CATEGORY

WELFARE OFFICER/LABOUR OFFICER/PUBLIC RELATIONS OFFICER

STATUTORY FUNCTIONS :
Staff Welfare and Reconciliation comprising inter alia
1. Establishing contacts and holding consultation for maintaining harmonious relations between hospital
management and its staff.
2. Projecting before the management the individual and collective grievances of staff for securing
expeditious redress.
3. Acting as a negotiating officer with association and trade unions of staff and workers.
4. Assisting management in formulating labour policies and interpreting these policies to the workers.
5. Exercising restraining influence over staff going on illegal strikes and help in peaceful settlement of
legal strikes.

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6. Helping workers to adjust and adapt themselves.
7. Ameliorating their working conditions.
8. Prompting management - staff relations which will ensure productivity and efficiency.
9. Securing provision of staff amenities like canteen, drinking water facilities etc.
10. Personnel matters relating to Class-IV staff

OTHER FUNCTIONS

ATTENDING TO
1. Complaints of and assistance to patients
2. Complaints against employees
3. Liaison with police, NDMC etc.
4. Personal problems and other difficulties of the staff
5. TV shows, sports activities and get-togethers
6. Call duty after office hours
7. Any other duty as may be specified by Medical Supdt. from time to time.

Financial Controller/Advisor
1. Preparation of the hospital revenue budget
2. Drawing and disbursing officer for pay and allowance of the hospital establishment
3. Processing of cases, drawl and disbursement of various advances admissible to and claimed by staff
4. Detailed scrutiny of store purchase/salary bills, passing of contingent bills etc.
5. Maintenance of financial accounts
6. Processing and collection of demands of dues of the hospital
7. Maintenance of accounts relating to non-government funds
8. Pension cases
9. Joint custodian of cash exceeding Rs.5000/- with the cashier
10. Endorsement of service books of staff in token of having checked them with the pay bills
11. Financial advice
12. Technical advice in costing
13. Any other duty that may be specified by the Medical Supdt. from time to time

STORES OFFICER
1. To work directly under the control of Medical Supdt. who is responsible for stores management
2. To ensure stocking different stores items in the Scientific manner as per the law

NURSING STAFF

CHIEF NURSING OFFICER (C.N.O.)

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1. She/he will be responsible for efficient running of Nursing Services of the hospital .
2. She will assist the Chief Executive of the hospital in formulating broad policies concerning Nursing
services.
3. She will disseminate the aim, objectives and policies regarding patient care to all cadres of nursing
services.
4. She will implement policies and procedures of hospital regarding nursing services.
5. She/he will plan future requirements of nurses and carry out recruitment of nurses from time to time.
6. She/he will plan and disseminate programme for continuing education re-orientation programmes for
nurses.
7. She/he will closely liase with other hospitals regarding improvement of patient care.
8. She/he will encourage research by nurses in their work areas.
9. She/he will guide and counsel the sub-ordinate nursing staff.
10. She/he will keep herself abreast of latest happenings in nursing care by attending National/
International conferences.
11. She will strive to implement standard nursing practices and maintain highest quality of care.
12. She will critically analyse the budgets for nursing services from main hospital and various centres
before being forwarded to Director.
13. Evaluate confidential reports of higher level nursing officers and recommend for promotion.
14. She will be assisted in her duties by Nursing Supdt.s .
15. She will keep the CEO informed about the happenings concerning the hospital.

Nursing Superintendent
Nursing Superintendent is responsible to the C.N.O. for planning organisation and development of
nursing services in the hospital in consultation with Medical Superintendent.
1. She will be responsible and overall incharge of Nursing services in a hospital or specialized centres
irrespective of the number of beds.
2. She will be responsible to the Medical Supdt. or Addl. Medical Supdt. or Chief of Centres of the
hospital or centre as the case may be.
3. She will be responsible for implementing hospital policies amongst various nursing units.
4. She will assist the CNO in formulation of hospital policy, particularly concerning nursing services.
5. She will officiate as CNO in the absence of CNO (The senior most amongst the NS will do so).
6. She will recommend personnel and material requirement for running various nursing service
departments of the hospital.
7. She will assist Medical Supdt./Addl. Medical Supdt. in recruiting nursing staff.
8. She will carry out regular rounds of the hospital.
9. She will accompany Medical Supdt./Addl. Medical Supdt. while making hospital rounds.
10. She will ensure safe and efficient care rendered to patients in various wards etc.
11. She will prepare budgets for nursing services.
12. She will be member of various condemnation boards for linen and other hospital stores.
13. She will be responsible for counselling and guidance of sub- ordinate staff.
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14. She will attend hospital/intra hospital meetings and conferences.
15. She will investigate all complaints regarding nursing care and personnel, and take suitable corrective
action.
16. She will initiate and encourage research in nursing services.
17. She will evaluate confidential reports of her subordinate staff and recommend for promotion, higher
studies etc.
18. She will maintain cordial relations with patients and medical social workers.
19. She will periodically interact with clinical heads to discuss problems in patient care.
20. She will educate nursing staff of all categories by conducting awareness programme on universal
precautions.

DEPUTY NURSING SUPERINTENDENT

Deputy Nursing Superintendent is responsible to the Nursing Supdt. and assist her in the administration of
nursing services in the hospital.

A. NURSING ADMINISTRATION
1. Supervise the nursing care given to the patients in various departments by taking regular round of her
area.
2. Act as a liaison officer between Nursing Supdt. and the nursing staff of the hospital.
3. Interpret the policies and procedures of the nursing service department to subordinate staff and
others.
4. Attend the emergency calls concerning nursing services or hostel problems.
5. Receive evening and night reports from the Assistant Nursing Supdt./Supervisors.
6. Keep records and reports of Nursing services
7. Maintain the records of attendance of nursing staff and leave of any kind.
8. Conduct regular physical verification of hospital stocks, i.e. drugs, equipments etc.
9. Initiate procedure for condemnation and procurement of hospital equipment/linen etc.
10. Maintain the confidential report and records of nursing personnel.
11. Assist the nursing supdt. in making muster duty roster for nursing personnel.
12. Assist the nursing supdt. in recruitment of nursing staff.
13. Assist the nursing supdt. in planning and organising nursing services in the hospital.
14. Officiate in the absence of nursing supdt.
15. Attend the official meetings.

B. EDUCATIONAL ACTIVITIES
1. Assist in planning/organising and implementing staff development programmes.
2. Ensure clinical experience facilities for student nurses in various clinical areas of the hospital.
3. Provide guidance and counselling to nursing staff.

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4. Arrange orientation programmes for new nursing staff.
5. Maintain discipline among nursing personnel.
6. Organise educational programes for graduate/ post graduate students from different hospitals with the
coordination of clinical instructor/lecturer college of nursing

C. GENERAL DUTIES
1. Escorts special visitors, Nursing Superintendent, Medical Superintendent for hospital rounds.
2 Arranges and participates in professional and social functions of the staff and students.
3. Maintains good public relations.
4. Any other duties assigned to her from time to time.

ASSISTANT NURSING SUPERINTENDENT

Asstt. Nursing Supdt. is responsible to Deputy Nursing Supdt. for the total nursing care of patients,
management and development of the unit assigned to her :-

A. NURSING CARE :
1. Assist the total needs of patients in the Unit and prepare planned nursing care.
2. Demonstrate and supervise the nursing care of patients in the unit.
3. Attend regular rounds in the unit with the medical and nursing personnel.
4. Reviewing reports from Sr. Gd.I regarding the nursing care of patients in each shifts.
5. Give counselling and health education to the patients and their attendants.

B. WARD MANAGEMENT :
1. Plan and arrange duty for nursing personnel posted under her.
2. To ensure availability of adequate nursing staff in all shifts.
3. Maintain cleanliness of unit its annexes and environment.
4. Liase with the engineering service department for proper up keep of the unit.
5. Keeping Deputy Nursing Supdt., Nursing Supdt. , informed of the needs of the patient care areas and
bring to to their notice any speical problems.
6. Guide the sister Grade-I to ensure supplies and equipments of different stores, and re-checking their
use and care.
7. Daily check of emergency and dangerous drugs, life saving equipments i.e. monitors, ventilators,
defibrillators, suction machines and O2 points etc., to ensure their proper functioning.

8. Periodical check of all stocks and supplies

9. Maintain good inter personnel relationship with all categories of staff, patients and their relatives.
10. Maintain good public relation with patients relatives and the public, and project positive image of the
hospital.
11. Maintain discipline of nursing and domestic staff.
12. Interpretation of hospital policies, rules and regulations.

22
13. Daily check of attendance and reporting the lapses.
14. Investigate complaints if any
15. Work evaluation and confidential reports
16. Guidance and counselling of nursing staff in the unit
17. Project the annual requirements of drugs supplies and equipments for the units.
18. Take care of legal aspects and report about the medico legal cases in the ward.

C. TEACHING AND SUPERVISION

1. Plan and implement a proper orientation programme for new nursing staff, student nurses and
domestic staff.
2. Participate in the service education of nursing personnel and attend the meetings
3. Give incidental and planned teaching to nursing personnel in the unit, as well as domestic staff.
4. Participate in clinical teaching for student nurses in co- operation with the nursing tutor.
5. Perform any other duties assigned to her for time to time.

NURSING SISTER GRADE-I

The Nursing Sister Grade-I is responsible to the Assistant Nursing Superintendent for the total care of patients
in the wards and supervision of the Nursing Sister Grade-II, student nurses and domestic staff. She would
also be assisted by Nursing Sister Grade-II. Clinical and domestic staff. The main aim of the Sister Grade-I
should be to foster team spirit in her area of work as a team leader.

A. NURSING CARE OF PATIENTS

1. Assess the total needs of patients and prepare plan of nursing care
2. Admission and discharge of patients
3. Demonstrate and carry out efficient nursing care, taking care of personal comfort and toilet of patients,
administration of drugs and treatment, observation and recording of vital parameters.
4. Supervise patients diet
5. Attending rounds with medical/nursing personnel
6. Assist medical staff in examination of patients and treatment
7. Participate and help with clinical investigations/ procedures
8. Demonstrate and carry out preoperative and post-operative care of patients
9. Maintenance of patient’s records
10. Care of patient’s personal effects in accordance with hospital rules
11. Giving and receiving reports
12. Follow prescribed rules in case of accident or death of a patient.
13. Give information and health education to patients and their attendants
14. Intimation to nursing supervisors of any emergency or unusual occurrence in the ward

B. WARD MANAGEMENT

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1. Handing over and take over charge of patients at the end of the shift.
2. Assignment of work to nursing sister Grade II and domestic staff.
3. Coordinate and facilitate work of other staff, e.g. physical therapist, social worker, dietitian, voluntary
worker etc.
4. Maintaining good inter personal relationship among all categories of staff and with patients and their
relatives.
5. Maintain cleanliness of ward, its annexes and environments.
6. Proper upkeep and repairs of linen and ward equipment.
7. Make indents for drugs, surgical supplies, stores and issue
8. Keep custody of dangerous drugs and record of their administration.
9. Daily check of emergency drugs and life saving equipment.
10. Maintenance of stock registers, inventories.
11. Investigate complaints if any.

C. TEACHING AND SUPERVISION

1. Orientation of new staff and student nurses.
2. Participate in service education of nursing personnel and attend staff meetings
3. Impart planned and incidental teaching
4. Supervise sister Grade-II and student nurses
5. Supervise domestic staff
6. Consult and cooperate with nursing tutor in arranging clinical teaching
7. Perform any other duty as may be specified from time to time.

NURSING SISTER GRADE-II

Nursing Sister Grade-II is directly responsible to Nursing Sister Grade-I (ward in charge) for total nursing care
of the patient assigned to him/her.

A. DIRECT PATIENT CARE

1. Admission and discharge of the patients
2. To maintain the personal hygiene of the patients, including bathing, care of mouth, back, nails, hair
etc.
3. Care of pressures points as needed
4. To assist the patient in elimination, offering and removing the bed pans and urinals.
5. Bed making
6. Assist in feeding the weak and debilitated patients
7. Writing of diet sheet, supervision and distribution of diets
8. Assist in physiotherapy, ambulation and rehabilitation
9. Carry-out patient’s teaching and demonstration according to the need
10. Counselling the patients, and relatives

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11. Care of the dying and dead
12. Administration of medicine and injections to the patients
13. Assist in administration of intravenous injections, infusion and transfusion
14. Observing, recording and reporting of vital signs e.g. T.P.R. and blood pressure
15. Carry out technical procedures, such as Naso-gastric intubation, gastric lavage, oxygen therapy,
Dressings and irrigations, Enema, Catheterisation, hot and cold applications, suction etc.
16. Collecting, labelling and dispatch of specimens
17. Preparation for and assistance in clinical tests and medical/ surgical procedures
18. Urine testing for sugar and albumin
19. Observation, recording and reporting of all procedures and tests.
20. Escorting serious patients to and from the department/ wards.

B. WARD MANAGEMENT
1. Handing over and taking over charge of patients and ward inventory in each shift.
2. Maintenance of therapeutic environment in the ward
3. Keeping the ward clean and tidy
4. Routine care and cleaning of dressing trolleys, cubboards, apparatus, mackintosh etc.
5. Care of clean and soiled linen
6. Disinfection of linen, beds, floor and bed pans, and fumigation of rooms etc.
7. Preparation of room, trolleys and sets for procedures.
8. Preparation of surgical supplies
9. Maintaining interpersonal relationship with patients, relatives and healthy team members
10. Orientation of new staff/ students
11. Demonstration and guidance to student nurses
12. Participation in staff education and staff meetings
13. Participation in professional activities
14. Demonstration and supervision of domestic staff
15. Report about the medicolegal cases if any admitted in the ward
16. Any other duty that may be assigned by Sister Grade-I from time to time

GROUP D CATEGORY

Hospital Attendant/Ward Boy

1. He will receive the patients on admission and assist the patient in getting into or out of bed.
2. He will attend to the personal hygiene of patients, washing and cleaning teeth, changing clothes,
giving enema etc.
3. He will prepare the patients for operations, laboratory x-ray and other investigations.
4. He will transport patients to various departments in the hospital.
5. He will help in feeding patients and giving drinking water to patients and washing utensils.

25
6. He will assist the nurse in handling and observation of patients and in simple basic nursing procedure.
7. He will assist the nurse or doctor in diagnostic and treatment procedures.
8. He will assist in collection and handling of pathological specimens.
9. He will assist the nurse in receiving supplies by running errands to other departments of the hospital
and in carrying messages to other departments and individuals in the hospital.
10. He will make beds for ambulatory patients and assist the nurse in making beds of non-ambulatory
cases.
11. He will assist the nurse in getting supplies from the laundry, disinfecting mattresses and dispatching
dirty linen to the laundry.
12. He will clean and do dusting of beds, doors, windows and other furniture. He will assist in debugging
and pest control of wards.
13. He will wash walls and doors in wards.
14. He will assist in sterilisation of instruments.
15. He will render first aid to patients in case of emergency.
16. He will prepare dead bodies, arrange for their transportation to mortuary and assist in terminal
disinfection.
17. He will do any other duty that may be assigned to him.

For general guidance a model functional organisational chart of a speciality hospital is drawn which can be
followed by incorporating major features of the job description of the key functionaries of a hospital
organisation.

PROCEDURE GUIDELINES AND STANDING ORDERS

For model general hospital In order to promote efficiency and effectiveness of all aspect of the Hospital
Services, it is advisable to systematise and standardise the procedures of Hospital Management within the
broad policy frame work of the organisation. The Director/Medical Superintendent of the Hospital exercises
command by issuing various orders for its operation. In a very small hospital much can be accomplished by
personal contacts but as the hospital increases in size it becomes a necessity to have larger number of
guidelines, procedures and its relationships therefore have to be defined in explicit terms and should be
published as a inhouse hospital document for its compliance.

Nature of the guidelines

Amongst the various types of orders issued from time to time in an organisation there are some which may be
of a permanent nature and some may be for one time use relating to solving some problem of temporary in
nature. These orders or guidelines are usually defined or described to explain certain procedures,
authority,responsibilities,position,classificationor interdepartmental relationships. These normally do not
change frequently even if there are changes of the incumbant. Such orders may be the reiteration of policies
and regulations laid down by higher authorities, put into practices, and has become a convention in
organisation. Such orders usually form the most part of a hospital manual or it can be termed as hospital
procedural guide. In order to be effective these orders should be read and understood by all concerned and

26
there should be a system by which all individuals particularly who are newly posted to the hospital should
become conversant with.

Formulation and Issuance of the orders

Formulation: All standing orders must have the approval of Hospital Management Board, the Trustee or
Ministry, Deptt. of Health or Director of respective hospital. It should be within the policy line order from work
of the organisation and issued by respective Govt. or the concerned authority from time to time. Each
Director/Medical Supdt. of hospital can make some changes within the broad frame already approved by the
authority. However, temporary or officiating incumbents should not alter or issue any standing order unless it
becomes an absolute essential and emergency situation. In such a situation approval for any amendment
should be taken from higher authority. Standing order are of two types:

a) Adminisrative policies and procedures.

b) Professional policies and procedures dealing with techniques and duties in the care of patients.

The subject which should be included in the manuals should clearly indicate:
a) Organization of the hospital and its department.
b) Authority/responsibility at each level of management.
c) Action to be taken in certain emergent situations.
d) Detailed procedures which are difficult to remember and are not readily available in various
regulations in a concise and comprehensive form.
e) Activities which are at variance with the usual way of doing the same thing in other hospital.
f) Subjects dealing with security, information, material, and cash documents and so on.
g) Proper maintenance of documents and records at various level.
h) Order of regulatory nature in situations where too much of discretion, is not conducive to good order
and discipline.
i) Orders readily available in various published volumes of rules and regulations should only be referred
to and not be repeated.

Issuance of the orders : The standing orders can only serve their purpose if they are kept up-to-date,
disseminated adequately and are readily available wherever and whenever required.

Following points have to be kept in mind while compiling such orders.

a) The orders should be divided into various parts covering major and allied activities in each section.
b) The existing organization structure should be followed in each of the section and sub unit of the
department.
c) The orders should be brief, to the point and clear so that these can be easily understood.
d) After the orders are in vogue for sometime, some of the orders may need revision thus spare
paragraph should be left blank at the end of each chapter/section/subsection of the orders so that
amendment can be made at suitable place and it can be incorporated when it is revised.

27
e) Sufficient copies of all orders should made available for distribution to all wards/departments and
respective officers for implementation and follow-up.
f) All officers whether it is consultant or technicans or nurse are expected to read and understand all
such orders.
g) At the time of joining a copy of the relevant orders must be given to all new employees of the
organisation.
h) Important orders regulating the conduct of patient information guidance for Do’s and Dont’s in the
hospital and certain information necessary the patient conveyance should also be compiled
separately and made available in all the wards and patients’ recreation room. Important policy like
visiting hours, out of bound area for outsiders, how to receive a mail in the hospital, method of
payment of hospital charges , meal time and similar relevant information should be included and read
out to patients when necessary by the ward sister/master at frequent intervals and can be prepared in
a brief information bulletin for the patients, in the local language. Such an information bulletin should
also incorporate the details about O.P.D. days of various speciality clinic and name of the concerned
specialist. The information about the payment system if any, the provision of hospital charges and
also ways and means of arranging appointment with the specialist can be documented. Such a
document can always be priced. Such document can always be published by the hopsital or by the
Social Welfare or voluntary agency affiliated to the hospital.

HOSPITAL PROCEDURE MANUAL FOR A GENERAL HOSPITAL:

Hospital Procedure Manual provides conceptual, technical and administrative information to all hospital
workers or to those who are associated with the hospital as a patient or an attendant. Written instructions in a
book form or as Booklet help in solving many problem, which otherwise may turn out to be only point of
reference for solving disputes discontentment or dissatisfaction amongst the staff. So such document can
always be taken as a guide to work for all practical purpose.

Philosophy of the manual

The basic philosophy of the hospital and its service organisation is to provide better care to the person who is
sick. The hospital functionaries apart from being a person with knowledge about diseases, are an instrument
for providing the care. It is therefore essential to remember that a communication channel by the provider of
the service and the patient should be clear and concise. The care component of the service should be explicit
and judicious. It is to be remembered that the patient or any person coming in contact with hospital staff may
not have knowledge about diseases and hence he or she may have number of queries and questions.
Therefore, the hospital management should operate on the basic working principle “Customer is
always right” and proceed with a sense of compassion to handle those people who come to the
hospital, and provide maximum alleviation of their suffering.
Administratively the hospital is under the control of the Director of Hospital or the Medical Superintendent who
is the Chief Executive. The telephone numbers and locations of offices and the residences of all important
officers of the hospital should be readily available to all who need to contact them. It must be kept up to date
and displayed for the consumers to make use of it.

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For all the administrative problems in the areas of public importance like emergency or casualty,
specialistclinic and admission department, public grievances, officer incharge of the area be available for
direct contact during the working hours particularly to attend to the patient’s grievances. During off hours the
administrative coverage of these areas can be provided by these officers by rotation.
It has been observed in some of major hospital, Central Control Room have been established which provide
very benificial effect in hospital managment for all practical purpose. Such a control room when established
should be easily accessible, for all hospital functionaries as well the general public for solving the
administrative problem of logistic, material supply of emergent nature and emergency medical care in disaster
situation and sorting out public grievances at the spot without any delay. It is also recommended that all
hospitals with more than 200 beds and in all district hospitals and other big hospitals, should have a control
room manned by a matured and trained personnel to deal such emergency situation. The control room should
be connected by Telephone - both external and internal and intercom system-Connecting to the admission
office, Casualty or Emergency Service, patient care areas and the Chief Executive of the hospital.

General Order
In all situation when the Hospital Authority is required to disseminate information to the general public or any
other external agency, some standard protocol are to be developed by the organisation.
Information to the public, Radio, T.V., Newspaper and communication to media in all matters relating to the
hospital are to be handled by the Chief of Hospital or by the Public Relation Officer or by any designated
officer.
The Authorised person should also disclose about patient’s condition to the relations or to the media in case of
a disaster situation or any public figure of importance.
Precaution must be taken not to disclose any confidential information. When there is any doubt as to the
willingness of a patient to have his or her condition of illness revealed, information should not be given without
his or her consent.

BASIC PERSONNEL MANAGEMENT ISSUES

Rules framed by the government or other concerned authorities are to be followed strictly in the matter of
recruitment or promotion. The strength of staff of each department needs be fixed as per the norm laid down
by government or the trustee or be fixed after applying operational research technique or other scientific
methods like work study technique to meet the actual requirement in any service areas.
An appointment letter indicating the terms and conditions of appointment should always be given to each
employee and his/her acceptance of the term and condition of employment are to be taken in writing and
recorded carefully in the personal file of the employee. Immediate notification of the employee’s appointment
or promotion are required to be sent to all concerned and particularly to the finance (Business) section of the
hospital.
Financial section should always ensure that the pay of the employees are always disbursed without delay and
make arrangement for necessary increment as per the laid down terms and conditions of employment.
Personal file, Service document recording and all other details, the confidential dossier of the employee needs
to be maintained and up-to dated regularly. The safety and security of such documents should be ensured so
that the employee should get his due promptly and efficiently.

29
Withdrawal and disbursement of monthly pay are to be made on the day prescribed (First day of every month).
There should not be any delay, to precipitate any de motivation for the hospital workers.
List of holidays to be observed by the organisation are to be exhibited prominently on board near the
personnel department, so as to plan and arrange the hospital services by the Supervisory staff well in
advance.
All employee’s time of reporting and departure can be recorded by time keeping office by Time clock punch
system and many modern devices available now a days as is practiced in many industrial concerns.
As any other organisation hospital employees also are expected to take leave after notifying to their
immediate supervisor. In case of any absence due to sickness or urgency of work, it is to be impressed upon
that employee that they should inform the head of the unit as soon as possible. Preferably by telephone or
any other means of communication in the same day. This will help the hospital management to prevent
disruption of services. In the interest of hospital services, all employees should be impressed upon to follow
such protocol.
All sectional heads are to issue duty roaster (area of work, time of coming and going) for preferably a month
at a time before the beginning of the month. If any employee proceeds on leave- temporary substitute needs
to be provided and an in built system of staff deployment should be developed for all areas of the hospital.

BASIC FINANCIAL ADMINISTRATION ISSUES

The main function of Finance or Accounts or Section of the hospital department is to look after the revenue
and expenditure of the hospital. The working philosphy of the department should be that at no stage there is
loss of revenue and continuous effort are to be made to increase it the maximum as practicable. Similarly
budget received from government or the from management should be allocated in such a manner that there is
a compatibility of projected work to that of the fund available. All revenue should be deposited in the
appropriate account as the case may be, depending on the private, public sector or governmental hospital..
The In charge of the department should be jointly responsible for all the cash transaction and custody of
cash/stamp along with cashier or the handler of the money.
Hours of payment to be received by the hospital are to be clearly exhibited. Arrangement for collection of
payment beyond the stipulated time for receipt or refund should be arranged in such a manner that the patient
or their relation should not be in inconvenience at the time of death or discharge of a patient beyond office
hour (stipulated time). Business manager of the organisation or the chief executive of the hospital should
always monitor the payment of bills to the firms, who supplies the medicine and other supplies to the hospital.
No payment should be delayed without any specific reason and this will ensure a good business relation with
the firm. Business manager or the Finance Manager as the case may be should be assigned to keep a watch
on expenditure under various heads so that there is a constant check and monitor to prevent any over
payment to any vendor or the supplier. Adjustment of account are therefore to be reconciled regularly with the
laid down finance rules.
Business manager has to prepare the budget in advance. This is done only after ascertaining expected
expenditure to maintain the volume of services or to augment the service as per the approved planned
programme. Replacement of medical and other diagnostic equipment and spares as and when required, are
to be made comensurating the projected workload. Such advance planning will ensure efficiency and

30
effectiveness of the hospital. Regular reporting about the achievement in terms of unit of service, financial
position, shortfall and anlytical reason for such a shortfall are the basis of a progressive hospital management.
Performance budget in a hospital has therefore been used increasingly for this purpose. Costing of various
services in a hospital for such purpose is a modern approach of hospital managemenmt. It will give the
administration the desired check and control.
Monthly report of these activities therefore needs to be supplied to Financial Controller to appraise him/her
about performance of the hospital. In-between, if there is any deviation from the routine activity. Chief of the
finance or the Chief executive are to be informed accordingly. Development of check list for the purpose is a
most efficient method for the guidance of the staff working in the Finance department for scruitinizing all
categories of bill and payment vouchers.
Inbuilt internal audit systems are to be introduced when such facilities are not available so that units can plan
and organise checks at regular interval, regarding all the item purchased. Physical verification and surprise
checks are the other established methods of control in purchase and materials management division. Cost
control strategies are very widely used in hospital situation both for check the leakage or waste of resources
as well as for method improvement of hospital services.

NURSING ADMINISTRATION ISSUES

Nursing service is one of the most vital service and plays a pivotal role in providing medical care. It is part of
clinical service thus, nursing superintendent or the matron as the case may be reports directly to the Director
or the Medical Superintendent of the hospital.
The main job of nursing administration is to plan, organise and implement the action in such a way that at all
times nursing staff are present in Wards, OPD and Operation Theatre in required number. For this purpose
a monthly duty roaster needs to be made stating name of the staff time (shift) date and place of posting.
Evaluation of services offered are to be conducted to get the feed back. Modern established method of
nursing audit and performance appraisal should also be introduced in all hospital situation.
Nursing Administration should issue detailed instruction to the nursing staff regarding nursing care, various
procedures to follow, reporting about serious as well as missing patients, control and management of
communicable diseases, isolation techniques, blood transfusion, control and administration of narcotics,
poisons, radio-active material etc. Steps to be taken about disposal of discarded limbs, its labelling, handling
and disposal etc. Nursing manual detailing all such protocols should be developed so that there is no
ambiguity on such process. This document should also be reviewed and updated along with the introduction
of newer technique and procedures.
There should always be a system by which any new staff joining has to be given orientation before being
posted in any area of the hospital so that the staff must be aware about working protocol and the facilities
available in his/ her or their duty place.
All Nursing Supervisors should be instructed to maintain safety control measures,for prevention of accident,
fire hazards due to anaesthesia, oxygen and therapy gas equipments, electric appliances, heating pad, hot
water bottle and any other such potentially dangerous items.
List of vital-life saving drugs, equipment like Suction machine are to be checked every day and to be
maintained by introducing check list.

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Standard guidelines for one of the nursing personnel to follow the doctor while he is on rounds to note
instructions from doctors and further follow-up advice wherever there is any paying patient, the bill and the
payment status are to be maintained up to date. A specific day of the week for weekly billing can be identified
so that outstanding bill for paying patient does not accumulate leading to problems of recovery at the time of
sudden death or discharge of such patients. It is always advisable to have a security deposit or all paying
patients at the time of admission in the hospital and final adjustment of the bill at the time of death or
discharge. The amount of such deposit should be set that at least minimum 10 days hospital stay charges.
All the case-sheets of the patients should be kept in safe and secure place. After discharge of patients, it
should be handed over to medical record section only, as per standard guidelines.
Nursing Sister-Incharge to manage maintenance and supervision and up-keep of the ward and other patient
care areas.
Demand and indent of various kinds of food diet (general, therapeutic) for the patients are to be prepared by
the staff nurse and she will be responsible for provision and distribution of the diet. Quality of nursing care has
to be ensured by adequately qualified and trained manpower. In service training and updating the knowledge
and skill development should be organised regularly.
Chief of nursing will prepare guidelines for following:
a) Engaging private nursing aid for the patients who can pay, depending on the hospital policy
b) Arranging in service training/on job training programme for various staff (sister, staff nurse, nursing
aid, intensive care nursing etc.).

BASIC MATERIAL MANAGEMENT ISSUES IN THE HOSPITAL

The primary aim of hospital supply system is to ensure the supply of quality goods at competitive price. At the
same time the main purpose of Hospital supply is to provide right material at right
time in right quantity at right price. There should not be any break-down in supply line so as to effect the
hospital services and patient care service get disrupted due to non-availability of medi
cine or emergency surgical supplies. Even spare parts of machinery and equipment are to be given due
priority. Life saving items must be made available at all the times. The purchase must be economic and as
per standard code procedure adopted by the hospital concerned.

Generally the store organisation of a generally modern hospital is of the following nature :
Medical (Drug and Chemical), surgical (instrument, equipment, suture, rubber glass, gauge, bandage etc.),
Linen, General (cleaning material, furniture, household item), Stationery (including office equipment-
typewriter, computer, calculator etc.). Besides, it is advisable to have separate store for the following items
which are of equal importance for hospital functioning:

a) Diet Items
b) Building maintenance material including electrical and mechanical spares
c) Spares for plants, mechanical pump, motor, wheel chair, patient trolley etc. It is advisable that all
government hospitals each of 500 beds and above must have an assistant material manager and the
hospital with more than 1000 beds material manager under direct control of Dy. Chief Executive of the
Hospital..
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 CHAPTER 3.1

OUT PATIENT SERVICES

KEY AREAS

• Historical perspective
• Functions of Out Patient Department
• Planning of Out Patient Services
• Planning of Out Patient Department
• Staffing
• Comman problems in OPD & remedial measures
• Working Rules

In the present days, the hospital outpatient department has attracted increasing attention than other areas of
the hospital as most of the patients can now a days be diagnosed, treated and even operated upon an
outpatient basis, thus involving less expense, efficient utilisation of hopsitals beds only for those genuine
patients who need inpatient care. This also facilitates avoidance of disruption of family life that hospitalisation
causes to the patient’s family. The outpatient services are also known as ambulatory services, where medical
care is provided to patients and not necessarily confined to the hospital bed.
Thus the outpatient department is defined as “that section of the hospital with allotted physical
facilities, regulated hours of operation and provision of personnel in sufficient numbers for assigned
hours, to provide care of patients who are not registered as inpatients while receiving physician’s
dentist’s or allied services”.
Historical Evolution : The origin of outpatient services can be traced to ancient Greek and Roman civilisation
when organised medical care and drug dispensing to the sick, was the part of temple or church activities.
During 11th century BC witnessed the setting aside official building to take care of the poor needy patients.
Subsequently around 5th centry BC, the idea of State organised plan of health care were established and
dispensaries as an institution came into being. Around 12th Centuary Arabian physicians also used courtyards
of their hospitals for treating outpatients.
The detail description of modern OPDs could be traced back to seventeenth century in Paris where proper
ambulatory services were provided at “Hotel Dieu”. Ambulatory medical services as an organised health care
activities began in England around 1696 at London with the support of Royal College of Physicians. Inspired
from such services “Society of Friends” in 1786 established outpatient services at Philadelphia, USA. These
services were usually sponsored by wealthy citizen of the society to serve the poor.
The ancient Indian civilisation had crude hospitals. Ancient literature reveals that in the 6th Century BC.
Buddha appointed one physician for every two to three villages, who used to provide medical care at the

33
doorsteps of the needy. Similar reference are also available indicating outpatient medical care institution
similar to those of modern hospital during the reign of Emperor Ashoka. During British India, hospitals were
built especially for the British official and for the other civilian employees. Such services were also were made
available to the general population on Oupatient basis. The first medical conference held in Calcutta between
December,24 and 29, 1894 inaugurated by the then Viceroy Lord Elgin II stressed the need of expansion of
outpatient services to serve maximum number of people.
By the end of the 19th Century, the dispensaries organised by local bodies and voluntary organisations started
getting affiliated to hospitals which resulted into providing better medical care. The present concept of
polyclinic in metropolitan cities originated in 1871 by the medical faculty of the University of Vienna. The
philosphy of a polyclinic is to concentrate all the speciality care clinics at one OPD area rather running a
various clinics at different places and time.
While the importance of outpatient services has expanded manifold and started attracting more and more
patients, the Americal Hospital Association in 1926 constituted a committee to lay down standards for
outpatient services the number of patients to be catered to in relation to the available facility both for
manpower and equipment.

IMPORTANCE OF OUTPATIENT SERVICES

The number of outpatient attendance in organised health institution of our country are not readily available,
however sporadic studies on inpatient bed vis a vis outpatient attendance reveals that on an average 25 to 30
patient can be attributed per bed in general hospital. It is also estimated that more than 500 outpatients are
said to be served per year for each hospital beds. Thus for approximately 6.3 lakhs hospital beds available in
the country, 1.57 crore of inpatients are normally treated per year and the services provided range from
treatment of common cold to sophisticated day care surgeries or procedures like lithotripsy, ESWL
cholecystectomy, ERCP, stereotactic surgeries etc.
Even in developed countries like UK, every person utilises the services of outpatient department of a hospital
atleast once a year and that of general practitioner four time a year. Most of the diagnostic and therapeutic
procedures practices for patient care needing hospitalisation increasingly carried out on an ambulatory basis
in a well equipped and planned outpatient department. Thus resulting in saving of direct expenses of hospital
and patient as well s hidden savings in terms of wages etc. This is possible only because of sophistication of
medical care practice and availability of newer technology.
For a hospital outpatient services projects its efficiency, and a good public relation image. Almost all the
patients (except the emergency patient coming to casualty OPD) it is the first point of contact with the hospital.
It is the first impression which can make or mark the reputation of a hospital. That is how it is also called the
“show window” of a hospital.

Functions of Outpatient Department

With the passage of time, the functions of OPD which earlier was supposed to provide curative health care
only, has expanded manifold and is expected to provide a wide scope of services including promotive,
preventive and rehabilitative services. These services are irrespective of the size or the type of the hospital,
be it of voluntary, government sector or in a private sector.

34
The WHO Expert Committee on organisation of medical care in its Technical Report Series 176 has
recommended the following broad functions for a outpatient department.
1. Provision of diagnostic services using the best possible modern medical techniques, including
prophylactic examination for the detection of any underlying ailment.
2. The ambulatory and domicillary treatment for all cases that can be treated at the clinics or at home,
without being hospitalised.
3. The admission or referral for admission to the hospitals of those patients who need it.
4. After care and medical rehabilitation as is part of continuing hospital care when necessary, after the
discharge of the patient from the hospital.
5. The promotion of health of the individuals under the perview of the hospital through of health
education and immunisation and nutritional advice etc.
6. Facilitate advice etc. the use of outpatient facilities for the training of medical and nursing and other
para medical staff.
7. The keeping of records and collection of data for epedimiological clinical, administrative and social
research and also for periodic assessment of health care services to the community.
Different authorities have enumerated different functions of a hospital outpatient department, in relation to the
level of care they are providing. The outpatient department of atertiary institute as compared to the clinics of
private practitioners should not be the basis of comparison in terms of diagnostic, preventive and
rehabilitative services, but it should actually complement the efforts of private practitioners(who still share the
bulk of outpatient services in our country.

The functions of OPD of a tertiary institution should include the following :

1. It should ensure availability of the major specialist services and diagnostic medical services, with the
knowledge, skills and necessary equipments and other back up services.
2. Provision of special treatment for which facilities may not exist elsewhere in the locality or the region.
3. As a source of support to the peripheral practitioner in continuing medical education programme with
the recent updated technical diagnostic services.
4. To act as a focal point from which integrated services may radiate to the community.
The outpatient service should also act as a filter unit for the hospital which would allow only those patients for
admission in the inpatient wards, who cannot be treated as an outdoor patient, thus ensuring the most
appropriate use of inpatient facility and hence of hospital resources. It would also act as referral unit to other
speciality clinics or services by referring the relevant patients to appropriate clinics and thus lessening the
woes of patients.
Thus a Outpatient is a person, who is utilising a general or emergency diagnostic, therapeutic or preventive
health care services provided through a hospital facility or heatlh programme, and who, at that time is not
registered as an indoor patient in the hospital.
Patients visiting outpatient deapartment can be broadly grouped in three categories :
a. General outpatient : Most of the patients visiting government hospital are of this category. They are
those patients who are given diagnostic or therapeutic services, on an outpatient basis other than
emergency condition and who was not been referred for such services by his attending physician.

35
 Such patients come to the department on their own and usually known as walk-in patients. It is
possible that majority of those patients who are coming from the adjoining areas are of this category
and most of them come from minor ailments.
b. Referred Outpatient : They are those patients who have been referred to the concerned OPD by their
treating physician for specific diagnostic or therpeutic procedures other than an emergency condition,
and who will in all probability return to the referring physician for future care.
In a health system where organised referral system is in force, most of the patients visiting a tertiary or
apex superspeciality institutions for specialised clinics fall under this category.
c. Emergency Outpatient : These are the patients who are visiting the emergency or casualty
department for relief and treatment of acute illness.

Outpatient Visit : The arrival of a patient at the Outpatient department of the hospital is to receive the
services provided therein. There are two types of visits :
1. New outpatient visit : The arrival of a patient to avail the services of outpatient department for the
first time. They are also known as “new cases” or “new patient”.
2. Repeat outpatient visit : An outpatient visit by a person subsequent to a new outpatient visit.
In a superspeciality hospital the average ratio between new patients and old patients is 40:60 on a rough
calculation.

PLANNING OF OUTPATIENT SERVICES

OPD is the first pointed contact between the hospital and the community, and very commonly called “show
window” of hospital, a well planned and scientifically designed OPD goes a long way in building up the image
of the hospital. A properly planned building with pleasant surroundings allays the fear from the mind of the
patients and their attendants who are in search of solace and comfort for mitigating their suffering .
The outpatient services one of the fastest developing functional area of the hospital. In recent past there are
many instances, where it is seen that the OPD building is too small to accommodate the patients and facilities
which are ever increasing It is aso interesting to note that many OPDs built with most modern architectural
design have been rejected by the community as it failed to commensurate the local customs and social
practices. It is therefore desirable to make the design to be an appropriate fusion of advanced technologies
with the social and cultural characteristics of the population the hospital is planned to serve.
Before designing an outpatient department, the review analysis of factors relating to the population and their
needs must be carried out. Few of the important factors to be considered for planning may include the
following :
1. Population and community characteristics : The population to be served by the OPD services
should be clearly defined and the expected patient load with the quality of service to be provided must
be determined as far as possible. The socio-economic condition of the population as well as local
customs are to be studied and taken into account for planning consideration of the building and the
support facility.
2. Vital statistics and health needs : The morbidity and mortality pattern as well as nature of the
population should be studied in detail to assess the specific clinical care need of the population.

36
3. Resources : existing programmes and services available for the population and expectation for future
services is an important factor which is to be considered while planning for any outpatient department.
4. Utilisation and available medical facilities : The medical facilities available in the population to be
served and the extent of their utilisation also needs to be assessed for identifying the quantum of
services to be provided. This would help in deciding whether similar facilities or advance facilities or
both are to be established.
5. The quality of the services available for the population are also to be considered, so that
comparatively better services could be provided which would meet the expectation of the people.
6. Trends : Trends of population growth both demographic and socio-economic, changes are to be
taken care of, as these factors are responsible for health and medical care need.

PLANNING OF OUTPATIENT DEPARTMENT

While planning the outpatient department, the approximate patient load expected in the hospitalmust be
defined. The patient load is said to be dependent grossly on the following characteristics:

a. Needs of the population, type and number of health care institutions available in he adjoining
areas.
b. Number of cases expected to be referred from other institutions or private physicians.
However, this is not true for the tertiary care institutions providing speciality services.
c. Reputation of the hospital
d. Nature of services to be provided by the hospital like superspeciality care of the selected
medical disciplines.
e. Type of hospital like whether it is a government hospital expecting to serve the whole
population of the adjoining areas or of the whole state, charity hospital, private hospital,
hospital serving only the employees and so on.

On an average it is expected that 2-5 patients visit outpatient department per hospital bed. For example, a
hospital with 800 beds could expect about 1600 to 4000 patients per day. However, the figure would be on the
lower side for private paying hospital and would be on the higher side for government free hospital. Jain
committee in its report (1968) have recommended that the outpatient services of a hospital should be planned
to provide services for 1% of the population of the area to be catered to.

The outpatient department facilities should be so planned that :

1. It is easily accessible for the patients with adequate public and private transport facilities.
2. Dignity and privacy of the patients to be respected.
3. It conforms to the social and cultural needs of the patient.
4. A quite and orderly pattern of work is achieved.
5. The facility should also be considered to meet the requirement of physically handicapped, old and
debilitated patients.

37
6. The design of the building should be in accordance with the function and work flow of the patients and
not vice-verse.
7. Clear cut provision of extension and expansion of the department so that it become possible without
the need to rearrange the basic circulation pattern.

Work Flow : The work flow of an OPD would be such that there is no cross traffic, at any point of the building
and service provisioning. There should be an uniform flow of patients, wherever possible, the doctors route
should not cross the patients route and no patients should have to retrace his path in the process of receipt of
the services. It is always beneficial to draw the flow chart of the various activities and movements of the
patient to be expected. Usually this can be predicted to a great extent before hand like from the enquiry
counter of the OPD to registration, waiting area, consultation room, investigtion facilities, to pharmacy and
then out of the system. The various interfaces between the patient and the system should be distinct clear and
separate as far as possible.

ZONING OF OPD
Broadly the department can be divided into four zones.
1. Public zone : It consists of entrance, reception and enquiry area, waiting area, public toilets to cater
the needs of general public visiting the hospital.
2. Clinical area : It comprises of consultation room, treatment room, operation theatre, injection room
which are primarily to be used for provision of medical care activities.
3. Administrative area : This includes OPD incharge’s room, registration room, store, accounts office
and are to cater to facilitate the administrative activities.
4. Circulation area : It comprises of about 30% of the total OPD area and includes corridors, lifts,
staircase for patient and other user movement in the work process.

Location of the OPD Block

The OPD block should be so located that it is conventiently accessible for patients coming by public transport
or their own vehicle, and therefore should be towards the front of the hospital and provided with its own car
parking area. The location should be such that it is close to diagnostic facilities like that of laboratory,
radiology, pharmacy, social services etc. which would also be utilised for the indoor patients. The OPD block
should be incorporated in the main building of hospital complex and each unit should be linked with the
relevant ward, but the patient flow should be such that the patients traffic should not pass through indoor areas
or disturb the inpatients while going to and from the OPD and to the common service areas.
Entrance to OPD : The entrance to OPD should be separate with display board clearly visible from the road.
There should be sufficient space between the entrance door and the road to prevent the queue of patients
extending into the road or other patient care areas. The main parking area should be little away from the
entrance door, but there should be sufficient space to accommodate few cars under a porch for non-
ambulatory patients alighting. For patients and trolley and wheelchair, there should be a gentle slow ramp and
at no stage the gradient of the slope be more than 5 degree.
Entrance Door : It has been stated that entrance to outpatient department may best be provided with two
pairs of double swing doors, one for entry and other for exit. This is particularly necessary for a large hospital.

38
The entrance of the doors must be separate which may be through the indoor areas. Whenever possible
automatic opening doors are to be provided. The total width of the door should be not less than 3 meters.

PUBLIC AREA

Reception and Enquiry : This is the first contact point of the patient with the hospital system. Wherever
possible reception and enquiry counter of the OPD should be separate from the main reception and enquiry
counter of the whole hospital or the institute. This should be located at or near the main entrance and should
be properly visible with proper sign posting. As compared to other functions of the OPD, it may receive less
importance for the hospital staff, but it is the place most sought after by the patient in their first visit. It should
be manned by a medical social worker or receptionist who is fully acquainted with the hospital, the policy and
procedures and details of the various functionaries. A senior nurse may also play the role during the peak
hours. The person should be cool minded and have patience to answer any type of questions or queries
repeatedly asked by the patients or their relation. An area of 64 sq.ft. is estimated to be minimum working
space required for each receptionist, the desk should be enough for the person in the counter to attend to the
patients while sitting and at the patient do not have to stoop to much while enquiring about the hospital
services.
The counter should be attractive with good communication system through telephone or through the computer
with the local area network (LAN) where possible connected to all OPDs/Clinics and other service areas. A
well illustrated guide map showing all the facilities and the way thereof should be displayed clearly.
Registration Office : The area and number of staff required for the registration office depends on the work
load, policy and procedures of the hospital e.g. if there is no appointment system, more number of persons
would be required to man the counter in comparison to that where appointment system for OPD consultation
are in existence. On an average one counter is manned by one registration clerk and normally should be able
to handle 15-30 patients per hour. Each floor or sub area of the different OPD department requires atleast 4 ft
x 4 ft counter with adequate drawers and shelving space. An area of 60 sq.ft. is the recommended free space
for each clerk allowing for circulation behind the counter. The counter should be covered from all sides. The
accounts clerk where financial transactions are carried out may also be positioned along with the registration
clerk in a separate counter and provided with a chest for the fund collected.
Records : The outpatient records section should be an extention of the medical record section of the hospital,
and continuous outpatient record system should be adopted to facilitate the physician reviewing, the treatment
processes of the patient. It is also necessary for medical education, research and other legal activities. In
general all medico legal records are kept up to 10 years and non-medical records for 5 years, after which they
are destroyed with the permision of the appropriate authority. On a average about 2 - 3 sq.ft. is recommended
space per bed for outpatient record section with adequate number of shelves for the records.

Waiting areas:
1. Central Waiting Hall : Next to the OPD entrance, there should be a main waiting hall facing the
reception and registration counters, it should be attractively finished as it gives the first impression of
the hospital. There should be a display board showing the number of disciplines/clinics and the
various service areas and its location. The surrounding wall of the area may be covered by decorated
picture frames which would also help in imparting health education material for the patient. Audio

39
 visual aids like closed circuit TV, aids like Central Announcement system, water fountains may also be
provided to give a pleasant environment. The space requirement for the main waiting hall varies from
one sq. ft per person in an average in a government or public hospital to a 8 sq.ft. in modern hospitals
where it can be afforded. The trolley bay area may clearly be demarcated at one corner near the main
entrance.
2. Subsidiary Waiting areas : In addition to the main waiting hall, there should be subsidiary waiting
space in front of each consultant rooms. These are utilised by the patients who had been registered
and are waiting for their turn for consultation. The space requirement of such sub waiting area
depends on many factors like whether appointment system is folowed or not and the timings of various
speciality clinics and also depending on area where patients are mostly dependent on wheel chair,
trolley etc. Speciality areas like children OPD, where attendant mother or parents are always there,
needs proportionately more space. The recommended requirement is 8 sq.ft. per one third of total
number of patients visiting the clinic in one session, as it has been seen that approximately one third of
patients wait outside the clinic at any point of time.

The waiting areas should be made comfortable as far as possible with adequate sitting facilities drinking water
and other basic necessity. The noise level should not exceed 150 deciable with adequate lights and
ventilation.

Sanitation facilities : Adequate toilet facilities are also to be provided which should have provision separate
for gents and ladies. Approximately 1 WC and 1 lavatory for every 20-30 patients as visiting the hospital are
adequate for this purpose. There should be separate toilet facilities for the staff. Provision of W.C. and
Lavatory for physically handicapped and non-ambulatory patient should always be kept in mind, while planning
the facility. Arrangement for drinking water from a water cooler with a dispenser are also to be provided and a
public telephone booth for convenience of patient and their attendants.

CLINICAL AREA OF THE OPD

Concept of unit design : A unit design can be obtained for OPD clinics if one has the information about clinic
schedule, functional procedures, the number of people using the clinic and the equipment that would be used.
When complete flexibility of room assignment amongst the doctors of various discipline attending the OPD is
desired, the design should follow the pattern of a identical units which should acommodate the doctor and his
basic furniture and equipment. This arrangement however may not be desirable always.
In medical clinic, it is fairly common to have one consultation and two examination rooms for each physician.
No other special treatment rooms are necessary.

The following are two acceptable designs in a modern hospital outpatient department.
Type-A : Consisting of inter comunicating combined consulting room and two or more examination rooms.
Such arrangement has greater flexibility in use. It should be large enough to have facilities for the patient to
undress and dress within the area preferably in space around the examination coach, which can be screened
by a curtain. An area of 170 square feet is recommended for each examination room.

40
In this pattern, the patient remains in one room, undresses if required, examined and dresses there itself while
another patient readies himself or herself for examination. Thus the patient does not use a separate changing
cubilcles of a separate examination rooms. The doctor moves from one room to another to see patients, but
deals with individual patient wholly in one room and completes his work with one patient before proceeding to
next and can therefore attend a relatively less number of patient, in a specific OPD timing.
As the privacy of consulting room is very essential. It is desirable to have a larger consulting room with one or
more examination rooms attached to it. In a more flexible arrangement, where there are a series of inter-
communicating consulting rooms without a separate examination room at all. The privacy in such situation
can be obtained by having a curtained area around the examination couch. In such arrangement the
physician after examining the patient and completing the clinical notes of one patient, moves to the next
connecting room to examine the next patient.
The advantages of these arrangements are :
1. Physician can continue to interview the patient while the patient is undressing behind the curtain. This
is not feasible when examination room is separate.
2. The doctor completes the clinical records and may continue to converse while the patient is getting
dressed.
3. Patients do not have to wait long after undressing.
4. Consultation and examination is ensured at the same sitting.
5. There is least wastage of consultant’s time in the OPD complex.
Type-B : It is generally advisable to allow one or two examination rooms to serve one consulting room or an
average. The consulting room in such situation should be 120 square ft. with 90 square feet for each of the
examination room.
The consulting room should be equipped minimum with a consultant’s desk or a tale, chairs washbasin,
adjustable light and a viewing box for x-rays. It would have enough space for the patients and a trolley for
instruments required in specialised examination room.
Inter communicability between consulting rooms; amongst the outpatient consultants are normally conducted
by a team of doctors, working together and consultants grouped in intercommunicating pairs. It helps active
consultations between the members of the clinical team. It also gives the maximum degree of flexibiility of use
and economy of time for consultations.
Examination Room : This is to be used for only examination of the patients. A room of the size of 86 square
ft. been found be adequate. The basic equipment in an examination room would be a mirror, clothes hooks,
curtain, changing cubicles, an examination couch of 6' x 3' size and about 2-1/2' high, steps for examination
couch, an adjustable lamp over the examination couch, an instrument trolley and x-ray view box, a wash
basin, a soap dispenser and towel stand and also preferably a wall mounted B.P. apparatus.
Consultation Room : In individual consultation rooms of the outpatient department the patients is expected to
be alone to explain his problems and receive advice, examination or treatment from the clinician. He must not
be over looked or overheared by anyone other than the doctor. While examining a female patient by a male
doctor however a female attendant should always be present who may be a nurse, ayayah or may be the
patient’s attendant. An average of 130 sq.ft. to 150 sq.ft. area is adequate for such purpose. The room must
have ateast a desk of 4.2' x 2.5' feet and 2.6' feet high, a swivel chair for consultant, two chairs for the patient
and attendant when required an x-ray view box and an intercom communication system.

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Minor Operation Theatre : Day care surgery of ambulatory patients has become an established practice in
modern medical care system. Although most of such operations are performed in main operation theatre of
the hospital complex or special units like lithotripsy unit which has special facilities and functions, yet a number
of minor surgeries can be done in the outpatient department itself. For such purpose in large hospitals one or
two operation theatre for minor operations in the oPD block itself are required. As much as 25-30% of minor
operations are performed in the OPD itself by many clinical departments of surgical discipline. However, to
determine the number of OT suites required for various speciality the followings parameters can be used.
1. Detail list of procedures to be performed in the OPD.
2. Approximate number of such procedures to be performed in each operative session of the day.
3. Average operation time required for each procedure.
The strict design and functional planning required for an operation theatre complex may not be applicable in
the minor OT of the OPD, but some basic facilities like operation table and light of appropriate sophistication
laminar air flow if there is central AC and of course aseptic conditions are a must. There should be a
changing room separate for staff and patients and a post operative recovery room facility adjacent to OT staff
and nursing care areas.
Injection room : It has been generally agreed upon that there should be one centralised place for administring
injections to the outpatients. This ensures faster and smoother flow of work saving space, time, staff and
equipment.
There should be curtained cubicles for the purpose of privacy. A resuscitation area is also to be earmarked for
an injection room with emergency trolley or the couch with an outlet point from the central oxygen supply and
suction and other life saving devices. Comunication system to call the doctor within shortest possible time,
whenver such resuscitation (e.g. anaphylactic shock) are required.
The temperature of the facility should be controlled in the comfort zone as patients are required to partially
undress themselves when injections are administered. In a large hospital OPD, the space required for such
an injection room could be about 400-500 sq.ft. and manned by a trained staff nurse with few assistance.
Sufficient waiting area for the patient with the requisite furniture are to be provided.

Pathological laboratory and specimen collection centre

This centre is to be planned, equipped and furnished to collect specimen of the outdoor patients of all
specialtiy required for investigation and to be sent to the central laboratory for tests and also to carry out some
of the simple laboratory tests there itself. This ameliorates the need of all patients going to the central
laboratory which is required to cater to the inpatients also. The timing of the central collection centre should
be so adjusted that specimen can be collected in the same day of the outpatient’s visit whenever possible and
results be made available by the next visit.
This centre is also to be planned to perform many simple tests like Haemoglobin, TLC, DLC, ESR, Urine for
glucose etc. More such tests which can now be conducted and the reports be provided with the help of
computerised machines available. But the policy of the hospital should always clearly state as to which are the
tests and the quantum of such test per shift to be performed in such centres. This will avoid duplication of
similar services elsewhere in the hospital.
For laboratory specimen collection centre for a general hospital of average 500 OPD attendance an area of
800-1000 sq.ft. has been found adequate with dedicated toilet facilities separate for ladies and gents and

42
wash basins. The waste generated from such centres are to be collected, segregated and transported for
final disposal as per standing guidelines of government under the Bio-medical Waste disposal rules and
regulation.
Pharmacy : This area of the OPD is utilises for sub-storing and dispensing of drugs, preparing mixtures
ointments and dispensing these medicines to the patients in the hospital both for indoor and outpatient
services. Now a days, there are a hardly any drugs which require some preparation as per practice most of
drugs and medicines are dispenses in readymade packet form. The policy of the hospital on this count should
laid down clearly guidelines about whether drugs are to be provided to all outpatients or not, if they are to be
provided then for how many days. A comprehensive drug list should also be made available for the
convenience of patients as well as the pharmacists. For a large hospital an area about 2000 sq.ft. is
recommended for the pharmacy and even for a small hopsital of 200 beds an area of approximately 500 sq.ft.
area can serve the purpose. This area includes the office of Chief Pharmacist, preparation and compounding
area, bottle washing area, stores, staff toilet etc. Sufficient space for queue of patients and waiting should
also be provided.
Clean Utility Room : In a large hospital with Central Sterile Service Department a separate room for receiving
stores and distributing them to the consultation room or treatment room are required. A space of about 170
sq.ft. is found to be adequate for such purpose.
Dirty Utility room : This room is normaly utilised for receiving used and soiled supplies from consultation
rooms and treatment room. It should have a sink, place to keep the brooms, slope and working tops for which
a minimum space of 100 sq.ft. is sufficient.

ADMINISTRATIVE AREA :

Officer Incharge OPD : Various authorities in the field of Hospital Management recommended that the day to
day management of the outpatient department should be provided by an officer of the rank of Addl. Medical
Supdt. with sufficient experience, maturity and qualification who could be assisted by appropriate
administrative and nursing services. The Administrative Officer Incharge of the OPD would be responsible for
maintaining smooth functioning of the OPD, listening and solving the problems of staff and patients. A space
of about 190 sq.ft. has been found adequate for such an office with an attached toilet and other support
facilities.
Nurse Incharge : A nursing manager of the rank of Dy. Nursing Suptd. or with equivalent seniority and
experience should be incharge of all nursing activities of the OPD. She should supervise the activities of all
the nurses posted at various clinics and treatment area of the OPD and giving the feedback to the
Administrative Officer Incharge. Her office may need a space of 190 sq.ft. in the OPD complex itself.

CIRCULATION AREA
The circulation area of the OPD comprises of corridor, stair cases, lifts and other areas for the movement of
patients and service trolleys. It may occupy as much as 30% of the total OPD areas. The minimum width
should be so much as that two trolleys each with an attendant by the side of the trolley can cross each other.
The trolley has width of 2.5 ft. accompanying attendant needs a space of 1.5 ft. means on an average 2 x 4 ft.
= 8 ft. width would be required in the corridors of the hospital. The same is true for ramps but the inclination of

43
which should not be more than 5 degree gradient, so that the movement of patient trolley can be smooth and
less tiring.

Lifts and staircases :

The number of lifts and staircases in the hospital, the OPD in particular should be sufficient to hold the
maximum expected number of people at any one time. Therefore, while planning the traffic pattern, peak
traffic flow, the attendants and store supply should be taken into consideration at the conceptual level. It is
always better to provide two sets of lift and staircase. Atleast one of the lifts should be large enough to
accommodate a stretcher trolley or even a bed.

Refreshment facility :
As the patients visiting OPD may be coming even from far of places and usually have to wait for various
processes and procedures, some refreshment facility for the patient and their attendants needs to be provided
for tea/coffee, cold drinks and snacks may be served through this cafeteria. Some authorities have of course
reservation about the provision of snacks in the OPD canteen, but certainly light snacks in a pre-packed form
will meet the patient and the attendants in a hygienic form. There should be no arrangement for regular meals
in this facility, which will create unhygienic condition of the hospital very easily. The responsibility of
maintaining cleanliness and provision of waste basket in such canteen should lie with the canteen contractor.
A space of about 500 sq.ft. is adequate for such a purpose in average general hospital.

STAFFING OF OUTPATIENT SERVICES :

The success or failure of any organisation depends more on the competency and attitude of the personal
rather than other factors like physical facility.
1. Posting of the OPD staff should be from amongst the main hospital on rotation basis should not be a
exclusive separate cadre.
2. There should be a full time administrator incharge for the OPD and should be continuously available
during the working hours.
3. All the clinical and support service workers who are working in the clinics should perform their duties
under Administrative supervision of the officer incharge.
4. Staff conference for clinical discussion of both ward and clinic cases should be held at regular
intervals for professional developmenmt.
5. To encourage consultation in complicated cases.

Medical staff :
The medical staff of each of service area consist of physician and the whole unit including consultant and
residents and interns and are administratively accountable to the officer incharge, even if they may have to
comply with clinical care protocol developed by the chief of the services or the department concern.

Nursing Staff :
Each unit of the OPD should have one nurse who may be assisted by junior nurses. They are to help the
doctors for carrying outpatient care services. However, it is a misconcept that only a nurse should be present
44
in the examination room while a male doctor is examining a female patient. Infact any female staff’s presence
would suffice such a job. They have to work under the overall supervision of Dy.Nursing Staff of the OPD.

Other Group D or Housekeeping Staff

Their number varies with the type of clinic and support services available and provided in the OPD.

Common problems in OPD and remedial measures

1. Overcrowding : The most common complaint in any OPD is overcrowding and long waiting time.
The reasons of which are unlimited registration of patients, late coming of doctors, absence of
appointment system etc., leading to long queue at every service ar rear.
The overcrowding may be regulated by limiting the registration timing and registering a fixed number
of cases depending on the resources available.
Traditionally appointment system has been found to be the best solution for long waiting time. In
comparison to individual appointment practical for doctors consultation block appointment system has
been found to be more suitable in our hospitals where a fixed number of patients are given
appointment at the same time. Some time slot should be left for serious patients who can not wait for
an appointment.
2. Queue Jumping : This is a common problem as VIP patients or hospital staff frequently jump over
the queue for their relations and friends. Often doctors find themselves helpless in these situations.
This problem could be prevented by establishing a “Patient Sequencing Policy” for the order in which
the clinets would be served, which is known both by the staff and the clients. An example of a policy
may be as follows :
a. Patients will be entertained into the clinics as close to the appointment time as possible.
b. Patients with the earliest appointment will be served first.
c. At all stations, patients who do not have appointment will be served after those having
appointments.
d. Patients who are more than 30 minutes late for their appointments would be treated as “walk-
ins”.
e. The only permissible deviation from this policy would be that very sick patients will always be
seen as early as possible.
3. Difficulty in locating departments Patients often find it difficult to locate various departments and
often they find no one to guide them.
Proper patient guidance system should be developed with illuminated display boards at every
crossings of traffic. In multi storeyed buildings, lines of different colours drawn on the wall leading
upto the particular clinic would facilitate easy floor traffic. Social guides in proper uniform should be
posted at every floors to help the patients.
4. Misplaced records : Patients very often find their records misplaced and often they have to undergo
through the same procedures repeatedly.
Proper record maintaining system be enforced. Computerisation of the record section inter connected
with other areas would solve the problem to a great extent.

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5. Misbehaviour of staff : Very often patients complain about misbehaviour by group-D and other
ancilliary staff. There should be organisation control of all the ancilliary staff under the officer incharge
of OPD. Dual authority of staff working in OPD should be abolished as far as possible.
These measures would surely go a long way in providing satisfactory and efficient services and
meeting the clients expectations. Following are some basic tips for day to day management.

Direction for patient’s movement

a) Lay-out map of diagramatic scheme for various OPD should be prominently be exhibited at the
entrance of the hospital.
b) Sign posting at all the strategic location about the hospital service areas with help the patients as well
as create a good public relation image of the hospital.
c) Working hours/days and holidays should also be displayed clearly on notice board.
d) Name of medical specialists always be available in front of the room. Provision of changing the
nameplate, depending on who is present on a particular date be made and followed. Number of
wheel-chairs/patient trolleys should be made available in plenty. No of such trolley and wheel chair
will depend on No.of OPD attendance and type of speciality services like Orthopaedics, Neurological
and so on. Number of benches/chairs in each waiting and sub- waiting area of the OPD and may be
made a permanent fixture of the area.
f) The Officer Incharge should be encouraged to take round atleast once in the morning to see that
every thing is going on well as planned and subsequent administrative round should also be made at
peak-period to see whether some more help or guidance is required or not.

Registration/Reception Enquiry/Cash Counter of the OPD

The member of such counters in the OPD depends upon the number of patients coming to OPD and the
number/types of OPD clinics functioning on particular days the size and physical layout of the hospital.
However, it should be ensured that separate counters are created for male and female patients for registration
and cash deposit counters. It is to be seen that in no circumstances registration and payment of cash for the
service should take more than 10 to 15 minutes in any hospital situation.
After registration patient should normally be examined on the basis of first come first serve in all situation,
except on emergency or when there is a prior appointment.

Working Rules for OPDs

Following are few important working rules which can be followed for the operational efficiency in the OPD.
a. The patients treated in the OPD are usually ambulatory and with minor ailments. So all acute or
seriously ill patients must not be referred to the OPD. they should be managed in the Casualty or in
Emergency department only.
b. Registration : A patient should be eligible for obtaining medical help in OPD only after getting
registered as per the hospital procedure.
c. Days : The OPD days of the clinical unit or the name of unit officer and specialities should be pre-
stamped on the OPD card and laboratory investigation forms of the respective OPD days for
operational efficiency.
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d. The OPD consultation system should be so organised that there should be continuously in treatment
and patient on revisit can go to the same clinical doctor without any difficulty as per the clinical
protocol of the hospital so that the investigation conducted, diagnosis of the sickness and treatment
given can be used for future reference of the patient.
e. All patient should be given indentification and appointment card plus clinical care advise complete in
all respect for undergoing investigation and appointment with the doctor.
f. Investigation forms must clearly indicate the name of the doctors or atleast the name of the clinic or
speciality department who has initiated or requisitioned. and registration number,charges paid and
signature of doctor who fulfilled the forms.
g. Provision of Centralised specimen collection centre ; will ensure that patients along with the
investigation forms and all kinds of specimens for test can easily be guided/directed to. After
collection of samples the specimen could be sent to various laboratories for test and the reports or to
central should be sent either directly to various OPD or to central collection point from where they are
redistributed.
h. Special test : In all case where appointments for speciality are required, patients may be directed to
report to various section, of e.g. for I.V.P. or Barium meal or Radioiodine test or ultra sound etc. where
patient can get the specific time, date and special instruction. Due payment also should be received
in advance so that there may not be any delay on the specified date of the test.

Referals and cross referral to other specialty :

The patients needing multiple consultation or for obtaining the opinion of other specialities the exact problem
for which the patient is being referred to must be written down on the referral step and accordingly the patient
be directed to the concerned OPD. Usually, there should be no insistence for re-registration of the patient in
the same outpatient department where he or she is being referred. While referring the case to other
speciality, it is always advisable to send the report or result on the investigation done and the list of
investigation requested for the patient so that repetition of the investigation to is avoided and thus valuable
time and effort of laboratory can be saved.

Method of admitting patient from OPD

The patient requiring admission to the ward for further investigation or treatment and management should be
admitted from OPD directly. However, it is always advisable to confirm from the office about the vacant bed
position in the ward. Only after doing so the patient should be referred to admision office for admission so that
necessary formalities like paying the charges, making of admission formality could be completed.

Miscellaneous
a. If the patient is a government employee or an industrial employee then he/she will be dealt as per
rules issued by government or the concerned organisation.
b. Minor OT : Those patients requiring minor surgical procedures should be referred there on the needful
as per standard guidelines developed by the concerned hospital.
c. Injection Room : Every OPD has provision for it and patient can get injection from there according to
the respective policy of the organisation.

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d. Dispensary or Drug Supply : After depositing the cost of medicine or as the rule may be the patient
should get medicine from OPD dispensary or drug store of hospital.
e. Medical certificate for leave/fitness : All the treating doctors can be authorised to issue medical
certificate for leave/fitness but such certificate shouldbe channelised or countersigned by the Officer
Incharge and record thereoff be maintained for future reference

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 CHAPTER 3.2

IN PATIENT SERVICES

KEY AREAS

• Objectives of Indoor Services

• Functions of In Patient Department
• Planning of In Patient Services
• Planning of Wards
• Concept of Progressive Patient Care

The nerve centre of a hospital services is the inpatient ward. This is the place, where the primary function of
the hospital is performed. Patients are received here, cared for, diagnosed, treated and discharged or
declared dead. Practically all of the other facilities of the institution - ranging from technical services such as
operating room, laboratory, or social service department to hotel or administrative services such as laundry,
kitchen or business office - exist to support the needs of the patients and the personnel on the ward.
It is also attributed that in patient services is the most important and largest single component of a hospital
services. More then 50% of the building complex of the whole hospital complex is normaly occupied by the
indoor services. When we refer to patients in a hospital it usually connotes to inpatients who are
accommodated in the hospital for overnight stay in order to receive clinical and nursing care. So the indoor
services are also known as “Nursing Services” and provided to such patients, who had been admitted in the
hospital, either for observation, investigation or treatment or a combination of these. The Units where the
services are provided are called the Nursing units or wards. However, these services are also provided in
other areas called Intensive Care Unit (ICU) and day care centres, but for the chapter, we will refer indoor
services as the services provided in the hospital ward only.

WARD :
The ward or nursing unit in a hospital is a place where inpatients are provided the medical facilities by a team
of doctors and nurses under the best possible conditions and includes under one roof the patient care area,
the nursing stations, the services area and ancillary facilities for the management of a sick patient.
Most of the equipment, staff and other hospital resources are concentrated in the indoor wards or the
facilities, and almost all the medical care teaching and research are dependent on the provision of these
indoor facilities. Representative of atleast different occupational status group are represented on a typical
ward of a general hospital contributes and visits the area for their professional persuit. These are
“Administration, Chief Executive, Medical Supdt., AMS”
Physicians - visiting staff physician or consultant, residents both senior or junior.
Nurse - Nurse supervisor or tutor, head nurse, staff nurse, student nurse

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Paramedical professional and technician - Dietician, laboratory technician, X-ray technician, Social
workers, occupation therapists, physical therapist.
Senior skilled workers - Trained attendants or nursing aid, medical technicians, dietician’s aid ward
receptionist or clerks.
Unskilled workers - Nursing Ayah, Hospital Attendant or Nursing orderly, Sanitary attendant or Safai
Karmachari, foor service maid Laundry attendant, sewer man, Plumbers.

Objectives of indoor services : Primary objectives of a inpatient service are

1. Accommodation and care of patients at a point in an illness when dependence on others is at its most.
2. The care provided to the patients are not only curative, but also promotive and rehabilitative services.
3. The care is to be provided in such a way that the patient feels at home inspite of his pain and
distressed condition and being away from family environment.

Functions of inpatient services can be enumerated as under :

1. Highest possible quality of medical and nursing care of the patient.
2. To provide necessary equipment, essential drugs and other items required for patient cure and care
process.
3. Furnish most desirable environment, substituting as temporary home for the patient.
4. Providing facilities to meet the needs of the visitors and attendants.
5. Provide highest degree of job satisfaction for the nursing and medical staff and to provide them
opportunity for training and research.

As the wards are like the temporary home for a patient during their stay in the hospital, all their needs are to
be catered for. Therefore, the hospital ward must be designed in accordance with the social needs, customs
and habits of the community in which the hospital exists.
It is very difficult to describe an ideal ward, as there are variations in the patterns of medical care in different
specialisations and also there are different types of patients with different demands and needs. These are
more particular for patients of paediatrics, obstetrics, opthalmology and infectious disease - such service
areas need special consideration.

Planning of wards :
The various factors which are to be considered before designing any inpatient ward are as follows :
1. Function : The exact function and type of patients who are to be admitted must be clearly decided
upon.
2. Location : The location of the indoor unit and its relationship with the other service departments and
other sister wards should be predefined, for example their relation to Operation Theatre (OT).
Intensive Care Unit (ICU) as well as the supporting services like that of Laundry, CSSD and hospital
stores.

50
3. Staff : requirement of the ward are also to be assessed and calculated for categories like the doctors,
nurses, nursing orderlies, sweepers, which should be adequately matched with that of patient pattern
and the nursing care need.
4. Space : Space requirement of each ward and the sub-units including the ancillary services should be
based on standard available for Indian climatic and social condition.
5. Flow pattern :The planing of the wards should be based on to the accepted principle of Hospital
Planning that is “Design should follow function”. The work flow as well as the traffic flow should be
taken into account and the floor plan should be according to the schedule and sequence of activities
in the work..
6. Communication: Most of the research data of a hospital are generated from the ward. The
communication system should therefore be clearly defined right at the planning stage not only for work
simplification - flow pattern of the ward but also communicating the technology available.

The planning of inpatient services should be such that all the wards are arranged in a block way, separate
from the out patient areas, but at the same time enabling to share the common services like kitchen, laundry,
central sterile supply department and other support service areas.

Arrangement of wards :
The various wards may be arranged in a horizontal or vertical way or a mix of them, depending on location,
site and type of the building.
The horizontal planning is suitable for hospitals with sufficient land. It has the advantage that it saves time for
internal movements as compared to the vertical pattern with or without lifts for the vertical transportation of
patients, trolleys and supplies. Such arrangements is advantagious for smaller hospitals with bed capacity of
200-250 only. If the number of beds are more than 250, it is always better to go for high rise vertical inpatient
block. As most of the hospital should have an expansion programme, such inpatient facilities can be
provided by increasing the number of storeys of the existing building if permissible, or constructing a similar
block adjoining the original block. Moreover, scarcity of land in urban areas favour more for highrise building.

Bed strength of a hospital :

The number of beds required for a hospital depends on the need of the patient population and other health
care facilities available. Usually the ratio of OPD attendance to bed strength is 10:1 i.e. if the daily attendance
in OPD is 1000 then 100 beds could be required for indoor facilities. This include beds for intensive care unit
which accounts for 2% of total beds ( as approx. 1-2% of total patients admitted are very sick requiring
continuous monitoring) and emergency beds (8-10% of total beds).
Ward size and configuration :

1. Size of the ward : The essential criteria for size of the ward is the capacity of the nursing team to
supervise and render patient care to each patient of the ward. The smaller the unit, the more effectively the
patient care would be, but it would be expensive to build and maintain more of such small units. On the other
hand it would be cheaper to build and maintain larger units, but in such cases supervision of patient is
compromised. A “10 bed unit” would more or less require the same facilities as regarding equipments and

51
other supporting services as for a “20 bed unit”. Therefore, it is a very difficult to suggest what should be the
standard size of a ward in a general hospital. However, it is to be kept in mind that the size depends upon the
nature of care needs to be provided to patients. Florence Nightingale - the mother of nursing services has
recommended in the year 1850 itself for a 30 bedded ward to be a ideal size of the ward and more or less the
same figure has been found to be the optimum size even today for operation efficiency and economic staffing.
This figure need not be accepted as a rule of thumb but an extreme need range of 20-90 beds are also known
to exist in different hospital settings. In acute wards with high turnover of patients which are in need of
extensive nursing care, the limiting number of beds required may be 20-25, whereas, the chronic wards in
which patient care need is of only supervision such as in case of tuberculosis hospitals or any chronic disease
hospital, the upper limit of beds may be 40-50 beds or an average. Two or three such units when constructed
in the same floor with common essential services in the centre, can serve the patient care in a general chronic
disease or long stay hospital.

2. Shape of the ward :

Pavillion type or traditional ward : Traditionally hospital ward is rectangular in shape and was first stablished
in France in 1770. Later after 80 years, Florence Nightingale adopted the same concepts and recommended
the design, which is still known after her name as “Nightingale Ward”. The functioning of the ward is based
around the head nurse, who also plays the role of housekeeper along with nursing care responsibility.
It is self a contained unit with 30-45 beds and all necessary arrangements like Kitchen, Store etc. are
accommodated in the same unit. This type of ward consisted of two rows of patients beds at right anges to
the longitudinal walls with bathrooms and toilets at one end and nursing station, doctors room and other
technical facilities at the other end. The length of such wards were some what around 30 meteres and it
housed 30-35 patients. This type of ward continued till the first quarter of the century. Functionally, it has been
realised the various problems faced by nurses and doctors as well as the patients, who were required to
traverse the whole length and breadth of the ward and so certain modifications were incorporated in such old
type of wards. The nursing station were shifted to the centre and facilities like Isolation room, wide verandahs
on either side of the ward were added so as to prevent direct sunlight to the inmates of the wards.

Advantage of pavilion type of ward

i) Easy to construct and maintain
ii) Nurses have direct supervision of all the patients
iii) Plenty of fresh air, cross ventilation and natural light

Disadvantage of pavillion type of ward

i) Danger of cross infection
ii) Noise, more light and glare to the patients
iii) No privacy for the patients
iv) No freedom from noise and other disturbances
v. Seriously ill patients who are placed close to the nursing counter requiring maximum attention of the nurse
is the centre of greatest traffic which is not desirable.

52
Riggs pattern of ward : In due course of time with more understanding and research outcome in medical
field leading to increasing complexities of nursing procedures, the concepts of cross infections, the pavillion
type of ward was found not to be practicable and efficient. In order to rectify the defect, the ward were divided
into small compartments or cubicles accommodating 1,2,4 or 6 beds, the cubicles being perpendicular to the
walls. This pattern of ward arrangement is called the Riggs Pattern..
Although such an arrangement to some extent reduced the chance of cross infection, noise and gave some
degree of privacy to the patients as compared to the pavillion type of ward, it has its own disadvantges, some
of which are like :
i) Absence of Constant supervision and communication between nurse and patient becomes difficult.
ii) With the constructions of cubicles, the walks become longer, resulting in more distance the staff has
to walk in the course of their duty leading to a efficiency factor like “Nurse fatique” and low productivity.
iii) Number of staff required is more.
iv) Expensive to build and difficult to maintain.
Some of these disadvantages can however be overcome by provision of call bells, signal lights, two way
speakers etc. To reduce the number of staff, the wards can also be designed appropriately like “T”, “Y”, “Semi
Circular” or “Double corridor” type.
Mix pattern of wards : Every hospital has the dilemma to choose between pavillion pattern, rigs pattern or
single room pattern. The existence of wide range of patient services as well as patient’s choices has added
more to the problem. With the development of central supplies and central food services, the concepts of
traditional large wards built as indepndent unit, has shifted more towards smaller wards with rooms for 4-6
patients and a few single rooms. The whole ward floor is divided into 2-3 sub units sharing common ancillary
facilities like pantry, dirty utility rooms, store rooms etc. This has resulted in maintaining effective separation of
the units while still maintaining single operational unit served by one team of nurses and ward doctors. This
types of smaller units have allowed much flexibvility in the use of beds as well as adapating to the demands
for admission. Earlier large wards used to admit patients of a single speciality in one ward only, and that too
separate for male and female patients. This lead to over utilisation of one ward and under utilisation of other.
For example in any one day, there may be more admissions of male medical speciality patients and less
admissions of female surgical patients leading to excess loaded male medical ward and less load in female
surgical ward.
This fluctuation in demand could be adjusted by the flexible use of sub units in each ward floor, where each
unit could be utilised according to demand.
An adequate number of single rooms has made it possible now a days to segregate patients who need
Isolation (patient with infectious disease with the risk of infecting others), those who need an attendant or
private toilet, seriously ill patients who need special medical apparatus like ventillators, monitors, x-ray
machines etc., patients who are dying or whose conditions are distressing to others. this concept has met the
needs of all categories of patients in a modern day medical practice.

The various components of ward can roughly be divided into four types, each component having
many sub-components.

53
1. Primary accommodation : The primary accommodation is the direct patients care accommodation. It
includes the ward cubicles as well as the single or double bed rooms and the isolation rooms. In general the
standard size of a hospital bed is 2 m. length, 1 mt. breadth and 0.6 m. heights. The minimum floor space for
a single bed is a multi bed room (having 4 beds or more is 7 sq.m. For single bed room the optimum
requirement is 14.00 sq.m. and for two bed rooms it is 21.00 sq.m. The recommended minimum distance
between the centre of two beds is 2.5 m. A space of atleast 0.25 m. should be left from the wall to the head
end of the bed adjacent to the wall Each bed should have a bed side locker to keep the patients personal
items and a comfortable chair for the attendant.
The above mentioned figures are for general ward beds and special wards if planned should have more space
for example in wards like obstetric ward and orthopedics ward, to accommodate basinnet and traction
appliance respectively. The floor space in these wards may be 10 sq.m. per bed in multibay cubicles.
Floor height : The height from the floor to the ceiling ideally should not be less than 3.0 m and more than 3.65
m. The head space i.e. the minimum vertical distance from under the beams, ceiling rans, light and other
fixtures to the floor should be 2.60 m.
Dadoing - This is important for cleaning and maintaining of the ward the hygiene and should be atleast upto
1.20 m. high at all rooms and corridors. However, with the advent of better building materials and wall paints,
such limits can however be lowered.
Doors - The minimum width of a door in a hospital patient care area should be more than 1.20 m. and height
of 2 ms so as to wheel in and out a standard hospital bed without any obstruction. For wards where a mobile
needing X-ray machines and other heavy equipments are to be wheeled in, the door should have a width of
1.6 m and a height of 2.1m communicating adjusting to the dimensions of the machine. The same size is also
applicable for a single and double bed rooms. Each door should have a viewing glass pane so that treating
staff of the patient can peep into the room as and when required.
Windows - Adequate number of windows should be provided in the wards enabling sufficient light and air to
come in. The area for windows should be atleast 20% of the floor area. If windows are located only in one wall
and it should be 15% of the floor area, if the windows are to be located in opposite walls. The windows must
be fixed with proper grill for safety and security purpose. For wards having centralised airconditioning system.
Only glass panes are to be fixed. To avoid direct sunlight, sunscreens, washable curtain or vertical venetian
blinds are also fixed in modern hospital inpatient wards.

Ancillary Accommodation :
Nursing Station : This is the “nerve centre” of the ward unit. Their location should be so that the nurse can
keep a watch over as many patients as possible. The correct balance between privacy of patients and direct
supervision by the nurse are very difficult to maintain, as they are both inversely related. In the Riggs pattern of
ward, the cubicles adjacent to the nursing station are usually earmarked for acutely ill and serious patients
which is partitioned from the nurses’s station by a large glass pane through which the nurse can directly
observe the patient.
The nursing station should have a space of 6 x 6 meters with the following basic components:
i) A nurses counter which separates the corridor with the nursing station should acts as barrier. There
should be adequate space at the one side of the counter to allow passage of a trolley without
obstrction. The counter should have built in drawer and side shelves with adequate leg space.

54
ii) Sisters room with attached bath and WC. The room should have cupboards for medicine with locking
facility to keep dangerous drugs. A trolley containing life saving medicines and other equipments
should always be kept ready.
iii) An inbuilt drug cupboard for keeping stationaries and proper rack for case files and other items of day
to day requirement.

The signal light’s pannel of the patient should be so located that it is constantly visible to the nurse. The
intercom and computer connected with LAN should also be provided at the nursing counter.
Doctor’s room : The number and size of doctor’s room is determined by the number and doctors posted in
the ward. It should also serve as the clinical conference area and for examination and consultation of the
patients. It should be of a reasonable size with minimum facilities like a examination couch, sofa, desk and
chair and a wash basin.
Treatment room : This room is utilised for special examinations, minor treatment, lumbar puncture and other
procedures, dressings, intravenous injections and dressings etc. which cannot be carried out in the ward. This
reduces the cross infection, provides better facilities to the doctors and nurses as well as the patient and at the
same time other patients in the wards are not disturbed. A space of 20 sq.m. is more than adequate for such
purpose with the couch, sink and the room should have tiling upto floor height for easy cleaning and
maintenance.
Clean Utility room : This room is adjacent to or may be included in the treatment room. It is used to receive
sterilised articles like packed dressings, instruments from C.S.S.D. as well as for preparation of trolley for
minor procedures. A small sterilizer can also be provided in a surgical ward. A room of 12 sq.m. is adequate
for such purposes.
Pantry : This has replaced the function of kitchen used to be a part of the wards in earlier days. It is used for
temporary storage and distribution of meals and to warm up meals. Preparation of beverages and even
preparation of “Chappati” etc. can be locally made.The pantry is equipped with facility for hot water,
refrigeration, hot case and facilities for storage of crockery and cutlery.
The room should have a large sink and adequate drainage system as one corner. A space of 12 - 15 sq.mts.
is adequate for such purpose.
Stores : A small store in each ward for storing linen and general stores are required. There should be
adequate number of cupboards and inbuilt almirahs for such purpose. The space required is 10 - 12 sq.mt.
Day room : Ambulatory patients admitted in wards feel isolated and psychologically depressed, so accordingly
a separate area for sitting and relaxing is advocated and helps in recovery process. This also encourages
patients to move about at the earliest. This room can also be used as a dining space or for meeting visitors
and relatives. The room should be attractive and comfortable for the patients and be equipped with television
set, comfortable chairs, a table with provision for magazines and newspapers so that patients can come and
relax and need not go outside the hospital. Such a room can also be created at the closed end off the corridor.
Approximately 15% of the wards space or a minimum of 15 sq.mt. is sufficient for such a purpose.
The pantry, store and day room can be common to all the ward units in a single floor.

55
Sanitary Accommodation :
Bathroom and toilets : The fittings and other elements in these utility room of the hospital wards are to be in
acccordance to the social class of the patients and their cultural habits. The average requirement are as
follows :
- One bathroom for every twelve beds or part thereof
- One WC for every eight beds or part thereof
- One urinal for every sixteen beds or part thereof
- One wash basin for every ten beds or part thereof
- One dustbin for every fifteen beds or part thereof

In case of bed ridden patients, bed pans are provided and the average requirement is sbout one bed pan for
every ten patients of course cheap plastic bed pan are now readily available, which an average patient can
afford to buy for his or her exclusive use.
The above scales do not include such facilities provided for the single and double bedded rooms, and that of
staff. It includes only the patients requirement and does not include that of the attendants. Even when indian
type of WC are provided. It is recommended that one western WCs must be provided in each sanitary block
to be used by patients who cannot squat or for phsyically handicapped. There should be adequate and non-
interrupted hot and cold water supply. Tiling or dadoing of the bathroom and toilet should be upto complete
floor height. The floor should be non-slipery but easy to clean like made of commonly available Kotastone.
there should be adequate illumination in each of these facilities lights.
Dirty Utility room : A dirty utility room also known as sluice room is to be provided in each of the ward for
emptying and cleaning of bed pans, urinals and sputum mugs and for temporary storage of stool and urine
specimens. The room should be such located that it is near the bathroom and toilet. It should be fitted with
bed pan washing machine or single large sink with free supply of water. Some sort of stainless steel hanger
are also required to be filled for keeping the bed pans and urine pots. A fly proof cupboard is recommended
for storage of urine and stool sample. In addition a separate space for sorting and storing of soiled linens are
also required with facilities of washing and disinfecting them when even required. A minimum space of 12
sq.mt. should be provided for such purpose. The sluice room should ideally be adjacent to the toilet complex.
Janitors room : A separate room for keeping mops, grooms, buckets and cleaning materials for the sanitation
staff or safai karamchari are to be provided in each floor with adequate supply of hot and cold water. Provision
of storage floor scrubing machine or other sanitary equipment be made.
Auxillary Accommodation : Some of auxillary accommodation recommended for a modern hospital ward
includes clinical side rooms (ward laboratory) clinical conference room, duty medical officer room, nurses rest
room, group-D employees changing/rest room. A trolley bay for keeping trolleys and wheel chairs should also
be provided. These accommodations need not be provided for each individual ward but it may also be
provided on floorwise so that the facility can be used by 2-3 wards on each floor.

Other facilities :
Central oxygen and suction supply : In large specialised hospital the wards must have piped oxygen supply
and suction including compressed air supply for intensive care area, and the outlet points should be wall
mounted and connected to the Central manifold room. This arrangement should always be included in the

56
planing stage itself. For areas where seriously sick patients are treated, every bed should have an oxygen
and a suction point. In other areas, one wall mounted oxygen and suction point for adjascent two beds should
be sufficient. The wall mounted adoptors should be such that it is easy to fit with the flow meters and there
should not be least of chances for leaking.

Physical facilities :
Lighting : In General ward, lightening of 100 Lux is sufficint. For treatment room and nurses counter 150 Lux
is recommended. During night, provision of right lane of 15 watts is sufficient for each bed. Single and double
bedded rooms may be provided with additional bed head lights. There should be provision of one emergency
light in each cubicles and other patient care rooms.
Electrical points : One 5 Amp. and one 15 Amp. power sockets are minimum to be provided for every two
adjacent beds. Each bed should have a call bell with buzzer and light indicator in the nursing station for
facilitating the patients to call the nurses.
Water : Adequate supply water both hot and cold water are to be provided round the clock. An approximate
daily requirement of water would be 300 ltrs. of water per bed per day. Provision for proper drinking water
supply should also be made with possibly mechanical filter system.
Ventilation : Ceiling fans should be required in the following scales in a major Indian cities located in a topical
country like our:

a. Single or double bed room : one 1200 mm. dia.ceiling fan

b. Four bed room : Two 1200 mm. dia. ceiling fan
c. Six bed room : Four 1200 mm. dia. ceiling fan
It would be preferred to have a Central Air condition. Supply so that the temperature is maintained at comfort
zone (77-80o F). There should be 8-10 air changes per hour.
Corridor : The corridor should have a width of atleast 8 ft. and 20% of the wards space may be required for
this purpose.

CONCEPT OF PROGRESSIVE PATIENT CARE :

Progressive patient care aims at the hospital facilities or services and staff around the medical and nursing
needs of the patient. It is basically tailoring of hospital facility to meet the patients needs, in other words’ the
right patient on the right bed with the right services. Under this concept, patients are grouped according to
their seriousness of illness and the need for care, rather than according to age, sex, type of illness or
economic status. Although this is a modern concept adopted by many countries the origin of the system could
be traced back to the time of Florence Nightingale who advocated that the seriously ill patients should be kept
near the nursing station while the least ill patients were placed at the farthest end. This concept has gradually
been adopted in India also by many hospitals.
Elements of progressive patient care (PPC) : It is a dynamic concept and involves six elements following
the natural history of disease. First is :
a. Intensive Care
b. Intermediate Care
c. Self Care

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d. Long term Care
e. Home Care
f. Outpatient Care
a. Intensive Care : Intensive care unit or intensive therapy ward is a nursing unit that is staffed and
equipped to cater acutely ill patients who need continuous observation and extensive care with potentially
reversable reasons. The unit providing such care is known as Intensive Care Unit (ICU).
b. Intermediate Care : The intermediate care unit caters to the patients who are moderately ill and
includes patients transferred from intensive care unit or post operative patients. In general wards, such
patients are kept in the observation cubicle adjacent to the nursing counter so tht continous vigil could be
maintained. A moderate proportion of patients admitted in hospital are in need of such care.
c. Self Care : The self care unit is for those patients who are ambulatory and convalescing or have been
admitted for diagnosis, therapy and preoperative patients. Such patients do not require close observation and
special nursing care and are able to look after themselves. These patients are kept at the middle or rear end
of the ward depending upon their need.
d. Long term Care : The long term care unit are for those patients requiring prolonged nursing care and
services which are not normally available at home and specially those who require these services for a
prolonged period. Examples of such patients are colostomy patients or diabetic patients who need insulin dose
regulation and so on. Such patients need skilled palliative and rehabilitative treatment care.
e. Home Care : These are those patients who need occasional supervision and instruction by physicians
and nurses in maintaining the continuity of care after the patient has left the hospital. These facilities are
provided to the patients at his home by a unit of medical team who visits the patients in their home at suitable
intervals and give instructions, medicines and even expert nursing advice.
f. Outpatient Care : These are the patients who come to the outpatient department and receive
treatment on an ambulatory basis.
Although inpatient intensive care is to be provided at a separate facility - the Intensive Care Unit (ICU), the
ward system has the responsibility to take care of intermediate, self and long term care patients. All the
resources are therefore to be so arranged to take care of these patients according to their needs. Home care
is provided by a special team of medical professionals, whereas outpatient care is concerned with the OPD.

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 CHAPTER 3.3

INTENSIVE CARE SERVICES

KEY AREAS

• Objectives ,Concept of Intensive Care Services

• Types and Functions of Intensive Care Units
• Planning and Designing of I CUs
• Policies and Procedures
• Staffing

Intensive care in the hospital practice is a concept as old as that of the institutional care system of sick and
injured in a medical care setting. However, the planning and organising an intensive care unit of hospital as a
separate facility can be traced back only to the war time development of medical care arrangement for the
Army personnel in the field. To start with such a medical care programme was established by creating
resuscitation tents adjoining the operating room in most of the military medical set up. In such an
arrangement the Anaesthetist normally took charge of the critically ill patients and field blood banks provided
the support till the acutely ill patients were fit enough to be taken in for surgery. However, with the
sophistication of medical care technology it has become increasingly difficult to provide all life saving
monitoring and therapeutic equipment like ventilators, defibrilators in a field location of medical care units.Thus
it has become a neces-
sity for the modern medical organisation to plan special care area for continuous and constant monitoring of
critically ill patients and also to provide necessary life saving measures irrespective of the underlying cause of
sickness. This special care area has been conceived to accommodate only limited number of patients, and its
primary aim is to provide the life support and thereby enhance the healing process. In the modern hospital
this area is called intensive care ward or a unit and has become an important wing of critical care medicine
and has become an established and essential service for management of critically ill patients.
The following are the basic components of an Intensive Care Unit.
I. A Centralised Facility - available to all medical care units so as to utilise adequate space, competent
staff and high cost monitoring and therapeutic equipment for the care of a patient,which are normally not
available in a general ward.
2. A package of service - which includes medical and nursing care based on continous observation and
monitoring of the vital functions so as to support and sustain these functions by Electric Mechanical means
when necessary as a part of recovery process, which cannot be organised else where in the hopsital on more
economic means.
The everincreasing input of the technical knowledge and high degree of sophistication in intensive care unit,
has led to considerable reduction in morbidity and mortality in our hospitals and this inturn has resulted into
increased demand for intensive care services and beds to the clinicians as well as the patients by and large.
59
So there is considerable pressure for the physical expansion of facilities, beds, equipment, staff and so on in
Intensive Care Units in our hospitals.
The Intensive care facility with the inputs in terms of people the equipment and facilities is one of the most
expensive area of the hopsital to create and also for operation of services and maintenance. It is important,
therefore, to plan and manage only optimal intensive care facilities so that it is cost effective.
Hence, keeping in view of the scarce hospital resources and escalating costs, the hospital administrator has to
constantly ensure, correct and full utilisation of the available beds and initiate necessary measures by laying
down policies, procedures and realistic criteria for admission of genuine cases, needing intensive care, rapid
turnover of beds and reduced average length of stay of the patients, to give benefit to maximum number of
critically ill patients.
Committee on Plan projects while giving report on General Hospitals (India) has emphasized the fact that best
attention to very ill patients cannot be given in general ward and only way to give best treatment, was to put
the patient in a special unit, intensive care unit, with better equipment, more nurses and better staffed. It is
stated that ICU is primarily meant for patients in a critical stage of illness and not for all seriously ill patients.

In the modern hospitals the spectrum of intensive care unit is wide. Due to increasing number of
specialities and super specialities in the medical practice separate intensive care units are being
created for such newer subspecialities. These are :
1. Coronary Care Unit (CCU) or (ICCU) : For patients with myocardial infarction or cardiac arrhythmia.
2. Medical Intensive Care Unit : For critically ill cases of general medicine.
3. Surgical Intensive Care : Looking after post-operative cases requiring more intensive treatment and
care.
4. Intensive Care for Burn (Burn Care Unit) : Burn cases requiring specialised care and barrier
nursing.
5. Neonatal Nursery : Established near delivery rooms for care of neonates, who require therapy like
Exchange Transfusions and incubator treatment for premature infants with respiratory distress
syndromes, etc.
6. Paediatric Intensive Care Unit : For treating critically ill cases of paediatric ward e.g.meningitis,
encephalitis, post-operative cases of meningocele, inperforated anus and umbilical hernia.
7. Dialysis Units : For haemodialysis and peritoneal dialysis cases.
8. Neurosurgery Intensive Care Unit : For post-operative intensive care of neurosurgery cases.
9. Renal Transplant Unit : for cases of Post Operative Renal Transplant.
10. Cardiac Surgery : for Post Operative Open Heart Surgery cases.

These are all known as unidisciplinary units run by respective units only requiring anaesthetists’ help
sometimes for respiratory support.
But there are large number of patients who require multidisciplinary approach for treating acute conditions and
also requiring strict supervision, additional nursing care, continuous monitoring and special care by specially
qualified staff and very often mechanical aids to support their vital functions.

60
Such patients may require prolonged artificial ventilation, extensive treatment for shock, cardiac monitoring,
biochemical corrections of severe metabolic acidosis, treatment of cardiac irregularities by defibrillator and
cardio-respiratory resuscitation, etc.
Many of the patients of unidisciplinary unit also require the help of intensive care unit when condition
deteriorates and facilities are not adequate to treat those complications.

Steps in the Development of an Intensive Care Unit

The following are the standard steps for developing ICU within hospitals :
1. Planning and organisation
2. Training basic nursing staff and physician staff in hospitals with existing ICUs and teaching
programmes in critical care.
3. Building and equipping the unit
4. Opening the unit
5. Developing special standards and protocols for monitoring and life support techniques.
6. Training non-physician personnel (inhalation-therapists, physical therapsits, nursing
assistants and others).
7. Continuing education of physicians and nurses.
8. Developing full time coverage for physician specialists from various disciplines.
9. Developing research programmes.

It is always advisable that planning and organisation of an ICU should be conducted by a broad based adhoc
committee having representative members from anaesthesiology, internal medicine, cardiology, paediatrics,
surgery, nursing, administration and engineering.

Regionalisation of Intensive Care Units

Staffing and equipment and type of hospital mainly determine the hospital’s category of ICU capability four
types of ICUs for hospital categories I to IV. These are as under :
1. Type I ICUs can be established on regional basis usually in Category I hospitals i.e. large
comprehensive regional teaching hospitals. Ideally, they could have round the clock critical care
medicine physician coverage in ICU.
2. Type II ICUs within house ( not in ICU ) full time physician coverage by at least senior residents,
needed in Category II hospitals i.e. other major teaching and community hospitals.
3. Type III ICUs - Intensive care by specially trained nurses and respiratory therapists with strong ICu
medical direction, on call, at home, are common in Category III hospitals can provide safe basic
intensive care provided there is a rational referral policy for selected problem cases.
4. Type IV ICUs - Cateogory IV hospitals have no ICUs but should be prepared for patient transfer with
life support general elective surgical procedures, utilising general anaesthesia should be performed
only in hopsitals that have ICUs and major definite emergency surgery should ideally be done only in
hospitals with type I or II ICUs.

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Planning Considerations

Location :
Intensive Care Unit should be easily accessible to accident and emergency departments, operation theatres
and inpatient areas. It also depend upon the architectural pattern of building i.e. single storeyed or horizontally
spread hospital or multistoreyed where vertical traction is applied.
In single storeyed hospital, ideal location should be near to the emergency service, recovery room, outpatient
department and the indoor ward. However, in multi storyed building with efficient vertical traction, the ICU is
recommended to be located on the top floor. This will keep the ICU away from main stream of traffic, low
cross infection and quiet surroundings.
An important factor has to be kept in mind when choosing the proper location of ICU within the hospital -
namely, the availability of space for step down beds. Step down beds allow for transfer of patients who needs
continued monitoring or skilled care at a level less than that provided in parent ICU. Experience shows that
many ICUs suffer from over-crowding and unnecessary pressure to admit more patients than they can
properly care for, simply because there are no suitable hospital beds for this intermediate level of care.
It is always to be kept in mind that such step-down beds be located close to the parent ICU, so that the
professional staff of the intensive care unit can follow up patients when required within the step down unit. If
step down beds are not available, the cliniciansmay have the tendency to keep the patients in the ICU longer
than it may otherwise be necessary, leading to over-crowding and inefficeint operation.
Size
There are varying views regarding number of ICU beds required in a hospital, different authority recommends
different views regarding size of ICU. However, there is a broad agreement that the optimum size for an
intensive therapy unit should be 6 - 8 beds. Units of less than four beds are stated to be not viable
because the workload and inputs required in terms of manpower and equipment will not be economical. It is
also suggested by authorities that one to two percent of total bed strength of the general hospital has usually
been found to be adequate to meet the need for intensive therapy of services. A hospital of over a thousand
beds has been suggested to have more than one unit.
Safar et al (1961) have recommended 2.0 per cent of total hospital beds in a general hospital for ICU. Sixty
per cent of these should be earmarked to surgical and forty per cent medical speciality, when possible.

Number of beds required in Intensive Care Unit

Clinic Percentage of total Hospital beds

General Surgery 3-5

Gynaecology 1.0
Orthopaedics 1.0
E.N.T. 0.5
Medicine 3.0

62
As it is suggested that a ICU unit should not have less than 6 beds or more than 12 beds, but two such units
could always be linked.
A general hospital with less than 200 beds may not have a central ICU because of low utilisation and being
uneconomical but in such circumstances, ICUs facility should be organised in individual wards only.
Design
Modern hospital architects recommend many types of lay out for intensive therapy units but available literature
does not show any particular advantage to any of the design, barring the provision of certain basic
requirements.
An ICU therefore for a new building often may assume whatever shape is considered best; may be
rectangular, square, or even circular. Cubicles with floor to ceiling partitions on each side and glass panels
at an appropriate height (usually 48 inches) on each side commonly accepted design allow the patient to be
seen by a nurse and at the same time provide a visual barrier and to some context partial sound barrier
between patients lying in adjacent beds (Kinney, 1982).
Some of the other design concepts also suggested that all beds can be put in one hall i.e. in an open ward
whereas some advocate that there should be single bedded units or cubicles. The advantage with such
cubicles is said to be the reduction of cross infection hazards. Whereas there are suggestions which advocate
to have cubicles and balance beds could be locted in an open ward. For example, in a 8 bedded ICU, 6 beds
can be in open ward and 2 beds can be single unit cubicle. Such designs can take up the advantage of both
the closed cubicles to that of open cubicle plans.
Space
The size of the intensive care units are normally described in terms of beds, however, the essential concept is
the space required for the equipment and maintenance facility in the unit itself. The bed space per bed is
recommended to be about two to three times to that of an ordinary ward which is suggested as 18 to 20
sq.mt. per bed. Some authorities found 2 single bedded ICU room each having a floor space of 21.6sq.mt.
inadequate. It is therefore recommended that 30 sq.mt. for each single room minimum of 15 sq.mt. per bed
is a basic necessity for an open bed areas and 22.5 sq.mt. for isolation cubicles is recommended so as to
meet the need including adequate circulation areas.
Aim should be that the space available be such that each bed gets an area of about 10 sq.mt. with sufficient
space all round it for undertaking emergency clinical and nursing procedures.
Studies in Indian climate conditions have recommended floor space for a ward in an open unit be 10 sq.m. per
bed and 24 sq.m. per one bedded room.
Committee on Plan Projects (Report on General Hospitals of India, 1964) has recommended that the area per
bed within the ward should be 7sq.mt. for normal beds in a hospital have recommended 25-30 sq.m. per bed
for signle bed areas and 20 sq.m. in multiple bed areas. The service area should be atleast equal to the bed
area. Thirty to Fifty percent beds could be in single bed areas.

Other facilities

Varandahs
Committee on Plan Projects (1964) has expressed that provision of varandah can be substituted by Sun
breakers to provide some degree of comfort at less cost than varandah.

63
Floor Floor is recommended to be of conductive type as most of the equipments used in ICU are electrical
and such a provision will safeguard against accidental electrocution.
Terrazo in general or use of marble to reduce noise due to walking or falling or article is advocated now-a-
days. A terrazo floor mixed with finely divided particles of carbon forms an ideal surface, which can be easily
washed and cleaned with a suitable detergent or antiseptic.
In order to maintain cleanliness as well protection against damage to wall by movement of trolleys, dado is
advisable in ward and corridor. Walls can also be painted with to give a soothing effect on the eyes.
Roof or ceiling should be painted and corners to be rounded off. There should not be any projection as a
source of dust collection. Fittings and fixtures should be made flush to wall surface.
Insitu mosaic floors with least possible joints with brass/copper strips 6 mm apart both ways to carry out any
static electricity produced by earthing is the necessity, irrespective of size or dimension of the ICU ward.
Walls : The insitu mosaic finish for full height of wall is preferable.
Noise Factor : It has been universally accepted that asthe medical requirement of intensive care patient noise
pollution is not acceptable so noise control measure is an important step in the planning stage. It will be better
to have resilient floor in the ICU which will deaden the sound of moving equipment and staff. It is all the same
time recommended that in order to keep noise at minimum and soft piped music sometimes can be provided
as a distraction.
Lighting : This needs to be carefully planned. Patients areas should be uniformly lighted and free from glare
of any sort. Adjustment to dim light should be possible at patients bed side. In order to facilitate any nursing
or medical intervention provison of high intensity light . In case high intensity light is required, provision to
supplement general lighting with portable lamps should be available.
Lighting beneath the beds will also be needed to check drainage of bottle and under bed seals. All electric
circuits should be concealed. As observation of patients colour is important, hence blue or green light are not
admissible in this unit.
Tungsten filament light can be replaced by fluorescent tubes of the intensity of 15-30 lumens per square foot
without production of dark shadows. The ward itself should be best provided with fluroscent tubes of Philips
colour no. 32 or 34. Each bed area should be capable of illumination from the ceiling to a maximum of 30
lumens per square foot (300 lux) at bed level.
Emergency Light ICU electricity supply should have alternative source of supply in the similar way as that of
an operation theatres and other vital areas. Emergency portable light should be available in each cubicle,
laboratory and other ancilliary rooms and minimum four for open type ward and one at sisters duty station.

Comfort Conditions

Air-conditioning : Ideally in India, central air- conditioning is essential to cope with extremes of weather and
to prevent dust. Maintenance of humidity at about 50-60 per cent is recommended to be idle and the
temperature to be 20o to 25o celsius.
Cafeteria and Refreshment : Some amenities like pantry refreshment from cafeteria may be made available
to the staff in since they cannot leave ward now and then.

64
Ventilation and Circulation
Clean and dust free air circulation is idle for any intensive care unit. Majority of droplets in the normal
atmosphere and dust particiles are in the 10 micron range or below. Such air can only be sterilised by
exposure to radiant energey from an ultra-viiolet source or by actual removal in the ventilating system. For
this reason, the type of ventilation in intensive care areas assumes extra importance.
It is therefore suggested that there must be minimum 10 air changes per hour to clear droplet nuclei. If 10 air
changes per hour or more is there, it is possible to clear droplet nuclei reasonably rapidly and to maintain less
than 10.0 per cent of the total which normally would be present. There should not be any recirculation of air
and hence central air-conditioning with rest of hospital services in ICU is not desirable.

Positive Air Pressure in ICU

The ICU should always maintain at a positive air pressure relative to the air pressure of the corridor or general
traffic outside to prevent passage of contaminated air in reverse direction Hence exhaust fans causing
negative pressure in cubicles or open wards are not recommended by the hospital architects..

Ancilliary Accommodation and other physicial facilities

While the patient area of the hospital is the most important area in the unit, certain other rooms for ancilliary
and support area are essential. These include a staff lounge/changing room, a cleaner’s room, a dirty utility
sluice, a staff lavatory, a visitor’s room, a laboratory and a doctor’s room and preferably a conference room. It
is essential to have adequate and comfortable arrangement for duty and work rooms for medical officers,
sisters and a sleeping room for the night duty medical officer.
Over and above the following other ancilliary rooms are essential in addition to those mentioned:
1. Central office for records
2. Storage room with ample space for heavy equipment
3. Storage room with ample space for linen
4. Minor surgery room for venesection, tracheostomy and change of dressings etc.
5. Small workshop for minor repairs of apparatus.
6. Waiting room for relatives with sleeping facilities, bath and lavatory.
7. Rest room for paramedical staff, bath and lavatory.
8. Air conditioning plant room.

Nurses Duty room or Central Nurses Station

The nurse’s duty room always be planned in such a manner that it should be strategically positioned from
where they are able to keep a continuous vigil over the patients to monitor their condition coveniently with
shortest possible distance from all beds.
This room normally should contain a cupboard to hold certain items, drugs and documents, a drug cupboard,
sink, chair, a table, telephone, call system and rack for various records and forms. Suitable size of the room
for the purpose is suggested to be about 10 -12 sq.mt. In an ICU with a circular design, it is ideally placed in
the middle.

65
It should more of glass partition, making it possible to observe all patients either directly or indirectly by closed
circuit television. The nursing station desk should be large enough with sun mica top or any other material
which can be cleaned easily. The desk should provide sufficient working space for several people and to
accommodate the central monitoring equipment, charts and acoustically shielded telephone booth. An
effective audio-visual nurses’ calling system can also be installed here.

Nurse’s Rest Room with ancilliaries (Staff Lounge/Changing Room)

It is also important to provide a nurse rest room, a lavatory and a cloak room in the same complex. The area
recommended for such a room in a general wards is 4 sq.mt. but for ICU ward, this room should be minimum
80 sq.ft. as the number of nurses posted in ICU are more than a general ward set up.
The room can also be used for discussion of problems relatives to administration and technical procedures of
ICU which may be sorted out between medical and nursing staff of the facility.

Clean Utility Room :

This room is to plan for sterilising the instruments and packing surgical drums. The work is to be carried out in
this room, however it be done in the treatment room also. If this separate room is desired, the size may be 10
-12 sq.mt. in area.

Treatment Room :
Planning of a treatment room in ICU is essential for carrying out minor surgical emergency procedures. It will
help to reduce the chance of cross infection in the ICU. It also will facilitate the patient and the doctor to
receive the benefit of better facilities and privacy without disturbing the other patients. Its size may be
approximately 12 sq.mt.

Pantry :
The pantry in the ICU should be equipped with hot water boiler, refrigerator, water cooler, hot case and
facilities for storing cultleries etc. An area of 12 sq.mt. is required for such a ward pantry

Store Room :
A large stores room is recommended to keep the general stores, linen supply, surgical instruments, and
storage of equipments not in use, mattresses, and medical stores and also, huge and bulky machines like
Boyles apparatus, respirators, defibrillators and oxygen cyclinder and so on.
Minimum size of the store should be 20 sq.mt. There should be a separate enclosure for keeping electro-
medical equipments like defibrillators, cardiac monitors and respirators to avoid any damage to the
equipments and also for easy handling.

Repair Workshop :
Some of the users of the department have recommended that a small workshop for minor repairs of
apparatus be located in the ward itself. It would be ideal to have such repair workshop in order to overcome
difficulty in transportation and delay in repair of equipments from such facility located at a distance.

66
Dirty Utility Room (Sluice Room) :
The size of sluice room in the ICU has been recommended to be 10 -12 sq.mt.

Doctor’s room with Ancilliaries

The room to house the doctor on duty is highly desirable so that the doctor can sleep in the unit itself and
thereby ensure his availability.

Janitor’s Room (Cleaner’s Room)

A janitor’s room is essential in the ward. An area of 60 sq.ft. has been recommended. It must be equipped
with hot and cold water and necessary cleaning material for maintenance and upkeep of the ICU.

Laboratory or Clinical Side room :

A small clinical side laboratory is essential for underlying certain procedures to be carried out on the spot and
therefore should be equipped with a drain board, a laboratory sink table, storage cupboards, electrical plugs
and sockets (5 amp and 15 amp), etc.
It is absolutely useful for blood gas and acid/base balance determination which should be done in the unit
itself. Routine haematological and biochemical investigations could be done in the hospitals central
laboratories rather than in the clinical side laboratory.

Room for Class-IV Staff :

Class IV staff or Hospital Attendant are also a part of ICU team member. He or she is required to work during
nights in large hospitals and as such, the provision of a retiring room is essential. The area recommended is
12 -18 sq.mt.

Relatives Waiting Room :

A room for relatives or attendants of the patients can be planned outside the unit but it should be located
adjacent to ICU area itself The room should be suitably furnished with comfortable relaxing chairs. The
relatives may also be provided facilities to sleep in the night. Attached toilet and bath room is inescapable
requirement for such a facility. A public booth telephone near the ward is essential in todays hospital.

Circulation :
While planning the circulation space within the ward unit, alone is being considered (Report on General
Hospitals, 1964). A clearance of 1 metre has been recommended between the beds. They should be well lit
and ventilated. Before entering the ward, there should be an area where people should be able to remove the
shoes, put on hospital sleepers, gown and mask, and routine procedure. Keeping infection control measures
in mind..
The corridor connecting the hospital facility should be minimum 3 mt. wide so as to allow passage of trolleys,
equipments like Boyles apparatus and ventilators, and portable X-ray machine etc. The overall proportion of
circulation space to that of patient care area should not exceed 20 per cent of the total floor area of the ward
unit including circulation within the ward.

67
Windows :
Windows in the ICU should be made dust proof providing rubber strips in the gap. Total window opening in
ICU recommended to be 15.0 per cent of floor area of the room. The size of the window are to be kept at 1
metre above floor level.

Doors :
The doors in the ICU should be wide enough to permit unobstructed passage for patients trolleys and other
machinery and equipment. These doors should be double acting two leaf type required for patient care and
minimum 5 - 10 feet. wide.

Trolley Bay :
Storage space for trolleys and stretchers are part of ICU facility and it should be an enclosure of 8 - 12 sq.mt.

Electrical Installations :
The number and of plugs and sockets in the size of ICU ward near each bed area, Central monitoring panel
and laboratory are to be planned meticulously. Minimum four to six 4-6 electrical points near each bed and a
special socket for diagnostic radiography (30 amp. socket) should be provided. Thus minimum 6 plugs ( 3
plugs x 15 amp. and 3 x 5 amp. plugs) should be near each bed for attaching suction machine, respirators,
spot light, cardiac monitors and defibrillators, etc. The bed side panels of central supply of medical gas and
suction etc. should incorporate this.

Call System/Communication System

There should always be a patient call system. Bed side switch board should contain a push bell for inviting the
attention of the nurse in the ICU ward. Nursing station should have a call bell system for calling doctor. For
each 3 - 6 beds, there should be a panic button to be used when there is a cardiac arrest to alert the whole
clinical unit and operating room staff.
Telephone facilities for internal and external cals for the ICU, forms the part of hospital telephone system. At
least, 2 telephones are required in this area and to make it sure that an free line is available at all the time in
case of emergency.

Paging System
Wireless Paging system is very useful for calling consultants and Residents from the respective area of their
work place or when they are away from hospital.

Piped Supplies
Centrally controlled piped oxygen supply with compressed air and suction facility with the outlets are required
at each bed station with suitable flow meters, each outlet should be capable of delivery of 20 litres gas per
minute at a pressure of 60 pounds per square feet. Two oxygen cylinders are also to be provided as a
standby with a warning system and automatic change over control for any emergency purposes. Compressed

68
air should be available with one outlet and flow meter for each bed for the ventilator service. When the air is
supplied by a compressor, the air must be filtered, dried and oil free for medical care purpose.
Piped vacuum is an essential means of providing suction. Two outlets with manometers are also necessary at
each bed and air extraction should be 40 litres/minute when the vacum is in the pipeline is 500 mm Hg below
standard barometric pressure of 760 mmHg.

Dietetics
Patients requiring long term intensive care and for prolonged ventilatory support. They normally end up with
malnutrition with complication by a hypercatabolic state. So, it is very important that hospital dieticians should
take active interest in the nutritional status so as to meet calorie requirement of the patients. Menu planning
and preparation of special feeds for intensive care unit patients are also equally important as a therapeutic
process.

Administration
Administration of a Intensive Care Unit needs a balance approach, particularly for laying the policy, framing the
rules regulation, clinical care responsibility etc. It is therefore recommended administration of the area should
be through participative approach and therefore by means of committees.
It is suggested very widely that each of ICU should have its head nurse and medical administration be
assigned to the Resident of the unit. It is he who makes the decisions as to which patients stays and who
leaves the unit and it is he who is responsible for clinical care decision in emergencies.
Representative of hospital administration staff are to be available in coordinating supportive services of
patients care in areas of housekeeping for ordering and maintaining equipment and supplies. In most
countries intensive therapy units are administered by the department of Anaesthesiologist however a close
collaboration of Hospital Administration is always necessary.

ICU Director of Officer Incharge

It is advisable that there should be an ICU Director or Officer Incharge selected on the basis of experience,
competence, interest and availability rather then speciality affiliation. ICU Director or Officer Incharge must
have at least one full time or part-time associate director (depending on workload) to provide the presence of a
staff physician in the ICU during day hours and for night and week and consultation coverage.

ICU Committee
In most of the hospitals all over the world, an ICU Committee exists to govern ICU and to lay down policies
and procedures. The concept of the Committee is as old as the beginning of ICU era. ICU Committee should
be appointed consisting of one representative each of surgery, medicine, neuro-surgery, nursing
administration, a representative of hospital administration and an anaesthesiologist preferably as Chairman.

Authority and Responsibility

Team work based on mutual respect is prime factor in providing effective service than authority established by
edict and it should be guiding principal of ICU functioning. However, certain policy procedures are required to
be laid down in clear unambigious terms for avoiding conflict and confusion in patient care and daily
69
administration. This may be perfected and updated from time to time based on the experience and newer
problems as it arises.
The basic principles in the administration of ICU particularly for dealing with administrative and discharge
procedures can be as under :
1. A patient who is transferred to an ICU should still be considered to be the patient of transferring unit.
The basic speciality continues to be responsible for the treatment.
2. The medical officer (Anaesthesiologist) incharge ICU should have full authority as to the transfer and
discharge of the patients from the unit.
3. The administration and organisational responsibility for the unit must be entrusted to one departmental
head.
Experience has shown that smooth functioning of intensive Care Unit depends on inter-depart
mental cooperation and based on the following three factors :
1. Well defined responsibilities and authority;
2. the physical set up; and
3. standardization of certain procedures

Sample ICU Rules/Regulations as drafted by Boyd (1964)

Rules concerning Rules mainly applicable Rules principally

primarily with meant for visitors
members of the to patients
medical staff

1. The doctor I/c Regardless of Visitors should be

patient will be social status restricted to the
responsible for (private, semi- immediate family
admission/transfer private ward) members
into andout of ICU transfer to be
made to that
accommodation of
the special care
unit, best suited to
the patients need.

2. Doctor I/c Patients not to be Stringent control of

will be responsible admitted to number of visitors
for informing the special care units at bed side
patient and his unless condition
family about is critical
condition of ICU

3. Prior to discharge, Ordinarily infectious Check on the

70
summary must be made cases are not to be duration of visit
by attending physician admitted in ICU

4. A special committee Terminal care cases, No more than 2 at

will continue to chronic cases and any time
review the functioning disturbed or
of ICU as well as disturbing patients Less than 5 minutes
help in management and are not to be duration every hour
difficulties admitted

Paediatric cases will

be admitted in ICU

The following diagnosed

cases will normally be
considered eligible for
admission in ICU
a) Coma, b) acute
myocardial infarction
with shock arrhythmia,
respiratory failure,
c) acute haemorrhage
and electrolytic
problems,

Rules concerning Rules mainly Rules principally

primarily with applicable meant for visitors
members of the to patients
medical staff

d) poisoning, and
e) appropriate
surgical cases

a) Under following
exceptional circum-
stances post-operative
cases can bypass
recovery room and go
to ICU

i) cardiac arrest
ii) open heart cases
iii)at the special
request of the
operating surgeon

b) Critically ill
71
 cases can go
directly to ICU

Every two weeks this Committee makes rounds in the unit and holds a conference to ensure that the ideas
and philosophy of special care unit are being put into effect.

Admission Criteria
As discussed above a definite objective criteria should be laid down for admission and discharge of patients
based on the patient’s condition, degree of illness and nursing and medical needs. As a general guidelines,
patients in need of observation of vital signs and the total support of physiological systems should only be
admitted in ICU. Other than above, those patients who are critically ill and require continuous nursing or
extensive equipment support should be chosen for admission. Experience shows that between 2 and 5 per
cent of all the acute medical and surgical case only qualify for ICU admission.

The following are few clinical parameters, which comes under these categories:
1. Major operations after which continuous observation in relation to control of bleeding is required,
maintenance of an adequate airway or of cardiovascular integrity, metabolic or infective toxemia, or
relief or prevention of shock.
2. Selection should be irrespective of speciality, age or sex but the clinical unit responsible for the case
must not take the place of the admission ward, the past anaesthetic recovery room or special units.

The anaesthesiologist on duty has to assign priority to patients to be admitted on the basis of the most critical
needs. Due to limitations as the ICU facility is always planned in a limited number of bed space of the unit, it
is considered to be most important to guard against the admission of non- salvageable patients. It is equally
important to guard against the tendency of house officers or resident staff to keep patients in the unit far
beyond the time of true need for intensive care of the patients.
Discharges from the unit should usually always be done following a discussion between the anaesthesiologist
Incharge in ward and physician/surgeon responsible for the primary care of the patient.

Clinical parameters of cases with post-operative complications who are normally recommended for
admission in ICU. are, cases with

1. Cardiac complications
2. Respiratory complications, central and peripheral depressions, upper airway obstruction
3. Depletion of circulatory blood volume, due to blood loss, plasma loss or combination of these
factors
4. Acid Base Exchange disorder; respiratory acidosis or alkalosis. Metabolic acidosis or alkalosis
5. Clotting problems ; deficiency or malformation of platelets. Decrease in clotting factor,
fibringinolysis
6. Electrolyte imbalances : depletion of chloride ion, sodium ion, potassium ion, elevation of
blood urea nitrogen (BUN)
72
7. Anuria

It is universally recommended that infectious and contagious disease patients should not be admitted
in ICU. This includes post-operative cases with active pulmonary tuberculosis.
In a general hospital the intake of a patient in a ICU is through the emergency to a general bed and then to the
ICU beds. Intensive care beds are technical beds and for general statistical purpose it is not counted as
hospital bed complement and patients are also not admitted to this unit directly but belong to the admitting
speciality unit. After recovery, patients from ICU are required to be transferred back to their respective parent
units. Hence in hospital statistics, ICU admissions are not reflected in routine statistical reporting.
By virtues of the nature of work and type of patients and severity of sickness of ICU, 10-30 per cent mortality
is acceptable as normal or inherent in the set up. Terminal care cases, chronic cases and psychologically
disturbed or disturbing patients are not normally admitted in the ICU.

Admission :
Intensive care bed should not be treated as emergency ward bed. It should not be considered as extension of
post-operative ward or general ward bed and should have clear guidelines of admission as indicated below :

Admission to the ICU comes from generally three areas :

a) the emergency admitting service of the hospital
b) the general wards in the hospital and
c) the post-operative recovery room.

Most cases are admitted from the Casualty Department. The house officer on duty is the first to see the case
and will decide whosoever to contact the ICU team. Certain type of cases such as drug induced coma, severe
haemetemesis, myocardial infarction, respiratory failure and multiple injuries must always be considered for
admission to ICU.
It is imperative that unless the strict criteria is applied and steps are taken to regulate the admission and
transfer of patients in ICU and out of ICU, it will result in denial of benefit of ICU facilities to genuine deserving
patients. Admission of terminally ill cases will result in higher mortality rate which in turn will lower the morale
of the staff resulting in low morale and lack of confidence in the efficiency of ICU. Hence, admission criteria
should be well defined and strictly adhered to in any ICU.

Policies and Procedures

As indicated earlier, policies and procedures should be laid down clearly in writing for each hospital for
intensive care unit. The smooth functioning of an ICU depends on availability of motivated personnel with
competence in critical care medicine (CCM); on well defined responsibilities and authorities; on
standardization of certain procedures; on the leadership quality and administrative directive of medical director
and the nursing administrator.
One of clear directive of patient care responsibility is that primary physician who recommends admission in
ICU and remain incharge of the patient in the ICU till he is discharged.

73
TREATMENT ORDERS :
All treatment orders in the ICU should be written by the medical or surgical resident incharge of the patient.
Exceptions are however:
a) orders for respirator care when required are to be written by the anaesthesiologist
b) orders for post-operative mediation and immediate (recovery room) post-operative care which are to
be written by the anaesethesiologist and/or surgeon; and
c) emergency orders which are to be written by any physician attending the patient.
Singleness of control is regarded as fundamental in the organisation of the unit (Hercus et al, 1964).

Respiratory Care :
In the area of clinical decision making decisions for start and discontinuance of respiratory care should always
be made by mutual agreement between the physician incharge of the patient and the anaesthesiologist only.

Role of Anaesthesiologist :
One Anaesthesiologist staff should always be assigned full time to the intensive care unit to maintain
contunuity of special treatment. The anaesthesiologist should also make rounds several times a day prferably
jointly with physician.

Bed Utilisation :
A never full concept should be adopted for ICU. Ideal bed occupancy rate in a ICU is 80.0 per cent. However,
a bed occupancy rate of less than 80.0 per cent is indicative of under utilisation of the unit, however it is
desirable to leave a few beds always available for emergencies.

Visitors : It is recommended that ICU patients should not be denied visitors. However, kindness and
sympathy must not be sacrificed in the interest of efficiency or critical care in ICU.

Equipments : As is well known in the medical practice that in any emergency the determining factor of
survival is the time gap between the onset of symptom and the initiation of therapeutic procedure. For these
reasons, specially tested stationary equipment having attachment to the walls near each bed are prime
requirement of a ICU planning.

The following equipments and monitoring system are the basic necessity for an intensive care unit.
Tracheostomy and intubation sets for all age groups, sets for venesection, instruments for thoracotomy and
pleural drainage, trolleys with dressing materials, emergency trolleys for cardio-pulmonary resuscitation,
ventilators, central venous pressure recorder, cardio-scopes, defibrillators and pacemakers of pervenous
types and Ambu Ruben resuscitator with face mask. Mobile X-ray machines, incubators, oxygen tank and
hypothermia machine with electric thermometers also must be available.

74
Patient monitoring system exhibiting pulse and ECG should be available at each bed head. For coronary care
area much more sophisticated patient monitoring is required which can register arrhythmias and produce both
visual and audible signals. The signal should be available at the Nurse’s desk. In addition to these,
physiological recorders for arterial blood presssure and cardiac output measurement by Dye Dilution
technique by computers and blood volume estimator are preferred.
Apart from these, it is also recommended by various authorities that there should be facilities for instant
measurement of acid base and oxygen tension in arterial blood by Astrarfo Electrometric technique and a
modified clocks electrode and be available in adjacent laboratory area where a spirometer test also can be
carried out.
Although inspite of the ICU being supplied with disposable and CSSD items, it has been felt that a small
portable electrically heated pressure steam sterilizer of minimum of 175 mm diameter x 300 mm length for
emergency use will be of immense value for its efficiency.

Role of Computers in ICU:

The use of on line computers for rapid calculation and assessment of condition based on various parameters
and for immediate information about patients, has established its utility in western world.
With a closed circuit television system, nurses and physician when working at the central desk, could
supervise the entire unit, including the isolation rooms. Television cameras giving an overall view of the whole
unit, make it unnecessary for the staff to go in and out of isolation room repeatedly. This also diminishes the
risk of spreading bacterial infection within the unit.
Modern hospitals are having a central data processing system that combines a mini-computer data storage
unit and a television tube display with facilities to record the data as and when required by presetting the
timings on computerised channel for patient care services.

Maintenance of Equipment
Cost of equipments in modern hospitals are increasing day by day. As it is not denying that these high cost
equipment can deliver the desired result only when these are functionally built free and running to its best
capability. So, the primary aim of administration is to improve patients care through organised preventive
maintenance programme of all such equipment.
Failure of vital equipments means loss of life in critical cases. Preventive maintenance of equipment will save
life, save hospital from bad reputation, reduce average length of stay (ALS), therapy effecting economy and
improve the public image of ICU and hospital as such. Trained technicians and electronic engineers with all
necessary spare parts should always be available in small ICU. There should preferably be a workshop within
the ICU premises for repair and replacements of defective parts.

Staffing :
No definitive medical staffing pattern of ICU can be referred to in the literature however, the staffing pattern of
ICU can be dealt here in three broad categories :
1. Medical staffing
2. Nursing staffing
3. Class D personnel staffing (auxilliary staff)

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The principle of staffing and managing a general ICU are directly related to the number of beds in the unit and
the size and workload of the particular hospital.

Medical Staff
It is stated that no single physician can cover an acutely ill patients for 24 hours per day, for 5-6 days (the
average length of stay). Some authorities are of the opinion that an attending supervisor with sole
responsibility of administration should be appointed for the ICU and he should be assisted by a resident from
each of the medical, surgical and anaesthesia services, who would be on call 24 hours a day.
Normally 60.0 per cent of the total patients being surgical, it is necessary that a surgeon is always available in
the premises of hospital ward. It is recommended by some that a minimum of 2 doctors be available round the
clock. Work study conducted in some of the hospital in India has stated that the formula given out for ICU is
one doctor per 5 - 6 intensive therapy beds and out of these least one resident or house physician should be
available round the clock.
The Report of a working group on ICU appointed by the Swedish Board of Health (1967) recommended 0.17
to 0.20 doctor per bed. In an ICU with 10 beds, this would mean a requirement of two to three physicians for
a unit of 12 - 14 beds.

Nursing Staff
The nursing care plans of a ICU patient must be developed by calculating nursing hour need of the patients
and therefore should have the approval of the nursing department, the anaesthesiology department and other
patient care department like medicine, paediatrics and surgery who feed the patient load to the ICU in the
hospital.
The way in which work in a ward is planned and allocated amongst the staff available has a considerable
influence on the continuity fo care, nurse patient relationship and quality of care in the department. Therefore,
the qualities required of an intensive care nurse are of a high order and this must be fully understood by those
responsible for selection and deployment of the staff.
The ICU head nurse or nursing supervisor should be selected on the basis of special intensive care
experience. She should demonstrate a high degree of clinical nursing competence as well as skill in
supervision and teaching. Nursing staff pattern differs from unit to unit and hospital to hospital.
The ideal staffing ratio of one fully trained nurse per patient (Patient : Nurse Ratio - 1 : 1) as recommended
universally is not always realistic, particualry in view of shortage of trained staff and also due to cost factor in
our indian scenario. An acceptable patient/nurse staffing ratio, depends on many local factors, including the
medical set up of the unit, type of patients admitted and proportion of patients requiring artificial ventilation or
other specialised therapy.
If the condiiton of patients requires constant observation, one nurse must be assigned to each room. If these
patients are less critical, two nurses may then care for six patients in three rooms.
Some of the practical suggestions on the context in the western world are :

Intensive Care Unit Staffing Pattern

Days PM Night Required
Surgical ICU

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Registered Nurses 5 3 3 17
Practical Nurses 3 2 2 10
Orderlies 1 1 1 4-1/2
Receptionist 1 - - 1-1/2
Administrative Secretary 1 1 - 2-1/2
Ward Helper 1 - - 1

Medical ICU
Registered Nurses 3 2 2 9
Practical Nurses 1 1 1 4-1/2
Administrative Secretary 1 1 - 2-1/2
Ward Helper 1 - - 1

The basic principle however is continuous visual supervision of patients by nurse is absolutely mandatory.

For calculation of staffing needs; round the clock coverage, for one individual at a time on job, it requires four
to five persons on the employment, considering 940 hours work including vacations, week ends and holidays.
Including the necessary allowances. So, a complement of 4.25 nurses per bed and total of 34 for an eight bed
ICU would be required for one nurse per patient ratio. In some developed countries nurses specially assigned
to ICU with 2.2 nurses per one patient on an average.

Class D staff and other paramedical staff

To keep the ward clean tidy and hygenic including other patient care activities e.g. wheeling of patient in and
out of ward for diagnostic procedures, X-rays, carrying of blood samples to laboratory etc. adequate number of
sweepers, ward attendants and stretcher bearers are required.
Such ancilliary staff in most of the ICUs is normally same as for any nursing unit. But ICU requires more staff
than in a conventional nursing unit. In an extremely busy ICU, these staff have got an important role to play.
No definite pattern of staffing has been laid down for intensive care units in our country.
Technical Staff : The planning for staffing and training of other technical staff should be considered in the
initial stage of planning of ICU. A team of trained technical manpower must always be available in ICU to
ensure the functional efficiency.
Physiotherapist, inhalation therapist, electronic technician, bio-medical engineers and laboratory technician are
the basic requirement to give necessary technical support to ICU.
The increasing number and complexity of electronic and other monitoring and life support devices, call for an
electronic technician to check equipment daily to prevent electrical accidents and equipment failure is also to
be considered as a part of man power planning. In addition to these engineers, computer experts and other
non-physician specialists are necessary for sorting out any problem or designing any innovative equipment
Inhalation therapists have been found to be particularly valuable for maintaining, desiging and modifying
respiratory equipment for meeting special demands and for participating in resuscitation, which is an activity
always put an additional strain on nursing staff.

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 CHAPTER 3.4

ACCIDENT AND EMERGENCY SERVICES

KEY AREAS

• Objectives ,Concept of A&E Services

• Types Emergency Care Facilities
• Planning and Designing of A&E Services
• Policies and Procedures
• Staffing
• Working Guidelines

The accident and Emergency Care facilities of hospitals is one of the mainstay in the chain of medical care
offered by the present day hospitals. The need for purposeful emergency health care delivery through an
Emergency Department is well recognised, and all hospitals must be able to provide basic life support through
their Emergency Services to the patients in need.
India is a fast growing industrial country. In such a country the rate of accidents and surgical trauma is
increasing rapidly at the same pace with which, the industrialisation is speeding up. The process of
urbanisation, and industrial development, growth in population, increase in number and variety of vehicles on
the road, coupled with a tendency to introduce faster means of transport, are going to add considerably higher
incidence of accidents and surgical trauma in our society. These factors are bound to influence the
presentation and change in the degree of severity of the accidents also it is therefore necessary to formulate a
necessary infrastructure to combat this problem before it assumes tremendous proportions. Plans for future
must be drawn up, so that the community is ready to face the menance of high mortality and morbidity due to
accidents and sustained trauma.
A conceptual organisation of an Accident and Emergency Care System for a large metropolitan city is
presented in the following paragraph can be applied to small towns or residential institutions and industries
also keeping in mind, the basic principles.
Preamble: In keeping with the modern functional concepts of dealing with the problems of accidents, surgical
trauma and emergencies on the pattern of Russian and Western countries, it is essential that a system has to
be evolved, which is able to tackle the accidents and resultant surgical trauma, from the site of occurance.
For this, trained manpower, a transport and specialised modern communication system, which is most
trustworthy and a treatment centre which is well processed to receive such emergencies are the essential
ingredients.

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A comprehensive accident and trauma service has been in existence in France under the name of SAMU,
under which the whole country is divided into large number of manageable units. Each unit has a SAMU
centre. In case of occurence of any accident, the ambulance is rushed out of the Centre, the moment the
message is received from the site of occurence and while on move receives radiotelephonic directions from
the SAMU centre to navigate it to reach the site of casualty with the sole idea of not to loose any time. As
soon as the casualty is sighted by the paramedical occupants of the ambulance who handle the vehicles, they
get in touch with SAMU centre and after rushing to the target immediately transmit to the SAMU centre, the
clinical data that is necessary for the SAMU Centre to take decisions, on the spot, so that the paramedicos
who are handling the casualty at the site can Institute resuscitative measures immediately without any delay.
In fact, in most of the cases the patient is stablised while at the site. Patient is then carried under the
instructions of the doctor manning the controls at the SAMU Centre, and brought to the Centre. All along, in
the transit, the clinical parameters are being radioed to the SAMU Centre so that the doctors of the Centre are
prepared to meet the type of casualty. It will thus be seen that a casualty becomes the concern of the SAMU
Centre while it is at the site of occurrence and not when it comes within the premises of the SAMU Centre,
when it may become too late to do anything at all. It has been observed that if proper medical attention is
provided to a casualty within the first 15 minutes there are greater chances of saving the patient as compared
to chances it has if medical aid comes after 15 minutes of occurence of accident.
The saving of the valuable time and the speed with which emergency aid is rendered to trauma victims are the
two most vital components of an emergency service system, which has to be drawn up with a hospital as a
nucleus. This is a model on his we can draw our casualty or Emergency Medical System.
In such services, it will be seen that, functionally, the hospital does not come first but is to be used as base
camp, whereas peripheral services or outreaches of aid to the injured at or around the very place and time of
occurrence. Such a system does not only saves lives, but also reduces morbidity, since expert aid would be
available from the minute the casualty was handled. Thereby, the patient, if he survives, will have greater
chances for rehabilitation back into the society.

Management of accident and emergency cases therefore are to be considered under the headings of :
a. Prevention : By developing guidelines and enforcing strategies like use of auto seat belts helmets,
alcohol and driving, prevention of fire hazard.
b. Treatment : Immediate management - on the spot and while transporting further treatment to the
institutional level
c. Education : For the general public and those who are involved in managing

The Accident and Emergency management system as a comprehensive system can be approached by
following sequential manner for planning purposes.
1. An efficient communication
2. Speedy transportation of the victim to the emergency centre
3. Pre-hospital therapy - in the form of immediate first aid and resuscitation starting from the place of
accident.
4. Medical treatment at fully equipped hospital/centre Common denominators of any successful
emergency medical care are :

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 - Availability of adequate physical facilities, equipments and supply of all life saving drugs and
dressings
- Immediate professional attention
- Continued and Constant medical support
- For speedy diagnosis and resuscitation so as to make it possible of integrating a patient into
an existing system of patient care services in the Institution.
The theme of emergency services in any situation is to initiate active resuscitation to provide life support and
medical intervention

Types of Emergency Care Facilities

From the Professional Hospital Management point of view the types of emergency care facilities are grouped
as :
Type - I : It consists of major emergency facilities with round the clock specialists in the hospital with backup
of multidisciplinary clinical and diagnostic facilities.
Type - II : It is the basic emergency care facility where the emergency room physician is located in the hospital
with the services of specialists on call.
Type - III : It is the hospital that provides stand by emergency facilities with perhaps and emergency room
registered nurse and a physician on call.
Type - IV : It is a referral emergency room facility that has only an emergency nurse or medical technician in
the hospital and that transfers patients to other facilities for life support systems.

ORGANISATION OF ACCIDENT AND EMERGENCY DEPARTMENT

Emergency Department ideally is a discrete and captive diagnostic and therapeutic service area of the
hopsital. It is neither inpatient nor a outpatient service in terms of its scope or manner and type of its function.
While organising the services, it is essential to recognise the complex, crucial and sensitive nature of these
services. This perspective is important to ensure that it is recognised as a primary rather than an ancillary
service and the concept of patient centred care must remain paramount while planning and organising the
facility in any set up.
Acording to various exponents of modern emergencies care system traditional hospital and emergency
department have been most inefficient because they provide for three separate and distinct chain of
command, administration, medical and nursing. As such, an effective and efficient organisation can be
designed only by clearly defining a single chain of command for the operation of the services. However, there
is no denying that the involvement of administration, medical staff and nursing staff has a distinct role to play
in all aspect of its functional requirement. So, it is mandatory that a definite chain of command is established
for a hospital emergency department.

POLICIES AND PROCEDURES

Emergency department policies and procedures are to be formulated and documented and made readily
available to all staff members of the department. The policy manual, when drafted and adopted, should
function as a reference document for all staff members. It should incorporate any possible need of any
information particularly problems that may arise in the emergency department, including statements released
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to press, interaction with law enforcement officers, interaction with other community agencies and social
service needs.
In order to keep the manual updated, it should be revised from time to time and when new guidelines are
developed. The policies must clearly reflect the philosophy of the hospitals’s administrative, nursing and
medical care goal in the emergency department. Therefore, preparation of a policy and procedure manual
would necessitate all the concerned departments and service centres. Since emergency department deals
with various kinds of medico-legal cases, it is also desirable to have the views the document before it is
adopted.
It is mandatory therefore that policy and procedure manual should contain information concerning the
organisation of the hospital who are ocncerned directly or indirectly with emergency department. It is also
equally important to incorporate a continuing education programme for the procedure of every emergency
department personnel and the responsibility of which should rest with the Chief of emergency department.
Further, the capabilities standards of emergency department should be included in the procedures manual
because they include not only the details of hospital organisation but also the requirements for equipments,
organisation of the department itself, financial considerations, and relationships to the administrative
authorities. It is imperative to introduce quality control procedure in the department and documented for
everybody to follow. As a step towards this there should be a system of review of all the deaths that occur
especially in the case of any patient who dies in the emergency department or in the hospital within 48 hours
of admission should be carefully reviewed.

FUNCTIONS OF ACCIDENT AND EMERGENCY DEPARTMENT

The function of an Accident and Emergency depends on the responsibility by assigned to it as well as its size,
location and type of services available in it. They are broadly as follows. The stress on one or the other
function however alters in every hospital to suit its own needs.
1. To treat and manage all unannounced patientsbrought to the hospital at any time of the day.
2. To deal with accidents and injuries on a 24 hour day basis
3. To take up minor or major surgical procedure according to the policy of the hospital with the
concurrent physical facility and expertise available.
4. To prevent infectious cases from entering the mainstream of the hospital wards by treating them with
proper segregation in the exclusive casualty beds
5. To train and teach the medical and other health care workers
6. A place for Research in clinical medicine and other Biomedical Services
7. To be used as a diagnostic and therapeutic centre
8. Handling and following up of medico-legal cases as per the law of the land
9. Liaison with police and other statutory agencies.

The extent of its responsibility however varies in every hospital to suit its operational requirement.

STAFFING IN ACCIDENT AND EMERGENCY DEPARTMENT

Over and above the best of the sophisticated communications and transportation equipments are also of
prime importance in Emergency room planning. The personnel manning the emergency department should
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therefore will depend on the extent of sophistication and work load well trained professionally competent and
in adequate number of each category of the staff is the key to the success of any emergency room
functioning.
This Emergency Department care staff includes physicians, para-medical staff and administrative personnel.
Each hospital after careful study must determine which method of physicians coverage is most appropriate to
meet the functional need. As the service grows and expands the utility of the staffing pattern can be reviewed
with the availability of physicians for complete coverage, and readjusted if and when required.
One of the most acceptable method and is extensively practiced in our country is the concept of full time
physician in the Emergency Department. This is also known as “Alexandria Plan” (Full-time plan). The draw
back with this plan has been that often there were too few physicians able and willing to work as full time
emergency physicians. Another method of coverage that has been in wide use which involves the rotating of
staff members known as “Pontiac Plan” (Part time plan), developed in Pontiac, Michigan, USA. Here the
physicians provide the services in the Emergency Department round the clock by rotation. The rationale
behind this method was that physician should be able to give first aid, provide life saving measures, and make
a tentative diagnosis and refer for specialist service when required. However the drawback of this plan was
that there were great disparities in skill and physicians took their turns in rotation.
Irrespective of the plan of deployment of staff, the various categories of the professional and para-professional
personnel for a modern Accident and Emergency are as follows :

Basic specialists
1. Physician
2. Surgeons
3. Anaesthetists
4. Orthopaedic Surgeons
Resident Staff
1. Senior Residents
2. Junior Residents
G.D.M.Os.
1. G.D.M.O. I
2. G.D.M.O. II
Nursing
1. Assistant Matron
2. Nursing sisters
3. Staff nurses
Technicians
1. X-ray Technician (Radiographer)
2. Laboratory Technician
3. ECG Technician
4. O.T.Technician

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The number of each category will depend upon the quantity of work to be provided, the type of the hospital.
For a general emergency department of a district hospital containing approximately average 50 to 100 patient
per day, it is suggested that based on 8( eight hourly shift )the following should be the staffing norm.
—————————————————————————————————————
Casualty Casualty Casualty Junior House
Medical Medical Medical Resident Surgeon
Officer Officer(CMO) Officer(CMO)
Junior Junior
Surgical Paediatric
Specialist Specialist
—————————————————————————————————————
1. Medical One One One One One
Staff

2. Nursing
Staff
i.Sister Incharge One per shift
(supervisor)
ii.Staff nurse Ratio of one is to one (1:1) that is 5-6 per shift

3. Group-D Five to six per shift

employees or
hospital attdt.
or nursing orderly
including stretcher
bearer

4. Safai Karamchari Two per shift

5. Operation Room One per shift Assistant (ORA)

6. Radiographer One per shift

7. ECG Technician One per shift

8. Medical Social One per shift

Worker

The number of each category will depend upon the quantity of work to be provided, the type of the hospital.

In addition to the above categories of staff, plaster technicians ambulance drivers and ambulance attendants
are also necessary for efficient and smooth functioning of emergency department.
In an emergency setting the role of a nurse is very different from the role played by the traditional nurse on a
medical or surgical ward. The emergency nurse at various times must institute life saving measures, perform
triage, and perform a myriad of other highly skillful nursing tasks - many time under great stress. For the sake
of continuity and most efficient patient care, staffing of nurses in an emergency service should be permanent
members of the department and not rotated from other units in the hospital.

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The recommended nursing requirement for staffing is seven to nine nurses per day for each 100 patients in an
ideal setting.In a similar situation the basic physician staff are to be on the premises of every hour of every
day. In high trauma regions, it is recommended that full staffing is maintained even with a lesser number of
patient load. It is further recommended that one full time emergency physician are to be added for each 7000
cases seen annually.
The role of sweeper is of immense importance for maintaining cleanliness in accident and emergency
department. It is advisable to hire the private agencies for this purpose rather than employing the sweepers on
full time permanent basis, wherever it is possible. It is emphasised that members of any emergency
department not only have to be highly skilled and competent. In addition, they should also be able to work
calmly and with self control. All staff members should receive a thorough orientation and training, in the
aspects including training in how to deal effectively with the public. Experience shows that the majority of
disputes in an Emergency Department in our hospitals arise on this account. The staff should be able to
communicate well with patients and with family and friends who seek relief from fear and anxiety and pain and
in a state of emotional disturbances.

Planning Considerations

LOCATION, LAYOUT AND DESIGNING OF ACCIDENT & EMERGENCY DEPARTMENT

As the patients approaching Accident and Emergency Department are in a state of urgency and at the same
time minimum time should be wasted in receiving medical care it is advisable that the department be located
on the grould floor with easy access for patients and ambulances. It is best to have it separated from the main
entrance of the hospital, and easily visible from the road with proper lighting and signs. It is important that
ambulance entrance to the emergency department be large enough to admit one or more ambulances.
a. Accessibility : Since most of the patients who are brought to hospital by ambulance/other vehicles
the architect must design the street or approach so that ambulances can discharge or take their
patients and drive away without having to reverse in the hospital gate. This will allow no traffic
cogestion to occur in the approach to the ambulance entrance. The entrance of the department
should either be at street level or at the most, with a few easy steps with side rails provided on either
side for walking patients and a smooth and easy ramp to allow trolleys and wheel chairs to be brought
to the waiting room from the street itself.
b. Flexibility : Flexibility of the plan is the next important consideration in designing the Accident and
Emergency Department. It should be so designed that control of movement is easy that variations in
which occur from time to time may be taken up with the added facility. It is therefore vital the layout of
this department be carefully planned so that in an disaster situation it will be able to cope up the initial
number of patients reporting to the hopsital and arrange triage for proper management.

Design of the area may be :

i. Circular Design : In this type of design a large central hall forms the basis of the Accident and
Emergency Department and various tretment rooms radiates from this hall or off the corridor. This

84
 requires a careful planning and ensures that the department has been designed to integrate with the
main hospital complex.
ii. Elongated Design : Under this design the cases are admitted to waiting room which leads in to a long
corridor with rooms leading to the various activities of treatment are undertaken. This corridor need
not necessarily be straight, it can be of U-shaped where the department is designed to surround a
central court.

PHYSICAL REQUIREMENTS OF ACCIDENT AND EMERGENCY DEPARTMENT

Physical Facility

An ideal Accident and Emergency Department should have the following functional areas for its operational
efficiency. The concept of “Design follows the function” should be the guiding principle.
1. Reception and registration
2. Trolley Bay
3. Casualty Medical Officer’s room (CMO room) or examination room
4. Triage area
5. Resuscitation room
6. Treatment dressing and injfection room
7. Observation wards with sufficient number of beds according to the policy of the hospital
8. Nursing counter
9. Waiting area for patients as well as attendants
10. Dressing room
11. Operation theatre
12. Waiting room for patients as well as visitors
13. Laboratory facilities
14. Radiolgoical facilities
15. ECG room
16. Plaster room
17. Isolation room
18. Linen room
19. Clean utility room
20. Dirty utility room
21. Room for public telephone
22. Space for keeping stretchers and wheel chair
23. Duty room for medical officers
24. Room for ambulance driver
25. Police room
26. Toilet facilities for patiens as well as staff

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27. Brought in dead (BID) room

INTRA-HOSPITAL RELATIONSHIP
For the operational efficiency of an Accident and Emergency Department, the physical and functional
relationship with other service department of the hospital have to be smooth and hassle free. There must be a
very close working relationship between these departments which include indentical equipments, identical
methods of medication and close personal communication and contact. The monitoring and resuscitative
equipments used in the emergency department as well as inpatient departments should be compatible if not
identical. Transfer of patients from one area to the other should be done with the complete knowledge and
understanding of both departments.
The Accident and Emergency Department relation with the radiology department of the hospital are very
frequent and more in number. So efficient patient flow in the department should be ensured which will
eliminate long patient delays that are encountered in X-ray examination. Prompt film interpretation and
reporting system greatly enhance the emergency department efficiency.
Laboratory services are other important frequently used by emergency service department. The list of
laboratory services available inhouse in the Emergency Department and Tests which are to be done
elsewhere in the hospital are to be clearly indicated or displayed in the emergency room for the reference of
the clinical staff. It should also indicate the type of sample required method of collection and time required for
the test and the result thereoff.
Many times patients are to be transferred directly from emergency department to operation theatre. So a close
liaison and good communications system are absolutely necessary to avoid delay and expedite the initiation of
the procedures. Thus a smooth working relationship between emergency department and operation
theatre,laboratory and other support service area is essential in order to facilitate efficient patient care
services.

EXTRAMURAL TRANSPORTATION OF PATIENTS

It has always been emphasised that crucial time should not be lost in transporting serious and injured victims
from the site of accident to the hospital. Precious lives can always be saved if, timely pre- hospital care is
provided to the cirtically injured cases at the site and initiate the management of the patient, while transporting
the patient to the hospital. In our indian scenario organised Ambulance services for a community indepedent
of hospital does not exist. However, it is desirable that such services should be available to all the patients in
the community who needs emergency medical care, till such time. every hospital must have atleast few well
equipped ambulances with trained staff in cardio-pulmonary resuscitation for the purpose. Ambulance driver,
stretcher bearers and other related staff should be given training in induction of basic life support measures to
patients. The guidelines of ambulance services depends upon on the policies of the hospital, type of services
available and bed strength of the hospital, catchment area of the hospital as well as the community needs.
The ambulances may be owned by the hospital or hired on contract from the private agencies for the hospital
need. The ambulance services are of immense help in establishing linkages with the other speciality and
super speciality hospitals for transferring and referring patients for investigative and treatment purpose.

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RECORD SYSTEM
Good medical and administrative practice demand that the hospital initiate medical record on each patient
visiting the emergency department.It is also the necessity for the hospital to safeguard itself from litigation
consumer protection issues and also as a statutory requirement for the case of medico legal nature. Most
emergency department medical record needs to be simplified compared to the extensive in-patient record. It
should be designed in such a manner to have administrative and basic statistical data about the profile of the
patient and appropriate column for clinical information data such as blood pressure, temperature, plus
adequate space for physicians and nurses’ notes are to be made. Generally the emergency room record
should preferably be limited to one single sheet for easy documentation and movement. However, when a
patient is admitted to the hospital, the emergency room record accompanies the patient and is made a part of
the patient’s formal inpatient medical records. When the patient is not admitted, the emergency room record
should be retained in the emergency department itself and a copy be sent to the medical records department
for proper storage and future refrence.

GOVERNMENT COMMITTEES REGARDING EMERGENCY SERVICES IN INDIA

Some of important recommendation for improvement of hospital emergency service made by various
authorities are :
1. Administrative strengthening of accident and emergency services by providing a whole time Additional
Medical Superintendent as Officer Incharge of the Department.
2. Provision of all facilities of reception, information, and dedicated diagnosis and therapeutic facility for
the accident and emergency patients in the emergency department itself.
3. As far as possible, the emergency department should not be dependent for support services from the
other areas of the main hospital.
4. All patients on arrival are to be dealt with extreme care and sympathy by trained staff.. Reception,
medical record and documentation, comunication both intramural and extra mural system in the
department should be simple, fault free and continuously made efficient.
5. As per rule ten per cent of hospital beds should be provided in the emergency department, which
should be an integral part of emergency. Services department and must be under direct charge of
specialist working in the department.
Another important observations in the operational aspect of hospital emergency are factors like posting of
junior doctors and thus precious time is lost in completing preliminary investigations and calling senior doctors
for decision making. It is also observed that the emergency wards are always overcrowded and even limited
infrastructural facilities which are available elsewhere in the hospitals have not been put to optimum use
because of poor maintenance or lack of trained staff.
It is universally recommended that the staff of accident and emergency department are to be adequately
trained in resuscitative procedures. Because of non-observance of hygiene and certain medical procedures,
patients contract new diseases when they are admitted to the hospitals, so a regular monitoring of infection
rate in hospitals must be a ongoing process.
Based on the recommendation of American College of Emergency Physician (ACEP) the following guidelines
should be followed for the operational efficiency of emergency department:

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1. There should be written policies and procedures document which is updated reflecting policies and
procedures to be followed in the department and its relationship with other departments in the
hospital.
2. The department should have a full time Administrative Incharge and the staffed 24 hours daily by
qualified emergency medicine specialist.
3. The department should be accessible to ground transportation in all kinds of weather. If possible
arrangements should be made to receive and despatch patients by way of air transportation, if
possible, in areas of remote inaccessible areas.
4. Round the clock availability of laboratory personnel capable of performing immediate analysis of blood
gas pH, serum electrolytes and other body fluids.
5. The department should be equipped with basic minimum facilities like ventilator, cardiac monitor,
defibrillator, pace maker, apparatus to establish central venous pressure, sterile surgical sets, gastric
lavage equipments, intravenous fluids and devices to administer the same and life saving drugs.
6. Radiological investigation services should be within or easily accessible to emergency department.
7. There should be a predetermined plan for the diagnosis and treatment of alcoholic or drug abuse
patients.
8. Operation Theatre (OT) should be within or easily accessible to the Accident and Emergency
Department with availability of operating room personnel within a reasonable period of time.
9. Blood bank or blood storage facilities should be easily acessible to Accident and Emergency
Department.
10. Special training in life saving procedures should be provided to all categories of staff.
11. There should be a continuing medical education (CME) programme for all category of personnel.
12. A list of on call specialists, with their availability, location and telephone number should be maintained
and easily accessible in Accident and Emergency Department.
13. There should be availability of emergency care reference material such as for tetanus, burns and
poisioning and emergency medical identification and treatment manuals and text books.
14. There should be adequate patient/visitor waiting area, separate from the emergency treatment area.
15. There should be an isolation area/ward for patients suffering from diseases like rabies, tetanus and
burns.
16. Medical records should be reviewed regularly by Emergency department Medical staff.
17. There should be a periodic and comprehensive review of services jointly by the emergency
department staff and ambulance personnel who are catering to the hospital, so as to assess the need
and improve the performance.
18. Communication equipments for intra-hospital coordination should be available, either for immediate
medical consultation with a specialist to assist in resuscitation or referral to other appropriate hospital.
19. Public information services should include sign posting on the hospital indicating to the general public
the scope of emergency medical services available.
20. A disaster plan should be prepared, and updated regularly and well rehearsed in order to deal with
mass casualties at short notice.
Emergency care is not simply pre-hospital transport and hospital based facility. Rather it is a complex
responsibility involving many other agencies like police, rescue agencies like fire services, social organisation,
88
communication departments so planning of the services have to be multi-discplinary and incorporate inter-
sectoral coordination.

WORKING GUIDELINES
As has been discussed in earlier, the emergency services in a hospital is a facility to provide courteous and
prompt medical attention and care to the patient attending the hospital such a facility in the hopsital is
normally, planned, equipped and staffed to attend to emergency cases for first aid or resuscitation as the case
may be and further care in the hospital. Every patient attending the hospital is expected to be examined by
one of the doctors on duty and necessary treatment initiated without delay. A seriously ill patient should
always be given priority over less seriously ill patient like the patients suffering from any surgical or medical
problems requiring prompt care. It is generally expected that emergency room service deals with case of
laceration, foreign bodies, septic wound, sprains, fracture, dislocation, collapse, shocks, haemorrhage, poison
cases, burns, multiple injuries, chest/heart problem, acute severe pain or distress, dog/cat bite, medico-legal
cases or any other emergency condition, which the patient or their relation perceives to be serious enough, to
get prompt and adequate medical attention. With this background in mind the following should be the working
instructions.
a) Department will function round the clock all 365 days.
b) All patients attending the department are to be promptly registered by entering their full personal
particulars such as name, age, sex, address. Every day on top of the registration register date be
written and serial number be given to each visiting patient thereon. Time of reporting and nature of
illness/complaint should be noted and recorded for record purpose.
c) Simultaneously a patient card in duplicate has to be prepared stating exact time and date of arrival,
indicating name, sex, address, casualty attendance registration number and the stamp of casualty.
The card in duplicate would be one for patient to carry and another for medical record (record
keeping) and it should not be given to the patient.
As indicated earlier it is meant for writing the history, physical finding, investigation reports, opinion of
consultants etc. and it should include the provisional diagnosis in big capital letters. The card for the
patient should clearly show the provisional diagnosis, relevant investigation advised with the report,
the treatment and advice given and further instruction for the follow-up management. The casualty
emergency room medical officer (CMO) or Asstt. CMO must put his/her signature and name legibly,
wherever an entry is made.
d) Instruction for ambulatory patient-care Emergency Room (Casualty)
As indicated earlier, all patients reporting to emergency room, irrespective of the degree of severity of
their illness, must be examined promptly by Emergency Medical Officer. Those who are in need of
ambulatory care should be given necessary treatment, first-aid and be advised to follow treatment at
home or advised to attend the relevant OPD or clinic on their next turn. As stated earlier, a precise
medical record of the patient should be written on the card meant for record keeping with the
instruction and for the final disposal. The patient should be given only the prescription which should
state the provisional diagnosis, treatment and the instruction for further management.
e) Instructions for patients requiring admission

89
 Patients requiring hospitalization for further treatment should also be worked-up as mentioned above,
and preliminary treatment should start promptly. The consultant of the relevant unit or department
under which the patient is to be treated after admission should be informed.

It is better to use intercom or inhouse telephone to find out the bed position from admission office, so that
sister in the ward can be given instruction before hand, about patients admission. It may also help smoothen
treatment procedure to be fast and easy.
Admission in Private Ward/Paying Ward/Nursing house in the hospital: When a patient attending emergency
room and requires admission if he/she wants private ward or nursing home bed, he can be admitted after
depositing necessary advance payment (money at admission office) but precaution should always be taken
that prior information be given to keep the available bed ready to receive the patient and CMO should also
ensure that patient is fit enough to be treated there and that the concerned clinical unit is ready to manage the
case in the private ward room.
Patient Needing admission and in need of Surgical Intervention:Those patients who require immediate
admission and surgery should be formally admitted in the hospital as per the hospital procedure and are to be
prepared for operation as per the preoperative instructions. The following steps are also essential:
a) Taking history and physical examination, investigations be conducted as per the clinical protocol.
b) Arrangement for blood if required are to be made.
c) OT/anaesthesist be informed in advance so that OT can make arrangement to receive the patient.
d) All Patients will be prepared for operation after obtaining the necessary informed consent in writting
from the patient (when possible) or else the need of kin (if the patient is not in a fit condition).
e) Necessary premedication sould start as soon as possible.
f) After operation patients are shifted to a ward as usual.

INSTRUCTIONS FOR ACUTELY, SERIOUSLY ILL PATIENT

All serioulsy ill or injured patient brought to the Casualty should be promptly attended and admitted for
treatment irrespective of availability of vaccant bed. It is to be noted that no serious patient should be denied
attention on the ground of non-availability of bed as is directed by judiciary. Under emergency situation the
CMO should be given the authority to admit the seriously sick on any vaccant bed in the hospital even if it
belongs to any other clinical unit transfered to emergency bed or to transfer to any other hospital after
resuscitation and stablising the clinical conditon.

MEDICO-LEGAL CASE
A medico-legal situation can be defined as one where there is an allegation, confession or situation of causes
attributing to body injury or danger of life. Further any case of road side accident should also be treated as
medico-legal case.
a) All medico-legal cases should be stamped MLC. on the face sheet itself on capital letter. All such
cases be thoroughly examined and investigated.
b) Prompt medical aid should be provided.
c) In all such cases care for record keeping must be taken apart from patient prescription and card for
record keeping, it should also enter all relevant information into a separate medico-legal register.

90
 Filling of medico-legal register are to be in duplicate, so that one copy can be given to police/court
and one can remain in medical record which are to be used at later date as an evidence/exhibit in
court during the legal process. Medico-legal register is therefore an important document of hospital
emergency service.
d) All X-ray, and investigation forms should be clearly marked as an MLC case and it can be done by
stamping M.L.C. - and kept in one composite document (case-sheet).
e) All samples and exhibits of the medico legal case are important from the court procedures purpose so
that items like gastric lavage in case of poisioning, blood stained cloth or bullet removed from body,
arms used in case of fire or semain stained cloth in case of rape, should be sealed and kept under
lock and key till they are delivered to the police and signature of the police should be obtained in the
receipt book.

The following instructions should be carefully handled and it is advisable to take help of forensic expert,
whenever available.

INSTRUCTIONS REGARDING DEATHS IN THE CASUALTY DEPARTMENT

Patients who die in emergency room (casualty) should be issued death certificate by the Casualty Medical
Officer (CMO). The standard format of the death certificate (described elsewhere) should be used. CMO
should take every effort to promptly inform the relatives of all such patient. As a humanitarian approach when
the relatives arrive in the Casualty, all due help be provided for the disposal of the dead body and medical
social worker where available should be instructed. Information of ALL DEATHS NEED TO BE GIVEN TO
Chief of Hospital Administration preferable within 24 hours If the death is of any VIP it should be done at once
on phone. If he/she is not available then the next on the hierarchy should be informed.

INSTRUCTION REGARDING PATIENTS WHO ARE DEAD ON ARRIVAL

a) All cases of “Brought in Dead”, where the actual cause of death is not known, should be handed over
to the Police for suitable action.
b) The name of such cases should be entered in the Casualty attendance register along with all the
possible details about the dead person obtained from the accopanying relatives and their names and
addresses should also be noted and recorded in the remark column of the attendance register.
c) Where death has occured due to natural causes and there is no suspicion of any foul play, the dead
bodies may be handed over to the relatives on their request and this must be recorded with signatures
of relatives/ attendants.
d) All other cases where death has occured due to accident, assault, burns, suicide, poision, rape or any
other causes where it is suspected that death has not been due to natural causes, must be registered
as MLC and the police authorities should be informed accordingly.

INSTRUCTION REGARDING ADMINISTRATIVE ASPECT OF EMERGENCY

This is one of first contact points with public and therefore, it must be staffed properly and kept in
presentable manner. For keeping it up to date following guidelines should be followed:

91
a) The Casualty or Emergency Medical Officer along with Sister Incharge should take regula rounds,as
soon as they come for duty, to check that all instruments required for patient care are available and
that they are in proper working condition. A printed checklist with all imporant check points can be
filled daily and corrective action be initiated where there is a deficiency. The cleanliness of area as
well as all the patients who are in position should also be checked and maintained.
b) The checklist should include the functional status of the the following special equipments:
i) Suction machine
ii) Blood pressure instrument
iii) Laryngoscope with blades of different size and with battery cells
iv) Defibrillator
v) Ambu-bag
vi) ECG machine
vii) Disposable syringes and needles
viii) Infusion bottles
ix) Oxygen cylinders
x) Emergency drug tray

Sister Incharge in her administrative round should further check and ensure that all power plugs are
also in working condition. If there is any shortage of material or problem regarding working status of
the equipment, she would arrange to rectify it as soon as possible.
c) All the staff of casualty service should be in uniform and it is expected that CMO/ACMO; would put on
white coat with the name badges.
d) Smoking should not be allowed. Their should be sign board stating NO SMOKING IS ALLOWED.
e) Sufficient number of wheel chairs/patient trolleys should be kept outsidethe casualty to bring the
patient in.

MISCELLANEOUS
All patients for whom there is requirement for special treatment i.e. patients suffering from heat stroke,
psychiatric illness, infections disease would be examined first and then they would be shifted as soon as
possible to ward for further specific treatment. Those who require to be transfered to other hospital would be
helped to do so. Every hospital should have a inhouse Disaster Plan so as to initiate action to organise
medical care to large number of patient’s brought to the hospital in a short notice in a disaster like situation.

An Emergency Care Centre suggested equipment of Type-I

Sl. Equipment Specifications Qty.

No.

1. Major With stainless steel top 2

hydraulic side and control
operation complete with all

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 table standard accessories

2. Shadowless i. ceiling track model 2

lights size : 45 cms.
ii. Mobile model
size : 50 cms.

3. X-ray machine i. 200 mA, bucky table 1

and column stand
ii. 50 mA,portable type 1

4. Boyle - stainless steel frame 2

Apparatus - 2 flowmeters each with
extended range
i. for oxygen 0.1 to 2 and
ii. for nitrogen oxide-0.05
to 1 and 1.25 to
10 litres/mm
Sl. Equipment Specifications Qty.
No.

5. Suction (a) Electrically operated 6

machine vacuum: 700+ 10 mm hg
regulable, flutter free
vacuum control knob.

Volume 35 ltrs/min (jars

capacity 3 ltrs)

(b) foot operated 2

6. Defibrillator Mentioning :document time, 3

monitor date and energy selection
Heart rate : continuous
Monitoring display
Three leads :- paddle monito-
select ring for
rapid
patient ECG
Individual :- For greater
batteries reliability
Synchronizer:- Reverts to a
synchronous mode
Mine energey:- five to 360
settings joules

7. ECG Machine Lead Selection :- 2

Leads : - 12 lead selection
Selector : I,II,III aVR, AVL
postions aVL, V, 1mV
FREQUENCY RESPONSE

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 Frequency : 0.05 Hz to 100 Hz
Response (-3dB)
Time :3.2 seconds
Constant: (internally)
adjustable to 1.6 seconds
Filter : Muscle filter at
36 Hz (-3dB)

Sl. Equipment Specifications Qty.

No.

8. Instrument Dimensions:430 x 200x 150 mm 2

Sterilizer Capacity : 2000 W
IS No. : IS 5022-1979
- 220/250 V, single phase,
50 cycles

9. Boiler - small 2
machine - big 2

10. Dressing drum Stainless steel,different 8

sizes

11. B.P.Apparatus with stethoscope,mercurial 2

12. Plaster saw Electrically operated 2

13. Oxygen cylinder 18

14. Laryngoscope - adult 3

- paediatric 1

15. Oxygen mask - adult 2

- paediatric 2

16. Ambu bag - adult 2

- paediatric 2

17. Weighing - adult 2

machine - paediatrics (10 kgs 2
capacity)

18. Hot water 6

bottle

19. Wheel chair - standard 6

20. Refrigerator - 265 litres 2

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Sl. Equipment Specifications Qty.
No.

21. Generator 2.5 Kw portable type 2

22. Trolley - standard 6

23. Transport 6
ventilators

Table-3 : Equipment Requirement for Providing Basic Life Support for pre-hospital care

For Airway Maintenance

* Oropharyngeal airways of different sizes
* Nasopharyngeal airways sizes 14-30
* Esophageal Obturator airway

For Artificial Ventilatory support

* Manually operated, self filling bag valve mask units,
1 adult, 1 paediatric
* Pocket face mask with one way valve for oronasal ventilation
* Jaw lock
* Oxygen therapy equipment
1 fixed system of 300 liter reservoir
1 portable system of 300 litres
* Suction equipment
1 fixed suction for providing airflow of over 30 1/min. with vaccum of atleast 300 mm. of hg within 4
sec.
1 portable suction operated by motor/hand/foot.

For Patient Monitoring Activities

* Sphygnomanometer with separate cuffs for adults/ children/ infants.
* Dual head stethoscope
* Skin temperature indicating devices

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For Transfer of sick/injured
* Wheeled Ambulance stretcher
* Folding ambulance stretcher
* Folding stair chair

Table-4 : Equipment requirement for providing advance life support

* IV fluid infusion kit
* Tracheal intubation kit
* Pleural decompression kit
* Drug injection kit
* Tracheostomy and Cricothyrotomy kit
* Portable cardiac monitor and defibrillator
* Venous cutdown kit
* Minor surgical repair kit

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 CHAPTER 3.5

OPERATION THEATRES

KEY AREAS

• Objectives ,Concept of A&E Services

• Types Emergency Care Facilities
• Planning and Designing of A&E Services
• Policies and Procedures
• Staffing
• Working Guidelines

This area of expertise has revolutionised the use of hospital facility and also made visible impact of hospital
services to the community. The pattern of hospital care has been undergoing a number of quiet but radical
changes in the last half century one of the special are of development is Surgical procedure and practices.
These functional changes necessitated the emergence of special care facilities which required the special
care expertise and one without the other is non-productive.
Modern day surgery is characterised by an increasing elaboration and a growing tendency for specialisation
and division of labour. One man surgery of the past has been almost replaced by Team Surgery concept and
complicated and lengthy operative procedures have become common practice in any major hospital.
Surgery occupies a unique position in a hospital. It is clothed in an atmosphere of mystery and is pervaded by
hope and fear. Very often these surgical operative procedures form the cornerstone of the overall patient care
provided by the hospital. If performed at the correct point of time by skilled practitoners, dramatic cures have
been achieved leading to patient and professional satisfaction.
Surgical facilities and the staff needed to man the facilities are the most expensive single part of service
component in any hospital. They represent the central and glamorous life saving activity. By its very nature
surgery is dynamic and expensive. Its successes and failures are highly visible. This extra visibility, has in
turn, made this surgical vocation more fascinating in the eyes of its clientele. It has also been proved that
within the hospital services, the Operating Room Costs form the largest percentage of expenditure. A
considerable portion of the money spent on Health Care Delivery is related to the Surgical Services. Hence,
the necessity of maximum utilisation of the existing resources needs no amplification. A sizeable portion of
the patients seeking admission to the hospitals are doing so for surgical operative procedures and it can
roughly be estimated to be more than fifty percent.
Conventionally from management point of view and even in clinical practice the operative procedures are
classified as :
1. Major surgery or minor surgery
2. Emergency or Elective surgery
3. Ambulatory surgery or Day Care Surgery

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Emergency or Elective Surgery
Emergency suergeries are those that are carried out as quickly as possible after a diagnosis has been made.
Delay would lead to deterioration of patients condition.
Douglas has divided it further into exogenous i.e. those emanating from outside the hospital and
Endogenous i.e. those originating from within the hospital. This division is important in forecasting the
numbers of operating rooms needed, staffing pattern and facilities needed.

Ambulatory Surgery/Day Care Surgery :

This is comparatively a recent addition to types of surgery and pioneered by Butterworth Hospitals, Michigan,
USA in 1961. It is also known as “One Day Surgery”, “In and Out Surgery”, “Not for Admission Surgery”,
“Same Day Surgery”; the concept as it suggests is based on limiting or eliminating hospital admissions for
surgery. Due to the rising cost of hospitalisation, shortage of hospital beds and overcrowding of operating
room facilities, this type of surgery is resorted to. This innovative method of delivery of quality medical care to
the patient originated from USA.

Operating Complex :
In order to facilitate any of such operative procedures, it is imperative for any hospital management to create a
physical facility conducive to scientific requirement and provision of support manpower. At the same time the
machinery and equipment required have also to be catered to depending on such facility and provisoning of
the equipment. Concepts of operating theatre, operating suite and operating department are described below:
1. Operating Theatre : An operating theatre is the room in which surgical operations and certain
diagnostic procedures are carried out.
2. Operating Suite and Theatre Suite : An operating suite comprises the operating theatre together
with its own ancilliary areas, namely anaesthetic room, a room for setting up instrument trolleys, a
disposal room, a scrub up and gowning area and an exit area which may be part of the circulating
space of the operating department.
3. Operating Department : It is an unit consisting of one or more operating suites together with
ancilliary accommodation provided for the common use of these suites such as changing room, rest
room, reception, transfer and recovery area and circulating space.

Planning Considerations :
The essential planning considerations while designing an operating department are :

Zoning : It is universally agreed that operation is to be performed under the most aseptic conditions. To
ensure this aseptic condition the operating department is divided into four distinct zones:
- Protective Zone
- Clean Zone
- Sterile Zone
- Disposal Zone

98
These zones are bacteriological zones of varying degrees of cleanliness. The bacteriological count diminishes
from the outer to the inner zones. 100% sterility must be ensured in the sterile zone.
Why zoning? the zoning of the operating department has got the following advantages :
- Minimises risk of hospital infection
- Minimises unproductive movement of staff, supplies and patients
- Increases efficiency of staff working in the operation suites - ensures smooth workflow.
- Reduces hazards in the operating suites
- Ensures proper positioning of the equipment
- Ensures optimum utilisation of the operating suits

Description of the Zones :

a) Protective Zone : It usually provides facilities like (i) reception (ii) waiting room for patients’ relatives
(iii) changing rooms (iv) pre-anaesthesia room (v) store room (vi) autoclave (vii) trolley bay (viii) control
area of electricity.
b) Clean Zone : It provides facilities such as (i) pre-operating room (ii) recovery room (iii) Theatre work
room (v) plaster room (vi) x-ray unit with dark room (vii) sisters work room (viii) staff work room (ix)
anaesthesia store.
c) Sterile Zone : This zone has facilities like : (i) operating room (ii) scrub room (iii) anaesthesia room
(iv) instrument sterilisation and trolley area.
d) Disposal Zone : This zone provides facilities like (i) duty wash up room (ii) disposal corridor (ii)
Janitor’s closet.

Operating Theatre Construction :

Accmmodation :

Committee on Plan Projects Govt. of India (1964) indentifies two different types of accommodation for the
operation theatre as given below :

1. Principle Accommodation Zonal Location

(a) Operating Room(s) Aseptic zone
(b) Anaesthesis room Aseptic Zone (c) Scrub room
Aseptic Zone
(d) Sub-sterilisation room Aseptic Zone

2. Ancilliary Accommodation
(a) Anaesthetist room Clean Zone
(b) Anaesthesia storage Clean Zone
and equipment room
(c) Instrument room Clean Zone
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 (d) Sub-sterilizing room Clean Zone
(e) Doctor’s room and toilet Clean Zone
(f) Stretcher bay Clean Zone
(g) ORA’s room Clean Zone
(h) Pre-anaesthesia room Protected Zone
(i) Recovery ward Protected Zone
(j) Post-operative ward Protected Zone
(k) Dirty Utility room Clean Zone
(l) Relatives waiting area Protected Zone
with toilet
(m) Pantry Clean Zone
(n) Plaster room Clean Zone
(o) Miscellaneous areas Clean Zone
for storage etc.

Published literature refers to two types of operating suites which are normally in operation in the United States
of America and United Kingdom. American operating suite is simple in design consisting of operating rooms
in pairs with a small sub- sterilising room in between. Trolleys etc. are prepared and checked in operating
room itself. British (European) operating suite consists of operating rooms, a lay up room, wash up room,
anaesthesia room, exit room, scrubbing up room and other ancillary accommodation.
Twin operation suite concept is also described in Hospital Building Note no. 22 (1965). In this concept, two
theatres are connected through the anaesthetist’s room which is in between. Two separate scrub up and
gowning rooms are attached to each theatre. The theatre are further connected to the common disposal
room. The scrub up room and the corridor on the other side of which are situated sterile supply room, female
and male staff changing rooms.

Location :
Location of operation theatre or suite in the Hospital Building needs detailed consideration. It should satisfy the
following basic conditions in the overall layout of the hospital. The principles of locating operation theatres are
considered to be in a :
1. Quiet area located to provide isolation from main stream of common corridor and traffic in terms of
staff, supply and visitors.
2. Should not get least exposed to any source of direct contamination of dirt or microbe.
3. Hospital Support Service facilities like CSSD (Central Sterile Supply Department), X-
ray, laboratory and blood bank should be preferably in its proximity as far as practicable.

Orientation :
In the past, the primary consideration had been to ensure adequate day-light within the operation theatre and
to avoid glare. Position today is different as surgical operations are invariably conducted in artificial light, and
mostly stand by generator is provided to cope up at the time of power failure. It is considered that north

100
orientation for operation theatre may not be entirely ruled out in view of the possibility of interruption of electric
supply (CO PP, 1964).

Air-conditioning of Surgical Suite :

Air conditioning also helps in maintaining the aseptic condition of the operating room by letting only controlled
air to pass inside. It also improves the efficiency of the Air-conditioning in a broad sense means air cooling (or
warming), air humidification or drying and air sterlisation to some extent. In an operating suite and more
preferably in the whole surgical department air-cooling, humidifying and relatively high sterlisation is a must to
prevent post operative wound sepsis. Surgical team by creating a pleasant environment and helps maintaining
the vital functions of the patient by providing the optimum comfortable environment.
In order to provide clean air in sufficient quantity to remove as rapidly as possible contaminants liberated by
the surgical team and patient. It is universally recommended that the ventilation of the emergency operation
rooms should provide fresh air at comfortable temperatue with adequate filtration or precipitation to eliminate
dissemination of bacteria laden dust. The requirements of air supply to operation room recommended by
American Hospital Association (1962) are as under:
1. Temperature 72 - 76o F
2. Relative humidity 55.0 per cent or above
3. Ten to twenty air changes per hour
4. Hundred per cent fresh filtered air entering from above the roof.
5. No recirculation of air when operating rooms are in use
6. Positive pressure within the operating room to prevent the entry of air from surrounding areas.
7. Exhaust air taken off from a point near the floor in order to remove dust and heavy anaesthetic
gases.

The most advanced type of air-conditioning technique used in such a situation are called as “Laminar Flow
System”. In laminar flow or unidirectional type of air flow, air passes through high efficiency particulate
(HEPA) filters and either flows downwards from many vented or gridded ceiling to the floor outlets in a piston
like action at a velocity of 70-100 ft. per minute or flows horizontally from one side to another. Studies have
indicated that this procedure is quite effective in materially reducing the bacterial contents of the air and from
exposed surfaces.
Two types of laminar flow are seen to be in use (a) Horizontal; and (b) vertical downwards.
In practice, downward laminar flow is more appropriate for operating theatre because of its less air velocity (60
ft. per minute). The laminar air flow has the following advantages :
1. Control over the direction of air movements;
2. Rapid removal of organism arising from the surgical team;
3. No cold draughts or discomfort by the operating team during cooling of the theatre air;
4. Rapid control of theatre temperature between 65o F and
75 o F ( 18.3o C to 23.8o C) in a few minutes;
5. Quick dilution of anaesthetic gases;
6. Airborn particles are far less likely to agglomerate, as netainment will not normaly occur;

101
7. Air stagnation in part of theatre will not occur

Modern air treatment plant for an operating room consists of a blower to move the necessary amount of air, a
prefilter to remove particles, and an air conditioner which heats, cools and dehumidifies or humidifies the air.
Current standard requires for operating room air a minimum of 12 - 15 air changes per hour, positive pressure
compared with corridors, temperature between 18.3 and 23.8o C (65 - 75o F), humidity of 50 - 55 % and
depending upon the locality, upto 80 per cent recirculation, with the use of effective filtering. In some cases,
even 100 per cent outside air with no recirculation is also suggested for the purpose of sterility and infection
control in the operation theatre.

Lighting
Lighting or in other words illumination in an operation theatre is an important requirement for the efficiency of
the services. It is always essential to provide adequate light for surgeon, anaesthetist, nursing and other staff
in the operation theatre complex. The volume or quantity, the quality and the direction of lighting are some of
the factors to be considered.
The principles of the lighting requirements of an operating room are :
1. Lighting of high intensity, capable of speedy and accurate adjustment with good focus;
2. Produces minimum heat;
3. Illumination of depth of the wound without glare on the surface;
4. Near day light in colour;
5. Shadowless;
6. Freely adjustable to any position or direction;
7. Spark proof and safe where inflammable gases are used.

Equipment Planning Factors :

The term “equipment” in the Hospital Administration context covers all items necessary for the functioning of
the hospital and includes both non-technical (e.g. furniture) and technical equipment. Short term consumable
supplies such as fuel, stationary, food, drugs and dressings are not included under the broad heading of
equipment. Equipment is classified into three groups and the examples of such equipment belonging to each
group pertaining to operation theatres is given as below (Hospital Equipment Note No.22, 1965).

Group - I :
Items usually supplied and fixed by the contractor for the facility like :

- piped anaesthetic gases, suction and oxygen connectors;

- illuminator, x-ray drier film; double-socket outlet; voltage;
- Socket outlet (x-ray apparatus);
- Clock, electric; and lamp, operating theatre lights etc.

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Group - II
Items having a permanent or semi-permanent location and having a significant effect on space and/or
structural requirement which may either be supplied by hospital authorities and fixed by the contractor, or
supplied by hospital authority and put in position by them like :

- operating table;
- trolley, dressing;
- stool, surgeon’s;
- stand blow (single and double);
- stand drip; and
- table, instrument

Group - III
Smaller items, usually storage items, supplied and put in position by the hospital authorities like :

- Sphygmomanometer;
- Stethoscope;
- Thermometer etc.

Further such equipment can also be grouped in three categories, based on the methods of purchase and on
suggested accounting practices in regard to depreciation.

Group - I
Built in equipment usually included in construction contracts. Examples are hospital cabinets, fixed sterilizing
equipment and surgical lighting etc.

Group - II
Depreciable equipment of five year’s life or more, not normally purchased through construction contracts,
large items of furniture and equipment having a reasonable fixed location in the building but capable of being
moved. Examples are furniture, apparatus, diagnostic and the therapeutic equipments and wheeled
equipment.

Group - III
Non-depreciable equipment of less than five year’s life normally purchased through other than construction
contract; small items of low unit cost and suited to store room control. Examples are Chinaware, silverware,
waste basket, dressing jars, cathetors, surgical instruments, linen, sheets and blankets etc.

Operating Load in the Theatre

Operation load of a hospital is always related to the bed strength and more so with the surgical beds, however,
there is an increasing trends in the number of operations performed in a hospital from year to year and are not
103
necessarily related to the increased number of admissions. This is possibly due to the innovative hospital
practice of Day Care Surgery.
It is said that approximately 0.1 operations are done per surgical bed per day. Each surgical bed needs one
hour’s operations per week.
Division of number of surgical beds by the expected length of stay also gives approximate number of
operations performance. So the operating room requirement in a hospital is a issue which needs deeper
thinking and analysis of various factors.

Operating Room Requirement

A fully equipped operating room is one of the most expensive facilities to build and maintain in a hospital. It
follows that the number of operating room should be carefully calculated to achieve their maximum utilisation
or productivity.
Many authorities are of the opinion that rather than taking into account the number of operations per day, the
number of operating rooms depends more on the following factors :

1. The number and types of surgeons available in the hospital, vis-a-vis the patients thereoff.
2. The number and nature of procedures undertaken in the hospital.
3. The average length of stay of surgical patients in each of the speciality
4. The average time for operating, preparation and clean up required in each of the speciality
procedures.
5. The amount of time the operating rooms are staffed and available for use for routine as well as for
emergency procedures.
6. The amount of “operating room time” used for emergency procedures.
7. The amount of “idle time” of operating rooms and staff that may be considered necessary or
acceptable.

So it can be well argued that there is no single method for assessing the requirement of number of operating
rooms in a hospital. The factors affecting the operating room requirement are also other factors like :
1. Location of operating rooms - If they are scattered in different places, it is difficult to ensure the
continuous use of each operating room.
2. Size of the operating room - standard operating rooms normally provide maximum flexibility of use.
3. Working hours and weekly working days of operating rooms.
Different authors have recommended various formuale for calculation of number of operations per day in a
general hospital with basic surgical speciality:

1. Macaulays Formula :
No. of operations per day = No. of surgical beds
surgical patients Average length of stay

2. Steward’s Formula :

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 No.of operations per day = 1 x average surgical census
Average length of stay
3. Formula by Rele and Timmappaya :
No. of operations : = No.of surgical beds x bed occupancy rate x 365
Average length of x 100 x no. of working days
4. No.of operating : = No. of operations per day
rooms needed Average capacity of the operating rooms

The average capacity of the operating room will also depend upon the work schedule. If hospital working
hours are 8, a maximum of 3.5 procedures can be done per day.

Size of Operating Room

Different authorities have recommended different floor area for operating rooms. McGibony (1969) says that
the room should not be less than 6 by 6 metre to allow adequate area for necessary equipment and
circulation of personnel. MacCaulay (1966) says that the usual size of operating rooms is approximately six
meters square, which is adequate for most purposes. COPP(1964) considers that the size of the theatres
should be either 5.4 x 3 or 6 x 5.4 metre and in any case not more than 6 x 6 metre.
In the interest of economy and operational flexibility it is often desirable to make all operating rooms about the
same size, so that they can be used interchangeably for orthopaedic surgery, neurosurgery, cardiac surgery
and general surgery.
However, it is universally argued that the size of operating room should be limited to just what is functionally
essential. Large size room gives rise to problems of air-conditioning, washing and cleaning. Sizes of major
and minor theatres should be the same but minor room will have less expensive equipment (Committee on
Plan Projects, 1964).

Shape and Design of Operation Theatre

Virtually every imaginable shape has been applied to operating room. All seem usable, but none appear to
hold any real advantage over the conventional square or rectangular shape of the room.
Ever increasing newer surgical skills and development can only be utilised fully if the operation theatres are
properly designed and equipped.
Thus, it is important to develop written functional programmes based on the analysis as to the needs,
utilisation, type of surgery to be done, extent of research and educational programme so as to brief the
architect in proper perspective for planning of the immediate and long range projected activities of the OT
complex.

The general layout of an operating suite is frequently based on hospital plan. Broadly, four type of operating
suites have been identified :

1. Single corridor plan

2. Double corridor plan
3. Square corridor plan

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4. Round building plan

Single corridor plan of operating suite is an un- satisfactory plan in which operating rooms are found to not
large enough; corridor is narrow and crowded and the staff have to walk a longer distance for equipment and
supplies.
Double corridor plan is mostly adopted. In this plan, building has to be wider in which operating rooms are
on one side and the service areas placed in between corridors. It has got definite advantages as wider and
shorter unit reduce travel distances which results in efficiency and economy.
Square plan is a shortened double corridor plan, which suites only small operating suites.
Round building plan was popoular in the western world for its visual control and short distances but this
advantage is lost in larger suites.

The design of the theatre should be flexible enough for minor adjustment whenever necessary.

There are four basic elements which should determine the overall area, the internal layout, the staffing levels
and equipment requirement of an operating department and should always incorporate sufficient storage
areas, staff relaxation area, and tea or snacks bar.
Instrument maintenance and repair facility. The following factors need tobe considered :
A. Workflow - i.e. circulation system of patients, staff, supply and disposal.
B. Instruments sterilising policy : i.e.,
a) Central sterilising service Department
b) Theater sterilising service Department
c) Sterilising Room Servicing Twin Theatres
C. Instruments distribution to theatre :
a) Centralised Case Cart System
b) Supply holding room attached to each theatre
D. Type of operating suite

Instruments Sterilising Policy

Central Sterilising Service Department (CSSD) and its relation with the Operation Theatre
With the introduction of the wrapped standard-pack system for the majority of surgical procedures, the CSSD
can be located anywhere, either within the hospital or even outside it. However, if the major function of the
CSSD is to service of one hospital only, it is always advisable to locate the CSSD close to the Operating
Department which is its major user and thus it will facilitate the maximise the use of skilled manpower
resources and an optimum surgical instruments flow.

Theatre Sterilising Service Unit (TSSU)

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It is a dedicated sterilisation facility in operation room complex for routine as well as emergency sterilisation of
equipment and instruments with the availability and cost effectiveness Flash autoclave like Ethylene oxide
steriliser such facility are increasingly incorporated in modern operation theatre complex.
However, on economic and efficiency grounds, it is hard to justify two sterilising services within a hospital. It is
possible, however, to maximise the flow of instruments and the use of skilled manpower resources by
interlinking, either horizontally or vertically, the CSSD with the Operating Department, thus eliminating the
need for a seperate TSSU.

Sterilising Unit between Two operating theatre for Unwrapped Packs

This method is often adopted where the overall case load is small, where there is a shortage of surgical
instruments and where the Operating Department’ nursing staff is responsible for sterilizing the instruments
also. However, disadvantage to this system is that when the autoclave breaks down or requires maintenance,
both theatres will be out of commission. Also, the scattered location of autoclaves within the operating
Department will also require a complicated and expensive ducting and air handling system.

Instruments Distribution
The instrument distribution system directly effects the efficiency of Operation Theatre utilistion time and staff.
It may be Case Cart System. In this system for each surgical procedure, a cart (Trolley) containing
instruments as well as linen, bowls, dressings and other items needed, is prepared in CSSD (or TSSU). This
cart is delivered directly to the theatre and held in a parking bay adjoining the theatre. Unwrapping of the
instruments is carried out within the theatre. This system is most frequent in USA and Europe.

Supply Holding room : With this type of instruments distribution, each theatre is provided with a sterile supply
room, where sterile packs are held for the entire session. Trolleys are prepared in this room for each case;
unwrapping of instruments- packs takes place here, hence the need for sterile conditions. This system is
mainly used in the UK.

POLICIES AND PROCEDURES:

In order to make effective use of operation theatre facility the most important factor is drawing the operation
schedule. The time lost between cases in a given operating theatre may amount to as much as 15-50 minutes
depending upon the hospital, its personnel, the number of surgical instruments available and discipline
prevailing in the theatre. It is important to ensure that there is no wastage of operating-time of the surgical
team nor is there any over-crowding of the operation list resulting in postponement of operations.
Some of the points which should be borne in mind by all concerned are given in succeeding paragraphs. The
most important of these are i) Discipline of OT ii) Availability of instruments
Time saving technique depends considerably on operating room discipline. A well run OT requires an untiring
and energetic theatre matron, a dedicated and disciplined Chief Surgeon, an anaesthetist who is keen on high
standard of efficiency and a trained and well motivated para medical staff. If instruments are ready in advance
of the appointed time, if the assistants are in the room, gowned and gloved and the anaesthetist helps to

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coordinate the presurgical details before entry of the operating surgeon the duration of occupancy of that room
by a particular patient will be decreased considerably.

Punctuality :
Punctuality by everybody concerned with the operating schedule is important. It is to be impressed upon to all
concerned that the first case of the day should begin promptly when scheduled i.e. operation may be at 0800
hrs. All delay in starting a procedure should be investigated and discipline enforced with suitable penalties and
motivation.

Theatre Staff :
The chief of the surgical team should always take personal interest in the training of theatre staff. Each
member of the team including the junior-most operation room assistant (ORA) and even the sweeper should
be put through progressive training to bring them to a high pitch of efficiency so that they carry out their duties
more or less by reflex action or “mechanically”.

Operating List :
It is imperative to make the operation list judiciously and tentative time of operation when possible should be
indicated against each. Efforts should be made to ensure that the cases are not postponed barring
unforeseen and exceptional circumstances. Rigidity of “working hours” should not normally be allowed to
come in the way of completing the list for the day. Other reasons for postponing operations such as non
availability of theatre linen. Lack of sufficient instruments and inadequate preparation of patients should be
reduced to the minimum by suitable administrative measures.

Outpatient Cases :
It is seen that it is a common practice to see that out-patients requiring minor surgical procedures such as
special dressing, change of plaster, injection of piles, incision of a whitlow and so on, reporting to the OT early
in the morning and being taken up late in the afternoon at the end of the list. This practice not only puts the
patients into inconvenience but also creates avoidable dissatisfaction of patients and their relations.
Few of the suggestions can be implemented :

(a) Awareness on the part of all concerned staff that the above practice is highly demoralizing to the
patients and all efforts should be made to plan and organise prompt attention for OPD cases.
(b) Where there is only one Surgeon in a hospital such cases should be dealt with either on OPD days in
the afternoon or on the following day in the morning using the minor OT.
(c) Where more than one surgeon/trainee or resident staff in surgery are available, the OPD surgery
should be listed separately for the day and a surgeon detailed for the same. Seperate provosioning of
anaesthesia service are always necessary for this.
(d) All outpatients scheduled for such procedures should be called by appointment at the appropriate time
when they are expected to be dealt with.

Transportation of Patients :
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Transportation of patients from and to the ward should be organised only by the anaesthetist at a suitable time
depending upon the time of operation. For this purpose adequate ambulance/nursing assistants should be
made available on a regular basis.

Staffing
The principle of staffing in a operation theatre complex should be that the OT complex should be self sufficient
in terms of the experience as well as the number of its staff. Apart from exceptional cases and to meet
disaster situation. It should be able to deal promptly with anything any time from within its own resources in all
areas like nursing and paramedical as well as medical staff.
For the administrative convenience and keeping in mind the concept of the unity of comand, the staff should
be under the administrative control of officer incharge of operation theatre department. The following
categories of staff are commonly in position:

Specialists :
1. Surgeons
2. Anaesthetist

Resident Staff :
1. Senior Resident
2. Junior Resident

Nursing :
1. Assistant Matron/Assistant Nursing Superintendent
2. Nursing Sister
3. Staff Nurses
4. Student Nurses, when applicable

Technical
1. X-ray Technicians (Radiographers)
2. Technical Supervisors
3. Operation Theatre Technical Assistants
4. Operating Room Attendants
5. Operating Theatre Attendants

Others
1. Sanitary Personnel or Safai Karamcharis
2. Nursing orderlies/Ayas
3. Chowkidars or Security guard
4. Peons or messenger
5. Clerks or Medical Transcriptionists when available

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The success to provide an efficient and optimal surgical services depends upon the number, competency and
attitude of the personnel working in a surgical suite. The number of personnel should be such as to perform
and carry on the work in a systematic and efficient manner commensurating the type of equipment and also
no. of days and number of shifts the OT functions. Few of the important job assignment of the designated staff
are as under:

Operating Room Sister (Head Nurse) :

She should be a senior qualified nurse, experienced in nursing techniques of operating theatre and be
responsible for the administrative control of a designated unit in operating theatre.

Staff Nurse : She has to be an adequately qualified nurse and her role is to provide nursing care in the
operating department and as a skilled member of the theatre team to act as the scrubbed or circulating
asistant during operating procedure. As a registered nurse she has the responsibilities involving the storage,
checking and administration of drugs, as well as other functions like.

1. Participating as a scrubbed member of the theatre team and carry out safety check of swab,
instrument and needles.
2. Acting as a circulating member of the operating team.
3. Assisting other members of the team in preparation and cleaning of theatre.
4. Identification of the patient, premedication and necessary documentation.
5. Providing assistance to the anaesthetist and surgeon as and when required.
6. Ensuring that appropriate stock levels of all life saving emergency drugs and also all routinely used
drug are maintained in the operating suite.
7. Implementing safety measures in relation to storage and administration of blood, drugs and static
electricity and explosion hazard and fire

Operating Department Assistant (ORA/OTA)

To provide skilled assistance in the operating department and act as a member of the theatre team. To care
for specified equipment relevant to his skills, his functions are :
1. Cleaning, preparation and minor maintenance of instruments.
2. Assisting in movement of patient in the operating Department.
3. Providing assistance as a circulating member of the theatre team in positioning and preparation of
patient on the operation table.
4. Assisting the anaesthetist and surgeon as and when required.
5. Providing supplies and plasters in operating department.

Operating Department Orderly :

To carry out portering and general duties in the operating Department as :

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1. Preparing patient trolleys, lifting patients and moving them between beds, trolleys and tables.
2. Receiving and storing stores and equipment
3. Cleaning theatre and assisting with cleaning within the department.
4. Carbolization of various theatre equipment and trollyes.
5. Cleaning theatre footwear

Sweepers or Safai Karamcharis : The duties of the sweeper should encompass the following functions :
1. Cleaning and assisting in carbolizing the floor of operating theatre.
2. Collecting and sorting soiled linen and also disposing of all biomedical waste as per the statutory
guidelines.

There are no definite guidelines in western literature regarding the staffing of an operating theatre, however,
various recommendations have been put forth as regards the number of various categories of staff working in
operating theatre complex.
The operation theatre being used by multiple department and with large number of workers with different
categories it is controlled through the “Committees”. These committees should be represented by all
categories of staff including the various speciality and sub-speciality. The policies arising from the
deliberations of such committees have to be operational and participative. The primary responsibility of the
committe is to prepariton of a policy manual which needs to be familiar with the relevant laws and regulations
including :

1. Safety of proceudre, admission of the patients and visitors.

2. Technical surgical policies
3. Nursing administration
4. Operating theatre policies including the type of cases and staff authorised to perform surgery.

The policies and procedures are to be the guidelines for action and decision making. They are to be written by
appropriate members of the department and approved by the administrative authority. The operating room
policy and procedure manual should include the following rules regarding:

1. Admission of patient to operating room

2. Anaesthesia - general or local
3. Aseptic techniques
4. Cleaning and maintenance of equipment
5. Disinfecting and processing of instruments and supplies Housekeeping - cleaning
6. Functions of circulating nurse, scrub assistant
7. Operating room rules and regulations
8. Records, anaesthesia, operations
9. Specimen, collection and disposal, amputation of limbs and other organs
10. Safety - sponge, needles and instrument count, electrical machine and fire hazards.
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Ocassionally when patients are transferred directly from the emergency department to the operating room. So
a close liasion and good communication of different participative departments are absolutely necessary to
avoid errors in treatment, duplication of medications and unnecessary transfer delay. Emergency department
personnel must be thoroughly familiar with operating room policies regarding medicine given pre-operatively
and handling of artificial devices such as dentures and valuables. Minor and major surgical procedures may
be performed in the emergency department, however, if an anaesthesia is to be administered, rules
governing its use must be established.
McGibony (1969) remarks that some discussion has revolved around the differentiation between major and
minor surgery, as referred to early but from the stand point of view of the patient and professional
competency, there appears to be few reasons on the subject to arise. However, since it does arise in relation
to determining qualifications of the surgical staff, and because of cost factors to the hospital, it must be
considered. Certainly any procedure involving hazard to life, including all general anaesthesia, should be
classified as major.

Policy on the Cleaning Technique

As it is scientifically established that contamination of an operation theatre will affect its utilisation and
therefore for cleaning a full proof technique must be developed not only for instruments and equipment but
also the room and the equipment and to contain and confine organism. So whoever is charged with the
responsibility of Hospital Hygiene in OT should have specific established routines and develop written
instructions for everybody to follow.

Four types of clean up procedures have been recommended viz preparatory, operative, interim and terminal.

The concept of universal precaution practice have to be kept in mind at all levels of operation on theatre
technique as is recommended and discussed elsewhere in the book. The Biomedical Waste disposal rules are
also to be implemented as is developed for hospitals.

1. Preparatory Cleaning : Before begining the first scheduled procedure of the day damp dusting
should be the routine practice by a clean cloth dampened with detergent or disinfectant. This is
expected to remove dust particles from flat surface of table, equipment and specially overhead light.
This is preferably done one hour before scheduled incision time.
2. Operating Cleaning : Areas contaminated by organic debris, such as blood, sputum and body fluids
during the operation should receive immediate attention. An in-use dilution of phenolic detergent
germicide, iodophor, or other broad spectrum germicide can be applied from a squeeze bottle to the
soilage. Sponge should be discarded to plastic linen receptacles.
3. Intermediate cleaning :
a. General : As soon as an operation is completed and patient is taken from the room, clean up is
initiated to ready the room for the next patient. Personnel engaged for the task must have their gowns
and gloves in appropriate receptacles prior to leaving the room. All linen, soiled or not, is to be placed
in linen discard bag for the laundry.

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 b. Instruments : Instruments should be placed directly into perforated trays for processing in a
washer sterilizer, or may be covered for transportation to the central service for terminal sterilisation.
Basin and trays are also washed and autoclaved.
c. Furniture : Horizontal surface of table and equipment of any other formative price which have
been involved in surgical procedure should be cleaned with an appropriate in-use solution of detergent
germicide.
d. Floor : Experts agree that wet vacuuming is the method of choice for floor care in the operating
room. Mops are widely used even though such practices has proved to be not in a position to achieve
the degree of microbiological cleanliness felt necessary by most authorities. If wet mop must be used
at all a fresh mop must be used each time and no buckets are to be used in such practices. Dry mops
are not to be used in the operating room, whether it is treated or untreated. A central wet vacuum
pick-up procedure often takes less time than good mopping procedure.
4. Terminal Cleaning : At the completion of the days schedule for each operating room, more stringent
and rigorous cleaning are required in all areas as indicated earlier. Casters and wheels of operating
room trolleys or equipment should be cleaned and kept free of suture ends and debries. Wall should
be checked for soil spots and cleaned accordingly as a routine.

Operating theatres represent a major capital cost in any hospital construction. Therefore, Operation Theatre
must have a level of productivity to commensurate with this level of expenditure. A measure of productivity of
operating theatre would be an analysis of the level of utilisation in relation to a consistent period of activity.
Over and above routine functional efficiency certain procedural factors may be responsible for under utilisation
of opoerating theatres. These constitute the activities of housekeeping and nursing staff who undertake clean
up procedures after one procedure is over and set up the operating room for the next procedure. If the
personnel engaged in such activities are prompt and realise the importance of operating room facilities, the
utilisation of the operating theatre can increase, without compromising the quality of services.
A well run operating theatre requires dedicated leadership of the nursing team, a dedicated and disciplined
chief surgeon, and of course the anaesthetist and motivated supporting staff.

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 CHAPTER - IV

NURSING AND WARD MANAGEMENT

KEY AREAS

• Objectives ,Concept of A&E Services

• Types Emergency Care Facilities
• Planning and Designing of A&E Services
• Policies and Procedures
• Staffing
• Working Guidelines

Nursing Care is the person to person application of scientific principles for the sake of achieving, a
physician’s therapeutic purpose. It is a personal care of the patient, closely associated with the work of the
physicians.

World Health Organisation has defined the nursing services as ”that part of the total health
organisation which aims to satisfy the nursing needs of the community”. The major objectives of the
nursing services is to provide :

1. The nursing care required for the prevention of disease and promotion of health.
2. The nursing care of the patient required :
a. in the interest of his mental and physical comfort
b. by reason of the disease from which he is suffering

The unique characteristic of hospital nursing that has developed gradually is that the nurses are assuming
many activities that are not essentially nursing and creating some of the major issues concerning the current
nursing care. The advancement of medical knowledge and practice and increasing use of parenteral therapy
chemotherapy and newer therapeutic modalities like inhalation therapy has created a peculiar situation in the
hospitals, leading to the question whether the nurse should take up the ever increasing responsibility of
intravenous infusions, medication and inhalation therapy etc. where the physician or the anaesthetist and his
technician are charged for this kind of job as per the normal practice. At the same time the intelligent
observation and decision that the nurses have to continue to care the critically ill patient needing such therapy.
It is observed that the nurses are taking additional responsibility for care increasingly of the patients when
necessary. They are found to be obtaining medication from the pharmacy and compounding prescriptions
making menu and supervising food preparation, supervising the care and distribution of linen, making
arrangement for the patient to travel home, finding placement for an abondoned child. Supervising and
teaching the cleaners or maids in the ward and the record keeping of all sorts in the ward and are gradually

114
drifting the nursing services from the main philosophy of nursing “the conscious practice of human
relationship”.

Today the major functions of the nursing activities in hospital are :

a. those dealing with organisation and control of the patients environment and to secure for him
maximum mental and physical comfort.
b. Those concerned with his immediate personnel care.
c. Those performed under the direction and in cooperation with the physician
d. Administrative duties of ward management

The job responsibility of the nurses, developed by the Govt. of India is shown seperately in this book.
The organisation of the nursing services in a hospital is a complex procedure. There are no set standard
pattern, applicable for staffing and organising the nursing service in all situations. So the problems of
organising and staffing have to be worked out by method based on needs of the patients in the particular
situation with the known principles of management.
The philosophy of patient care determined by the hospital authority determines the standard of medical and
nursing care in the hospital. Although, generally the need of the patient is said to be the basic criteria o
f the nursing services, but inevitably the nursing care of patient depends on the availability of fund and
manpower resources in a hospital.
Objective criteria for adequacy of nursing care based upon the needs of patients have not been determined
as yet. So empirical evidence is the best evidence that can be offered as a guide. The judgement of the
patients and the hospital workers on bed side, therefore have to be relied upon for the evaluation of adequacy,
of the nursing service.
A sound administrative and organisational structure of the hospital is the principal factor for the organisation
and administration of a hospital nursing services. A strong central administrative direction is the fundamental
need for the success of the nursing service in a hospital.
The nursing service is the closet of all the services to the patient in a hospital. It is round the clock minute to
minute service and deployes normally the largest number of personnel in the hospital. So the management
and supervision of the nursing personnel is the vital factor in establishing the standard of nursing care.
Setting of the standard mainly depends upon the judgement of the nurses themselves and is guided by the
Chief of the nursing service.
The planning, organising, directing and cooordinating the individualised care of hospital patient is the vital
function of the nursing administration. All other nursing function and activities as manifested today are related
to it. The personnel management - maintaining an appropriate hospital environment and development of
education programme, personnel and working relationship are the functions in a hospital revolve around the
individual care of the patients only.

Administrative policy pertaining to the nursing services

The personnel and economic resources of a hospital forms the basic guideline for organising the nursing
service, but it is influenced to the greatest extent by the beliefs and the standard of the professional staff. The

115
support of the hospital administrator and the physician is equally vital to have the understanding and
agreement concering the standard of patient care to be provided.
The concept of centralised laundry, kitchen, sterilisation, provisions, including the medical, surgical and
general stores and the medical records are the determining factor for utilisation of nursing man hour in the
hospital. The practices like a nurse, sterilising the equipment in the ward, sorting and storing linen in the ward,
supervising the dish washing in the ward, and initiating the records of patients in the ward; if dispensed with
can make the highly valued nursing hour, for better use in individual patient care. Privatisation of such
services are gradually being introduced in a modern hospital keeping such philosphy in mind.
The practice of taking temperature for 30 to 40 patients, every 4 hourly by the nurse with the two,
thermometers available and safely sterilised in between; putting the responsibility to the nurse incharge of all
the breakage and loss in the ward are some of the issues which need to be critically evaluated before
expecting a standard nursing care to the patients by the hospital authority.
The autonomy of authority for a ward sister to group critically ill patients irrespective of the unit consultant
incharge of the patient in the ward is the biggest limitating factor for a ward sister in planning the nursing care
of the patients.
The personnel policy adopted in a hospital toward the nursing personnel is the other area of importance, which
effects the other area of importance, which effects the morale of the nursing staff and thereby the output from
them. These are mainly the inservice education promotional avenue, the provsion of perks etc.

Relationship of Nursing Service Organisation to Hospital Organisation

Probably the recruitment, selection and training of nurses represent the most universal problem in the
provision of any type of nursing care in hospital or public health services. For planning the patient care in
orderly manner, the responsibility for the leadership and direction of hospital nursing service should be
assigned to a director nursing service (Chief of Nursing Service), and should be answerable directly to the
chief executive of the hospital.
The basic organisation of hospital service and nursing services, their relationship to one another, lines of
authority (or communication) should be clearly laid down in the organisation chart.
Such a chart should come as a result of organisation after considering the objectives, responsibility and the
feasible programme of a specific hospital. It may be simple or complex but it should reflect the plan of
nursing service that is provided. A sample chart can be as under :

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 MEDICAL SUPERINTENDENT

Officer I/c Nursing Supdt Dy.Medical Supdt.

Clinical care
Dy.Nursing Supdt Service areas

Ward Sister Sister Tutor

Staff Nurse Student Nurse

A organistion chart, therefore should indicate the authority, responsibility and the lines of communication.
Relationship with other hospital services are normally indirect and need to be clarified in the chart.

Effective working relationship in the hospital depends on effective communication. Each member of the staff
must know how her work, contributes to the care of the patients, and how it fits in with that of others to provide
total hospital services to the patient. Chanel’s of communication can best be explained to the personnel by
the use or organisation chart of the hospital and the nursing services. The chart indicates the level of authority
and responsibility, and shows the worker her place in the whole organisation. In explaining the channel of
communication it needs to be pointed out the three directions of communication i.e. up, down and across or
horizontal.

Utilisation of Nursing Personnel

It is seen that the adequate category and number of persons bear little relation to the quality of nrusing care
provided for patients. Studies have shown that an excellent quality of care can be provided by a minimum
number of trained workers under good supervision in an organised setting. At the same time study of
hospitals has revealed that the primary problem in personnel administration is inadequate supervision.
Supervision of nursing personnel is particularly significant because of the number and categories involved in
the care of patients and continuous round the clock service.
Supervision has been defined as a cooperative relationship between a leader and one or more persons to
accomplish a particular purpose. So that successful supervision by the nurse incharge is based on her love of
people and the desire to assist each worker to develop her ability and to contribute her best efforts to the
nursing care of patients.
For the utilisation of nursing personnel their development for patient care is most vital. But the concensus of
nursing leaders and hospital administrators indicate that there is no reliable method by which a general
standard can be applied to determine the ratio of nurses to the patients. There are number of factors which
influence the same.

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a. Size and lay out of ward - Open or partitioned wards
b. Type of cases - Acute, chronic mental ,children
c. Type of hospital- Teaching, nonteaching research oriented
d. Number of important
patients or private
ward facility
(nursing home)
e. Type of equipment - Modern labour saving devices and centralised or
decentralised services
f. Amount of domestic and house keeping work carried out by nurses or nursing aids or
assigned on contract basis.
g. Amount of paper work and documentation carried out by the nurses.
h. Length of stay of patients as per the clinical protocol.
i. Availability of student nurses for basic hospitality care

Assignment of duties : There are three patterns of assignments of duties among the nursing staff practiced
in a ward unit of a hospital.

a. Functional method
b. Case method
c. Team method

a. Functional method : In this method various basic nursing function like temperature taking medicine
injection, treatment procedure and so on are divided amongst the available staff nurses allowing one or two
nurses per function for the entire ward. The advantages are saving of equipment, the individual nurses
become skilled in their particular function, best utilisation of aptitudes, saving of time and so on. The
disadvantages are that the patients are compartmentalised, he feels insecure as he is attended by a number
of nurses, there is hardly any opportunity for staff development and the work becomes repetitive and
monotonous in this sytesm.
b. Case Method : Here a few patients are completely assigned to each staff nurse and she carries all
the total nursing of her group of patients. It has the advantage that the patients are emotionally secure, the
nurse gets the satisfaction of seeing the patient though all stages of disease and management. But this
method requires large number of nurses.
c. Team Method : In this method an experienced staff nurse is made responsible for the care of a group
of patients with the help of a set of junior nurse and nursing aids. She gets the nursing done under her
supervision in addition to carrying out the important duties and procedures herself. The nurse acts as a head
nurse for a limited number of patients and as a leader of a team. This method satisfies the emotional need of
the patient as well as development and job satisfaction of the entire nursing team.
d. Staffing : In planning an improved staffing pattern that is responsible and attainable, it is
recommended that an assessment of the existing staff of the hospital wards be used as a starting point. It is
suggested that the assessment should begin with a group discussion of “daily time assignment”. Only one
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ward can be studied as an example in the first place. This discussion could be followed by a similar study and
discussion for other wards, one by one. Consideration of each ward by the entire group is a good way to
create understanding of another’s problems. It also stimulates group participation in identifying the most
pressing problems of the nursing service as a whole and results in group discussion and making plans for
solving these problems.

Rough method for findings out the nursing time available per patient per day is :
1. Find the average number of working days per year by a nurse (substract from 365 the total
number of leaves and holidays)
2. Find the average number of actual working hours worked per year by a nurse (multiply
average number days worked by number of hours worked per day.
3. Multiply the working hours per year by the total number of nurses to get total number of
nursing hours per year
4. Divide the total number of nursing hours per year by 365 to obtain the number of nursing
hours per day
5. Divide the total number of nursing hours per day by the average daily patient census to obtain
the number of nursing hours per patient.

Results Average time taken per patient in each shift of duty in 24 hours in three categories .

SHIFT OF DUTY
Morning Evening Night Total
Categories of patients Minutes Minutes Minutes Minutes

Completely I 196.50 149.83 86.75 433.08

dependent
Partially II 97.17 54.83 83.42 186.42
dependent
Ambulatory III 71.83 41.08 10.67 123.58
dependent

From above the number of patients in each category and in each shift of duty that can be used by one
nurse are :

Category Morning Evening Night

I 2.4 3.2 5.5

II 4.9 8.3 14.4.
III 6.7 11.9 45.0

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With this figure the ward administrator can estimate the total number of nurses needed for their ward
according to be categorisation of patients based on the degree of their need.
Lastly in conclusion, for a hospital administrator to expect a standard efficient nursing care in his hospital, it is
essential to examine critically the administrative, personnel policies, the facilities, supplies and equipment
provided for the nursing services. It is also equally important to evaluate the extent of authority, and
responsibility delegated to the nursing staff. Lastly it can be closed by the saying that your patients to have
good care which includes nursing care, then strengthn them, do not weaken, through the nursing initiative.

THE FACTORS INVOLVED IN GOOD WARD MANAGEMENT

There are many important factors involved in good ward management, each of which the nursing
administrator needs to understand thoroughly so as to administer her ward competently. These include (1) a
knowledge of all the duties to be performed on the wards, (2) a planned program for each day’s work (3)
beginning the day on time (4) preventing interruptions (5) establishment of ward routines (6) use of
democratic methods in establishment of ward policy (7) orientation of new staff members (8) maintenance of a
suitable environment (9) provision of supplies and equipment for efficient work ( 10) clear-cut doctors and
nurses orders (11) accurate records (12) full reports (13) maintenance of high morale among al membes of
the staff (14) establishment of good working relationships within the ward and with other associates (15)
delegation of responsibility (16) well-planned assignments (17) well arranged time for personnel (18) good
teaching and supervision.
Knowledge of the ward - To manage a ward efficiently it is necessary that the nurse incharge be thoroughly
familiar with all the activities which must be performed. Some activities occur daily, some weekly, some only
under special circumstances. Those that occur regularly can be planned and fitted into a program. The
inexperienced head nurse and those who carry the responsibility for the ward in her absence will find it as a
great help to have activities which have to be performed on each day of the week or month listed in a ward
policy book where the information will be available for ready reference.
Planning the Day’s program - To prevent loss of time, each day’s duties should be planned in advance and
proper assignments need to be made. It is advisable to keep the same assignment to the nurse incharge of
the patient for a long period rather than frequent change except when a change is necessary for educational
or other reasons.
Starting the Day on time - Good management is greatly facilitated by starting the day’s work promptly. Every
nurse should be expected to be on the ward at the hour assigned. The night nurse, whether or not all her
work is completed, should be prepared to give the night report at the designated time. Similar should be the
arrangement at the change of each shift.
Preventing Interuptions - Since time is wasted in going from one activity to another, good management
requires avoidance of interruption whenever possible. This is true for all personell including the nurse
incharge changes in assignment of patients and time should be kept to a minimum although adjustment for
new patients admitted and emergencies are to be planned within the framework. One nurse, however, may
be assigned to care for new patients and the rest of her assignment arranged accordingly. This will save
interruptions for those with heavier work loads.
Establishment of ward routines - Ward management is facilitated by the development of systematic
procedures for dealing with the details of administration. By the adoption of a system for accomplishing routine
activities and special assignement to senior nurse, nurse incharge can free herself for more ocnstructive
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activities like planning and provision. If ward routines are established for handling orders, writing and giving
reports, checking medicine cards, summarizing charts, handling telephone calls,checking and ordering
supplies, keeping cupboards stocked, distribution line, collection specimens, there is more time left for
individualised nursing, for supervision and teaching.
Methods of establishing ward routines - Each head nurse should be aware of problems and situations on
her ward which interfere with good nursing and those which cause interruptioin, delays and frustration.
Consultation with staff and student nurses, and with other nursing personnel should be encouraged and such
inter action brings to light problems in ward management and brings both solution of the problems. It is seen
that often the establishment of a ward routine or the changing of one which exists makes a marked
improvement in the care of patients or results in saving of time for the personnel in the hospital.
Limitations of routines - No system can be constructed to meet all the needs that arise on a busy hospital
ward. In fact care must be taken that the system does not detract from good patient care rather than, to
contribute to it. It is very often experienced that bath schedule in a ward, which requires that a nurse ahdere
to it regardless of a patient’s personal needs, or a system for serving diet trays that does not consider
individual preferences for food or permit a patient to be served out of turn in order that he may eat with his
neighbours, may be worse than no routine. A bath schedule or a plan for serving diets, as well as other
routines, are valuable in so far as they serve to provide better nursing care. When most activities fit into a
system there is time to look for the exceptions which need to be made and to provide for the variations which
are indicated. In no occasion the system should the system become more important than the individuals who
are affected by it i.e. the patients and the members of the staff. A system which is so inflexible that it permits
no initiative or originality on the part of nurses has seen to have demoralizing effect on the working nurse. So
efficiency can be carried so far as to be non-educational, as for example in the use of functional method of
assignment.
Use of Democratic methods in Establishing ward Policy - When ward objectives are to be determined and
policies to be established or changed, it is always better to generate cooperation and participation of the entire
staff is to be looked forward through discussion and active participation. Results are far more effective in the
end if time is taken to talk things over and solicit the suggestions of the staff. If a policy is quickly dictated by
the head nurse at the hospital management, she may not get the best of interest and full cooperation of the
ward personnel. Good administrators get things done as quickly as possible but they keep people also happy
in the process. It is always good for the head nurse to encourage suggestions from staff members but not to
necessarily offer a quick yes or no answer. The suggestions may not have been completely well thought over
and at times if the nurse is asked to elaborate her plans and present them to her associates on the ward it
may so happen that she may herself decide whether or not the suggestions have merit.
Orientation of new personnel - Good ward management is dependant upon a well developed program for
orientation. No ward can function smoothly unless the personnel is acquainted with the situation in which it is
suppossed to work. New staff members must be familiarised with the general policies of the institutions, the
routines of the department and ward, the individuals with whom they will be working and their relationships to
these persons, the patients for whom these staff will be caring for, the accepted nursing and medical
procedures, the geography of the hospital and ward, the location of equipment, and the like, introduction to the
hospital and the general policies of the hospital which affect the particular staff members should be handled by
the central nursing office only and by the supervisor, or, for student nurses, by the school of nursing. The
head nurse, however, is in the best position to do this activity in a normal situation.

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 CHAPTER V

LABORATORY SERVICES

INTRODUCTION
The hospital laboratory service is changing very rapidly. Automation and newer techniques have created a
dramatic and challenging environment in the hospital diagnostic services. It is seen that a general hospital
has been converted in the last last 20 years from a sophisticated nursing home to a research, diagnostic &
treatment centre for the community. These changes bring up new and greater demands on the pathologist
and the clinical laboratory in all hospitals be it small, medium and large. Although the term laboratory has
been in popular use, historically the pathologists prefer to use the term department of Pathology. Because of
this preference and its acceptance by the average medical profession but now the concept of laboratory
medicine has taken a deeper root. This department provides those clinical laboratory services which apply the
knowledge and techniques of basic sciences in diagnosis, prognosis, treatment, and prevention of disease in
a health care set up.
Before World War I, this department which was known as the department of Pathology was small, ill-equipped
and remained neglected. The services offered were minimal, consisting of simple urinalysis, blood counts, a
few chemical determinations and some bacteriology. Few surgical specimens were examined and few
autopsies were performed. After World War I, this began to grow as a result of variety of influences. The
physicians became acquainted with the valuable services pathology could offer, the number of medical
journals increased, and the discoveries and advances became more widely adopted in a short period of time.
During the years 1875 to 1900, the (Golden age of bacteriology), most of the important pathogenic
microorganisms were isolated. However, many years elapsed before this knowledge
was widely applied. Blood banking, as a practical procedure, dates from 1937. The need of space and
facilities for the department increased, requiring expansion and redesigning of buildings. Since World War II,
there have been new stimuli to the growth of the field and it continued to grow as knowledge of health and
disease expands. The department of Blood Banking, the clinical Pathology, Microbiology, Biochemistry has
subsequently branched out of the parent pathology department over the years.However, due to the patient
care function the core department continued to be referred to laboratory services or hospital laboratory.
Historically the hospital laboratories have developed mainly from four sources; Pathological anatomy;
biochemistry; microbiology and hematology. Generally, the first laboratory service given by hospitals was in
pathological anatomy, and in some countries this science still seems to dominate the laboratory service. The
non-clinical departments of medical schools have had a definite influence on the scientific and technical
development of laboratory procedures. The stimulating influence of clinical departments on laboratory work
cannot be overestimated, it has in many instances dominated the evolution of hospital laboratories or the
present day laboratory medicine.

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GENERAL FUNCTION
In the medical literature pathology is the branch of medicine which employes “methods and instruments of
precision for the examination of secretions and excretions of human body and its functions, in order to: (a)
diagnose disease, (b) follow its course (c) aid in its treatment (d) ascertain the cause of death and the result of
treatment by means of autopsies and (e) help advance the science of medicine by means of research”. The
hospital laboratory services or the laboratory medicine and its highly trained medical and scientific staff bridge
the gap between the rapidly advancing front of science and the care of the sick and maintenance of health.
With the advance of medical science, the clinical laboratory progressively became more important as the
basic source of analytical information concerning the patient. “The Pathologist is not only the medical
biologist, chemist, and mathematician of the hospital, he also acts as a consulting colleague to the patient
care physician by correlating the total picture of Pathology with the clinical picture, and provide all possible
help in solving difficult clinical problems by application of his laboratory facilities”.

Thus the mission of the hospital laboratory medicine includes:

a) Provision of comprehensive & accurate analytical test results.
b) Collaborative consultation with the clinicians regarding the most useful application of scientific
procedures to patient care.
c) Training of professional and technical staff.
d) Research.
e) Adaptation of laboratory medicine of useful advances in basic science.

In considering the function of hospital laboratories the WHO Expert Committee (1959) observed
that the following services are traditionally supplied by hospital laboratories:-

a) Morphological Pathology

i) Morbid anatomy (autopsy)

ii) Histopathology and histochemistry
iii) Exfoliative cytology.
The provision of service in morbid anatomy and histopathology has long been a prime function of hospital
laboratories. The Committee noted that, in many hospitals histochemistry was a commonly used diagnostic
method and though not generally available in all laboratories, exfoliative cytology is constantly expanding as a
useful diagnostic procedure.
b) Clinical Pathology This includes determination of carbohydrates, lipid protein, and electrolyte
constituents of blood, urine and other body fluids, and also of their metabolism. In larger laboratories
endocrine substances and enzyme reactions are determined. Another group of tests measures levels of
drugs and toxic substances.
c) Microbiology
i) Bacteriology
ii) Parasitology

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 iii) Mycology
iv) Virology
v) Immunology

d) Haematology The study of blood, the bone marrow, the reticulo-endothelial system, and those diseases
associated with alterations of its cytological constituents; the study of the physico-chemical features
associated with haemorrhages and blood dyscrasias, immunohaematology; and the laboratory procedures
associated with blood transfusion.

In some countries the following additional fields are being developed as laboratory services:-
a) Medical Biophysics The handling and administration of radio-isotopes are not generally controlled by
hospital laboratories; the increasing use of radio-isotopes in diagnostic procedures, however, makes it
necessary to include medical biophysics as one of the developing hospital laboratory services.
b) Clinical Physiology These investigations include electrocardiography, phonocardiography, heart
function test, blood volume estimation, spirometry, estimation of basal metabolism, renal function tests and
portal pressure determination.
c) Allergology In a few instances, laboratory tests for allergy are performed in the hospital laboratory.

Some authors classify functions of laboratory in two groups as under:-

a) Anatomic pathology which includes the study of the tissues of the human body, with the naked eye by
gross anatomic pathology, and with the microscopic anatomic pathology.
b) Clinical pathology which includes:-
i) Bacteriology
ii) Serology
iii) Biochemistry
iv) Haematology
v) Parasitology
vi) Blood Bank
vii) Histology
viii) Urinalysis
ix) Endocrinology
x) Basal metabolism

GENERAL REQUIREMENTS FOR THE ORGANISATION OF HOSPITAL LABORATORIES

The organisation of personnel into workable functional units of the laboratory becomes a problem of deciding
“What is to be done?” and “How will this work be organised, physically and technically?” The factors which will
influence the type, size and organisation of hospital laboratory are as under:-

(a) Existing Hospital Laboratories : Hospital laboratories were first developed in the major centres of
health care institutes. In developing further services, it has become essential to make a complete survey of

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all existing hospitals and, in the light of the situation with respect to regional intermediate and local hospitals
to decide upon a system of priorities for the establishment of further laboratories.
(b) Local Health and Population Conditions The general health status of the population, the climatic zone of
the country, the epidemiology, the age structure, density and distribution of population, and its socio-economic
circumstances influences the decisions as to the extent and location of hospital laboratories. Not only the
needs of the immediate population which have to be considered but also the health status and epidemiological
problems of adjacent territories are to be taken note of.
(c) Extent of Public Health Services : The extent of public health laboratory services, were expected to
exercise a determining influence upon the development & hospital laboratories. At the same time, the
overlapping functions of these two types of laboratories made it essential for them to work in the closest
harmony and to be integrated as far as possible in our total health care system.
(d) Available economic support As the financial resources are limited, development & expansion of the
regional hospitals towards the periphery according to a predetermined plan is recommended as a priority
sector in the infrastructure development of Hospital Laboratory Services.

As per WHO, the organisational structure of hospital laboratories could be based on the following criteria:-

(a) Desirability of providing the best service possible in the most economic way under the limitations of
budget and space available.
(b) Necessity for maintaining the scientific quality and reliability of all laboratory work.
(c) The great advantage of the closest liason between the laboratory personnel carrying out the analysis
and the physician in charge of the patient in his/her treatment process.

For the purpose of laying down minimal standards the WHO has also grouped the hospital laboratories in
three categories, i.e. regional, intermediate and local, depending on the location, bed strength and the
specialities available in the hospital. As per these recommendations minimum the standards of functional
organisation, space and personnel are given against each for ready reference.

The Regional Hospital Laboratory

This is the largest laboratory of this group expected to serve the largest number of hospital beds, usually 300
or more. It is recommended in largest cities, and are to function as a reference laboratory and should be a
part of a teaching hospital. The laboratory at this level are to consist of most of the units of clinical and
morphological pathology. At this level research is an important function for which proper provisioning have
been recommended. Another problem area which has been highlighted is the greater demand of services
which may be presented by large number of out patients attending hospitals. In order to meet the requirement
such patients, it was suggested that simply equipped laboratories which could undertake large number of
repetitive tests, such as haemograms and other routine, stool, urine and sputum examinations, for out patients
can be established and this will be cost effective. The more complex tests for out patients could be referred to
fully equipped main laboratory of the hospital.

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a) Location and Space of laboratory complex should be located centrally for easy access by the
clinicians. At the same time it must be so situated that future physical expansion will not be impeded. In
designing a regional hospital laboratory services the requirement of space could be based on the services
planned, number of specialised units to be provided, the number of staff in each unit and the level of research
to be carried out and finally the possible future expansion. The space required to cater for professional,
administrative and clerical staff, media and solution preparation room, autopsy facilities: laboratory room for
each of the sub-discipline, wash up, sterilisation and store rooms; research space for large refrigerator
and incubation rooms; photographic unit; library, record room; teaching and demonstration laboratories; and
conference rooms, and these activities should be within the hospital laboratory services.
b) Personnel The staff requirement should consist of medical professional, non-medical professional,
technical and non-technical branches. The size of the staff will however depend on the size of the department
and the workload. The laboratory workload will again vary, depending on the census, and the quality and
kind of medical practice in the hospital. However, in addition to the Senior professional in charge of the
laboratory there are several other pathologists and non-medical graduates who are to head the sections.
Junior pathologists and technical staff, together with an adequate administrative and clerical staff are also
essential. In a large laboratory of this magnitude laboratory aides and animal attendants are necessary, and in
addition staff to deal with preparation, storage, and despatch of media, solutions, reagents including quality
control.
Intermediate Hospital Laboratories recommended by the same expert group are expected to cater to the
hospitals having 100 to 300 beds strength with medical care services of basic medical speciality. While
recommending location, the scope and functions, it is forseen that these laboratories must be equipped to
carry out the important procedures in chemical pathology, mircobiology and haematology, whereas the
services of morphological pathology may be referred to a central, regional or other reference laboratories; in
bigger hospitals, where such facilities are expected to be available.
a) Location and Space It is recommended whenever possible such laboratory units could be grouped
under the supervision of a single pathologist in a central place of the hospital, and should be easily accessible
to the clinical departments. Location, however, should normally be planned in such a way that future
expansion are not interfered with. Accommodation planned in the complex should cater to the professional,
technical and clerical staff and also adequate space for work up of the laboratory, washup, sterilisation and
store rooms, autopsy facilities, research and staff recreation facilities.
b) Personnel Provision of laboratory staff should include a senior pathologist and such assistant
pathologist (medical or non-medical graduate) as are required. Technical, laboratory aids, and clerical staff
should be in proportion to the volume of the work. Computer literacy for all such personnel are the
requirement of all laboratoary set up.

Local Hospital Laboratories

Hospitals of this category are expected to cater to the need from 10 to 100 beds and the scope of service are
to range from the minimal routine test facility to that of the facility found in the smaller intermediate hospitals.
Site of the laboratory however will depend upon the workload, which again will dictate the necessity and
number of pathologist, non-medical graduates and technical staff required.

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SPECIAL CONSIDERATION
Authorities in the field recommend that the department of Laboratory Medicine should be centralised in
hospitals upto 400 beds size. In metropoliton cities such hospitals to be built on the vertical rather than the
horizontal plane. For those hospitals with more than 400 beds, a central department should be established
and sub laboratories located in decentralised areas. The sub-laboratories should be equipped and staffed to
handle the large volume items such as urinalysis, haemograms, and simple clinical procedures. The more
complicated and time consuming procedures could be referred to the central department. There are,
however, certain exceptions to the total centralisation of the department as under:-

a) Location of the department in relation to other units and overall design and function of the institution
may alter the position
b) Animal house can be located in an area where odours are not objectionable.
c) The morque can be located separately from the main department.
d) Records and slides not of current interest can also be stored away from the
department for teaching, research and reference purposes.

There are two basic plans for the physical arrangement of the department of Laboratory department are
suggested. Plan No I is to house the pathology work areas in one large room whereas the second basic plan,
No.2, is to provide a separate room for each section and even to subdivide sections into smaller units, each
with an individual room. The advantages of one arrangement becomes disadvantage of the other assignment
hence the advantages are given below:-

a) Plan I
i) Satisfies a small hospital with low volume of work.
ii) Construction cost is less
iii) Possibility of losing or misplacing specimens is less.
iv) Provides flexibility in interchange of staff depending on the volume of work.
v) Less movement of staff is involved.
vi) Facilitate easy supervision
vii) The floor space per technologist is less (normal requirement 10.1-20 sq.
mt.).

b) Plan II
i) Keep pace with the increase in the size of the hospital.
ii) Technologist working in small group can be more efficient and can work with less
interruptions.
iii) The nature of work of some sections requires isolation. Particularly a separate
room for bacteriology is essential for maintenance of better controls.
iv) The technologists become expert in the work of the section, because of regularity
of the same work.

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 v) The instruments and other equipment of the section receive better care.
vi) Stock solutions and reagents are properly ordered and maintained.
vii) Privacy needed for bleeding donors, collecting blood specimens, determining
basal metabolic rates becomes easier.

Some authority recommend the need for planning of five major sections in a hospital laboratory medicine
department:

(a) Bacteriology, immunology and parasitology,

(b) Biochemistry and diagnostic radioisotopes,
(c) Blood Bank Section which is of course treated as a separate department by itself
(d) Haematology and hemostasis section &
(e) Tissues preparation section.*
* Joseph A. Heeb in the similar context suggests the following factors to be taking
into consideration for planning of a laboratory service department.
a) Determine the services to be provided.
b) Determine space requirement for personnel and equipment in administrative, technical and auxiliary
area.
c) Divide technical areas into functions or units and keep areas open in small laboratories, and also to
provide segregated areas in large labs.
d) Determine procedures to be performed in each areas and space and equipment required,
both portable and fixed.
e) Determine the volume of work to be performed for each work unit or function.
f) Determine functional rearrangements, such as, location of the lobby at the entrance to the
department and centralise the reception area.
g) Mark the future expansion areas.
h) List articles and special building requirements for equipment to be installed.
i) List environmental requirements, such as, light, ventilation, air conditioning and isolation of equipment.

ORGANISATION AND STAFFING

The Laboratory Medicine or erstwhile pathology services include those technical services personally
performed by the pathologist and those performed under his responsibility and supervised by the medical
technologists. The pathologist examines all surgical specimens; perform autopsies, does frozen sections and
tissue consultations in the operating rooms obtains biopsy specimens including bone marrow, needle biopsy of
spleen, liver kidney, tumors etc.; and diagnoses and interprets histology of tissue from autopsy, surgical and
biopsy specimens, exfoliative cytology, bone marrow, and related material. In the clinical division the
pathologist establishes the methodology and instrumentation for the various procedures, conducts quality
control programmes, supervises special procedures and reviews all unusual and abnormal results. Under the
supervision and responsibility of the pathologist, services performed by the medical technologists fall into five
major sections.

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a) Bacteriology, Immunology and Parasitology Section
i) Cultures and chemical, immunological and animal studies used for identification of
bacteria, fungi, spirochetes and viruses.
ii) Antibiotic sensitivity procedures.
iii) Preparation of vaccines.
iv) Intradermal testing and studies of antigens and antibodies.
v) Procedures for detection and identification.

b) Biochemistry and Diagnostic Radioisotopes Section

i) Biochemical analysis of blood, body fluids, body excretions and tissues for the determination of
nutrition and metabolism functions, acid-base balance, hormones, function tests, retention of substances,
abnormal molecular and related procedures.
ii) Diagnostic radioisotopes include blood volume determination, thyroid function studies, fat digestion
and absorption studies, iron absorption and renal and liver function studies.

c) Blood Bank Section

Responsible for the drawing of blood from donors, the processing of donors blood, the typing and compatibility
procedures, the manufacture of blood products and the transfusion service.

d) Haematology and Haemostasis Section

i) Studies of blood : Haemoglobin determinations, Cell counts and differential counts, haematocrits,
sedimentation rates, staining and differential counts on bone marrow aspiration.
ii) Cell count and differential counts of spinal fluid, urine and other body fluids.
iii) Haemostasis studies are concerned with the evaluation of blood coagulation mechanism and vascular
factors in the diagnosis and treatment of haemorrhagic diseases.

e) Tissue Preparation Section

i) Processing of tissues and preparation of microscopic slides from autopsy and surgical specimens.
ii) Preparation of smears for exfoliative cytology study.
iii) Histochemical studies and use of special stains as aids to diagnosis.

The number of departmental personnel, and to a lesser degree the number of positions, is directly related to
the work load and the size of the hospital. The laboratory workload will vary, depending on the census,the
quality and kind of medical practice in the hospital. The ratio of personnel needed are based on beds, patient
days, or number of procedures, a basic starting point to complete daily man hours needed are to be obtained
on an average (Median) figure representing tests per patient per day. The average number of tests
performed becomes an excellent index for determining average man hours. However, some authorities quote
that on an average 20,000 specimen or test on average should be attributed to a technician in a general
hospital with the basic medical services. However, modernisation and authorities in this section of hospital

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support services has changed the entire concept and now the staff requirement can be calculated on the basis
of automation of the services.

The larger the laboratory work load; the greater is the need for functional groupings and specialisation. Mc
Coy considers that the ratio of pathologists and technicians should be based on the number of procedures, as
stated in the next page.

This ratio still holds good in our hospital situation.

30,000 examinations One pathologist and

per month One Asstt. Pathologist

Over 15,000 examinations One Bacteriologist

Over 30,000 examinations One Biochemist

For each 10,000 examinations One Clerk

As regards the requirement of technologist, data developed by Seward E Owen and E P Finch, from a survey
of 350 general hospitals, are given below:-

Tests performed annually per medical technologist

Laboratory Unit No. of Tests

Haematology 13,400
Urinalysis 30,720
Serology 11,520
Biochemistry 9,600
Bacteriology 7,680
Histology 3,840
Parasitology 9,600

MacEachern a renowned hospital management authority recommends that under the direction of the
department or under the head of each sub-department should be one or more technicians, the number
depending upon the completeness of the laboratory and the volume of work. The ratio of pathologists and
technicians to hospital beds, recommended by him is as :-

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Beds Pathologist Technicians Stenographer
Less than 1 part time 2-3 full time as needed
50-100 1 part time 3-5 full time part time
100-200 1 full time 5-8 full time part time
200-300 1 or more 8-10 full time 1 full time
300-500 3 full time 20-30 full time 2-3 full time

CONTROL OF PATHOLOGY SERVICES

The director has the responsibility for all pathology services performed within the hospital. This comprises
control of the collection of specimens, performance of procedures, the areas where procedures are performed
and the personnel involved.

Work Control Programme

The services offered by the department to a patient are done only upon the request of a physician. The
following working principles have been recommended :-
a) In order to avoid misunderstanding and errors in the patient name, location and examination ordered,
the request forms shall be made out by the floor nurse or other authorised floor personnel. The department
will not consider procedure to be ordered until the request form is received.
b) The time the report is needed may be indicated by use of terms as routine, today and stat, depending
on the urgency.
c) Request forms should be delivered to personnel at a central point in the department which makes
necessary arrangements with the proper section. This will avoid duplication in collection of specimens.
d) The department will schedule certain procedures for specified days, and may limit the number of other
procedures scheduled on any day.
e) The services of the department must be available every hour of every day.

Quality Control Programme

The reports of the department are used in the diagnosis and treatment of patients; greater the accuracy of the
determination greater value to the clinician. The quality control programmes are measured in terms of
accuracy and precision. The common meaning of the term accurate is the true or actual value. In pathology
this term permits an obtained value which may be the true value or slightly above or below the true value. The
variation is due to the fact that the clinical condition is a dynamic process, and the results must have a
reasonable time relationship to the collection of specimen. Other factors which enter into the decisions are,
volume of specimen, viscosity, presence of interfering substances, equipment errors, technologist errors etc.
The term precision indicates the ability to perform repeated determinations on one specimen and obtain
results which are closely grouped. This is not a direct measurement of accuracy. If an error or errors,
repeated to an equal degree in each of the repeated determinations, the result may be very precise but not
accurate.

The following quality control measures have been recommended:-

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a) Preparation of standard solutions consisting of known pure substance dissolved in water, in which the
concentration of the substance is known. This can function as accuracy controls when they are included daily
with the determination of unknowns.
b) Extensive use of standards, usually obtained commercially, which are prepared with serum as a
solvent vehicle. These serum standards are available containing either constituents in the normal range or
constituents in an abnormal range. This also acts as excellent accuracy control.
c) The use of standard deviation is the third quality control method. The standard deviation is obtained by
the performing at least ten duplicate analysis, taking the difference between each pairs, squaring each of the
differences, adding the squares of the differences and apply the formula :-
NOTE N = Number of duplicate analysis. If one performs 100 analysis on the same material + 1SD will
include 68% of results, + 2 SD will include 95% of results and + 3 SD will include 99.7% of results.
The procedure / method with the lowest standard deviation should be the best.
d) Testing of the equipment and instrument is another quality control measure.
The best control programme is based on the Pathologists and department personnel’s awareness of the
sources of errors and faithful adherence to an organised plan.

REPORTS AND RECORDS

The basic function of the report is to provide promptly and accurately the results of pathology examinations &
with the growth in size and complexity of the department, the problem of reports and records has also grown.
No pathology report is valid until the medical staff receives the report signed on it.
Many systems of reports and records are available. There is no one system that is best for all institutions.
The one must satisfy the purposes of many groups whose requirements can be incorporated into the
principles on which the reports and records are based. It should meet the following requirements:-
a) Request forms should be simple and easy to use. The clinical pathology reports should carry the
normal values of the procedures not commonly ordered.
b) The department should have an indexing system whereby records of all procedures performed on a
patient are available.
c) The minimum time the record should be kept would be governed by the time period of the statute of
litigations. In most cases it is three years.
d) It should meet all legal requirements, particularly in cases of autopsy, notifiable disease & in the event
of refusal of a procedure by a patient.

Functions and Scope

The primary functions of hospital laboratory service are to provide :
a. Facilities for the application of scientific techniques for diagnosis and control of diseases
b. Indices for prognostic evaluation
c. Scientific data, including postmortem studies to evaluate clinical and therapeutic
procedures
d. Laboratory facilities for medical education and research

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e. Control Blood transfusion services where indpendent blood transfusion officer is not
present.

Organisation
Most of the hospital laboratories are headed by Chief Consultant/ prof. of Pathology. In those hospitals which
have double role to play that is of teaching and patient care; the professor are of equal rank of director
management, however the Director’s order will be final.
Apart from central laboratory, few hospitals have laboratory facilities in casualty services and in wards which
are called side laboratories so that medical students can carry out some tests.

Hospital Laboratory is divided into :

a. Clinical pathology
b. Chemical pathology
c. Haematology
d. Bacteriology
e. Serology
f. Parasitology
g. Virology
h. Mycology
i. Immunology, etc.
j. Histopathology

The list of test carried out by different sections should be attached for information. The charges are different
in different hospitals thus it should also be attached in Annexures.

Operational Management :
a. All the samples of OPD should be collected in central place and should be distributed to various
laboratories and reports be distributed to various OPD/wards as soon as they are ready centralised
distribution can also be advantagious in smaller set ups.
b. All samples from ward should be collected by sister/ doctors and could be taken to various laboratories.
c. Those laboratories which can organise to get samples collected by their own from wards will also serve
better.
d. Laboratory should provide 24 hour services
e. Requests for laboratory test for emergency cases should be attended expeditiously. Report may be
given on phone and written report may be forwarded as soon as possible.
f. Quality control should be introduced in the laboratory services to ensure reliability of the tests.
g. Laboratory reports should be signed by the person who did the procedure and be countersigned by the
doctor concerned.

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h. It is desirable to organise refresher courses for all technicians periodically to keep them well informed in
advancement in laboratory practices.
i. Technical procedure manual should be written for standardising laboratory techniques. Instructions for
preparing the patients should be available in easily understandable language.
j. It is desirable that technicians are rotated in various disciplines of the laboratory periodically so that they
may gain all round experiences.
k. To ensure efficiency, automation should be introduced.
l. Messenger system for bringing specimens from the ward and outpatient departments to the main
laboratory should be introduced.
m. Preventive maintance of machine is essential

Disposal of Infected material

Following procedure should be followed for disposal of infected materials :
a. Used slides, swabs test tubes should be dipped in 2% phenol, 5 - 10% lysol or 2-5% chlorosol solution
b. Media containing culture should be autoclaved and then discarded.
c. Infected animal carcasses should be dipped in disinfectant and then burnt. Incinerator facilities should
be available to the laboratory.

Physical Medicine and Rehabilitation :

The department’s main aim is rehabilitation and prevention of handicaps and disabilities. The department
should be headed by qualified medical officer trained in Physical medicine.
The department is mainly divided into the following section :
a. Physiotherapy
b. Occupational therapy
c. Rehabilitation

Physiotherapy section should be under the charge of qualified and experienced physiotherapist.
Occupation therapy may be divided into two sub-sections :
a. Remedial occupational therapy and
b. Diversional occupational therapy should be under the charge of occupational therapist having
appropriate qualifications and experiences.

Rehabilitation section similarly may be divided into various sub-sections like :

a. Physical rehabilitation
b. Mental rehabilitation
c. Social rehabilitation
d. Vocational rehabilitation
e. Economic rehabilitation and
f. Post rehabilitation depending upon the need and resources of hospital.

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Each sub-section should be headed by a person of appropriate qualification and experience.

Every section should have its own objectives such as :

a. The objective of physical rehabilitation should be prevention or minimising of physical deterioration,
rebuilding of strength and restoration of physical function.
b. The objective of mental rehabilitation should be to boost morale and restore emotional stability.
Psychiatric social worker should head its sub-section.
c. Social rehabilitation should aim at the adjustment of the patient in society in the least disturbing way.
Medico- social worker should head sub-section.
d. Vocational rehabilitation should plan for returning the patient to productive lines. The sub-section should
be headed by a vocational counsellor.
e. Economic rehabilitation will provide financial aid and other incentives for patient to regain their earning
capacity. Voluntary social welfare agencies should be associated with this sub-section. A paid social
worker should, however, head this sub-section.
f. Post-rehabilitation will follow up cases already rehabilitated by the hospital - voluntary social welfare
agencies should be associated with this sub-section besides the paid social worker. Proper records of
such patients should be maintained in this section.

This department needs proper planning and has to be organised, adequately staffed and equipped and should
work in close-coordination with all departments of the hospital, and other voluntary agencies such as
(HOSPITAL WELFARE SOCIETY). If it does not exist it should be started. Every hospital should have branch
of it (Women Welfare organisation for hospital, Rotory club, Lions clubs, Chambers of commerce, etc.) for the
supply of artificial limbs, jobs to disabled, and financial help etc. Social welfare department must involve all
voluntary social organisations for getting assistance.

It must work from 8.30 to 17.00 hrs. on all working day

The charges for providing service should be minimum.

Just like other OPD, all patient coming for diagnosis and treatment will be registered whether new or referred
ones and proper file should be maintained for follow-up. In years to come the service required by this section
will increase due to more accidents, industrialisation, and ageing problem.

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 RADIOLOGY SERVICES

INTRODUCTION
The medical care in a hospital no longer depends only on the programming for better medical and surgical
management but it mostly depends on the availability of prompt efficient and skilful functioning of diagnostic
services. Among the many modern diagnostic techniques, x-ray examinations or modern imaging services
have revolutionised the medication and treatment procedures in the hospital. The modern radiologic
department which is popularly known as imaging department functions as a centre for the provisioning of
patient care as well as teaching medical, dental, nursing and allied personnel. It is also an important link in the
research programme of any medical institution. A carefully planned department therefore assures an efficient
flow of service that may be scheduled as per the patient care load, availability of machinery and equipment
and also operational policy of the department. It should be so located that there is a minimum of movement
and distance to travel for the staff and the patient while utilising the services. The mission of the radiology
department revolves around the acquisition, manipulation, storage, retrieval and analysis of images of the
human tissue and organ. Since early 1960s, significant progress has been made in the conversion of analog
images of human tissue and organs into digital formats. Such digital handling of images has had a dramatic
impact on the ability of the modern day radiology to manipulate and to analyse radiographic studies for clinical
and research purposes. The shift to the digital formats has resulted in the introduction of computer technology
in medicial diagnostic and therapeutic purpose. The areas include CT, digital subtraction angiography (DSA),
MRI, PET, Nuclear Medicine, Ultrasound and so on.
The teletherapy unit includes treatment of varying intensities ranging from superficial radiation theraphy to
cobalt therapy and tetatron, linear acclerator, including Gamma Knife, X-knife etc.

FUNCTIONS
The primary function of a traditional radiology department is the provision of radiologic services of adequate
quality and quantity to hospitalised patients; secondary functions include clinic and other out patient services,
teaching and research.

PLANNING
The planning of the department like any medical care facility is based on patient traffic, which includes
accessibility, promptness of attention, comfort, convenience, privacy, thoroughness of examination or
treatment. The main aim is to provide prompt and accurate examination and treatment in a pleasant
surrounding. This can be achieved by following an appointment system so as to schedule the activities for
operational efficiency of the department. Emergency medical care need has to be thought of in all such
planning. The secondary planning consideration is based on work flow, as the efficiency and speed with
which reports is expected to be delivered. The tertiary planning is based on technicians traffic, in order that a
minimum deployer personnel can expedite the examination and treatment with ulmost efficiency and minimum
fatigue to the personnel and equipment stress. The Quaternary planning is based on achieving most effective
traffic pattern for the radiologist and provisions for staff so that they may interview, examine and treat patients
as quickly and thoroughly as possible.

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The planning and design of the radiology department is guided by the following factors:-

a) Daily average number of patient examinations done. This depends on the type of hospital, community
need, proportion and extent of out patient committment and in patient examinations and the pattern of
facility usage.
b) The quality and extent of diagnostic and therapeutic services to be provided.
c) Number and type of X-ray machines needed for the designated service.
d) The staff needed for the estimated peak volume of work during the day including emergency
department as well the extent and demand of the services in the operation theatre as well as the bed
side services in the ICU and other patient care areas.

Henry Garland, an authority on the subject suggested that the department of radiology should be planned and
organised according to the estimated patient load during the five year period to follow, with due allowance for
prospective expansion for teaching, associated research programmes and other developments. It has been
estimated in the western world that a 100 bedded hospital will have an average of 35 radiological
examinations a day. One third of this workload is contributed by inpatients and the remaining are out patients.
The staff needed for this volume of work in a conventional radiology department includes :

a) 1 Radiologist, 2 or 3 Technicians, 1 Receptionist, (for reserved and off duty reliever)

b) 1 File Clerk and 1 Orderly ( as needed)

In planning a cobalt installation, it should be that each type of machine and its location within the building will
present a different problem which will require an individual solution. Therefore, during preliminary design
stages, close cooperation between architect, radiologist and radiation physicist is necessary to develop an
efficient and economic layout.
The design of the structural system of the building of teletherapy unit depends on (a) the type of machine (b)
strength of the source (c) desired location, and (d) the shielding required for floor, walls and ceiling.

PHYSICAL FACILITIES
The diagnostic X-ray department should be located on the ground floor, conveniently accessible both to the
out patients and inpatients, and to other related medical services. When it is planned to include megavoltage
radiotherapy equipment it may be advisable to choose a location below the ground surface, and ensure
adequate air-conditioning. However, it should be born in mind that high moisture content is dangerous where
high voltage apparatus is used. In the average hospital it is preferable for the diagnostic and therapeutic
divisions of the department to be located together.
The fundamental requirements of the department are best satisfied by locating the X-ray rooms at one end or
a wing of the building. In such a location, the activity within the department will not be disturbed through traffic
going to other parts of the hospital, and less shielding will be required because of the exterior walls.

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LAYOUT
Based on the workflow the user radiologist are expected to plan the most suitable ways for arranging and
operating the administrative functions of the Radiology department. Some of the variables involved are
assignment of personnel and functions, reception of patients, sequence of patient examination, film
distribution, and staff viewing facilities. However, the planning and layout of the department should be free
from individual bias. The following items of physical facilities are essential for radiography:-

a) Administrative Spaces
Waiting Room 15.15-30.30 sq.mt
Receptionist 8-10.1 sq.mt
Clerk
Doctors Viewing Room
Radiologists Office 20.20 sq.mt
Film files

b) General Facilities
Dressing Rooms
Patients toilet room 15 sq.mts.
Technicians toilet and workers

c) Storage facilities
General Storage
Clean linen and gown storage 10 sq.mts.
Janitor’s closet

d) Diagnostic X-ray rooms

X-ray equipment room 25 sq.mt
Control booth 40 sq.mt.
Storage cabinet and waiting counter

e) Film processing and distribution areas

Dark Room 10 sq.mt
Film processing area
Collection and distribution area

f) Barium mixing facilities 5 sq.mts.

g) Optional Facilities

Inter communication system

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 Refrigerator
High speed film dryer

h) Electrical installations
Voltage
Illumination
i) Radiation protection
j) Air Conditioning
k) Fire safety

Waiting Room The size will depend on the patient load. One exclusive waiting hall for the patients and the
attendants be so planned as to serve waiting patients need before and after registration for the service. This
is to be planned and located at the entrance of the department. From here the patient be directed to the
assigned changing room. A separate area may also be provided for wheelchair and stretcher borne patients.
Sufficient chairs or benches are to be provided for waiting patients and their attendants.
Receptionist Counter The administrative functions and business records of the department, scheduling of
appointments, receiving of patients and assigning of patients to dressing rooms are to be handled by the
receptionist. The size of the counter should be sufficient to accommodate a clerk’s seat and record chests. It
may be 8 to 10 sq.mt and juxtaposed to the waiting hall.
Doctors’ Viewing Room Should be located near the office of the Chief Radiologist so that he may be
immediately available for consultation. Its location within the administrative unit provides privacy so that
diagnostic comments and discussions will not be overheard by patients.
Radiologist’s Office In large hospitals the department is placed under a specialist. He needs a spacious room
where he engages himself with the study of films and holding discussion with other specialists. Adequate
number of viewing boxes are essential.
Film File Storage Since it is desirable to keep active films for at least five years sufficient linear feet of filing
space should be provided. Built in cup boards may be provided in the Chief’s room or in the radiology
museum if planned.
Dressing Rooms Three dressing rooms for each x-ray machine should be provided so that equipment and
staff can function without delay. Each room should have a looking mirror. For the purpose of patients;
valuables, the doors may be equipped with locks. A dressing room suitable for wheel chair patients may be
provided.
Patients Toilets Toilets should be available nearby for patients undergoing fluoroscopy, and other waiting
patients. A minimum of two toilets should be provided for each X-ray room. One of the patients toilet rooms is
designed to accommodate a patient in a wheel chair. One toilet should be provided with a bedpan flushing
attachment. Each toilet room should be equipped with a grab bar for use by elderly or weak patients.
General Storage For bulk supplies, a storage cabinet equipped with sliding doors and adjustable shelves may
be located in the corridor near the X-ray rooms. Materials such as films, opaque solutions, developing
solutions, and office supplies are stored here.
Radiographic units Theatres may consist of any one of the following equipment and the number of rooms
could be one or more depending on the size of the hospital:-
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 a) 50 MA Units
b) 100 MA Units
c) 200 MA Units
d) 500 MA UNits

The optimum size of X-ray room is about 252 ft. Ceiling height requirements vary for different X-ray machines,
but a minimum of 9 ft. 6 inch is recommended. The machine and transformer should be placed so as to allow
adequate space for admitting of a bed or stretcher in the room. Mounting the transformer on the wall is
recommended to save floor space.
It is recommended that the control panel be wired to a signal outside each X-ray room to indicate when the
machine is on, to prevent other personnel from entering the room.
Control Booth It is essential that the control booth be located to the right of the machine so that the patient
may be observed when the table is inclined, since machine with end pivoted tables tilt to the right. Under this
arrangement additional shielding is not necessary as the primary beam would be directed towards the outside
wall.
Dark Room This room is located between two X-ray rooms to facilitate handling of films. The size of the dark
room need not be more than 100 sq.mts. The following items may be provided:-

a) A hatch window between the X-ray rooms and dark room.

b) A counter for loading and stacking cassettes.
c) A partition to separate loading counter from the film processing area.
d) A light lock between the dark room and the lightroom, equipped with interlocking doors.
e) A utility tank with a drain board, located opposite the processing tank, for mixing chemical solutions
and hand washing.
f) A film processing area consisting of developing tank, fixing tank and washing tank placed in that
order.
g) Exhaust fans.

Film Drying Atmospheric drying is generally resorted to. As this is time consuming, a steel cupboard, filled
with a network of heating elements at top and an exhaust fan at the bottom, may be improvised for the
purpose. Film dryer units are also available.
Barium Mixing Facilities Small rooms of size 10 sq.mt. to 12 sq.mt each may be provided for the preparation
of barium meal and for injection in large hospitals.
Radiation Protection Protection against ionising radiations in excess of tolerable amount is necessary. The
barrier design should be checked by a qualified expert before the construction plans are approved and the
completed installation should be surveyed with radiation detecting devices before the facility is used.

Primary barriers should be provided on all surfaces of the X-ray rooms which are exposed, or which may be
exposed, to the useful beam between the X-ray tube and occupied areas. Secondary barriers should be

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provided on all other rooms surfaces where protection is needed. In determining secondary barriers,
consideration should be given to direct or leakage radiation or other scattered radiation.
Air Conditioning Air conditioning with positive ventilation and a well defined pattern of air movement within the
department is necessary to provide an acceptable environment. In order to prevent odours from the
radiographic and fluoroscopic rooms, darkroom, toilet, and janitors closets, the ventilation system should be
designed so that a negative air pressure relative to the adjoining corridors will be maintained in these rooms.
This can be done by adjustment of exhaust fan in the rooms and corridors. The following conditions are
recommended for the comfort of the patients and personnel:-
a) Administrative and Waiting Areas A temperature of 72o F with a relative humidity of 50% and a
ventilation rate of 1-1,1/2 air changes per hour.
b) Patients and technicians corridors A temperature of 75oF to 80o F with relative humidity of 50% and 2
air changes per hour.
c) Fluoroscopic and X-ray rooms A temperature of 75o F to 80o F with RH 50% and 6 air changes per
hour.
d) Dark Room A temperature of 72oF with RH 50% and 10 air changes per hour.

Facilities for Radiotherapy may be provided to hospitals, as listed below in order of the capacity for
penetration:-

Size of the hospitals

a) Infra X-ray therapy (15-02 Kv) Small (Dermatology,Gynae)

b) Contact therapy (150- Kv)|ENT, Eye)
c) Superficial therapy (10-18Kv) Medium
d) Intermediary therapy (80-160 Kv)
e) Covergent therapy (160-300 Kv)
f) Rotation deep therapy (160-300 Kv) Large
g) Cobalt therapy Large

Physical facilities for Radio Therapy will include the following:-

a) Waiting Room One for each Sex, of size 10-15 sq. mt. with toilet facilities.
b) Physicians Room The specialist incharge of the department should be provided with a room of size
15 sq.mt. The staff of the department should also be provided with a room of size 150 sq.mt. A toilet should
also be provided.
c) Therapy Rooms Each therapy room should have adequate space for accommodating the therapy
apparatus, the high voltage generators control desk and dressing cubicle for patients.
i) Contact therapy room will include the apparatus, bed and dressing cubicle within
size 12 sq.mt.

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 ii) Superficial and intermediary therapy rooms will include the apparatus and bed.
Control desk and dressing cubicle are provided outside the influence of radiation.
Size of room may be 15 sq.mt. in addition 5 sq.mt. for control desk and dressing.
iii) Deep therapy rooms will be designed functionally similar to superficial and
intermediary therapy rooms. To prevent deep penetration, strong protection is
required. The size of room may be 20 sq.mt.
iv) Cobalt therapy involves deeper penetration and greater radiation and requires
protection of still higher order. The size of the room may be 30 sq.mt.

Structure of Radio Therapy Rooms The design of structure should be such as to prevent escape of radiation.
The thickness of walls, floors and ceilings has to vary with the intensity of radiation. For superficial and
intermediary therapy rooms 13.1/2" thick walls and 6" thick RCC roofs will be adequate. They may be painted
with lead paints. For deep and cobalt therapy rooms the walls and ceiling should be of RCC 12" and 14" thick.
Doors should be made radiation proof.
Mobile X-ray Unit In large hospitals X-ray facilities are required additionally in the emergency, orthopedic,
dental and operating departments. The equipment may be of mobile type.

ORGANISATION AND STAFFING

The department should be under the direction of a qualified radiologist. Henry Garland estimated that one
radiologist is necessary for every 25 patients per day. Busy departments will therefore, need several qualified
radiologists to work in the diagnostic and therapy divisions. The increased use of computer based digital
equipment and the arrival of magnetic resonance imaging (MRI), Positron Emission Tomography (PET)
Scanning, cyclotrons, and sophisticated contrast media require a cadre of basic scientists within the
department who can provide quality assurance and scientific support for the sophisticated procedures utilizing
these new and often prototype technologies.
The number of technicians required for a load of 30-35 patients per day varies from two to three, depending
on the type of examinations performed and the amount of non-technical help available. It has been estimated
that 2.5 films are required per examination of each patients. At least two clerks or secretaries are required per
30 patients to interview patients, make appointments, type and transmit reports and maintain accurate
records.
Patient traffic flow pattern within the department should be evolved by the radiologist in consultation with the
chief technician, the representatives of the administrative, medical and nursing staff. It should be ensured that
unnecessary waiting and criss cross patient flow are avoided by adopting a suitable system.

RECORDS
Policy for Reporting All diagnostic and therapeutic procedures should be reported by the radiologist.
Diagnostic reports should be reported as rapidly as possible. Reports for therapeutic procedures are usually
provided at the end of the course.
Film Identification Every X-ray film should permit identification of the patient, the date of examination and the
orientation. Identification may be by means of a direct radiographic method (lead letters and numbers), a
photographic method or adhesive labels affixed after processing.

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Film filing As a general rule, only a portion of the current films can be available in the X-ray department itself.
There is no perfect numbering system. One method is to prefix every X-ray number by the year. Another
method is to have a permanent inactive file number. As regards shelf space, it has been estimated that 2,1/2"
running spaces are required for each 25 diagnostic X-ray examinations films.
All records are indexed in such a manner as to make them readily available for subsequent references. No
better system has been devised than a card index similar to that used in the medical record office. X-ray
diagnosis index should be used to enable a study of groups of films pertaining to the same radiological
condition.
Film storage has always been a major problem in the hospital. At present Nitrocellulose films have been
replaced by acetate X-ray films. Standards have been determined for filing acetate films. The following
precautions may be noted:-

a) Both exposed and unexposed films should be stored in metal or other fire resistant container.
b) Exposed films not of recent date and surplus stock of unexposed films should be stored in a vault as
under:-
1. It should be located inside the building.
2. Ventilation should confirm to approved standards.
3. Light should be provided by ceiling fixtures protected by vapour proof globes; no
portable light being allowed.
4. Automatic Sprinklers should be sufficient in number.
5. Automatic fire door with the fusible link inside the vault is essential.

RADIATION PROTECTION
The need of the radiological department shall be responsible for observance of any regulations or codes of
practice (International commission on Radiological protection 1955) on radiation protection, and for the
instruction of all personnel regarding radiation hazards and methods of control. The following measures are
recommended:-

a) Personnel Tests All new personnel in radiological work shall have a pre-employment blood
examination. Blood count, haemoglobin and total and differential white cell count.
b) Protection

1. When new equipment is installed or when new X-ray departments are opened the site is monitored by
a recognised specialist. Modern equipment is shock-proof provided insulation/earthing is serviceable.
2. Personnel monitoring is carried out either by photographic or by ionising methods. Where the
quantum of work is considerable, it is advisable for X-ray workers to carry photographic devices (Film
badge). In other cases where isotopes are used for diagnosis, treatment and research ; it is
absolutely essential for all personnel involved to carry ionisation devices (Dosemeter) for protection.
3. The lead aprons and gloves should be worn by technicians.

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Experience has proved that the best precaution in the case of total irradiation of the body with X-ray or gamma
rays, is not to exceed a ‘tolerance dose’, generally accepted as 0.3 r per week. For local irradiation, 4.5 r per
week is assumed to be the limit.
Because hospitals vary widely in size and scope, no uniform design and facility can be made applicable to all
types of hospitals. However, most of the principles for planning, and designing the physical facilities will apply
both to large and small institutions. There is no doubt that in larger hospitals there will be sub-divisions of
diagnostic radiology into subspecialties, such as, angiocardiography, neuro-radiology and paediatric radiology.
Use of automation in radiographic exposures, in processing, in recording diagnosis and in transmission of
records will replace the present methods; sothere will be increasing use of televised roentgenograms
permitting immediate consultation for smaller affiliated hospitals located at a distance. Despite all these
dramatic developments, a majority of patients will still be interested in personalised medical care provided with
competence and kindness and at a reasonable fee. There will continue to be need for personal efficiency,
tact, promptness and gentleness. So the following are the summary guidelines for he operational efficiency of
the department.
The Chief consultant of radiology should normally be the head of the service and he will be responsible to
Director of hospital. Even in those places where there is dual role like a teacher and consultant for patient
care a hospital management point of view all head of service must be responsible to Director of hospital or
Medical Superintendent for the smooth functioning of patient care services.
All the duty roaster of the technical staff are to be prepared by senior most technicians with approval of head
of department and are to be followed.

Basic Working Policy

a. The department should provide round the clock services for emergency care.
b. For OPD and routine inpatient, it is better to introduce appointment system
c. The requisition form should be of standard size and if possible a clear colour code of the form for
different type of test etc. The colour code can also be implemented for purpose like urgent, serious
urgent or routine nature of the requisition.
d. Requests for radiological service should be accompanied by written requisition of specialists, senior
resident on prescribed form only with a clearly written short history and information.
e. Similarly radiology department also should prepare instruction to be followed by patient for special test
and printed in the local understandable language for the patient convenience.
f. Radiologist are to report only after study of the film and will sign it and then be sent to respective ward/
unit/OPD from where the requisition for the tests are made.
g. The policy of the issue of the film are to be decided to the requisitoning unit and also to paitent on
discharge are to be decided upon by the hospital. However, in all medico legal cases it is to be
preserved in the hopsital (department) only and to be presented to the court of law, if the legal process
demands for.

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Administrative Policy
a. There should be check list regarding working condition of the machine including its maintenance
check points.
b. There should be planned preventive maintenance by supplier and a log book indicating its use and
idle time if any.
c. Regular in-service training be given to all technicians.
d. All used or unused film must be kept safely. Retrieval must be easy.
e. All instructions on “Radiation safety” should be followed and the physicist should keep watch on it.
f. Following registers/documents are to be maintained :
i) X-ray register
ii) Deep x-ray treatment register
iii) Cobalt treatment register
iv) Inventory of non-exposed stores and equipment
v) Film account
vi) Radium needles account
vii) Expendable store account
viii) Indent book
ix) Instruction mannual for all the technical staff are to be developed depending on
the local working condition.

BLOOD BANK SERVICES

INTRODUCTION:
The blood bank service forms an integral and important component of the supportive services in the hospital.
It is either a separate department or it forms a part of the haematology department of the hospital. It is
responsible for collection, processing, storing and distribution of human blood and its products. American
Association of Blood Banks has defined Blood Bank as a medical facility designed, equipped and staffed to
procure, draw, process, store and distribute human whole blood or its derivatives.
Today blood transfusion has become a valuable and versatile therapeutic procedure in medical sciences. The
spurt in the demand of blood as a therapeutic agent has come as a consequence of the advancement in
medicine. While side by side, technological advancement and the process of urbanisation and
industrialisation has introduced certain new hazards to human health (stress diseases, accidents), leading to
greater demand for blood and its components in treatment and preservation of life.
Clinicians to-day treat patients, to replace blood or its components naming Red Cells, Plasma, Platelets,
Coalogulation factors. This has led to the development of preparation and use of blood components in recent
years. More so the need and demand to make the most economic use of blood has led to the further
extension of such therapy, so that a single donation can be used to treat several patients.
The practical application of blood transfusion and advances in transfusion technique, such as plasma fraction,
plasma pheresis and development of equipment like cell separator has revolutionised the treatment philosphy.

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Histocompatibility, antigents and tissue typing are prerequisites of leucocyte transfusion and organ
transplantation of modern medical practices.
Concepts of organ transplant, cardio-thoracic surgery, neuro-surgical maneouvers have become practicable
today, because of modern blood bank services. The management of patients of cancer, congenital
disturbances burns and other diseases has also placed heavy demand on the blood banks for blood and its
components. This increased relationship between transfusion and clinical practices highlights the importance
and responsibility of today’s blood bank.
In the past blood banking had not been recognised as an independent medical speciality and in most
hospitals, blood banks have existed as an arm of another department, usually medicine and surgery. Recently
blood banks acquired stature and greater autonomy, at the same time they are being subjected to increase
external control, especially at state and national levels.
Today to establish run and manage Blood Bank Services needs staturory licenese and are subject to state
control in our country.
The modern concept of blood bank organisation and operation should be based on work load rather than the
bed strength of the hospital. It is said that in countries with modern health services and extensive blood
transfusion services, it is possible to arrive at an approximation of the amount of blood used each year in
terms of the number of hopsital beds. However, estimates linked to number of hospital beds are misleading
as they cannot take the number of patients treated into account. Number of patients occupying the same
number of beds in a year is variable. It depend upon the effectiveness of treatment, the efficiency of the
hospital, the disease involved, and type of diseases. It is therefore more realistic to base estimates of need
upon the number of patients treated in a year.
In many developing countries, blood transfusion services are still not functioning in a standard protocol. This
situation is mainly due to a great shortage of qualified staff, both professional and technical needed to offer
such services. There is a wide gap between the highly organised transfusion services of the industrialised
countries and the developing nations. The goal for the latter must be creation of the kind of facilities offered
by the National Blood Transfusion Service of the United Kingdom as well as in some other developed
countries, where it is run from regional centres by specialist staffs and aims to send blood of any group
anywhere in the area at any hour and to supply it always in a volume in which it is wanted Indian Redcross
Society has initiated such service in India also, however it is a long way to go till a perfection comes in the
direction.
In India Blood Banking has lagged behind the developments in other fields of medicine. For want of adequate
supply of blood and blood products many patients who can be helped are denied adequate attention. The
need to develop proper blood banking practice in the country is of utmost importance both from the point of
view of primary health care at district and sub-district level and as well as for sophisticated medical care in
larger hospitals.
The country lacks uniformity and standard procedure in the field of blood banking such as (1) proper use of
anti-coagulant (2) adequate closed sterile system for collection, component preparation and storing of the
blood (3) immuno haematological technique in cross matching (4) testing for hepatitis B antigen. The
observance of these essential steps for transfusion of blood, would reduce the risk of blood therapy to the
receipient. These shortfall has since been corrected after the implementation the statutory rules.

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ORGANISATION AND STRUCTURE OF A BLOOD BANK
The most important step in the organisation of a blood transfusion service is to appoint a person qualified and
experienced in transfusion medicine to head it.
Blood banks at apex institutions or large metropolitan medical colleges having undergraduate and
postgraduate teaching programmes and super specialities should have separate department of transfusion
medicine headed by a professor.
In state medical colleges and district hospitals the blood banks should be a part of the laboratory services. It
should be headed by a Reader/Asstt. Prof. in state medical colleges and by a consultant pathologist in charge
of laboratory services in district blood banks.

The major functions of blood transfusion service are:-

1. Recruitment of donors and maintenance of donor’s records.
2. Collection, preservation and distribution of blood and blood components.
3. Laboratory procedures.
4. Teaching, training and research.
5. Clinical/therapeutic functions.

A model organisation chart of a Blood Bank Service in a teaching or research hospital care be as under :

Professor/Transfusion Medicine (Director) Transfusion Medicine:

Reader/Asstt. Prof. in Clinical Pathology

Donor Donor Therapeutic Routine Blood

Recruitment Bleeding functions laboratory components
|
| Day
Care
IN-HOUSE Mobile Transfu- Serology Infectious
sion Disease testing
Hepatitis Syphilis
Malaria
AIDS

Patient Testing Donor Testing

Routine Emergency

State Medical Colleges,

Specialised Hospital Specialities,
Medical and Surgical,
No Superspecialities Teaching Hosp.
Non Teaching Blood Bank.

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LOCATION AND SPACE
The Blood Bank should ideally be located at ground level, closely associated with the hospital it serves or with
a major hospital if it serves more than one hospital. It should be close to the emergency services of the
hospital and preferably close to the operating theatres.

All areas of the blood bank should be contiguous.

The areas of the blood bank can be broadly divided into :

Donor Recruitment offices
Bleeding complex
Therapeutic area
Laboratories
Administrative and Clerical offices
Teaching facilities.

Donor Recruitment Office

Donor recruitment is vital to the success of a blood transfusion service. Recruiting voluntary donors requires
techniques of mass contact, therefore the donor recruitment offices should have
a) Adequate space for the Donor Organiser and Clerical staff and for equipment such as typewriters and
Xerox machines.
b) Good telephone facilities manned atleast 12 hours each day.
c) Adequate recording and retrieval facilities (computersied or manual) to store and update data on
voluntary donors.
d) Access to printing facilities for preparing donor publicity materials.

Bleeding complex
The bleeding complex should be located close to the front entrance of the hospital, so as to ensure a high
visibility and easy accessibility to the donating public. Donors should be able to go to the donor complex
without having to go through hospital corridors or hospital security areas.

The bleeding complex should consist of the following rooms:

1. Reception Room
2. Medical Examination Room
3. Bleeding Room and Apheresis Room
4. Rest Room
5. Kitchen/Pantry

Rooms 1,2,3,4 should be interconnected and located in such a manner, that traffic is in one direction only and
a donor who is going in to donate, should not clash with a donor who has already donated blood.

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Therapeutic Area
Would be used by patients who require transfusions of blood or clotting factors at frequent intervals such as
patients of thalassemia or hemophilia.

Laboratories
The lay out of the laboratories should be such that there is minimum movement of persons in the corridors
and laboratories and limited entry of outsiders to the laboratories.

Laboratories of the blood bank are as follows:

a) Laboratories for processing donor blood
b) Component Laboratories;
Basic: Will prepare
- Fresh frozen plasma
- Cryoprecipitate
- Platelets
- Packed RBC
- Leukocyte poor RBC etc.
- Relevant coagulation work
Advanced : Will prepare
- Freeze dried and heated
- Coagulation factors.
- Plasma fractionation.
The component laboratories should be adjacent to the bleeding complex so that blood, as it is collected, can
be processed without undue delay and without encountering problems in transporting it to the component
laboratory.
c) Donor serological laboratory
ABO + Rh grouping
Antibody screening
Identification of antibody in positive screen
Labelling donor blood and stocking tested blood
d) Infectious diseases laboratory
AIDS
Malaria
Syphilis
e) Quality Control
f) Laboratories for processing patient blood
g) Issue counter/room : will
Issue blood and blood components to patients.
Receive patient samples for testing.

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 Store crossmatched blood and basic components.
The issue counter/room should be located at the entrance to the blood bank so that patient samples can be
received and blood and blood components issued without disturbance to the laboratories.
h) Patient Serological Laboratory : will cover
Emergency
Non Emergency
ABO + Rh grouping
Antibody screening
Identification of antibody in positive screen
Crossmatch blood
Antenatal work up
The emergency section of the patient serological laboratory should be adjacent to the counter room
followed by the routine laboratory.
j) Special laboratory : will do
Platelet and granulocyte serology
HLA work

Administrative and Office area

a) Consultants offices
b) Departmental, administrative and clerical offices
c) Staff common room
d) Service area:-
Store
Wash room and distillation plant
Toilets
Housekeeping

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 TABLE-I
STANDARDS FOR SPACE FOR BLOOD BANK

_________works 24 hrs________

Cat.I Cat.II Cat.III

3-7 UOB/Hosp Bed 8-15 UOB/Hosp. 16 UOB or more
1000-6000 UOB Bed.6000-15000 Over 15000 UOB
consumed per year. UOB consumed consumed per year
UOB- eg. per year. consumed per units
District Hosp. eg. year.
of Health service Hosp. State eg.
blood Hosp. Corporation Medical College Apex Institute
Hosp., No super- Hosp.Speciali- Metropolitan
specialities Hosp. sed Hosp. Medical College
non teaching TeachingHosp. Hosp.All

Superspecialised
(in Meters squared) Teaching Hosp. and Blood banks

Bleeding Complex
1. Reception Room 25 25 40
2. Medical Examination Rooms 15 25
3. Bleeding Room 40 55 100
4. Refreshment Room 15 25 30
5. Kitchen/Pantry 5 5 10
6. Apheresis area 40
7. Day Care/Therapeutic area 30 50

Laboratory Area
|1. Laboratory for routine
door work 25 50
|2. Laboratory for 25
routine patient
& Ante natal work 35 50

3. Laboratory for
specialized work: 50
platelets HLA
granulocyte serology
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4. Issue Counter 20
5. Emergency Laboratory 18 20 20
6. Hepatitis, HIV,VDRL, 20 25 30
Malaria
7. Wash room distillation 20 25 30 plant etc.
8. Component basic & 25 30
coagulation work
9. Component advanced
freeze drying 50
|
General Areas
1. Doctor’s office 15 15x3 20x1
15x1
2. Donor Recruiter social 25 30 50x3 worker clerical staff
3. Blood Bank Office 15 20 25
4. Stores 20 25 35
5. Technician’s Common 15 20 25 Room
6. Toilets 5x2 5x2 5x3
7. Trainee doctor’s Room 25
8. Library/conference room 30
Total 248 460 895

Note

1. Bleeding room and refreshment area and laboratories will be air-conditioned if ambient temperature
is above 28o C.
2. Laboratories should have emergency power.
3. Minimum space for Blood Bank in category I=100 M2
4. Minimum space for Blood Bank in category II=300 M2
5. Minimum space for Blood Bank in category III=895 M2
FUNCTIONAL AND OPERATIONAL ASPECTS

Recruitment of Donors

Organisation of a successful blood transfusion service is not possible without an assured supply of voluntary
blood 365 days of the year. Thus a most important function of a blood bank is donor recruitment and bleeding
of donors.

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Success in donor recruitment and maintaining donor records requires an intensive and sustained publicity and
educational campaign by means of television programme, publicity pamphlets, letters and telephone calls to
schools, colleges, organisations such as Rotary and Lions, and individual donors. Such work requires trained
staff headed by a donor organiser and including, social workers, nurses, clerical staff, good telephone
facilities, vehicles and drivers.

Blood Collection
Donor bleeding should be conducted by all hospitals with more than 100 beds. Blood collection should be at
the hospital blood banks and at specific satellite centres. The major hospitals collecting more than 10-15,000
units should organise mobile blood collections within areas designated for each hospital or transfusion region.
This decentralised system is most likely to ensure a regular inflow of blood to the hospitals, since different
categories of donors, namely patients relatives, individual voluntary donors and donors from different
organisations can be tapped. In such a system, no hospital is entirely dependent on an external source of
blood, which can work to its disadvantage.
In the event of a community of civil defence disaster, several blood collection centres would be available to
collect blood.
To facilitate blood collection, bleeding rooms should remain open 7 days of the week. This ensures that
donors can donate blood at their convenience.
Although the European blood transfusion services have large regional transfusion centres, rather than hospital
based blood banks, which are responsible for donor recruitment and bleeding donors, the geographic
differences of a warm climate, vast distances, poor transport and communication facilities precludes a total
change to such a system in India.

Policy and Procedure Selection of donors and bleeding donors should be laid down

Labelling and storage of Donor Blood

a) Donor blood should be stored at 1-40C in monitored blood bank refrigerators.

b) Untested, tested and cross matched blood should be stored in separate refrigerators.
c) All donor units should be labeled with standard coloured ABO & Rh labels.
d) Crossmatched blood should bear a suitable label giving particulars of patient for whom it is
crossmatched so as to ensure that blood goes to correct patient i.e. Name, Age, Sex, Ward, Bed and
Central Registration No.

Tests on Donor and Patient Blood

a) Written procedures of each test routinely used should be available in the laboratory manual.
b) Technicians who perform test should record the results in appropriate registers and should put the
date and sign results.
c) All results will be counter checked independently by 2nd technician who will also sign results.

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Receiving Patient Samples for Crossmatching in Blood Bank
a) Name, Age, Sex, Ward, Bed and CR No, of patient samples and requisition forms must match.
b) Only a hospital employee (Doctor, Nurse or Nursing Orderly) should receive the blood on behalf of
the patient.
c) Blood issue form or register should be signed by person receiving blood and technician issuing blood.
d) Blood should be transfused without delay.
e) All empty blood bags should be returned to the blood bank within 24 hrs.

Movement of Donor Blood

Donor blood, after collection, is moved to the component room for blood component preparation. The pilot
tubes collected alongwith the blood bags go to the routine laboratory for grouping and serological work up, and
to the infectious disease laboratory for tests for hepatitis, syphilis, AIDS, etc.
Once components have been prepared, and tests on pilot tubes completed, the blood bags are moved to the
donor blood labelling area, where each unit is appropriately labelled with blood group and other relevant
information.
The labelled and tested blood is stored in the stock refrigerator in the donor serology laboratory.
Each morning, sufficient donor units are shifted from the stock refrigerator to the current refrigerator located in
the patient laboratory, to be used for crossmatch procedures. Once a unit is crossmatched, it is moved from
the current refrigerator to the crossmatch refrigerators located in the issue room for issue to patients.

Donor Blood Stocks

A physical verification of all blood in all the refrigerators should be done every 24 hours.

All donor units should be listed serially in the blood bank master log, and all data about each unit should be
available in the masterlog.

Movement of Patient Blood

Patient samples are received in the counter room by the counter technician. Emergency requests are
separated and sent to the emergency laboratory for immediate grouping and crossmatching (If time permits)
and issue of blood.

Routine requests are numbered serially and sent to the patient laboratory for serological workup.

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Crossmatched blood is labelled with crossmatch label containing patients Name, Age, Ward, Bed, CR No.,
Blood group and stored in crossmatch refrigerator to be issued to patient when required.
CHART
MOVEMENT OF EACH UNIT
OF DONOR BLOOD

Bleeding Room

Blood collected
in Blood bag and
Pilot tubesm stored in
untested refrigerator

Issued to patient
Pilot tubes sent to Blood bag sent to
Crossmatch
refrigerator
in
issue counter

Crossmatched
blood stored in

Infectious donor
disease Lab laboratory Component Room Current refrigerator
for preparation in patient laborator for
of blood cross matchng
components

results Donor Blood Enough bag

| labelling area shifted each
result day to
|
Labelled tested
blood stored in
tested stock
refrigerator
in donor laboratory

BLOOD TRANSFUSION COMMITTEE

To ensure appropriate use of blood and minimise wastage, it is essential for a transfusion committee to meet
periodically as part of medical audit.
Members of the committee would consist of the Medical Director/Administrator of the Hospital, Blood Bank
Chief, clinical representatives from all clinical units that consume large quantities of blood, both medical and
surgical, representatives of the nursing staff and blood bank technical staff.
The functions of the transfusion committee is to ensure a safe transfusion practice for the hospital. This
involves two main divisions i.e. systems audit and clinical practice audit, systems audit consists of blood bank
procedures i.e.

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a) No. of units transfused of whole blood and blood components
b) Patients transfused and units transfused per patient
c) Proportion of whole blood to red blood cell, transfused
d) Crossmatch to Transfusion reaction
e) Out date rate
f) Transfusion reactions
g) No. of uncrossmatched and fresh unit requests
h) Turn around time from receipt of sample and issue of blood
i) Emergency requests
j) Units returned unused
k) Surgical cancellation due to unavailability of blood
l) Late requests for pre-operative crossmatch
m) Distribution of requests.

Medical practice audit would consist of criteria and justification for transfusion of whole blood, redcells, and
various components into audit and pediatric patients.

STAFFING AND EQUIPMENT(See Table-II)Blood Banks have been divided for the purpose of staffing and
space into 3 categories, based on blood usage per bed:

1. Hospital using 3-7 units per bed : comprising non-teaching hospitals namely district hospital, service
hospitals and corporation hospitals. Bed strength may vary from 100 to 800.

2. Hospitals using 8-15 units per bed : comprising state medical colleges and speciality hospitals. Blood
Bank functions 24 hrs. Bed strength may vary from 400 to 1000.

3. Hospitals using 16 or more units per bed : comprising apex institutes and large Metropolitan Medical
Colleges having all specialities and superspecialities. Blood bank should be an independent
department of Transfusion Medicine. Bed strength may vary from 800 to 1000 or more.
TABLE - II

STANDARDS FOR STAFF FOR BLOOD BANK

_______works 24 hrs_______
(UOB-UNITS OF 3-7 UOB/Hosp. Bed 8-15 UOB/Hosp.Bed 16 UOB or
BLOOD) 1000-6000 UOB 6000-15000 UOB more per
consumed per year consumed per year bed over
100-800 bedded Hosp. 400-1000 bedded 15000 UOB
District Hospital Hosp. State consumed
Health Service Medical Colleges year 800-
Hosp. Corporation Hosp. specialized bedded
Hosp., No super- Hosp. Blood Bank Hosp. Apex
specialities Hosp. functions 24 hrs/ Institute
non teaching day. Teaching Hosp. Metropoli-

156
 tan Med.
College
Hosp. All
super-
specialities
Hosp.
+Blood
Bank.

Bleeding Complex
1. Jr. Doctor 1 1-2 2
2. Nurses 2 3 4
3. Social Workers 1 2 3
4. Lab. Attendants 1 1 2

Apheresis Room
1. Nurses 2
2. Lab. Attendant 1

Laboratory
1. Tech. Supervisor 1-2 4
2. Tech. Assistant 2 4 8
3. Lab. Technician 4 11 13
(4 for shift work)
4. Lab. Asstt 1 2 4
5. Lab. Attendant 2 4 5

Donor Organiser
1. Associated/clerical staff Part time 1 2
2. Social Worker 2 5 10
(for mobile teams)
3. Vehicle + Driver Part time 1 3

Service Staff Clerical Staff

1. Clerk Typist Part time 1 2
2. Store keeper “ “ 1 1
3. Cleaner Sweeper “ “ 1 2

157
Medical Doctor MD (Transfusion),MD (Path)
1. Professor 1
2. Asstt. Prof/Reader 1 1
3. Lecturer 2 3
4. Pathologist 1
Resident
(Part time)
BLOOD BANK EQUIPMENT LIST

Routine Work1. Refrigerator

Capable of maintaining temperature of 10-40C having visual and audio alarm system, temperature display.
Preferably with recording thermometer, air circulation, 24 hrs. power supply and stand by generator.

Inside of stainless steel. Removable or pull out shelves.

Quantity Number and size will depend on size of blood bank.

Minimum No 3. i.e Untested blood 1
Tested blood 1
Tested and crossmatched blood 1

2. Centrifuge Table Top Capable of 3500 xg with accurate timer in 1 min increments upto 30 minutes.
Accurate tachometer. Acceleration to desired speed in approx. 30 sec., rapid deceleration. Rotor for swing
head capable of taking minimum of 16-20, 12x100mm tubes and microplate carrier. Number depends on size
of blood bank but approximately equal to number of day technicians on duty.
3. Water bath 37o c with temperature control of + 10o C. of Fibreglass.
4. Incubator 37o c with temperature control of + 10o C.
5. Hot air oven for drying glass ware.
6. Microscope binocular
7. 1 Kg balance for weighing blood bags during blood collection.
8. Tube stripper cutter and aluminium clips to seal blood bags.
9. B.P. Apparatus
10. Domestic refrigerator without freezer compartment.
11. PH Meter - Not essential for category one blood bank.
12. VDRL Agitator
13. Weighing Machine for donor
14. Distillation & Double distillation plant
15. Analytical Balance - Not essential for category 1 blood bank.

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Additional equipment for blood bank collecting 10,000 Units as more
1. Dielectric tube sealer - Quantity 2
2. Vortex mixer
3. Magnetic stirrer
4. Analytical balance
5. Plasma separation stand : Quantity Minimum 2
6. Clean air station (laminar flow)
7. If using microplate technique : Microplate agitator

Blood Component WorkBasic Equipment

1. Blood Bank refrigerated centrifuge for 450 ml blood bags. Swing head 5000 xg with wind shield.
Temperature of 0-25o C. Timer at 1 Min. interval upto 60 min. Accurate tachometer.
2. Freezer - 70o C with alarm system, temperature display, and recording thermometer. 24 hrs. power
supply and stand by power.
3. Freezer - 20o C to 40o C with alarm system temperature display, and recording thermometer. 24 hrs.
power supply and stand by power.
4. Dielectric tube sealer
5. Plasma separation stand
6. Tube stripper, cutter, and aluminium rings
7. Platelet agitator cum incubator for platelet storage
8. Clean air station
9. Weighing scale of 2 kg with sensitivity of 100 mg.
10. 1 kg balance in 5 mg increments for weighing plasma bags.

Additional small equipment

1. Blood bag stand (stainless) for keeping bag upright.
2. Test tube racks.
3. Flexible table lamps with concave mirror
4. Micropipettes - 2 ml upto 1000 ml.

NATIONAL AIDS CONTROL PROGRAMME

1. It ensures establishment of HIV testing facilities.
2. Support for testing of other blood transmissible diseases.
3. Training of manpower development and programme management.

SUPREME COURT DIRECTIVES JANUARY, 1996

1. No unlicensed blood bank after May, 1997
2. Complete ban on professional blood donors afer December,1997.

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3. Mandatory testing of blood for HIV, Hepatitis Syphylis and Malaria
4. Formation of National Blood Transfusion Council and State Councils
A National Blood Policy has been framed and published in the Gazettee of India initially on December, 15th
1997 and subsequently on April 15th, 1999, otherwise called as Drugs and Cosmetics (Amendment) Rules
subsequently.

MINISTRY OF HEALTH AND FAMILY WELFARE

(Department of Health)

NOTIFICATION

New Delhi, the 15th December, 1997

G.S.R. 702- (E) - Whereas the Central Government is of the opinion that circumstances have arisen which
render it necessary to make rules without consulting the Drugs Technical Advisory Board;

And whereas the Central Government proposes to consult the Drugs Technical Advisory Board within six
months of making these rules;

Now, therefore, in exercise of the powers conferred by sections 12 and 33 of the Drugs and Cosmetics Act,
1940 (23 of 1940), the following draft of certain rules further to amend the Drugs and Cosmetics Rules, 1945,
is hereby published as required by the said sections, for the information of all persons likely to be affected
thereby, and notice is hereby given that the said draft rules will be taken into consideration after the expiry of a
period of thirty days from the date on which the Gazette copies containing this notification are made available
to the public;

Any objection or suggestion which may be received from any person in respect of the said draft rules before
the expiry of the period specified above, will be taken into consideration by the Central Government; the
objetions or suggestions may be addressed to the Secretary, Ministry of Health and Family Welfare, Nirman
Bhawan, New Delhi.

160
 MINISTRY OF HEALTH AND FAMILY WELFARE
(Department of Health)

NOTIFICATION
New Delhi, the 5th April, 1999

G.S.R. 245- (E) - Whereas a draft of certain rules further to amend the Drugs and Cosmetics Rules, 1945 was
published as required by sections 12 and 33 of the Drugs and Cosmetics Act, 1940 (23 of 1940) at page 1 and
27 of the Gazette of India, Extraordinary Part-II, Section, Sub-Section (i) dated the 15th December, 1997
under the notification of the Government of India in the Ministry of Health and Family Welfare (Department of
Health) No. G.S.R. 702 (E) dated the 15th December, 1997 inviting objections and suggestions from all
persons likely to be affected thereby, before the expiry of a period of thirty days from the date on which the
copies of the Official Gazettee containing the said notification were made available to the public.

And whereas copies of the said Gazette were made available to the public on 31.12.97.

And whereas objections and suggestions received from the public on the said draft rules have been
considered by the Central Government;
And whereas the Central Government is of the opinion that circumstances have arisen which render it
necessary to make rules without consulting the Drugs Technical Advisory Board.
And whereas the Central Government proposes to consult the Drugs Technical Advisory Board within six
months of making these rules;
Now, therefore, in exercise of the powers conferred by sections 12 and 33 of the said Act, the Central
Government hereby makes the following rules further to amend the Drugs and Cosmetics Rules, 1945,
namely;
1. (1) These rules may be called the Drugs and Cosmetics (2nd Amendment) Rules, 1999.
(2) They shall come into force on the date of their publication in the official gazette.
2. In the Drugs and Cosmetics Rules, 1945 (hereinafter referred to as the said rules), in Part X-B, after
the heading and before rule 122-F, the following rule shall be inserted, namely;
“122-EA Definitions_ (1) In this part and in the Forms contained in Schedule A and in Part XIIB and
Part XIIC of Schedule F, unless there is anything repugnant in the subject or context.
(a) “apheresis” means the process by which blood drawn from a donor, after separating plasma or
platelets or leucocytes, is retransfused - simultaneously into the said donor.
(b) “autologous blood” means the blood drawn from the patient for re-transfusion unto himself later on;
(c) “blood” means and includes whole human blood, drawn from a donor and mixed with an anti-
coagulant.
(d) “Blood Bank” means a place or organisation or unit or institution or other arrangements made by such
organisation, unit or institution for carrying out all or any of the operations for collection, apheresis,
storage, processing and distribution of blood drawn from donors and/or for preparation, storage and
distribution of blood components;

161
(e) “Blood component” means a drug prepared, derived or separated from a unit of blood drawn from a
doctor;
(f) “Blood product” means a drug manufactured or obtained from pooled plasma of blood by fractionation,
drawn from donors;
(g) “donor” means a person who voluntarily donates blood after he has been declared fit after a medical
examination, for donating blood, on fulfilling the criteria given hereinafter, without accepting in return
any consideration in cash or kind from any source, but does not include a professional or a paid
donor;
Explanation : For the purposes of this clause, benefits or incentives like pins, plaques,
badges, medals, commendation certificates, time-off from work, membership of blood
assurance programme, gifts of little or intrinsic monetary value shall not be construed as
consideration.
(h) “leucopheresis” means the process by which the blood drawn from a donor, after leucocyte
concentrates have been separated, is re-transfused simultaneously into the said donor;
(i) “plasmapheresis” means the process by which the blood drawn from a donor, after plasma has been
separated, is re-transfused during the same sitting into the said donor;
(j) “plateletphersis” means the process by which the blood drawn from a doctor, after platelet
concentrates have been separated, is re-transfused simultaneously into the said donor;
(k) “professional donor” means a person who donates blood for a valuable consideration in cash or kind,
from any source, on behalf of the recipient - patient and includes a paid donor or a commercial donor;
(m) “replacement donor” means a donor who is a family friend or a relative of the patient’recipient.
3. In rule 122-F of the said rules, -
(a) in sub-rule (1), -
(i) for the word figures and letter “Form 27-C”, the words, figures and letters “Form 27-C or Form
27-E, as the case may be, shall be substituted.
(ii) in the second provision, -
(A) for the word, figures and letter “Form 28-C”, the words, figures and letters “Form 28-C or Form-28 C”
as the case may be, “shall be substituted;
(B) for the word, figures and letter “Form 27-C”, the words, figures and letters “Form 27-C” or Form 28-E,
as the case by be, “shall be substituted.
4. In rule 122-G of the said rules, -
(a) for the word, figures and letter “Form 28-C, at the two places where they occur, the words,
figures, and letters “Form 28-C or Form 28-E or Form 26-G or Form 26-I, as the case may be,” shal
be substituted.
(b) for condition (i) the following shallbe substituted namely;-
“ (i) the operation of Blood Bank and/or processing of whole human blood for components shall be
conducted under the active direction and personal supervison of competent technical staff consisting
of at least one person who is whole time employee and who is Medical Officer, and possessing -
(a) Post-graduate degree in Medicine-M.D. (Pathology/ Transfusion Medicines); or

162
 (b) Degree in Medicine (M.B.B.S.) with Diploma in Pathology or Transfusion Medi cines having
adequate knowledge in blood group serology, blood group methodology and medical principles
involved in the procurement of blood and/or preparation of its components; or
(c) Degree in Medicine (M.B.B.S.) having experience in Blood Bank for one year during regular
service and also has adequate knowledge and experience in blood group serology, blood group
methodology and medical principles involved in the procurement of blood and/or preparation of its
components.the degreee or diploma being from a University recognised by the Central Government.
Explaination - For the purposes of this condition, the experience in Blood Bank for one year shall not
apply in the case of persons who are approved by the Licensing Authority and/or Central Licence
Approving Authority prior to the commencement of the Drugs and Cosmetics (Amendment) Rules,
1999.
5. In rule 122-H of the said rules, for the words, figures and letters “Form 28-C or renewed licence in
form Form 26-G,” the words, figures and letters “Form 28-C or Form 28-E or a renewed licence in
Form 26-G or Form 26-I” shall be substituted respectively.
6. In rule 122-I of the said rules for the word, figurs and letter “in Form 28-C is granted”, the words,
figures and letters “Form 28-C or Form 28-E is granted or a renewal of licence in Form 26-G or Form 26-I is
made, as the case may be,” shall be substituted.
7. In rule 122-K of the said rule, for the words, figures and letter “grant of the licence have
been complied with, shall grant a licence in Form 28-C”, the following shall be
substituted, namely;
“grant or renewal of a licence have been complied with, shall grant or renew the licence in Form 28-C
or Form 28-E;
Provided that in the case of a drug notified by the Central Government under rule 68-A, the
application, together with the inspection report and the Form of licence (in triplicate to be granted or renewed),
duly completed shall be sent, to the Central Licence Approving Authority, who may approve the same and
return it to the Licensing Authority for issue of the licence.”
8. In rule 122-P of the said rules, -
(a) for the portion beginning with the words “A licence in Form 28-C” and ending with the words “the
following general conditions”, the following shall be substituted, namely;-
“A licence in Form 28-C, Form 28-E, Form 26-G or Form 26-I shall be subject to the special conditions
set out in Schedule F, Part XIIB and Part XIIC, as the case may be, which relate to the substance in respect of
which the licence is granted or renewed and to the following general conditions, namely;-
(b) after condition (xi), the following conditions shall be inserted, namely;-“(xii) All bio-medical waste shall
be treated, disposed off or destroyed as per the provisions of The Bio-Medical Wastes (Management and
Handling) Rules, 1996.
(xiii) The licensee shall neither collect blood from any professional donor or paid donor nor shall he prepare
blood components and/or manufacture blood products from the blood drawn from such a donor.”

163
9. In Schedule A of the said rules, -
(a) for Form 26-G, the following Form shall be substitued, namely; -
“Form 26-G”
(See rule 122-F)

CERTIFICATE OR RENEWAL OF LICENCE TO OPERATE A BLOOD BANK FOR PROCESSING OF

WHOLE HUMAN BLOOD AND/OR” FOR PREPARATION FOR SALE OR DISTRIBUTION OF ITS
COMPONENTS

1. Certified that licence number _________ granted on ____________________________

to M/s _________________________for the operation of a Blood Bank for processing of whole human blood
and/or for prepartion of its components at the premises situated at ____________________________ is
hereby renewed with effect from _______________ to _____________

2. Name(s) of items :

1.
2.
3.

3. Name(s) of competent Technical Staff :

1.
2.
3.
4.
5.
6.

Dated : Signature : _____________

Name and designation Licensing Authority

___________________________________ Central Licence Approving Authority

* delete, whichever is not applicable.”;

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(b) after Form 26-H, the following form shall be inserted, namely:-

“Form 26-I
(See rule 122-I)

CERTIFICATE OF RENEWAL OF LICENCE FOR MANUFACTURE OF BLOOD

PRODUCTS

Certificate that licence number ______________ granted on __________ to M/s.

_________________________ for manufacture of blood products at the premises situated at
__________________ is hereby renewed with effect from _______________ to _________________.

2. Name (s) of item (s):

1.
2.
3.

3. Names of competent Technical Staff :

a) responsible for b) responsible for

manufacturing testing
1. 1.
2. 2.
3. 3.
4. 4.

Signature ___________
Name and designation
Licensing Authority

_____________________________
Central Licence Approving Authority

165
(c) for Form 27-C, the following form shall be substituted, namely;-

“Form 27-C
(See rule 122-F)

APPLICATION FOR GRANT/RENEWAL* OF LICENCE FOR THE OPERATION OF A BLOOD BANK FOR
PROCESSING OF WHOLE BLOOD AND/OR* PREPARATION OF BLOOD COMPONENTS

1. I/we ________________________ of M/s ___________________ hereby apply for the grant of

licence/ renewal of licence number ________________ dated _______________ to operate a Blood Bank, for
processing of whole blood and/or* for preparation of its components on the premises situated at
_______________________________.

2. Name (s) of the item(s) :

1.
2.
3.

3. The name(s), qualification and experience of competent Technical staff are as under :

a) Name(s) of Medical Officer

b) Name(s) of Technical Supervisor
c) Name(s) of Registered Nurse
d) Name(s) of Blood Bank Technician

4. The premises and plant are ready for inspection on ____________

5. A licence fee of rupees ______________ and an inspection fee of rupees ________________ has been
credited to the Government under the Head of Account _______________ (receipt enclosed).

Signature _________________
Dated: ________ Name & Designation ______________

* delete, whichever is not applicable

Note : 1. The application shall be accompanied by a plan of the premises, list of machinery and equipment for
collection, processing, storage and testing of whole blood and its components, memorandum of
association/constitution of the firm, copies of certificate relating to educational qualifications and experience of
the competent technical staff and documents relating to ownership or tenancy of the premises.
166
Note : 2. A copy of the application together with the relevant enclosures shall also be sent to the Central
Licence Approving Authority and to the concerned Zonal/ Sub-zonal Officers of the Central Drugs Standard
Control Organisation”;

(d) after Form 27-D, the following Form shall be inserted, namely;-

“Form 27-E
(See rule 122-F)

APPLICATION FOR GRANT/RENEWAL* OF LICENCE TO MANUFACTURE BLOOD PRODUCTS FOR

SALE OR DISTRIBUTION

1. I/We _____________ of M/s.___________________ hereby apply for the grant of licence/renewal of

licence number ___________ dated ____________ to manufacture blood products on the premises situated
at ________________.

2. Name (s) of item (s) :

1.
2.
3.

3. The name(s), qualification and exprience of competent Technical Staff as under :

a) responsible for b) responsible for
manufacturing testing
1. 1.
2. 2.
3. 3.

4. The premises and plant are ready for inspection/ will be ready for inspection on _________________.

5. A licence fee of rupees ____________________ and an inspection fee of rupees

_________________ has been credited to the Government under the Head of Account ___________ (receipt
enclosed).

Dated :____________ Signature ______________

Name & Designation ______________

* delete, whichever is not applicable

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Note : 1. The application shall be accompanied by a plan of the premises, list of machinery and equipment for
manufacture of blood products, memorandum of association/ constitution of the firm, copies of certificates
relating to educational qualifications and experience of the competent technical staff and documents relating
to ownership or tenancy of the said premises.
Note : 2. A copy of the application together with the relevant enclosures shall also be sent to the Central
Licence Approving Authority and to the concerned Zonal/ Sub-zonal officers of the Central Drugs Standard
Control Organisation.

(e) for Form 28-C, the following Form shall be substituted, namely:-

“Form 28-C
(See rule 122-G)

LICENCE TO OPERATE A BLOOD BANK FOR COLLECTION, STORAGE AND PROCESSING OF WHOLE
HUMAN BLOOD AND/OR * ITS COMPONENTS FOR SALE OR DISTRIBUTION

1. Number of licence ____________ date of issue ___________ at the premises situated at

_________________.

2. M/s _________________________ is hereby licensed to collect, store, process and distribute whole
blood and/ or its components.

3. Name (s) of the item(s) :

1.
2.
3.

4. Name(s) of competent Technical Staff:

1.
2.
3.
4.
5.
6.

5. The licence authorises licensee to collect, store, distribute, and processing of whole blood and/or
blood components subject to the conditions applicable to this licence.

6. The licence shall be in force from _________ to __________.

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7. The licence shall be subject to the conditions stated below and to such other conditions as may be
specified from time to time in the Rules made under the Drugs and Cosmetics Act, 1940.

Dated : ___________ Signature _______________

Name and Designation ______________
Licensing Authority

___________________________________
Central Licence Approving Authority

*delete, whichever is not applicable

CONDITIONS OF LICENCE
1. The licensee shall neither collect blood from any professional donor or paid donor nor shall he prepare
blood components from the blood collected from such a donor.
2. The licence and any certificate of renewal in force shall be displayed on the approved premises and
the original shall be produced at the request of an inspector appointed under the Drugs and
Cosmetics Act, 1940.
3. Any change in the technical staff shall be forthwith reported to the Licensing Authority and/or Central
Licence Approving Authority.
4. The licensee shall inform the Licensing Authority and/or Central Licence Approving Authority in writing
in the event of any change in the constitution of the firm operating under the licence. Where any
change in the constitution of the firm takes place, the current licence shall be deemed to be valid for
maximum period of three months from the date on which the change has taken place unless, in the
meantime, a fresh licence has been taken from the Licensing Authority and/or Central Licence
Approving Authority in the name of the firm with the changed constitution.”;

169
(f) after Form 28-D, the following Form shall be inserted, namely:-

“Form 28-E
(See rule 122-G)

LICENCE TO MANUFACTURE AND STORE BLOOD PRODUCTS FOR SALE OR DISTRIBUTION

1. Number of licence ___________ date of issue ___________ at the premises situated at

___________________________.

2. M/s. ______________________ is hereby licensed to manufacture, store, sell or distribute the

following blood products:-

3. Name(s) of the item(s):

1.
2.
3.
4.
5.

4. Name(s) of competent Technical Staff:

a) responsible for b) responsible for
manufacturing testing
1. 1.
2. 2.
3. 3.

5. The licence authorises licensee to manufacture, store, sell or distribute the blood products, subject to
the conditions applicable to this licences.

6. The licence shall be in force from _________ to __________.

7. The licence shall be subject to the conditions stated below and to such other conditions as may be
specified from time to time in the Rules made under the Drugs and Cosmetics Act, 1940.

Dated : ___________ Signature _______________

Name and Designation ______________
Licensing Authority

170
 ___________________________________
Central Licence Approving Authority

*delete, whichever is not applicable

CONDITIONS OF LICENCE
1. The licensee shall not manufacture blood products from the blood drawn from any professional donor
or paid dono.”
2. The licence and any certificate of renewal in force shall be displayed on the approved premises and
shall be produced at the request of an Inspector appointed under the Drugs and Cosmetics Act, 1940.
3. Any change in the technical staff shall be forthwith reported to the Licensing Authority and/or Central
Licence Approving Authority.
4. The licensee shall inform the Licensing Authority and/or Central Licence Approving Authority in writing
in the event of any change in the constitution of the firm operating under the licence. When any
change in the constitution of the firm takes place, the current licence shall be deemed to be valid for
maximum period of three months from the date on which the change has taken place unless, in the
meantime, a fresh licence has been taken from the Licensing Authority and/or Central Licence
Approving Authority in the name of the firm with the changed constitution.”;

10. In Schedule F to the said rules, for Part XII B and Part XII C, the following shal be substitued, namely;-

PART- XII B

REQUIREMENTS FOR THE FUNCTIONING AND OPERATION OF A BLOOD BANK AND/OR FOR
PREPARATION OF BLOOD COMPONENTS

BLOOD BANKS/BLOOD COMPONENTS

A. GENERAL
1. Location and Surroundings : The blood bank shall be located at a place which shall be away from
open sewage, drain, public lavatory or similar unhygienic surroundings.
2. Building : The building(s) used for operation of a blood bank and/or preparation of blood components
shall be constructed in such a manner so as to permit the operation of the blood bank and preparation
of blood components under hygienic conditions and shall avoid the entry of insects, rodents and flies.
It shall be well lighted, ventilated and screened (mesh), wherever necessary. The walls and floors of
the rooms, where collection of blood or preparation of blood components or blood products is carried
out shall be smooth, washable and capable of being kept clean. Drains shall be of adequate size and
where connected directly to a sewer, shall be equipped with traps to prevent back siphonage.

171
3. Health, clothing and sanitation of staff : The employees shall be free from contagious or infectious
diseases. They shall be provided with clean overalls, head-gears, foot-wears and gloves, wherever
required. There shall be adequate, clean and convenient hand washing and toilet facilities.

B. ACCOMMODATION FOR A BLOOD BANK

A blood bank shall have an area of 100 square meters for its operations and an additional area of 50 square
meters for preparation of blood components. It shall be consisting of a room each for -
(1) Registration and medical examination with adequate furniture and facilities for registration and
selection of donors;
(2) Blood collection (air-conditioned);
(3) Blood component preparation (This shall be air- conditioned to maintain temperature between 20
degree centigrade to 25 degree centigrade);
(4) Laboratory for blood group serology (air- conditioned)
(5) Laboratory for blood transmissible diseases like Hepatitis, Syphilis, Malaria, HIV-antibodies (air-
conditioned);
(6) Sterilization-cum-washing;
(7) refreshment-cum-rest room (air-conditioned);
(8) store-cum-records

NOTES :
(1) The above requirements as to accommodation and area may be relaxed, in respect of testing
laboratories and sterilization-cum-washing room, for reasons to be recorded in writing by the Licensing
Authority and/or the Central Licence Approving Authority, in respect of blood banks operating in
hospitals, provided the hospital concerned has a pathological laboratory and a sterilization-cum-
washing room common with other departments in the said hospital.
(2) Refreshments to the donor after phlebotomy shall be served so that he is kept under observation in
the Blood Bank.

C. PERSONNEL
Every blood bank shall have following categories of whole time competent technical staff:-

(a) Medical Officer, possessing the qualifications specified in condition (i) of rule 122-G.
(b) Blood Bank Technician(s) possessing -
(i) Degree in Medical Laboratory Technology (M.L.T.) with six months experience in the testing
of blood and/or its components; or
(ii) Diploma in Medical Laboratory Technology (MLT) with one year’s experience in the testing of
blood and/or its components.The degree or diploma being from a University/Institution recognised by
the Central Government or State Government.
(c) Registered Nurse(s)
(d) Technical Supervisor (where blood components are manufactured), possessing -

172
 (i) Degree in Medical Laboratory Technology (MLT) with six months’ experience in the
preparation of blood components; or
(ii) Diploma in Medical Laboratory Technology (MLT) with one year’s experience in the
preparation of blood components, the degree or diploma being from a University/Institution recognised
by the Central Government or State Government.
Notes :
(1) The requirements of qualification and experience in respect of Technical Supervisor and Blood Bank
Technician shall apply in the cases of persons who are approved by the Licensing Authority and/or
Central Licence Approving Authority after the commencement of the Drugs and Cosmetics
(Amendment) Rules, 1999.
(2) As regards, the number of whole time competent technical personnel, the blood bank shall comply
with the requirements laid down in the Directorate General of Health Services Manual.
(3) It shall be the responsibility of the licensee to ensure thorough maintenance of records and other
latest techniques used in blood banking system and that the personnel involved in blood banking
activities for collection, storage, resting and distribution are adequately trained in the current Good
Manufacturing Practices/Standard Operating Procedures for the tasks undertaken by each personnel.
The personnel shall be made aware of the principles of Good Manufacturing Practices/Standard
Operating Procedures that affect them and receive initial and continuing training relevant to their
needs.

D. MAINTENANCE
The premises shall be maintained in a clean and proper manner to ensure adequate cleaning and
maintenance of proper operations. The facilities shall include :

(1) Privacy and thorough examination of individuals to determine their suitability as donors.
(2) Collection of blood from donors with minimal risk of contamination or exposure to activities and
equipment unrelated to blood collection.
(3) Storage of blood or blood components pending completion of tests.
(4) Provision for quarantine, storage of blood and blood components in a designated location, pending
repetition of those tests that initially give questionable serological results.
(5) Provision for quarantine, storage, handling and disposal of products and reagents not suitable for use.
(6) Storage of finished products prior to distribuiton or issue.
(7) Proper collection, processing, compatibility testing, storage and distribution of blood and blood
components to prevent contamination.
(8) Adequate and proper performance of all procedures relating to plasmapheresis, plateletpheresis and
leucopheresis.
(9) Proper conduct of all packaging, labeling and other finishing operations.
(10) Provision for safe and sanitary disposal of -
(i) Blood and/or blood components not suitable for use, distribution or sale

173
 (ii) Trash and items used during the collection, processing and compatibility testing of
blood and/or blood components.

E. EQUIPMENT
Equipment used in the collection, processing, testing, storage and sale/distribution of blood and its
components shall be maintained in a clean and proper manner and so placed as to facilitate cleaning and
maintenance. The equipment shall be observed, standardised and calibrated on a regularly scheduled basis
as described in the Standard Operating Procedures Manual and shall operate in the manner for which it was
designed so as to ensure compliance with the official requirements (the equipments) as stated below for
blood and its components.

Equipment that shall be observed, standardised and calibrated with at least the following frequencies;-

EQUIPMENT PERFORMANCE FREQUENCY FREQUENCY

OF CALIBRATION

1. Temperature Compare against Daily As often as

recorder thermometer necessary

2. Refrigerated Observe speed Each day As often

centrifuge and temperature of use as necessary

3. Hematocrit - - Standards
centrifuge
before initial
use, after repair or
adjustments,
and annually

4. General Lab. - -
Techometer,
centrifuge
every 6 months

5. Automated Observe controls Each day -

blood typing for correct of use
results

6. Haemoglobino- Standardize Each day -

meter against of use

174
 cyanomethemoglobulin

7. Refractometer Standardize -ditto- -

of Urinometer against distilled
water

8. Blood container Standardize -ditto- As often as

weighing device against necessary
container of
known weight

9. Water bath Observe -ditto- -ditto-

temperature

10. Rh view box -ditto- -ditto- -ditto-

(wherever
necessary)

11. Autoclave -ditto- Each time -ditto-

of use

12. Serologic Observe Each day of Speed as

rotators controls for use often as
correct necessary possible
results

13. Laboratory - - Before

thermometers intial use

14. Electronic - Monthly -

thermometers

15. Blood agitator Observe weight Each day Standardize

of the first of use with container
container of of known
blood filled mass or
for correct volume before
results initial

175
 use
and after
repairs or
adjustments

F. SUPPLIES AND REAGENTS

All supplies and reagents used in the collection, processing, compatibility, testing, storage and distribution of
blood and blood components shall be stored at proper temperature in a safe and hygienic place, in a proper
manner and in particular -
(a) all supplies coming in contact with blood and blood components intended for transfusion shall be
sterile, pyrogen-free, and shall not interact with the product in such a manner as to have an adverse
effect upon the safety, purity, potency or effectiveness of the product.
(b) supplies and reagents that do not bear an expiry date shall be stored in a manner that the oldest is
used first.
(c) supplies and reagents shall be used in a manner consistent with instructions provided by the
manufacturer.
(d) all final containers and closures for blood and blood components not intended for transfusion shall be
clean and free of surface solids and other contaminants.
(e) each blood collecting container and its satelite container(s), if any, shall be examined visually for
damage or evidence of contamination prior to its use and immediately after filling. Such examination
shall include inspection for breakage of seals, when indicated, and abnormal discoloration. Where
any defect is observed, the container shall not be used, or, if detected after filling, shall be properly
discarded.
(f) representative samples of each lot of the following reagents and/or solutions shall be tested regularly
on a scheduled basis by methods described in the Standard Operating Procedures Manual to
determine their capacity to perform as required.

Reagents and solutions Frequency of testing

alongwith controls

Anti-human serum Each day of use

Blood grouping serums Each day of use

Lectin Each day of use

Antibody screening and reverse Each day of use
grouping cells

Hepatitis test reagents Each run

176
 Syphillis serology reagents Each run

Enzymes Each day of use

HIV I and II reagents Each run

Normal saline (LISS and PBS) Each day of use

Bovine Albumin Each day of use

G. GOOD MANUFACTURING PRACTICES (GMPs)/STANDARD OPERATING

PROCEDURES (SOPs)
Written Standard Operating Procedures shall be maintained and shall include all steps to be followed in the
collection, processing, compatibility testing, storage and sale or distribution of blood and/or preparation of
blood components for homologous transfusion, autologous transfusion and further manufacturing purposes.
Such procedures shall be available to the personnel for use in the concerned areas. The Standard Operating
Procedures shall inter alia include :

1. (a) criteria used to determine donor suitability

(b) methods of performing donor qualifying tests and measurements including minimum and
maximum values for a test or procedure, when a factor is important in determining
acceptability.
(c) solutions and methods used to prepare the site of phlebotomy so as to give maximum
assurance of a sterile container of blood.
(d) method of accurately relating the product(s) to the donor.
(e) blood collection procedure, including in-process precautions taken to measure
accurately the quantity of blood drawn from the donor.
(f) methods of component prepartion including, any time restrictions for specific steps in
processing.
(g) all tests and repeat tests performed on blood and blood components during processing.
(h) pre-transfusion testing, wherever applicable, including precautions to be taken to identify
accurately the recipient blood components during processing.
(i) procedures of managing adverse reactions in donor and recipient ractions;
(j) storage temperatures and methods of controlling storage temperatures for blood and its
components and reagents.
(k) length of expiry dates, if any, assigned for all final products.
(l) critera for determining whether returned blood is suitable for reissue.
(m) procedures used for relating a unit of blood or blood component from the donor to its
final disposal.

177
 (n) quality control procedures for supplies and reagents employed in blood collection,
processing and re-transfusion testing.
(o) schedules and procedures for equipment maintenance and calibration.
(p) labelling procedures to safe guard its mix-ups, rceipt, issue, rejected and in-hand.
(q) procedures for plasmapheresis, plateletphersis and leucopheresis if performed, including
precautions to be taken to ensure re-infusion of donor’s own cells.
(r) procedures for preparing recovered (salvaged) plasma if performed, including details of
separation, pooling, labeling, storage and distribution.
(s) all records pertinent to the lot or unit maintained pursuant to these regulations shall be
reviewed before the release or distribution of a lot or unit of final product. The review or
portions of the review may be performed at appropriate periods during or after blood
collection, processing, testing and storage. A thorough investigation, including the
conclusions and follow-up, of any unexplained discrepancy or the failure of a lot or unit to
meet any of its specification shall be made and recorded.

2. A licensee may utilise current Standard Operating Procedures, such as the Manuals of the following
organisations, so long as such specific procedures are consistent with, and at least as stringent as,
the requirements contained in this Part, namely;-

(i) Directorage General of Health Services Manual

(ii) Other organisations’ or individual blood bank’s manuals, subject to the approval of State
Licensing Authority and Central Licence Approving Authority.

H. CRITERIA FOR BLOOD DONATION

Conditions for donation of blood

(1) General - No personal shall donate blood and no blood bank shall draw blood from a person, more
than once in three months. The donor shall be in good health, mentally alert and physically fit and
shall not be inmates of jail, persons having multiple sex partners and drug- addicts. The donors shall
fulfill the following requirements, namely;-
a) the donor shall be in the age group of 18 to 60 years.
b) the donor shall not be less than 45 kilograms;
c) temperature and pulse of the donor shall be normal;
d) the systolic and diastolic blood pressures are within normal limits without medication.
e) Haemoglobin which shall not be less than 12.5 grams;
f) the donor shall be free from acute respiratory diseases;
g) the donor shall be free from any skin diseases at the site of phlebotomy
h) The donor shall be free from any disease transmissible by blood transfusion, in so far as can
be determined by history and examination indicated above.

178
 i) The arms and forearms of the donor shall be free from skin punctures or scars indicative of
professional blood donors or addiction to self injected narcotics.

(2) Additional qualification of a donor - No person shall donate blood, and no blood bank shall draw blood
from a donor, in the conditions mentioned in column (1) of the Table given below before the expiry of
the period of deferment mentioned in the column (2) of the said Table.

Table : Deferment of Blood donation

Conditions Period of Deferment

1 2

a) Abortions 6 months
b) History of blood 6 months
transfusion
c) Surgery 12 months
d) Typhoid 12 months after
recovery
e) History of Malaria and 3 months (endemic)
duly treated
f) Tattooing 6 months
g) Breast feeding 12 months after
delivery

h) Immunization (Cholera, 15 days

Typhoid, Diphtheria,
Tetanus, Plague,
Gammaglobulin)

i) Rabies vaccination 1 year after

j) History of Hepatitis in 12 months

family of close contact

k) Immunoglobuilin 12 months

3) No person shal donate blood and no blood bank shall draw blood from a person, suffering from any of
the diseases mentioned below namely;

179
 a. Cancer
b. Heart disease
c. Abnormal bleeding tendencies
d. Unexplained weight loss
e. Diabetes-controlled on insulin
f. Hepatitis B infection
g. Chronic nephritis
h. Signs and symptoms, suggestive of AIDS
i. Liver disease
j. Tuberculosis
k. Polycythemia Vera
l. Asthma
m. Epilepsy
n. Leprosy
o. Schizophrenia
p. Endocrine disorders

I. GENERAL EQUIPMENTS AND INSTRUMENTS

1. For blood collection room :

i) Donor beds, chairs and tables : These shall be suitably and comfortably cushioned and shall
be of appropriate size.
ii) Bedside table
iii) Sphygmomanometer and Stethoscope
iv) Recovery beds for donors
v) Refrigerators, for storing separately tested and untested blood, maintaining temperature
between 2 to 6 degree centrigrade with digital dial thermometer, recording thermograph and alarm device, with
provision for continuous power supply.
vi) Weighing devices for donor and blood containers

2. For haemoglobin determination :

i) Copper sulphate solution (specific gravity 1.053)
ii) Sterile lancet and impregnated alcohol swabs
iii) Capillary tube ( 1.3 x 4 x 95 mm or pasteur pipettes)
iv) Rubber bulbs for capillary tubings
v) Sahli’s haemoglobinometer/Colourimeteric method

3. For temperature and pulse determination :

180
 i) Clinical thermometers
ii) Watch (fitted with a seconds-hand) and a stop-watch

4. For blood containers :

a) Only disposable PVC blood bags shall be used (closed system) as per the specifications of
IP/USP/BP.
b) Anti-coagulants : The anti-coagulant solution shall be sterile, pyrogen-free and of the following
composition that will ensure satisfactory safety and efficacy of the whole blood and/or for all the separated
blood components.

i) Citrate Phosphate Dextrose Adenine solution (CPDA) or Citrate

Phosphate Dextrose Adenine - 1 (CPDA-1) ——— 14 ml. solution shall
be required for 100 ml of blood.

Note-1 (i) In case of single/double/triple/quadruple blood collection bags used for blooc component
preparations, CPDA blood collection bags may be used.
(ii) Acid Citrate Dextrose Solution (A.C.D. with Formula -A) I.P. - 15 ml solution shall be required
for 100 ml of blood.
(iii) Additive solutions such as SAGM, ADSOL, NUTRICEL may be used for storing and retaining
Red Blood Corpuscles upto 42 days.

Note-2 : The licensee shall ensure that the anti-coagulant solutions are of a licensed manufacturer and the
blood bags in which the said solutions are contained have a certificate of analysis of the said manufacturer.

5. Emergency equipments/items:
i) Oxygen cylinder with mask, gauge and pressure regulator
ii) 5 per cent Glucose or Normal Saline
iii) Disposable sterile syringes and needles of various sizes
iv) Disposable sterile I.V. infusion sets
v) Ampoules of Adrenaline, Noradrenaline, Mephentermine, Betamethasone or Dexamethasone,
Metoclorpropamide injections
vi) Aspirin

6. Accessories
i) Such as blankets, emesis basisn, haemostats, set clamps, sponge forceps, gauze, dressing
jars,solution jars, waste cans
ii) Medium cotton balls, 1.25 cm. adhesive tapes
iii) Denatured spirit, Tincture Iodine, green soap or liquid soap
iv) Paper napkins or towels
v) Autoclave with temperature and pressure indicator
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 vi) Incinerator
vii) Stand-by generator

7. Laboratory equipment
i) Refrigerators, for storing diagnostic kits and reagents, maintaining a temperature between 4
to 6 degree centigrade (Plus/minus 2 degree centigrade) with digital dial thermometer having provision for
continuous power supply.
ii) Compound Microscope with low and high power objectives
iii) Centrifuge Table Model
iv) Water Bath : having range between 37 degree centigrade to 56 degree centigrade
v) Rh viewing box in case of slide technique
vi) Incubator with thermostatic control
vii) Mechanical shakers for serological tests for Syphillis
viii) Hand-lens for observing tests conducted in tubes
ix) Serological graduated pipettes of various sizes
x) Pipettes (Pasteur)
xi) Glass sides
xii) Test tubes of various sizes/micrometer plates (U or V type)
xiii) Precipitating tubes 6 mm x 50 mm of different sizes and glass beakers of different sizes
xiv) Test tube racks of different specifications
xv) Interval timer electric or spring wound
xvi) Equipment and materials for cleaning glass wares adequately
xvii) Insulated containers for transporting blood, between 2 degree centigrade to 10 degree
centigrade temperatures to wards and hospitals
xviii) Wash bottles
xix) Filter papers
xx) Dielectric tube sealer
xxi) Plain and EDTA vials
xxii) Chemical balance (wherever necessary)
xxiii) ELISA reader with printer, washer and micro- pipettes

J. SPECIAL REAGENTS :
1) Standard blood grouping sera Anti A, Anti B and Anti D with known controls. Rh typing sera shall be
in double quantity and each of different brand or if from the same supplier each supply shall be of
different lot numbers
2) Reagents for serological tests for syphilis and positive sera for controls
3) Anti Human Globulin Serum (Coomb’s serum)
4) Bovine Albumin 22 per cent Enzyme reagents for incomplete antibodies
5) ELISA or RPHA test kits for Hepatitis and HIV I and II

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6) Detergent and other agents for cleaning laboratory glass wares.

K. TESTING OF WHOLE BLOOD :

1) It shall be responsibility of the licensee to ensure that the whole blood collected, processed and
supplied confirms to the standards laid down in the Indian Pharmacopoeia and other tests published,
if any, by the Government.
2) Freedom from HIV antibodies (AIDS) Tests - Every licensee shall get samples of every blood unit
tested, before use, for freedom from HIV 1 and HIV II antibodies either from laboratories specified for
the purpose by the Central Government or in his own laboratory. The results of such testing shall be
recorded on the label of the container.
3) Each blood unit shall also be tested for freedom from Hepatitis B surface antigen, VDRL and malarial
parasite and results of such testing shall be recorded on the label of the container.
Note
a) Blood samples of donors in pilot tube and the blood samples of the recipient shall be preserved for 7
days after issue.
b) The blood intended for transfusion shall not be frozen at any stage
c) Blood containers shall not come directly in contact with ice at any stage

L. RECORDS
The records which the licensee is required to maintain shall include inter alia the following particu lars, namely;

1) Blood donor record : It shall indicate serial number, date of bleeding, name, address and signature of
donor with other particulars of age, weight, hemoglobin, blood grouping, blood pressure, medical
examination, bag number and patient’s detail for whom donated in case of replacement donation,
category of donation (voluntary/ replacement) and deferral records and signature of Medical Officer
Incharge.
2) Master records for blood and its components: It shall indicate bag serial number, date of collection,
date of expiry, quantity in ml. ABO/Rh Group, results for testing of HIV 1 and HIV II antibodies,
Malaria, V.D.R.L. Hepatitis B surface antigen and irregular antibodies (if any), name and address of
the donor with particulars, utilisation issue number, components prepared or discarded and signature
of the Medical Officer Incharge.
3) Issue register : It shall indicate serial number, date and time of issue, bag serial number, ABO/Rh
group, total quantity in ml, name and address of the recipient, group of recipient, unit/institution, details
of cross- matching report, indication for transfusion.
4) Records of components supplied : quantity supplied; compatibility report, details of recipient and
signature of issuing person.
5) Records of A.C.D./C.P.D./CPD-A/SAGM bags giving details of manufacturer, batch number, date of
supply, and results of testing
6) Register for diagnostic kits and reagents used : name of the kits/reagents, details of batch number,
date of expiry and date of use.

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7) Blood bank must issue the cross matching report of the blood to the patient together with the blood
unit.
8) Transfusion adverse reaction records
9) Records of purchase, use and stock in hand of disposable needles, syringes, blood bags, shall be
maintained.

Note : The above said records shall be kept by the licensee for a period of five years.

M. LABELS
The labels on every bag containing blood and/or component shall contain the following particulars, namely;
1) The proper name of the product in a prominent place and in bold letters on the bag
2) Name and address of the blood bank
3) Licence number
4) Serial number
5) The date on which the blood is drawn and the date of expiry as prescribed under Schedule P to these
rules
6) A colored label shall be put on every bag containing blood. The following color scheme for the said
labels shall be used for different groups of blood :

Blood Group Colour of the label

O Blue
A Yellow
B Pink
AB White

7) The results of the tests for Hepatitis B surface antigen, syphilis, freedom from HIV I and HIV II
antibodies and malarial parasite.
8) The Rh group
9) Total volume of blood, the preparation of blood, nature and percentage of anti-coagulant.
10) Keep constantly the temperature between 2 degree centigrade to 6 degree centigrade for whole
human blood and/or components as contained under III or Part XII B.
11) Disposable transfusion sets with filter shall be used in administration equipment.
12) Appropriate compatible cross matched blood without atypical antibody in recipient shall be used.
13) The contents of the bag shall not be used if there is any visible evidence of deterioration like
haemolysis, clotting or discoloration.
14) The label shall indicate the appropriate donor classification like “Voluntary Donor” or “Replacement
Donor” in no less prominence than the proper name.

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Notes :
1. In the case of blood components, particulars of the blood from which such components have been
prepared shall be given against item numbers (5), (7), (8), (9) and (14).
2. The blood and/or its components shall be distributed on the prescription of a Registered Medical
Practitioner.

II. BLOOD DONATION CAMPS

A blood donation camp may be organised by :
a) a licensed designated Regional Blood Transfusion Centre, or
b) a licensed Government blood bank; or
c) the Indian Red Cross Society
Notes :
(i) “Designated Regional Blood Transfusion Centre” shall be a centre approved and desig nated by a
Blood Transfusion Council constituted by a State Government to collect, pro cess and distribute
blood and its components to cater to the needs of the region and that centre has also been
licensed and approved by the Licensing Authority and Central Li cence Approving Authority for the
purpose.
(ii) The designated Regional Blood Transfusion Centre, Government blood bank and Indian Red Cross
Society shall intimate within a period of seven days, the venue where blood camp was held and details
of group wise blood units collected in the said camp to the Licensing Authority and Central Licence
Approving Authority.
For holding a blood donation camp, the following requirements shall be fulfilled/complied with,namely
;-
(A) Premises, personnel etc.
(a) Premises under the blood donation camp shall have sufficient area and the location shall be hygienic
so as to allow proper operation, maintenance and cleaning.
(b) All information regarding the personnel working, equipment used and facilities available of such a
camp shall be well documented and made available for inspection, if required, and ensuring :
i) continuous and uninterrupted electrical supply for equipment used in the Camp;
ii) adequate lighting for all the required activities
iii) hand-washing facilities for staff
iv) reliable communication system to the central office of the Controller/Organiser of the Camp
v) Furniture and equipment arranged within the available place
vi) Refreshment facilities for donors and staff
vii) Facilities for medical examination of the donors
viii) Proper disposal of waste

(B) Personnel for Out-door Blood Donation Camp :

To collect blood from 50 to 70 donors in about 3 hours or from 100 to 120 donors in 5 hours, the
following requirements shall be fulfilled/complied with :

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i) One Medical Officer and two nurses or phlebotomists for managing 6 - 8 donor tables;ii) Two
medical social workers
iii) Three blood bank technicians
iv) Two attendants
v) Vehicle having a capacity to seat 8 - 10 persons, with provision for carriage of donation goods
including facilities to conduct a blood donation camp.

C. Equipments
1. BP apparatus
2. Stethoscope
3. Blood bags (single,double,triple,quadruple)
4. Donor questionaire
5. Weighing device for donors
6. Weighing device for blood bags
7. Artery forceps, scissors
8. Stripper for blood tubing
9. Bed sheets, blankets/mattress
10. Lancets, swab stick/tooth picks
11. Glass slides
12. Portable Hb meter/copper sulphate
13. Test tube (big) and 12 x 100 mm (small)
14. Test tube stand
15. Anti-A, Anti-B and Anti-AB, Antisera and Anti-D
16. Test tube sealer film
17. Medicated adhesive tape
18. Plastic waste basket
19. Donor cards and refreshment for donors
20. Emergency medical kit
21. Insulated blood bag containers with provisions for storing between 2 degree centigrade to 10 degree
centigrade
22. Dielectric sealer or portable tube sealer
23. Needle destroyer (wherever necessary)

III. PROCESSING OF BLOOD COMPONENTS FROM WHOLE BLOOD BY A BLOOD BANK

The blood components shall be prepared by blood banks as a part of the Blood Bank services.
The conditions for grant or renewal of licence to prepare blood components shall be as follows :

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A. ACCOMMODATION
(1) Rooms with adequate area and other specifications, for preparing blood components depending on
quantum of work load shall be as specified in item B under the heading “I. BLOOD BANK/BLOOD
COMPONENTS of this part.
(2) Preparation of Blood components shall be carried out only under closed system using single, double,
triple or quadruple plastic bags except for preparation of Red Blood Cells Concentrates, where single
bags may be used with transfer bags.

B. EQUIPMENT
i) Air conditioner
ii) Laminar air flow bench
iii) Suitable refrigerated centrifuge
iv) Plasma expresser
v) Clipper and clips and or dielectric sealer
vi) Weighing device
vii) Dry rubber balancing material
viii) Artery forceps, scissors
ix) Refrigerator maintaining a temperature between 2 degreee centigrade to 6 degree centigrade, a digital
dial thermometer with recording thermograph and alarm device, with provision for continuous power
supply
x) Platelet agitator with incubator (wherever necessary)
xi) Deep freezers maintaing a temperature betweenminus 30 degree centigrade to minus 80 degree
centigrade
xii) Refrigerated water bath for Plasma thawing
xiii) Insulated blood bag containers with provisions for storing at appropriate temperature for
transport purposes

C. PERSONNEL
The whole time competent technical staff meant for processing of Blood components (that is Medical Officer,
Technical Supervisor, Blood Bank Technician and Registered Nurse) shall be as specified in item C, under the
heading “I. BLOOD BANKS/BLOOD COMPONENTS” of this Part.

D. TESTING FACILITIES
General facilities for A, B, AB and O groups and Rh(D) grouping.
Hepatitis : B Surface antigen, VDRL, HIV I and HIV II antibodies and malarial parasites shall be mandatory for
every blood unit before it is used for the preparation of blood components. The results of such testing shall be
indicated on the label.

E. CATEGORIES OF BLOOD COMPONENTS

(1) CONCENTRATED HUMAN RED BLOOD CORPUSCLES :

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The product shall be known as “Packed Red Blood Cells” that is Packed Red Blood Cells remaining after
separating plasma from human blood.

General Requirements :
a) Storage : Immediately after processing, the Packed Red Blood Cells shall be kept at a temperature
maintained between 2 degree centigrade to 6 degree centigrade.
b) Inspection : The component shall be inspected immediately after separation of the plasma, during
storage and again at the time of issue. The product shall not be issued if there is any abnormality in
color or physical appearance or any indication of microbial contamination.
c) Suitability of Donor : The source blood for Packed Red Blood Cells shall be obtained from a donor
who meets the criteria for Blood Donation as specified in item H under the heading “I. BLOOD
BANK/BLOOD COMPONENTS” of this Part.
d) Testing of whole blood : Blood from which Packed Red Blood Cells are prepared shall be tested as
specified in item K relating to testing of whole blood under the heading “I. Blood Banks/Blood
Components” of this Part.
e) Pilot samples : Pilot samples collected in integral tubing or in separate pilot tubes shall meet the
following specifications :
i) One or more pilot samples of either the original blood or the Packed Red Blood Cells being
processed shall be preserved with each unit of Packed Red Blood Cells which is issued.
ii) Before they are filled, all pilot sample tubes shall be marked or identified so as to relate them
to the donor of that unit or Packed Red Blood Cells.
iii) Before the final container is filled or at thetime the final product is prepared, the pilot sample
tubes accompanying a unit of Packed Red Blood Cells, shall be attached in a tamper-proof manner
that shall conspicuously identify removal and re-attachment.
iv) All pilot sample tubes, accompanying a unit of packed red blood cells, shall be filled immediately after
the blood is collected or at the time the final product is prepared, in each case, by the person who
performs the collection of preparation.

f) Processing :
i) Separation: Packed Red Blood Cells shall be separated from the whole blood :
a) If the whole blood is stored in ACD solution within 21 days, and
b) if the whole blood is stored in CPDA-1 solution, within 35 days, from the date of collection.
Packed Red Blood Cells may be prepared either by centrifugtion done in a manner that shall not tend
to increase the temperature of the blood or by normal undisturbed sedimentation method. A portion of
the plasma, sufficient to ensure optimal cell preservation, shall be left with the Packed Red Blood
Cells.
ii) Packed Red Blood Cells Frozen : Cryophylactic substance may be added to the Packed Red
Blood Cells for extended manufacturer’s storage not warmer than minus 65 degree centigrade
provided the manufacturer submits data to the satisfaction of the Licensing Authority and Central
Licence Approving Authority, as adequately demonstrating through in-vivo cells survival and other
appropriate tests that the addition of the substance, the material used and the processing methods

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 results in a final product meets the required standards of safety, purity and potency for Packed Red
Blood Cells, and that the frozen product shall maintain those properties for the specified expiry period.
iii) Testing : Packed Red Blood Cells shall conform to the standards as laid down in the Indian
Pharmacopoeia.

(2) PLATELETS CONCENTRATRES :

The product shall be known as “Platelets Concentrates” that is platelets collected from one unit of
blood and re-suspended in an appropriate volume of original plasma.

General Requirements
(i) Source : The source of material for platelets shall be plateletrich plasma or buffy coat which may be
obtained from the whole blood or by platelet phersis.
(ii) Processing :
a) Separation of buffy-coat of platelet-rich plasma and platelets and re-suspension of the
platelets shall be in a closed system by centrifugal method with appropriate speed, force and time.
b) Immediately after collection, the whole blood or plasma shall be held in storage between 20
degree centigrade to 24 degree centigrade. When it is to be transported from the venue of blood
collection to the processing laboratory, during such transport action, the temperature should be as
close as possible to a range between 20 degree centigrade to 24 degree centigrade shall be ensured.
The platelet concentrates shall be separated within 6 hours after the time of collection of the unit of
whole blood or plasma.
c) The time and speed of centrifugation shall be demonstrated to produce an unclamped
product, without visible haemolysis, that yields a count of not less than 3.5 x 10 (3.5 x 10 raised to the
power of 10) and 4.5 x 10 (4.5 x 10 raised to the power 10) i.e. platelets per unit from a unit of 350 ml.
and 450 ml. blood respectively. One percent of total platelets prepared shall be tested of which 75
percent of the units shall conform to the above said platelet count.
d) The volume of original plasma used for resuspension of the platelets shall be determined by
the maintenance of the pH of not less than 6 during the storage period. The pH shall be measured on
a sample of platelets which has been stored for the permissible maximum expiry period at 20 degree
centigrade to 24 degree centigrade.
e) Final containers used for platelets shall be colorless and transparent to permit visual
inspection of the contents. The caps selected shall maintain a hermetic seal to prevent contamination of the
contents. The container material shall not interact with the contents, under the normal conditions of the
storage and use, in such a manner as to have an adverse effect upon the safety, purity, potency, or efficacy of
the product. At the time of filling, the final container shall be marked or identified by number so as to relate it
to the donor.

(iii) Storage :
Immediately after re-suspension, platelets shall be placed in storage not exceeding for a period of 5 days,
between 20 degree centigrade to 24 degree centigrade, with continuous gentle agitation of the platelet
concentrates maintained throughtout such storage.

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(iv) Testing :
The units prepared from different donors shall be tested at the end of the storage period for :
a) Platelet count
b) pH of not less than 6 measured at the storage temperature of the unit.
c) Measurement of actual plasma volume
d) One percent of the total platelets prepared shall be tested for sterility
e) The tests for functional viability of the platelets shall be done by swirling movement before
issue.
f) If the results of the testing indicate that the product does not meet the specified requirements,
immediate corective action shall be taken and records maintained.

(v) Compatibility Test :

Compatible transfusion for the purpose of variable number of Red Blood Cells. A,B, AB and O
grouping shall be done if the platelets concentrate is contaminated with red blood cells.

(3) GRANULOCYTE CONCENTRATES :

(i) Storage : It shall be kept 20 degree centigrade to 24 degree centigrade for a maximum period of 24
hours.
(ii) Unit of granulocytes shall not be less than 1x10 (i.e. 1 x 10 raised to the power of 10) when prepared
on cell separator.
(iii) Group specific tests/HLA test wherever required shall be carried out.

(4) FRESH FROZEN PLASMA :

Plasma frozen within 6 hours after blooc collection and stored at a temperature not warmer
than minus 30 degree centigrade, shall be preserved for a period of not more than one year.

(5) CRYOPRECIPITATE
Concentrate of anti-hemophiliac factor shall be prepared by thawing of the fresh plasma frozen stored
at minus 30 degree centigrade.
(a) Storage : Cryoprecipitate shall be preserved at a temperature not higher than 30 degree
centigrade and may be preserved for a period of not more than one year from the date of collection.
(b) Activity : Anti-hemophiliac factor activity in the final product shall be not less than 80 units per
bag. One percent of the total cryoprecipitate prepared shall be tested of which seventy five percent of the unit
shall conform to the said specification.

F. PLASMAPHERESIS, PLATELETPHERESIS, LEUCOPHERESIS USING A CELL SEPARATOR

An area of 10 square meters shall be provided for pheresis in the blood bank.

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The blood banks specifically permitted to undertake the said apheresis on the donor shall observe the criteria
as specified in item H relating to Criteria for blood donation under the heading “I. Blood Banks/Blood
Components” of this Part. the written consent of the donor shall be taken and the donor must be explained,
the hazards of apheresis. The Medical Officer shall certify that donor is fit for apheresis and it shall be carried
out by a trained person under supervision of the Medical Officer.

(A) PLASMAPHERESIS, PLATELET PHERESIS AND LEUCPHERESIS

The donors subjected to plasmapheresis, plateletpheresis and leucopheresis shall in addition to the criteria
specified in item H relating to the CRITERIA FOR BLOOD DONATION, under the heading “I. BLOOD
BANKS/BLOOD COMPONENTS” of this Part being observed, be also subjected to protein estimation on post-
pheresis/first sitting whose results shall be taken as a reference for subsequent pheresis/sitting. It shall also
be necessary that the total plasma obtained from such donor and periodicity of Plasmaphereis shall be
according to the standards described under validated Standard Operating Procedures.

NOTE :
(i) At least 48 hours must elapse between successive apheresis and not morer than twice in a week.
(ii) Extracoporeal blood volume shall not exceed 15% of donor’s estimated blood volume.
(iii) Platelet pheresis shall not be carried out on donors who have taken medication containing Asprin
within 3 days prior to donation.
(iv) If during plateletpheresis or leucophersis. RBCs cannot be re-transfused then at least 12 weeks shall
elapse before a second cytaphereis procedure is conducted.

(C) MONITORING FOR APHERESIS

Before starting apheresis procedure, hamoglobin or haematocrit shall be done. Platelet count, WBC counts,
differential count may be carried out. In repeated plasmapheresis, the serum protein shall be 6 gm/100 ml.

(D) COLLECTION OF PLASMA

The quantity of plasma separated from the blood of a donor shall not exceed 500 ml. per sitting and once in a
fortnight or shall not exceed 1000 ml per month.

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 C.S.S.D.

Sterile supplies continue to be a major support area in the hospital. There is growing knowledge and
technique available with regard to sterilisation. While steam sterilisation retains its paramount importance,
Ethylene Oxide (Eto, EO) sterilisation is a widely used method for sterilisation. Heat sensititive and fragile
items which cannot be sterilised are sterilised by steam.
Support services have had to keep pace with the technological upgradation and this has also contributed to
the overall increase in the cost of providing health care. An important area in the support service is that of
sterile supplies, the concept of which has also undergone significant transformation in recent times. Newer
and better methods of sterilisation, introduction of more and more disposables into hospital practice and the
development of quality control systems have all been part of the efforts of the health community in the control
of hospital infection.
Sterilisation is now an essential prerequisite for certain procedures and devices, and a whole industry has
been developed to provide new, better, and more cost effective ways of ensuring sterilisation of medical
equipment and devices. Failure to implement the proper sterilisation process can and will lead to
contamination of critical instrumentation, infection of patient and potential loss of life.
Health care administrators, in addition to their concern for proper sterilisation processes and patient
protection, must also be concerned with the safety of their personnel and environmental contamination.
Appropriate mechanisms for minimising personnel exposure and environmental release must be developed
and incorporated in the operation of the health care facility.

Disinfection
Disinfection is a process that results in the destruction of infectious agents on inanimate objects, but does not
necessarily destroy all bacterial spores. The process may be the result of treatment with chemicals or physical
agents.

Sterilisation
Sterilisation is a process that results in the destruction or elimination of all forms of life, including bacterial
spores. Sterilisation is an obsolute in that a mateiral, when sterile, cannot be contaminated with any form of
viable organism. However, the term has also been used to denote the filter treatment of fluids that removes
bacteria, fungi and spores, but not viruses. Therefore, one must understand the limitations of the “sterilisation
process” before accepting the product as truly sterile.

Pasteurisation
Pasteurisation is defined as the heating of materials to temperatures of around 60o C for 30 minutes in order
to destroy pathogens that may be present, although other time, temperature relationships have also been
used. The process of pasteurisation is also used for the reduction of infectious agents in liquids and has
been tried in the processing of various devices, particularly anaesthesia equipment and various types of
endoscopes. It is however not suitable when need for a sterilised product is critical.
Filtration

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Filtration is another mechanism for treatment of air and fluids to reduce microbial contamination. While
filtration is often referrred to as a sterilisation process, it is possible for viral particles and bacteria to pass
through many filters.

ESSENTIAL PRE-REQUISITES BEFORE STERILISATION

There are a number of essential pre-requisite that should be observed before attempting to sterilise.

a) All items should be cleaned and dried which will ensure that the minimum number of organisms are
present on the item prior to processing. b) The packaging must be appropriate for the process and not
obstruct the passage of the steriliant while undergoing the sterilisation process. c) The machinery must be
able to perform its task within well defined parameters and d) the maintenance and logging of the process and
engineering work on the machinery is essential.

Sterilisation Processes
Sterilisation processes can be classified as under:

a. Heat sterilisation
b. Gas sterilisation
c. Liquid sterilisation
d. Sterilisation using Ionizing Irradiation
e. Other experimental technologies

a. Heat sterilisation

i) Steam sterilisation
Steam sterilisation is the most common of all the sterilisation procedures used in the health care
facility, because steam under pressure has been found to effectively destroy even the most resistant
bacterial spores and viruses during a brief exposure. Steam sterilisation is universally used except
where the heat and moisture damage may occur to the material being sterilised. In the simplest
steam sterilisation cycle, air is removed by displacement with steam. This limits the use of such
machines to sterilisation of unwrapped, nonporous items only. Porous load sterilisers have an
operating cycle which incorporates a vacuum assisted air removal stage prior to steam admission
assisted air removal stage prior to steam admission for sterilisation and can therefore be used for
wrapped goods. The combinations of time, temperature and pressure vary from steriliser to steriliser
and were published by the British Medical Research Council Working Party in 1959. Such time/
temperature relationship has been recommended as :

3 minutes at 30 PSI at 134o C

10 minutes at 20 PSI at 126o C
15 minutes at 15 PSI at 121o C

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 The advantage of the process is that steam is a non-toxic, non-corrosive and highly effective
sterilising agent. The process can be easily controlled. Exclusions to the process are items
comprising any material which will not withstand exposure to temperatures of 121-138 oC for the
appropriate period at pressures greater than atmospheric, e.g. thermolabile plastics and fibreoptic
endoscopes. It is also not suitable for waxes/oils, steam-impermeable powders and non-fluid items in
sealed containers.

ii. Sterilisation with hot-air

In this process articles to be sterilised undergo exposure at 160 o C for 2 hours, 170 o C for 1 hour or
180 o C for 30 minutes. The efficacy of this process also depends on the initial moisture of the
microbial cells. Compared with moist heat sterilisation, dry heat sterilisation is inefficient.
The main advantage of dry heat sterilisation is its ability to treat solids, non-aqueous liquids, grease/
ointments, closed containers and items which could be damaged by steam or moist heat.

b. Gas Sterilisation
Several gaseous agents have been used successfully to sterilise medical devices, instruments and
equipment, especially with the advent of plastics, electronics disposables, and other heat-labile
components into the medical field. The main methods in use are :

i) Ethylene oxide - This will be discussed in detail subsequently.

ii) Formaldehyde - Formaldeyde has been shown, under appropriate conditions of temperature
and humidity, to be both sporicidal and bactericidal. It is still used as a fumigant for rooms and
buildings in which massive contamination has occurred. It is the sterilising gas of choice for
decontamination of biological safety cabinets and high-efficiency particulate air (HEPA) filter units.
However, it has been demonstrated to be toxic to man, and has been classified as a potential
carcinogen.
iii) Low-temperature steam formaldehyde
This combination of dry saturated steam and formaldehyde kills vegetative bacteria, bacterial spores
and most viruses. All objects exposed to this process are placed in the chamber of an automatically
controlled steriliser in such a way as to ensure the removal of air followed by exposure at sub-
atmospheric pressure to the action of dry saturated steam at 73o C in which formaldehyde is
entrained. All surfaces must be exposed to the action of this steam/formaldehyde mixture. A variety
of cycles are described in which there are variations in the combination of steam pulses,
formaldehyde injection, holding stages, and the amounts of formaldeyde employed.
Preferred uses are items and materials, including appropriately wrapped goods, not damaged by this
process but unsuitable for steam or dry heat sterilisation. Plastics, electromedical qualified for this
process. Exclusions are sealed, oily or greasy items such items where chemical reaction may occur
between steam/ formaldehyde and the article, items contaminated with body fluids e.g. dirty returns
from operating theatres, clinics etc.

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 iv) Vapour Phase Hydrogen Peroxide
With increasing knowledge of the toxicity of ethylene oxide this has emerged as a new alternative
method of sterilisation for heat labile devices and instruments. This technology is currently under
evaluation. Studies by Johnson and Coworkers, and Klaps and Vesley have reported that vapour
phase hydrogen peroxide generators have shown sporicidal activity and that, in their studies, the
process shows promise as an effective and self alternative method of sterilisation.
v) Gas Plasma Sterilisation
Gas plasma sterilisation is a dry, low- temperature process combining a chemical vapour phase with a
gas plasma phase repeated multiple times under vaccum to ensure sterility. Plasma sterilisation may
become available on an industrial scale in the near future, spurred by increased interest on behalf of
medical manufacturers.

c. Liquid Sterilisation

i) Glutaraldehyde sterilisation
Inspite of having been used for over a decade doubts remain about its efficacy. Many authors have
maintained that liquid chemicals couldnot be used as an effective sterilisation technique and the
process is again being evaluated in the U.K.

d. Sterilisation by Ionizing radiation

While ionizing radiation is not commonly used in the hospital for the sterilisation of equipment and
medical devices, it is an important process in the manufacture and packaging of devices used in the
health care facility. Many of the devices that are supplied “sterile” to the hospital, such as plastic
hypodermic syringes and catheters, are formulated to be sterilised by gamma radiation and may be
damaged or may not properly function when sterilised in any other manner. These items are
considered to be “single use” items and are not expected to be recycled. Radiation causes little or no
damage to the materials treated and leaves no residual radioactivity. Radiation of drugs,
pharmaceuticals, and tissues for transplantation has also been successful.

Two accepted methods of sterilisation with ionizing radiation are in use. These are :
i) Gamma radiation
ii) Electron Beam (E-beam)

Gamma radiation has been the traditional method used in this field and reportedly exhibits better
penetrative capability than E-beam sterilisation. However, of late E-beam irradiation has become a
efficient as gamma irradiation in neutralising microorganisms.
Both Gamma and E-beam irradiation sterilise through the use of ionizing energy; in the case of E-
beam sterilisation, the source of this energy is an electrical machine, whereas gamma irradiation uses
a radioactive isotope. Beyond this the dynamics of the techniques in terms of how they achieve
neutralisation of microorganisms are essentially the same, namely through transference of energy
from the energy source to the product.
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 Ionizing energy can have a deleterious effect on polymers, and this is often cited as one of the main
disadvantages of both E-beam and gamma irradiation processes. These negative effects range from
colour changes to mechanical degradation such as increased brittleness. However, this effect is
much lower in case of E-beam sterilisation as compared to Gamma irradiation.

e. Other experimental technologies

A US company, PurePulse Technologies Inc. (San Diego, CA) is marketing a sterilisation technique
based on high intensity pulses of white light. The method is reportedly simple and effective, providing
rapid and continous on-line sterilisation while being easily monitored for process validation and
parametric control.

STERILISATION USING ETHYLENE OXIDE

The use of ethylene oxide (EtO) and its efficacy as a steriliant was first documented by Philips and Kaye in
1949. They proposed an alkylation reaction as the mechanism of action of this material and established the
basic conditions under which EtO was effective as a sterilising agent.

Spectrum of Action
There is a broad-spectrum action against vegetative bacteria, bacterial spores, fungi, viruses and other living
cells under optimal conditions of concentration, temperature, relative humidity and time.

C.S.S.D.: FUTURE TRENDS AND MANPOWER PLANNING

Phenomenal scientific and technological advancement - In the field of medical science during last five decade
have achieved spectacular and rewarding results in patient care particularly in the discipline of surgery. Gone
are the days post-operative infection associated with high morbidity and mortality. The factors which have
contributed to this improvement are :
a) A better understanding of concept of asepsis and infection giving better environmental control in OT’s
and hospitals.
b) Antibiotics
c) Availability of sterile supplies, instruments, linen from CSSD
d) After anaesthesia materials and techniques
e) Availability of advance technology in OT equipment and instruments, monitoring equipment, advanced
and newer operation procedures.
f) Highly trained/specialised medical/nursing/paramedical manpower.

In today’s hospital almost every discipline routinely carries out diagnostic and therapeutic procedures which
are performed under sterile conditions with sterile instruments by doctors and assistants wearing sterile gowns
mask, caps and gloves which if not properly sterilised would lead to rampant post procedure infections with
serious outcome for patients and legal, financial and ethical issues for the hospital.

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The central sterile supply department (CSSD) is the hospital support service which is entrusted with
processing and issue of sterile professional supplies including instruments and equipment of all departments
of hospital. In some hospitals I V fluids and crystalloid also form part of the service.
The personal clothing and OT linen are to be processed by both first by laundry and then by CSSD.These
norms are based on the presumption that one hospital bed will produce 1/2 to one cu.ft load for sterilisation in
a general hospital. However, the more scientific way of calculating the load on CSSD would also take in
consideration following factors in a modern CSSD which is cost effective, flexible, efficient.
1. Type of Hospital : General hospital, superspeciality hospital like Neurosurgery centre, or Cardio
thoracic surgery, trauma centre etc.
2. Policies of the Hospital : Regarding use of disposable, recycling of expensive disposables like cardiac
catheters provisioning of consumables.
3. Level of technology : Advance practices being used - In classical cholecystectomy large number of
instruments will be required unlike in a laparoscopic procedure.

Latest trends in CSSD technology

a) Sterilisation by Ethylene oxide gas (Eo2 steriliser). Useful for sterilisation of catheters, fibre optic
equipments like endoscope, components of machines being used in cardiac surgery like heart lung
machine, plastic material, anaesthesia apparatus, plastic materials which cannot be heat or steam
sterilised.
b) Sterilisation by propiolactone - not in much use.
c) Sterilisation by Radiation - Gamma Ray radiation - It is very expensive initially (capital cost of
infrastructure) but subsequently cost of sterilisation per cu.ft. load is low. Suitable for very large
hospital or a group of hospitals on cooperative basis. Microwave sterilisers for dry heat sterilisation are
available but not in much use due to limited spectrum of use.
d) Hydrogen peroxide vapor sterilisers - Used for sterilising expensive and delicate articles like
endoscope and other fibroptic equipments.
e) Microprocessor based steam sterilisation - Most of the newly established CSSD’s have installed these
sterilisers. These are highly automated sterilisers based on micro processor controls. They donot
require much skilled labour for operation but being based on micro processors require trained
manpower for maintenance, and uninterrupted and regulated electric supply for smooth operations.
They have added advantage of short cycle time over the conventional sterilisers.

Future Hospital Scenario

1. Rapidly evolving technology : Due to rapid development of latest state of art technology the hospitals
are coming under tremendous pressure to acquire and use this. It will force the administrators to
make CSSD organisations more flexible, manpower more responding to change and adopted newer
skills at short notice. Other innovations like bio-engineering laser and micro surgery imaging and
other bio technical advances are likely to reduce conventional OT procedures and may reduce loads
on CSSD. Robotics and mechanisations may find application in CSSD. The major design and
staffing implications may anticipate change, in corporate new technology into planning and design
flexible environments which can expand, down size or re-configure.

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2. Shift to Out Patient Care : This will result in decline in the traditional hospitals and compliments, which
will have implications for CSSD in reducing load. “By the end of decade out patients will out number
inpatients by 8:1 in the US. Only 15 to 20% surgeries performed will be hospital based.
3. Competition among hospitals - With the trend shifting from Government owned hospitals to
privatisation and even in Government hospitals services becoming payable, the hospitals have to
operate more like business organisations. The hospitals will be forced to compete with each other
and develop themselves into centres of excellence in some or the other disciplines. The excellence
will focus not only in terms of services but also at the cost for which they are provided. This means
every rope saved in support services can be utilised for patient care, and cost of overall services can
be reduced. This will need highly cost effective, efficient and flexible operations in CSSD. The
implication would be smaller multi role manpower with highly automated operations, smaller size
autoclaves with faster cycletime occupying small areas of premium land.
4. Aging Health Care Facilities : The hospitals set up in sixties and seventies will be due for
infrastructural change over, as most of them will have outdated technology, poor quality standards as
they were designed for services and delivery methods which no longer exists. It will be cheaper and
more economical to construct new facilities rather than remodel and re-equip these aging monoliths.
The change over may result in surplus staff in some categories while shortages in other. In these
modern hopsitals there will be emphasis on new technology, efficiency and quality. The staff has to
be prepared to adopt to new work methods by on job training, in service training, courses and updates
etc. More so because in the coming times there will be more decentralised hospital organisation
giving scope for independent decision making and consequent responsibility for overall performance
and standards. In CSSD, the Incharge will have to be more qualified better trained, able to take on
maintenance and repair by himself and also perform variety of tasks.
5. Social changes and their effect on hospitals : Information explosion literacy, rising public aspirations,
changing legal environment will force hospitals to adopt more aggressive public relations, be more
willing to share hospital generated statistics and data with public. This data may relate to rate of
hospital infection, average length of stay, post operative infection rate etc. The CSSD functioning will
be important as one of the factors contributing in reduction of hospital infections.
The rising consumerism and legislation related to consumers are going to be more stringent and more
widely applied to health care institutions. Hospitals will have to become more strict in quality control at
every level. In CSSD’s there will be introduction of automated cleaning methods strict quality check
while checking and packaging of the instruments and materials, better packaging methods, constant
check on sterilisation process (spore culture), better storage facilities. It will also mean improved
record keeping, assigning batch number and machine number to each load and keeping record of the
person undertaking sterilisation to trace it back in case of failure.

Categories of Manpower Required

Keeping in view the above facts of emerging CSSD Technologies and changing hospital scenario it is
envisaged that the following category of staff will be mandatory for efficient and effective functioning :
a. CSSD Supervisor

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b. CSSD Technician
c. CSSD Store Keeper cum Clerk
d. Ancillary Staff

CSSD Supervisor : will be middle management level positon. The person should be qualified in the CSSD
Technology, with 6 - 8 year experience of working in CSSD. He should be preferably exposed to capsule
course on material management.

Job Description :
i) He will be advisor to medical director on all aspect of CSSD functioning.
ii) He will be responsible for over all functioning of CSSD.
iii) He will ensure, uninterrupted supply of CSSD item to all areas of hospital.
iv) He will supervise cleaning, checking, assembling and packaging of all articles requiring
sterilisation.

CSSD Store Keeper cum Clerk: Educational and experience background - should have passed secretarial
course with knowledge of working on computers. He should be preferably exposed to courses in material
handling and store management.

Job description
i) He will be responsible for maintenance of all records in CSSD including receipts and
issues.
ii) Responsible for safe keeping of al stores under his charge.
iii) Smooth supply of disposables, replacement of broken items, issue of sterilised items will
also be his responsibility.
iv) He will also maintain Log Book on each machine and keep up-to-date maintenance record
and account of spare parts and produce the same for condemnation as and when
required.
v) He will ensure optimum stocking of all stores required for CSSD.

Ancilliary Staff : Educational and experience background- should have educational qualification minimum
class 10th pass, with aptitude for working in CSSD, after recruitment he will be trained for 3 months as a
trainee in various task in CSSD.

Job Description
i) He will receive the materials supplies and equipment for processing.
ii) He will carry out cleaning of equipment material, rubber and plastic goods.
iii) He will check items for breakages, instruments and needles for sharpness and assembling
of the equipment after washing and drying.
iv) He will make sets for various procedures and pack them for sterilistion

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v) He will do loading and unloading of sterilizers, and do various other duties like internal
housekeeping, under the guidance of CSSD Supervisor and Technicians.

The recommended number of above posts is supervisor one for each CSSD independent on the size and
number of machines in the CSSD.
CSSD technicians one per steriliser again irrespective of the numbers of the steriliser since they have to be
distributed in various shifts. Guiding principle should be based on the load i.e. one technician per 100 cu.ft.
load.
Store Keeper-cum-Clerk one for each shift.
Ancillary staff - Three persons for each technician or three ancillary staff for 100 cft. load.

LINEN AND LAUNDRY SERVICES

Professional Hospital Management in a modern context has become patient focussed. It has been
appreciated by all, that the patients do not get cured only by medical and nursing care, by drugs or operations
but by a combination of many other factors and each one of them has a definite role to play. Good food, clean
linen, a congenial atmosphere and good interpersonal relationship are some of the major attributes. These
supportive services of patient care are indispensible for a hospital to perform in the true perspective and
facilitate the cure process. Laundry and linen service has been recognised as a part of support service which
not only ensures prevention and containment of hospital infection, it also contributes to improve the image of
the hospital in the eyes of the public. A good and efficient linen and laundry services conjoint with diet and
food services are also strategically important for hospital marketing.
A patient when admitted and enters the alien environment of the hospital he gets tremendously influenced by
the aesthetics or cleanliness of the surroundings and the linen he is provided with. A clean bedding and clean
clothes have a soothing effect on the patient’s psyche. On the other hand dirty linen tends to result in
psychological dissatisfaction over the services which causes a chain reaction to affect other service areas of
the hospital and may lead to a bad or negative impression about the entire hospital.
These factors have a long term economic effect on the hospital management and as a result of these many of
the hopsitals in India have started setting up their own laundries. So,proper functioning of hospital laundry
services remain one of the major concern of hospital management. The main aim and objective of this
service is to provide adequate quantity of right quality linen to the indoor patients, to the operation theatres and
the medical and paramedical personal engaged in the care of patients, at the appropriate time; and at
minimum costs.
In India, the contract “Dhobi” or washerman system is prevalent in most hospitals since time immemorial.
Even at present many hospitals do not have institutional in-house laundries and are dependent on contract
dhobies. In the post Independence era, the first time that hospital laundries as a separate entity was
discussed by a Govt. of India Committee for planning and organising the hospital services popularly known as
“Jain Committee” (1968) on “Study group on Hospitals” suggested mechanisation of laundries in teaching
hospitals where one has to cope up with huge quantity of linen numbering more than 45,000 pieces per week.
Similar measures were also suggested for smaller hospitals where resources were available. It was also

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recommended that hospitals with a bed strength of less than 200 may employ small domestic washing
machines.
Thus we see that the importance of the linen and laundry service of the hospital has been given due
importance as early as 60’s. It is imperative therefore to see that the organisation of laundry and linen services
in the hospital, keeps pace with the changing technology and provides the best quality of services that is
possible. One can very safely say that with increasing privatisation of hospitals and patients being made to
pay for their treatment, there is every likelihood that the paying patients in the hospital will be quick to point out
flaws and loopholes in hospital services including linen and laundry services.
So, hospital laundries and linen services are getting their rightful place in the Hospital Management function
and are no longer a forgotten issue of the organisational family situated in a basement. Studies in hospitals in
India have shown that the breakdown of timely supply of linen to the operation theatre causes 3 to 4 percent of
operation reschedules. Similarly, more than 3 to 4 percent of Hospital Cross Infection can be attributed to
mishandling of infected linen in hospital. Linen Supply and Operational aspects of a hospital laundery is
therefore inseparable for the purpose of planning, designing and management of linen services in a hospital.
The Linen Service : The dictionary meaning of linen is flex or article of cotton. However, in hospital the term
is used for clothing of the patient, medical and paramedical staff and also cloth material used for patient care
services in operation theatre, bed, trolley including the mattresses, pillow, blankets, sheets, and towels etc.
Due to technological developments and newer products in the market hospital linen are now made of variety of
fibres which may not be natural cotton,but cotton is found to be the most frequently used material in the
hospital as it is cheaper and comfortable. However, in hospital artificial fibres like rayon, naylon, terylene
polyster or combination of this like teri-cotton or teriwool are used mostly as dress material for staff only.
Classification of Linen : For the purpose of management of linen service specially for purpose of planning of
material, purchase, stitching,washing process issue, condemnation andpolicy thereof, the hospital linen are
classified as under :

A. Patient linen/patient care linen :

The linens as per its use :
a. Bed linen
b. Body linen
c. Operation theatre linen
d. Staff linen
e. Department/service linen

B. Laundry Linen
The linen in the laundry is classified depending on the washing process it has to undergo:
a. Contaminated/infected linen
b. Soiled linen
c. Foul linen and
d. Radio-active linen

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Linen Supply System : A smooth linen supply sysem for patient care depend on :
1. Proper information regarding the demand of various items required by the consumer unit like wards,
OTs etc. and the hospital as a whole.
2. To ensure availability of proper material in adequate quantity and quality.
3. Provision of funds at proper item and budgetary projection.
4. Stocking and processing linen in sufficient quantity so that in the event of failure by the contractor or
washerman to supply the linen on time due to bad weather., strike in town, non-availability of washing
material etc. does not affect the hospital services.
5. Sufficient safeguard inadvance so that even when the hospital owns its own plants possible irrugular
linen supply in a situation like power failures, breakdown in machines or bad weather or strikes.

Operational Objectives : In order to effect efficiency and good linen management programme
every hospital will have to evolve its own objectives like :
a. Type of material to be used for patients use, and for staff garments,i.e. whether khadi to be used or
mill made cloth is to be used or artificial fabrics.
b. Frequency of change of linen, like whether the patient clothing is to be changed every day or twice in
week or thrice a week etc. The quantity of linen to be stocked in the patient care area or in the stores,
size and capacity of machines in the laundry.
c. Similarly, whether linen has to be washed by hiring Dhobies (washerman) or by contractor or inplant
system.
Once these objectives are clearly laid down proper planning can be made for the linen service or linen
management.

Linen requirement : Requirements of the hospital services on the basis of operational planning
of different activities :
1. Fixed areas (OPD’s and service departments) where patients are not staying overnight.
2. Operation theatre and labour room, where there is the specific need of the linen services required.
3. Indoor (inpatient ward and private wards or Nursing home care).
4. Staff garments for the health care workers.
Irrespective of the type of use the linen for the purpose of laundering is measured in weight and
expressed in K.G.’s. For the purpose of planning of laundry capacity the requirement for fixed areas,
like OTs and Labour Rooms are based on actual performance of the procedures, whereas
requirement for general wards and special care wards comes to 2-1/2 to 3 kgs of dry linen per patient
per day in Indian hospitals. If linen is changed every day altogether it comes to 3 to 4 kgs dry linen per
patient per day. It has been found that in a well run general hospital minimum 4 sets of linen per bed
is required which should meet the requirement of alternate day change. The ideal hospital however
should possess six(6) set per bed which has optimal patient occupancy.

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 Hypothetically in any single day :

1. One set is used

2. One set ready for use in the ward
3. One set being processed in the laundry
4. One set in transit to be delivered or to be received in the ward
5. Two sets reserved for weekends and holidays

Circulation of linen
In large hospitals the laundering person is in charge of linen supply, including delivery, repair, inventory
control etc.. In small hospital this is sometimes assigned to nursing administrator.
In later case she should have the information on quantity of each article in circulation, drawing of stocks for
replacement whenever necessary. All articles in circulation are to be included in the ward inventory and ward
sister should be responsible for their maintenance, so as to meet the needs of efficiency of the patient care
services.
Any of these two systems of circulation of linen can be followed depending on the size of the hospital and
availability of exclusive staff for linen service. In some of the hospitals the house keeping department has
taken over such function. But linen required for direct patient care activity continued to be the responsibility of
the nursing management.
However, for the purpose of laundering the system of linen supply may be decentralised or centralised for the
purpose of control.
Procurement : Procurement of material for hospital linen use is another area of concern for the Hospital
Administrattor today. This is due to the fact that there are a variety of fabrics with some advantages or
otherwise, available in the Market, and that makes it a difficult choice for the user to select the suitable variety
of fabrics for different hospital uses.
Studies in this context at an Indian Hospital shows some important deficiencies in hospital and similar findings
may be in abudance, if linen required in the hospital are objectively assessed.
1. Dimensions of linen viz. length, breadth and weight of the linen material needs to be standardised.
2. The weight of linen as a criteria for standardisation is very subjective in most linen barring a few items
like (e.g. bedsheets). It is also found to be difficult to weight every linen when the supply is received
and weight in most cases found to be varying for different lot of linen items of the some number.
3. Terrycot cloth is being used as surgeons gowns and kurta, payjama which may be harmful in areas
like OT because of the conductivity of the fabrics leading to fire hazard.
4. The blankets used in OT of woolen material which increase the conductivity of electricity and may be
hazardous from fire point of view in OT because of use of variious types of gases, cautery machines
etc.
5. Absence of proper supply of woolen socks and caps in Nursery for Intra Uterine Growth Retarded
babies from the hospital linen room.
6. Requirement of chapati wrapper for Indian system of food
7. Non-availability of linen to cover the dead bodies in the hospital.

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8. Surgeon’s mask are made of casement cloth, which is inferior in quality as compared to Poplin (100%
cotton) which also facilitates breathing.
9. Proper stamping of the name of the hospital on linen items to prevent pilferage leading to ugly
presentation.

So, the following remedial measures emerge out of such studies.

1. Codify and categorise them as per Alpha Numerical System of classification.
2. Weight of linen cannot be the sole criteria for selection of linen because refined and better quality
cloth used weigh less as compared to other type of cloth.
3. Poplin (100% cotton) to be used as surgeon’s wear andpatient’s wear in hospital premises.
4. To supply chappati covers in Kitchen.
5. To develop specifications for supply of woolen caps and socks for babies in nursery.
6. To supply khadi blanket for operation theatres
7. To identify cheaper quality cloth for covering the dead bodies.
8. To develop specifications for the size, shape and site of stamping or embroidering or weaving the
name of the hospital on the linen to curb pilferage.

Based on similar studies a model specification of the major linen items required along with the suggested
fabrics for each category are shown in the following pages.
Laundry system : The word laundry is derived from launderer, meaning a person who washes clothes.
The objective of hospital laundry service is collecting of dirty or soiled linen, cleaning and washing, processing
and supply of the linen material for patient care services.
Method of Laundering : There are various types of linen and laundery services practiced in the hospital
support service management.

A. The Contract system : In this, the hospital owns the linen but has no means of laundering. They hire
a contractor whose job is to collect the linen and after laundering deliver it to the hospital. In some
hospital the hospital creates space and facilities for laundering in its own premises. This system may
lead to mixing of linen with other hospital. It may also lead to less of hospital linen in transit and there
is always chance of cross infection. As this system is run by outside agency and there is every
likelyhood of time gap between colection and supply thus storage has to be maintained for bigger
stock of linen in the hospital. Hospital inplant laundry system are also seen to be run by contractors,
but similar problems of large stock of linen and ineffective control are the commonest experience.
B. The rental system : In this system hospital hires laundered linen from contractors, such a system
may prove to be expensive and should only be undertaken as a temporary measure only and that for
a small hospital upto 50 beds.
C. The Cooperative system : In this system single laundry caters to a number of hospitals. This
system is the most economical and can be used by many hospitals and is practiced in western
countries. It can ideally be adopted by our hospitals and nursing homes, particularly in metropolitan
cities. It has the advantages like cheaper cost of production, less investment in machinery and
equipment and convenient for smaller hospital to participate. There are disadvantages also in the
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 system like chances of cross infection and mixing of linen of different hospital. If there is disruption of
laundry functioning due to one reason or other it can effect the functioning of many hospitals, which
this system is catering to.
D. The inplant system : In this system the hospital owns and runs its own mechanical laundry services.
It has been established as the best method for washing hospital linen. It is not only safe and
dependable, but also convenient in comparison with other method of laundering hospital linen. Due to
lack of understanding and realisation of the importance of captive system of clean and quality linen
supply the introduction of mechanised laundery in Indian Hospitals is rather slow.

The following are the advantages of mechanical laundry system under the control and minimal
management.
a. Loss or damages of linen which can be achieved by effective supervision.
b. Regular and assured supply of linen within the limited inventory
c. Safe handling of infected linen
d. Control on washing formula and techniques
e. Control over the quality of finished linen
f. Control of cost by internal control over the laundery
g. Capability of rendering higher level of patient care and comfort.

Planning and Organisation of mechanical laundry service :

The planner of hospital laundery, like any other hospital service area needs to have indepth understanding of
the role and scope of linen service in patient, care the technology available, water supply and electrical system
and the modalities of functioning of the modern hospital. The same principles are to be used for modernization
of an existing facility. The planning group should consist of hospital administrator, the Matron or Nursing
Superintendent, the architect, the mechanical engineer, the laundry manager and the laundry consultant when
available.

The physical facilities, equipment, organisation and staffing pattern depends upon the following considerartion
:
Method of supply and collection of linen, linen requirement, locationof physical plant.

Method of Supply :
The following methods are commonly in practice :
a. Exchange trolly system
b. Topping up system
c. Requisitioning system
d. Daily quota system

Exchange Trolly System : This system can be practiced in hospitals where laundry and linen rooms are at
one site.

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Initial capital investment for introducing this scheme is high, however, saving can be achieved by the
elimination of the hospital linen room and time of staff for counting can be minimum. The system can function
well if hospital is equipped with lifts or other mechanised traction system.
Hoarding of linen at user level that is ward or other patient care areas can be reduced and the security of
linens be improved because if any linen item is not used it can be returned to central linen room, when the
next supply arrives.
Topping up system : This system of regulating linen supplies is relatively simple to start and maintain,
because it removes the problem of keeping trolly in ward and quota fixed for each patient care area can be
supplied to the ward/department as per predetermined schedule. However, the requirement of each
individual needs to be studied in depth, before introducing the system. The draw back in this system is that it
is difficult to obviate the need to count the linen thus saving of time by the hospital worker is not achieved.
Requisitioning system : This system is basically a means of communicating requirements in a written form.
It is necessary at users level to count linen before preparing the requisition. This is a slow and tedious
operation for ward staff. It sometimes leads to a build up of linen stock at user level, especially when
requisition is made on assumption rather than on actual counting. It is un-economical due to time spent in
preparing requisitions and it may need additional working hand for the success of the programme.
Daily Quota System : This system is very similar to that of the exchange trolly method, where a day’s
requirement is pre-determined and issued direct from a central linen room to the user level and it differs only in
the physical method of handling the linen. It eliminates the daily requisition and save time as well.
However, if the system is not controlled effectively stocks of linen can rapidly be built up at user department,
thus reducing central linen stock.
Some hospitals issue patient linen directly to the patient care unit in packs, which include all the linen needed
for the patient for that day.

PLANNING OF OPLS(INPLANT LAUNDRY)

Feasibility : Cost and service are the two major factors which are to be considered in planning a hospital
laundry services. Most authorities advocate that it is advisable for a hospital to instal and control a laundry. It
is seen that hospitals with more than 100 beds can run an inplant laundry economically and efficiently. It has
also been estimated that a hospital producing more than 7000 kgs of linen of per week is in a definite position
to run an inplant laundry economically. The primary objective of the laundry service however is to maintain
adequate supplies of clean and serviceable linen to user departments at a minimum costs.
Physical design : The physical plant of the laundry for the hospital services should incorporate several major
items of designing namely;
i. Location
ii. Space requirements
iii. Layout
iv. Physical facilities
v. Equipment to be used in the laundry

i. Location : The Govt. of India Committee on planned project in its report on general hospitals (1964)
states that the laundery should be located close to the wards, preferably in the ground floor. Similarly

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 Siddhu Committee Report states that whether the laundry is located in the main building of the
hospital or in a separte area it should be located convenient to user departments, so that time for
supply of linen to the wards and the laundry is saved and thereby economise the manpower need. The
entry of soiled and infected linen and exit of clean linen should always be physically segregated with
separate entrances. Similarly, it is also essential that the route of the soiled linen from the user
departments to the laundry and the flow of clean linen from laundry to user departments should be
different. Some authors have also recommended planning a mechanised laundry in the basement of
hospital building with proper drainage.
ii. Space Requirement : For planning the hospital laundry it is recommended an area of (580 sq.mt.) for
500 bedded hospital. The Committee on Plan Projects Report on General hospitals suggested that
many variables like size of hospital, type of the patients and type of equipments used are to be
considered for the space allocation. As a guide the following are useful :

Space requirement for hospital laundry

No. of beds Area in sq.mt.

50 200
100 250
300 300
500 400
1000 600

The Bureau of Indian Standards (BIS) in its draft agenda 1983 has recommended the following areas against
the bed complement :

BIS Space recommendation for hospital laundry

No. of beds Area in sq.ft.
25 - 50 315
51 - 100 441
101 - 300 2520
301 - 500 3245
501 - 750 4505

Some authors have said that laundry space is not dependent upon bed/area ratio but depends upon number
and size of the machines only. In fact availability of modern laundry machinery with computerised system no
longer requires big space as it used to be for mechanical machines of bigger dimensions.

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iii. Layout :
There are three types of layout referred to in designing a laundry plant.
1. Straight through : Plan of building and installation of equipment is in such a way that it is in a straight
line from the clean end to dirty utility end.
2. “U” Flow : where the clean end and dirty ends are in the same direction.
3. Gravity flow : takes advantage of gravity and underground. Mezzaine floors are so planned that dirty
utility end is on top and clean end at the bottom of the plane.
Basic aim of the proper layout should be a smooth flow of work through the laundry so that flat work does not
cross with press work and clean linens have no contact with dirty linen. This will obviate free movement of
workers in the work process.

iv. Physical facilities : should be considered under the following heads :

Material and decor : Some of the important consideration are:
* Flooring should be smooth, non-slippery and water impervious
* Walls should have smooth washable surface, free from allcorners, edges or projections, painted in
soothing pastel colours.
* Ceiling should be smooth, washable surface, high enough for installation and repair of all equipment.
Clear head room of 14 feet is recommended.
* Doors should be wide enought to admit heavy machinery and trolleys.

Ventilation : The number of air changes recommended in the laundry is 10/hr. Exhaust fans should be
provided liberally so that the heat emanating from the machinery is driven out, and a comfortable environment
is present all the year round. Air conditioning is now a days possible and gives best result. Particularly from
the hygiene point of view and productivity of workers.
Lighting : Day light should be used wherever possible. If day light is not possible the fluorescent lights
without glare and shadows are suitable.
Power Supply : It is usually 220-440 watts in three phase, with 4 wire alternative current system. The
distribution panel must be readily accessible, and preferably be located near the load centre away from the
direct path of escaping steam or vapour. The power supply to the laundry is recommended to be three grid
system so that in case of failure of one grid; the laundry gets power from another grid.
Steam : The requirement of steam in the mechanised laundry system is 178 C at 100 PSI (Pounds per
sq.inch). It should be delivered to the equipment in right quantity and at desired temperature. All the steam
pipes should be insulated for additional protection against heat. Return piping system must ensure removal of
condensation from the equipment.
Water : Provision of adequate water supply throughout the day is important. It is estimated that approximately
15 litres of hot water and 10 litres of cold water is required for every kg of linen to be washed. The hot
water/steam supply should be piped to thelaundry directly from boiler room. If the hardness of water exceed 3
to 4 grain, then softened water (by installation of water softening plant) is to be used, otherwise scaling of
elements in the machinery will be a constant problem.
Fire Safety Factors : Provision of fire extinguishers is a must in the laundry. Workers should be aware of the
use of fire extinguishers and must be trained for the fire fighting system installed. They should be instructed
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not to smoke in the laundry while working. All electrical equipments are to be switched off and inspected
before closing for the day. Instruction with that effect are to be given to the shift supervisior and made
accountable for the purpose. Fire exit ways should be clearly marked and identified.
Toilets, Lockers and Shower Facilities : Enough facilities should be provided so that workers could change
while going to work and after work. Soaps, oils etc. should be provided adequately.
Sewing Room (Tailoring room) : Tailoring of torn linen or minor repair of linen item is the responsibiity of
laundry system - this facility is to be planned and located near to clean linen and pack preparation room.
Items needing repairs are to be stored there thus enough space is to be provided.
Laundry Manager’s Office : It is to be centrally placed so that he/she may properly supervise the entire
laundry operation. Vision panels on walls would allow for direct view on the functioning of the workers.
Equipment Requirement : A well equipped modernised laundry will require the following equipments.
Laundry machines are available in different capacity in India e.g. from 5 kg. to 100 kgs. The number of
machines and its capacity is calculated on the basis of weight of dirty linen to be washed divided by working
hours so that linen needed to be washed per hour is known and accordingly machines can be purchased. On
the basis of 2-1/2 kg. linen per bed to be washed the requirement of machines will be as in the following chart
:

EQUIPMENT REQUIRED FOR MECHANISED LAUNDRY (SINGLE 8 HRS.SHIFT)

SIZE OF LINEN SLUICE WASHING HYDRO DRYING STEAM

CALENDER/
HOSPITAL PER DAY IN KGS. IN KGS EXTRACTION TUMBLERS PRESSING MIN
BEDS IN KGS. IN KGS IN KGS

50 125 7.5 25 12 25 ONE

-
100 250 7.5 35 20 35 ONE
-
200 500 7.5 75 35 30 ONE
3
300 750 12.5 110 60 45 ONE
3
400 1000 12.5 150 75 60 ONE
5
500 1250 12.5 185 100 75 ONE 5
600 1500 15 225 110 25 ONE 6
700 1750 20 265 135 25 ONE 6
800 2000 20 300 150 25 ONE 7.5
900 2250 25 335 175 135 TWO 7.5
1000 2500 25 375 185 150 TWO 9

* As yet in India hyro-extraction is not possible in washing machine, thus separate machines need to be
purchased.

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1. Washing Machines : The principle is that for maximum cleaning the dirt must be loosened from
fabric by combined action of detergent/soap and water, and by the mechanical movement of the soiled clothes
through the water. This may be of following types
a. Cylinder types : have perforated cylinder of metal. It rotates a number of times clockwise then
anticlockwise.
b. Vaccum-cup-types : an inverted funnel often called a vaccum cup or cone is plunged down on the
clothes forcing the water through them on the down ward stroke. As the pump is lifted suction pulls the water
back through clothes.
c. Agitator type : consists of blades or vanes attached to a vertical shaft that revolve in the bottom of the
tub and reverses its direction periodically, machines are sufficiently large.
In these machines the Motor drivers, which rotate the casket containing boiled linen at predetermined speed.
It washes clothes by agitational method of dropping and squeezing. Metal washers are better than wooden
washers and have greater load cpacity, hence have a longer period of use. The newer design of dump type
continuous flow automatic washers are ideal for hospital work.
These washers have automatic devices incorporated in them for accurate regulation of water levels or rate of
flow. Accurate water gauges, temperature indicator, timers and washer speed indicators are also essential in
the washing machines.
2) Hydroextractor : It is the first step in drying of washed linen. The hydro extractor is Motor driven,
works on the principle of centrifugation repelling water in the damp washed linen. By this process about 80-
90% of water is taken out from the washed linens. It has been established that the extractor capacity should
match the washing machine capacity. It has to be hand loaded out of trucks and unloaded after finish.
3) Drying Tumbler : It is the second stage of drying of washed linen. It functions to agitate the
hydroextracted mass of washed linen in a heat injected cylinder to complete the removal of moisture and
condition it for calendering and ironing from the previous step, most of the moisture is removed before clothes
go for ironing/calendering. This should be constantly supplied with air and steam at pressures which will
ensure the right temperature for good operation.
4) Calendering Machines : are electrically operated rollers with steam outlet through tiny holed pipelines
to do flat iron work of sheets, towels etc. so as to complete the drying process and also ironing and folding of
the dried linen.
These laundry machines are available in different capacities in India from 5 to 100 kgs. The number of
machines required in a plant is calculated on the basis of dirty linen to be washed divided by working hours of
the laundry. The manual on Hospital Laundry Operation published by American Hospital Association has
suggested the minimum machinery equipment needs for hospitals of varying bed capacities assuming that
these are general hospitals using 12 pounds of linen per day. Neuropsychiatric and Tuberculosis hopsitals will
use less while hospitals with more surgical services will need more.
5) Steam Press : These are concave-convex presses which utilise steam to press the linen. They come
in various sizes and have small holes on both the surfaces for proper ironing. These are used for ironing
patient clothing and other stitched material.
6) Hand Press : These are electrically operated irons of domestic type which are required to press
uniforms and other fancy linen items.

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7) Boiler : Steam is an important energy source for running most of the laundry machines. So,
provisioning of Boilers which produce hot water or steam are required for the lundry machines in an . Steam
boilers are needed in the drying tumblers, the calendering machines, and the steam presses, whereas for
washing machines hot water supply is better than steam.
Organising and Staffing : In view of the installation of machinery and equipment run on steam and boiler, the
hospital laundry employing more than 10 staff comes under the provision of statutory Factories Act Installation
of a steam producing boiler also calls for the strict compliance of boiler act. So, organisation and management
of hospital laundry are to be arranged and be guided under the provision of these

Acts and as ammended from time to time. A model organisation of hospital laundry in relation to the hospital
functioning is as below :
Figure : Organisational set up of laundry

Medical
Supdt.

Asstt.Medical Supdt. Engineer Elect.

Laundry Jr.Engg. Electrical

Manager I/c. Maintenance

Asstt.Laundry Manager

Laundry Supervisiors

Clerks Laundry Laundry Tailors

U.D.C. Operators Orderlies
L.D.C.
Sweeper
Laundry Boiler Khalasi
Mechanics Attendants

Thus the overall incharge of the laundry should be the Medical Superintendent or the Chief Executive who
delegates his authority to an officer who is made incharge of laundry. He is responsible for smooth and
efficient functioning of the laundry. Administratively he should have a laundry manager who is answerable to
him. His office is to be located in the laundry and he is responsible for the day to day supervision, organise
collection, washing and distribution of linen to the various hospital areas like wards OTs etc. The Engineer
Incharge (Electrical) is the technical advisor regarding the electrical equipments and the machines are to be
maintained and operated under his guidance and instruction.

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Regarding staffing, there are four categories of workers required in the laundry e.g. supervisory, operational,
semiskilled and unskilled. All workers who are involved in the operation of the laundry should be given training
in infection control and basic hygiene for his own protection as well as for maintenance of hospital hygiene as
a whole. There are number of formulae which can be helpful in calculating manpower requirement such as

(i) one person for each 30 beds in hospital

(ii) one person for each 60-75 kgs.of linen.

According to U.S. Department of Health, approximate number of personnel excluding the manager are as
follows :

No. of Beds No. of Personnel

75 7
100-175 12
200-300 15

However, the extent of automation and type of machines location of the laundry and also methodology of the
linen supply system will be important factor to be considered for actual determining estimation of staff needed.
After the recruitment of staff they have to be trained. The maintenance of a stable and efficient work force is
the ultimate goal of every management out of the 3 M’s i.e. ( Man, Machines and Methods) if major emphasis
is made on “men” the other parts are automatically taken care of. As in the other departments, laundry
employees require appreciation, recognition, prestige, security and a sense of belonging.

Operational Aspects (Washroom procedures)

The main laundering procedures in a hospital linen services are :
1. Dirty linen collection
2. Sorting into soiled and unsoiled linen
3. Sluicing
4. Washing
5. Hydro Extraction
6. Calendering or pressing
7. Folding
8. Delivery of clean linen to wards
9. Repair of linen if necessary and condemnation

1. Dirty Linen Collection : Collection of dirty linen from wards normally should be the responsibility of
the laundry. The laundry linen should therefore be collected by laundry staff every day or every alaternate day
from all wards and user areas depending on the policy, whether the linen is to be changed daily or alternate

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days. The dirty linen in the wards are to kept in the sluicing rooms till such time it is sent for laundering. Ideally
it should be sorted as soiled and nonsoiled linen by ward staff. The laundry staff should be assigned a
separate work group to collect the linen in trollies. as the case may be in two or three shifts. Accounting of
clothes however is done by the help of registers kept in wards and collection slips used by laundry staff. The
accounting of linen practiced in a decentralised system can be ensured by this method. In hospitals where
practice of clean exchange or topping up system or daily quota system, such accounting procedures are
minimal.
2. Sorting : Generally the sorting of soiled and unsoiled linen is to be done in ward itself. However, it is
suggested that the clothes are to be checked again in the laundry. Further sorting of soiled linen is to be
done into small linen and large linen, as the small size linen is to be washed separately, so that the small linen
is not washed away with water while draining the washing machine. Such sorting also helps in identifying linen
for sluicing.
3. Sluicing : The small OT linen and other soiled linen are to be put through sluicing operation in
machine whereas for bigger clothes this operation can be carried out in washing machine directly. Sluicing is
important step for disinfecting the linen as well as to give initial cleaning for removing stains. The inputs for
this operation are normally bleaching powder and soda.
4. Washing : Sluiced clothes as well as the normal dirty linen are then sent for washing in washing
machine. This activity however will be dependent on the basis of technology of the washing machine to be
used. The standard inputs for this operation are steam for heating, the water and for every 100 kg of linen
following washing agents are used in a available commercial washing machine in our country:
a. 1.2 kg of detergent powder
b. 2.0 kg of soda ash
c. 250 gms of bleaching powder
d. whitener for white clothes
The washing operation is carried out has normally the following steps, so as to ensure the hygienic condition
and aesthetically clean and acceptable. First is the flushing with pure water to remove surface dirt. Then
washing agents (a) and (b) are added and steam is released in the washing drum to make the temperature 70
celsius and actual washing is to be carried out. After washing, first rinsing needs to be carried out. For white
linen bleaching powder is necessary and next rinsing is to be carried out after some time lag. Next, the linen
is to be rinsed twice more. During the last rinsing whitener is also added. For coloured clothes rinsing can be
carried out straight away atleast three times so that there is no trace of soap or soda remaining. The clothes
then are to be taken out and then it is ready for squeezing operation in the hydro-extractors.
5. Hydro-extraction : The squeezing is done by centrifugal action, by putting the clothes in rotating
drums which are driven by electrical motors. The critical parameters are, balanced loading of the linen in the
drum and optimal rotationof the drum (proper RPM). When the water stops draining out of the drum, the linen
are to be removed out for drying or calendering process. The desired moisture content after the ideal
squeezing operation in the linen is found to be around 35% normally.
6. Drying : The clothes are then required to be taken to drying tumblers for drying. The tumblers are
normally electrically heated upto 125 degree celsius and have drums rotating in both directions. The result of
completion of this process are far fluffy and light clothes which could be viewed through the inspection
door/window.

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7. Calendering/Pressing : The bed sheets and similar other linen items like Drawsheet etc. after the
squeezing operation can be taken directly for calendering operation machine. The other clothes after drying
operation are to be put up for steam presses depending upon the size of the linen. Thereafter, they go for
folding. Input in this process is steam which comes from the boiler. Pressing by hydraulic presses followed by
steam from the boilers are aimed to free the linen from bacteria and make it sterile.
8. Folding : Folding can be carried out manually. Generally, linen is put into calendering machine which
have mechanical folding system. After folding the clothes are stored in the racks and are ready for
distribution.
9. Tailor : The damaged/torn clothes are required to be segregated after drying operation and if
repairable are repaired by tailors. Otherwise it is to be put up for condemnation as and when it is held.
10. Delivery of Clean Clothes : This operation is to be carried out along with the process of collection of
the linen by the staff of laundry.
Over and above, the adherence to this laundry process and updating it from time to time the linen service and
laundry procedures are to be supervised by a laundry or linen control committee.
The Linen Control Committee : Ideally all hospitals having an implant laundry should have a linen control
committee. This committee can comprise of the hospital administrator, laundry manager, linen
superintendent, house keeper, matron and any other hospital staff members deemed necesary. This
committee may perform the following functions :
a. Assessment of total hospital linen requirement
b. Purchase procedure
c. Issue and receipt procedure
d. Condemnation procedure
e. Various policies and procedures regarding departmental running e.g. job description, leave
policies etc.
Conclusion : Thus in conclusion the laundery and linen service is an important managerial function with an
objective of providing better “medical care” to the patients, in a clean, conducive environment. Managing
hospital laundry and linen service requires the manager to have special skill and abilities ranging from a
knowledge of manpower, utilisation, working of machine and control of washing formula. Efficiency and
effectiveness of nursing can increase by better organised laundry service.
The scientific and rational organisation and management of the linen service covering all aspects from
standardisation, purchase to condemnation offers vast opportunities for economy.

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 DIETARY SERVICES

In the traditional hospital setting, the department of dietetics and food services functions in two primary
modes. First, it is a manufacturing and distribution centre for meals. Second, the department provides a wide
variety of clinical services generally unrelated to the process of producing meals.
Today, the Dietary Services are an integral part of hospital and plays a vital role in public relations when a
person is hospitalised and is away from comforting surroundings of home. A well prepared, tasty and
attractively served food contributes enormously in helping him to adjust to the otherwise strange hospital
environment. Moreover, a nutritious diet contributes substantially towards the rapid recovery of the patient,
which means an earlier discharge and shortened stay in hospital, resulting in quicker bed turnover and more
effective utilisation of scarce, most needed of hospital beds.
It has been recognised that food service is one of the most important activities needing utmost care and
planning dietary service also is a most potent psychological force in patients acceptance of hospital regime
and its concomitant contribution to early recovery. This service is an equal responsibility of both the
management and the clinical services.
Thus the dietary department ranked as one of the major departments of a modern hospital. In any modern
hospital with well established dietary services, the direct cost of food and food services constitute 10-15% of
total hospital operating cost. This particular function being highly labour intensive, accounts approximately for
10% of total hospital personnel engaged in this service, which again represents approximately 50% of the
total food service cost.
Historically, the professional service of dietetics was conceived during 1st World War when variety of
problems arising out of the quality and type of food were faced by the war victims in the hospital. So the
concept of food production, preparation, conservation, distribution and consumption in a hospital as a
separate branch of speciality were advocated.

Two factors which have significantly contributed to the development of dietary department in hospitals are :
a. The increased attention given by the medical profession.
b. Increasing interest of women in home economics which included food and nutrition. The doctors
sought the help of persons trained in the sciences of foods and nutrition who could cooperate in planning diets
for patients and assume responsibility for the scientific preparation and services of foods.
Dietetics today is treated as a science and art of feeding individuals or groups under different economic or
health conditions according to the principles of nutrition and management. It includes consideration of the
planning of meals for the well and the sick, together with the selection, storage, preparation and serving of
foods with due emphasis on economic, social and psychologic factors.
Dietetics as a speciality in Indian sub-continent was not much known will the 1950s. The first formal course of
education in dietetics was started at the Institute of Public Health and Hygine, Calcutta in the year 1952 and
for the first time a hospital dietician as a position was filled in the Irwin Hospital, Delhi in the same year. Now
many educational institutions in the different states of India are running formal courses in dietetics. The Indian
Dietetic Association was formally established in 18th May, 1963.

The scope of dietary department in a modern hospital are :

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(a) It is directly responsible for the selection and purchase of food in a close working relationship with
purchasing agent and production of the food.
(b) It is responsible for the receipt and storage, preparation and distribution of food.
(c) It is responsible for cleanliness in its department and for dish-washing.
(d) It is concerned with menu planning, including special diets, the purchase of dietary supplies other
than food;
(e) On the job programmes for training personnel.
(f) Education in nutrition set up for various groups in patients and out patients, students in nursing,
students in medicine, and students in dietetics, assisting in research projects on metabolic diseases.

PLANNING CONSIDERATION
The kitchen is the heart of a hospital dietetic department. It is to be located on the ground floor. Generally
speaking an average of 5 square mt. per bed in the 50 bedded hospital and 1.5 sq.mt. per bed in the 500
bedded hospital is a minimal required space. In UK, 8-10 sq.ft. bed of space is provided. However, modern
electronic gagets and equipment has changed the concept of space thus recommended. However,
functionally all units should be so placed as to make for good straight line traffic flow, i.e., Receiving, storage-
Daily stores-preparation-Distribution-Dishwashing functions. There should be good access to all sections, with
as little cross-traffic as possible. The garbage storage units should be near the service entrance. The serving
area should be near the cafetaria The dietician office should be central, in a large hospital, however, where
the dietician has an assistant, the dieticians office may be in the administrative area.

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 MORTUARY SERVICES

The concept of health care of the population from “womb to tomb” in our Community Health literature clearly
indicates that in a health care set up part of a doctor’s duty is not only caring for the living but also in helping
to arrange for the disposal of those of his patients who die. However, many of our health care professionals
are less adept at this function than in their therapeutic role.
When a death occurs in a hospital or in a community set up, the first decision that the doctor has to make is
whether or not to report to the police if this has not already been done. This primary and fundamental decision
allowing “no sitting on the fence” and requiring a definite course of action depending upon which decision is
made. Much confusion frequently occurs because some doctors mix up the procedures for police cases with
that of other types of cases which results in administrative shambles causing delay in funerals and further
distress to the family.
Death, burial and funeral rituals have a important bearing in our socio cultural life, like any other civilisation.
This is probably due to the fact that men have been obstinately disbelieving the phenomenon of death as the
logical end of life. However, for a medical man and for the custodian of law, the aspect of death is entirely
different from the beliefs of a layman. Thus, it would be obvious that the question of death and the procedure
of the disposal of the dead is not only a medico-social problem but also has a psychological aspect attached to
it which makes it a very complex and delicate task. This aspect of hospital procedure involves a balanced
approach from psychological social, economic and administrative point of view.
In a hospital the effect of death and the sight of the dead body is a great demoralising factor for the others
and more so to the patients of the same ward. It thus becomes essential for the Hospital Administration that a
suitable provision is made where, the dead body can be removed quickly and quietly to a place where it can be
kept, pending final disposal.
From a practical angle, after the death of the person, a number of procedures are to be carried out under the
generic term “Post-mortem Care”. The body is washed carefully, the orifices are plugged and protected and
pads are applied to certain areas to prevent bruising. The rationale for these actions is generally presented as
“showing respect for the deceased”. Respect is not the only reason for these procedures, but there are
scientific requirement for proper upkeep of the body till it is disposed off. Thereafter, as per the religion of the
individual and the custom of the society it is sent to a specified area in the hospital for further examination by
an expert in this field ( i.e. either an expert in Forensice Medicine or a Pathologist). In the latter case, the body
is required to be preserved for sometimes and it is generally dissected to find out the cause of the death. This
is called an autopsy or post-mortem examination.
This type of examination to find out the cause of death may be for legal or scientific requirement depending on
the circumstance leading to the death. This area of the hospital where such procedure is carried out is called a
mortuary (or Post-mortem/Autopsy Room). On certain occasions, the body is also required to be preserved till
such time the disposal arrangement is made either by the relative of the patients or the hospital authority. This
place of preservation is called cold storage room and the entire area is called a mortuary complex.
A carefully planned mortuary complex is of great benefit to all those who come in contact with it i.e.
coroner/police, doctors, medical students, staff, relatives and friends of the deceased. One of the basic
requirement of a mortuary complex is that it is better to have natural light for proper identification or colour
changes in the body. It is essential to provide a suitable waiting area for the relatives who have to wait for, in
anguish till the administrative and statutory formalities are completed. Provision of police duty room, prayer
217
room, sufficient acommodation for the staff working there and also the facilities of air conditioning or other
suitable arrangement for proper air circulation need due consideration depending on the economic condition,
administrative and the legal responsibility of the complex.
Provision of mortuary facilities and services in a hospital has an important bearing in terms of public relation of
the hospital. Any shortcoming in the form of delay, inadvertent disrespect or negligence to the dead may bring
bad name to the hospital. Improper identification and wrong handing over the body due to procedural lapse or
casual approach by the worker in the hospital may have far reaching implications. It is, therefore, very
important to have proper facilities laid down and frame procedural guidelines to give best of services, if the
image of the hospital is to be kept high in the eyes of the community to which it is serving.
In order to conduct a post-mortem examination, certain basic pre-requisites in the form of place, equipment,
manpower etc. are essential. A brief outline on this aspects are as follows :

ORGANISATION OF MORTUARY COMPLEX

Organisation of mortuary complex depends on the type of services proposed to be offered within the existing
available resources.
The mortuary constitutes one of the important wings of any hospital more so of teaching hospital and therefore
careful planning and organisation is required for its smooth and efficient functioning.
For obvious reason, the location of the mortuary and autopsy room is always a problem and preferred to be in
an obscure place. This is normally because hospitals and physicians by large prefer to project their
successes rather than exhibit the dead body, which apparently indicates their failures. The location of the
mortuary is usually worked out in such a manner so that bodies can be transferred unobstructivity from the
elevator/ward to the mortuary and from there to an exit where the vehicle is awaiting.
Various authorities have expressed different views about establishing a mortuary complex. However, it would
be worthwhile to consider the purpose and the function of mortuary complex first. The mortuary broadly
serves the following purpose and is planned and organised for :
1. To keep the dead till the relatives claim and take over the body for disposal;
2. In the absence of relatives i.e. in case of unclaimed bodies, to keep the body as per the legal
requirement (normally 72 hours after death) before being given away to anatomy department for
dissection or to religious and charitable organisations (for cremation);
3. Dead bodies requiring pathological post-mortem examination are kept in the mortuary before final
disposal;
4. For medico-legal post-mortem work; and
5. Teaching the undergraduates as well as postgraduates.

In planning the acommodation, following functional aspects are to be considered:

1. Whenever it is proposed to build or rebuild a hospital mortuary, it should incorporate the possibility of
providing enough room or space for the needs of the local police authority as well as for the hospital
on a joint use basis. The main advantages of such arrangements are :
i) Post-mortem examinations ordered by coroner police would be done in the hospital. This
includes those patients also who die in the hospital. This would facilitate hospital medical staff and
also for the police authority;

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 ii) The capital costs therefore can be shared with local authority in building the facility. Similary
the running costs also can be proportionably shared on the basis of actual use. The saving therefore
can be achieved both for the local authority and the hospital. A joint mortuary can also save doctors’
time and efforts in many ways.
2. The joint facility may, however, may not always be feasible if the number of cases from outside are
exceptionally large.
3. Because of legal formalities bodies usually remain in mortuary from few hours to few days.
Sometimes, the period is longer if detailed investigations have to be carried out by the doctor or there
is delay in arrival of next of kin for taking over of the body etc.
4. More than one autopsies may be required to be carried out in one day and as such purely from the
practical angle it may become necessary to keep two or more tables in the post- mortem room to save
the doctors time.
5. A separate section of the mortuary may be needed in the hospital for the storage and viewing of
bodies of personnel who have died from an infectious disease; however, post-mortem and other
facilities could be common.

Directorate General of Health Services, Government of India, in 1976, issued specific guidelines in
respect of mortuaries. They aree :
1. the mortuary should remain open for collection of dead bodies round the clock;
2. the section is normally to be headed by a pathologist;
3. one technician is to be nominated who would be responsible for handing over
dead bodies after proper identification;
4. educated sweepers should, as far as possible, be posted to the mortuary;
5. dead bodies should not be retained for more than 72 hours without the permission
of hospital administration; and
6. dead bodies from outside the hospital should not be received without the
permission of the hospital administration.

The area for the functional purpose in the mortuary can be divided into various segments. These can,
broadly, be mentioned as under :
a. Reception and waiting area;
b. Cold room for body preservation;
c. Post-mortem room; and
d. Ancilliary areas, like the, consultant’s room, technician’s room, conference room,
prayer room, toilet and other support facilities for the staff and the visitors.

Reception :
The reception area of the mortuary is the place where the body is received and documents checked. It is
essential that this particular area is at a prominent place for easy accessibility. It should be easily

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approachable for relatives, friends, police, medical and other staff. Due care is needed to shield it from
outpatient department or ward block area of the hospital.
Provision of an accommodation for the bereaved relatives within the mortuary area needs to be thought of. It
should not be permissible for the relatives to wander easily into the refrigerator or dissecting room. So a
separate entrance is required for the relatives and this entrance should be well screened from the other
activities of the mortuary block. A lobby, anteroom or small hall is necessary as it is unnerving for many
persons to be confronted with a corpse as soon as they enter the building. The reception area should be
gently illuminated, warm and have comfortable chairs. A few plants and pictures will create a pleasant
atmosphere. A lavatory also must be provided with and kept scrupulously clean.
In western countries, mortuary complexes are normally provided with a specific area called “viewing room”
which is designed as a small chapel for use by the relatives of the deceased to view the body. This chapel
should not be cramped, as space is necessary for turning the body.

Post-mortem room :
In order to produce good results for post mortem, the examination should be carried out under optimum
conditions.
The post-mortem room is suggested to be treated like an operation theatre in all technicality and should be
ventilated, illuminated and cleaned upto a similar standard. After the days’ work is done, it should be ensured
that it is cleaned and possibly subjected for bacteriological test so as to ensure that the mortuary walls and
floor are sterile. The major difference between the mortuary and the operation theatre is that whereas in
operation theatre, utmost care is needed to prevent outside infection entering inside, and in mortuary, care is
needed to ensure that inside infection does not spread out. It is, therefore, essential that care is taken to
prevent people from wandering and avoid entering the room wearing their everyday shoes and wander out
carrying blood and infected material to other parts of the hospital.
The post-mortem room should be flyproof, well lit and should have running cold and hot water. It should also
be provided with facilities for the collection of specimens and also a tank should be available for storing large
specimens which may be required for further investigation to determine
the cause of death. A shelf with screw top glass bottles in which specimens could be taken away would be of
advantage in functioning. The mortuary room must have a proper instrument cupboard and must be provided
with mechanical extract ventilation like heavy duty exhaust fan.
While designing a post-mortem room, certain important principles are required to be kept in mind. First, the
working area should be capable of being hosed down from floor to ceiling which implies proper drainage.
Second, every device must be used to prevent unauthorised person entering the working area. Third, the
construction should be such that after cleaning the area, it should become clean andalso should look clean.
For the entry and exit of corpses from either the hospital or outside should be as unobstrusive as possible.
In order to facilitate quick transportation of the body, the post-mortem room must immediately adjoin the body
store. All facilities in this room should be sited in relation to the post- mortem table which is a centre of activity
in this room. The area should be adequate to accommodate two tables in a room. In smaller hospitals one
table will normally be enough but there should be enough space for installation of second table if it proves
necessary (Hospital Building Note No. 20 1972).

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Cold Room :
It is very essential to have an adequate cold room or sufficient number of refrigerators for storing the dead
bodies, viscera etc. so that the putrefaction changes are kept to the minimum and to preserve the normal
appearance of the body as far as possible till the final disposal.

Deep Freeze Equipment :

This equipment helps in arresting further decomposition and also to some extent in taking away the bad smell
present in the putrified bodies when they are kept for some time in this equipment.
The following scale is by various authorities in the field;
1. One body capacity atleast in each Taluk/Sub-divison and
2. Two body capacity at district level and medical college.

There are occasions when a body has to be kept for a fairly long time, for example in deaths from poisoning
where the nature of the poison is not established. In such situation it may have to await the closure of an
inquest pending prolonged analysis at a forensic laboratory. These investigations may take a month or more
for completion. To preserve the body for this length of time, deep freeze comes to rescue. The temperature
in a deep freeze is maintained at - 20o C. The body is not normally put into this store until the autopsy has
been carried out and tissues are already taken for histological examination. Before the body is placed in the
20oC refrigerator, a linen should cover the metal tray on which the body has to lie. If this is not done, the
corpse may adhere firmly to the tray and it may become difficult to remove the body for final disposal.
Provision should be made for storage of viscera in the mortuary complex. A cold room adjacent to the cold
storage and cooled by the same mortuary refrigerator can be utilised for the preservation of the organs of the
dead body. Care is needed to keep the medico-legal bodies and other medico-legal material separately in the
mortuary.

Following are the specific requirement of the cold room:

a. Double door entrance;
b. Direct access to post-mortem room and viewing chapel;c.Adequate space in front of
body racks for the withdrawal of tray and trolley;
d. Accommodation for one or more trolleys; and
e. Washable floor and wall surfaces, with hose point for washing down the entire room.

Ancillary area:
In order to achieve adequate results and provide basic necessities for those working in the mortuary, the
following areas should be planned and provided in the mortuary complex:
1. Consultants’room : This is required for the doctor and other clinical staff to change before entering
the post-mortem room. There should be separate lockers for personal clothes and for post-mortem gowns,
aprons and boots. Further, changing space or a second changing room are also needed in the large hospitals
where there are both male and female doctors.

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2. Anteroom : A small lobby is needed for discarding soiled garments and boots before the doctor
returns to changing room.
3. Doctors’ Lavatory : One W.C. one lavatory basin and a shower cubicle are required to be provided.
For female doctors, a second lavatory would be needed.
4. Attendant’s room : Normally there is minimum one attendant or staff, to assist in the post-mortem
examination and to look after the visitors. A table is also needed to keep records of arrivals ( of the dead body
) and other official documentation.
5. Attendant’s Changing Room and Lavatory : A W.C. and wash-basin is necessary together with a
shower cubicle and a clothes cupboard for the attendant.
6. Sluice Room : This room should open directly off the post- mortem room. A sink, connected to the
soil drain and a slab is required for the washing of bowls and instruments and their cleaning and disinfection.
7. Bier Room : This room should be free from hangings and drapes and finishes should be capable of
being easily cleaned and disinfected.
8. Stores : Normally three small stores are required :
a. clean store - This is for clean gowns, aprons, rubber gloves, gumboots, towels etc.
b. Instruments and equipments - This room holds reserve stock of instruments, unused
specimen jars, chemical solutions etc.
c. Linen - This is for clean sheets, drapes, towels and other linen.
9. Circulation space: Required for movement of body and the staff.
10. Doctors’ office : This room is required where reports are written. It may be used for discussion with
members of the clinical staff, so the size and dimension of the room should be adequately planned.

Construction and Finishings of the mortuary complex has to take special care for cleanliness, maintenance
and good hygiene, so the construction and finish needs attention of the Hospital Administrator, Architect as
well as those who use the mortuary.
Mortuary should be so oriented as to allow a maximum of light to all parts of the building and the greatest
possible exposure to the prevailing winds. These factors may constitue disadvantages during the limited
period of the year, however, excessive light can be shaded. Severe heat of the summer may also become
intolerable and for this reason, more consideration are to be given to the installation of air conditioners.
Floors should be constructed of material determined by their future use. There are two main types, the hard
floor and the resilient one, the latter being preferable in most part of the mortuary. Hard floors are built of
concrete, tile or terrazo. Concrete is least expansive but it does not have a good appearance and shows a
marked tendency to roughness in our climate. Tile is attractive but it is suited only to locations where wear and
tear is not excessive.
However, economy, longivity and easy maintenance for cleaning and hygienic purpose should be the
consideration. The primary reason is that floors should not to be spoiled by blood and other stains and may be
of tiles or standard terrazo to which 3.0 percent copper contents may be added to act as insect inhibitor. The
walls of the autospy room should also preferably be of ceramic tiles. The sub-committee report (Bureau of
Police Research and Development) of 1975 suggests that the floor and walls should be of marble having high
skirting (daddoing) upto 6 feet of glazed tiles.

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Staffing pattern
The requirement of staff in the mortuary differs from place to place and depends on the type of work
undertaken as also the quantum of work and the type of institute like teaching or non-teaching hospital.
The sub-committee report (Bureau of Police Research and Development) of 1975 lays down the following
staffing pattern and this has been accepted in principle by the Government.

a. For initial 100 autopsies per year

i) Medical officers - 2
(As one medical officer is likely to be busy in other important hospital work, teaching work, in
court attendance or if he falls sick, it is necessary to have two medical officers)
ii) Post-mortem technician - 1
iii) Post-mortem assistant - 1
iv) Sweepers - 4*
* Three sweepers for shift duty round the clock and one as a reliever.
v) Clerk/Steno-typist - 1
vi) Chowkidar - 1
vii) Peon - 1

b. For every additional 100 autopsies per year, following additional staff is required.
i) Medical Officer - 1
ii) Post-mortem assistant - 1
iii) Technician - 1*
* For teaching institutions

c. Technical Assistant -
i) For institutions conducting 300-500
autopsies per year - 1
ii) For institutions conducting more than
500 autopsies per year - 2

d. In big centre, personnel for phtographic work will be needed as under :

i) Photographer - 1
ii) Dark-room attendant - 1

The sub-committee notes that in teaching institutions, two senior staff members should not be counted while
assessing the total number of staff required as they will be busy in discharging their administrative, teaching
and research guidance work. It is also recommended that medical officers doing medico-legal work in
addition to their hospital and teaching duties be given extra remuneration. Also, (a) all medical officers while
giving second expert opinion be given suitable opinion fee per case, and (b) the sweepers working in mortuary
be given dirty work allowance (risk allowance) for this sort of work as is the practice in certain States in India.
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It is also suggested by another study that in a teaching hospital of 750 beds, the hospital mortuary should be
under the Professor of Pathology and the medical staff should be provided by them. This will be for both
medico-legal and non-medico-legal work. However, with the development of Forensic medicine as a separate
medical speciality, this does not hold good. The following basic requirements of other staff has been
recommended:

a) Technical Assistant - 1
b) Mortuary Technician - 4
c) Mortuary Attendants - 4
- Total : 9
It has been suggested that in any sizeable post-mortem room, and particularly in those of district and teaching
hospitals, the aim should be to produce a very different staff structure as those of most post-mortem rooms
today. There is a need for a grade of centralised post-mortem room attendant porter whose duties would be
collecting the bodies from the wards, looking after the mortuary, arranging the bodies for necropsy,
reconstitution and disposal of bodies, cleaning the post-mortem room and general services. It is also
recommended for a category like a grade of necropsy technologist. The necropsy technologist, after training
should, in due course, be “a better dissector than the average resident”. In addition to doing the bulk of the
gross dissection of a necropsy, he should be able to undertake special dissections for display and research
purposes, gross black and white photography and colour photography, injection and radiography of specimen
- all under the supervision of and in collaboration with his supervisors.

Equipments
The equipments required in mortuary vary widely. The equipments may be either fixed (e.g. cupboards,
refrigerator, tables, etc.) or in the form of instruments required for conducting the post-mortem examination.
Only those equipments which are of certain significance related to the mortuary complex are listed as under.
Since other basic equipments which are common to all other areas of hospital are not peculiar to the mortuary.

Autopsy Table :
The scale of number of autopsy table as suggested by the Sub-committee Report (Bureau of Police Research
and Development) of 1975 is as under :
- One table if the autopsies are 100 per year or less
- One extra table for every 200 autopsies
- No centre should have more than 4 autopsy tables

All these tables should be made up of stainless steel material with provision of water-flowing from head side
continuously and fitted with sink with pipe at the other end.
There are many designs of the table. However, basically, most autopsy tables have following common four
features:
1. The dimensions of the working surface are 7 ft. long and 3 ft. 6 inches wide;
2. have a horizontal “false top” to support the body;
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3. have an incline - recessed “trupe top” for drainage; and
4. have either a centred or foot drain
Traditional tables consisting of glazed ceramic slab with a raised edge and draining furrow are still used in
some centres. The latter leads through a coarse cover to a fall pipe which itself discharges on to an open
gullay leading from the table to a drain at the side of the room. Similar table may have a fibre glass and this
has an advantage in not being (like stainless steel table) so liable to chip. The recent addition to a table is the
arrangement of air inlets around the sides of it through which the air surrounding the body is sucked away,
thus eliminating all smells.

The Survey Committee Report on Medico-Legal Practices in India (1964) has recommended following
instruments for the mortuary rooms. This has been accepted as a standard set of equipments needed for the
post-mortem work and still considered to be ideal.

i) Basin E.I. 12" - 2

ii) Scales :
a) Platform scale for weighing the whole - 1
body (for medical colleges only)
b) Balance to weigh 100 gm and 10 kg - 1
c) Balance to weigh 0.2 gm and 10 gms - 1

iii) Cutting instruments - stainless steel:

a) Organ knife 10" blade, solid forged - 1
b) Organ knife 6" blade, solid forged - 1
c) Caltin solid forged - 1
d) Cartilage knife 5-1/2" blade, solid - 2
forged
e) Cartilage knife 4" blade, solid forged - 2
f) Brain knife 10" blade, solid forged - 1
g) Resection knife 3" blade, solid forged - 2
h) Scalpels, solid forged, 6 sizes - 1 set
i) Bistoury, probe pointed solid forged - 1

iv) Scissors : stainless steel :

a) Scissors; blunt/blunt 8" - 1

b) Scissors; blunt/sharp 6" - 1
c) Scissors; dissecting 5" with one - 1
probe point for coronary artery

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 d) Scissors; dissecting 5" with one - 1
probe point for coronary artery
e) Scissors; bowel, bernard 11" - 1

v) Forceps; stainless steel:

a) Bone cutting forceps 10" straight - 1

b) Bone cutting forceps 10" angled - 1
c) Rib-shears 9-1/2" - 1
d) Dissecting forceps 6" - 1
e) Disssecting forceps 8" - 1
f) Dissecting forceps 10" - 1

vi) Post-mortem scissors :

a) Saw, Bernard 11" stainless - 1

steel blade
b) Saw, Bernard 9" stainless - 1
steel blade

vii) Miscellaneous:

a) Coronet stainless steel - 1

b) Needles, post-morterm half curved - 1 dozen
and double curved
c) Probes silver with eye 10" - 1
d) Chisel, straight 3/4" blade - 2
e) Chisel, spine with locating point - 1
stainless steel
f) Gouge, 3/4" blade, stainless steel - 1
g) Measures 12" stainless steel - 1
h) Hammer with wrench stainless steel - 1
i) Mallet, boxwood with metal bands - 1
j) Small table 20" x 24" x 12" for the - 1
dissection of the organs
k) Measuring jug (one litre) - 1

To above list, the recent addition is an electric saw mostly used for opening the skull. Also provision of a
portable hospital steriliser for instruments is ideal. This list covers almost entire range of equipments for post-
mortem examination. However, the following basic instruments are absolutely essential.

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 a. Scissors
b. Forceps
c. Scalpels
d. Brain knives and a saw; and
e. occasionally a pair of bone forceps

The following additional equipments are also recommended by some of the authorities;
a. Suction pump
b. Body scale
c. Repairing materials :
- Thread white
- Cotton wool (absorbent)
- Wool waste
- A variety of discarded clothes
- Malleable wire
- Polythene bags
d. Aspirators
e. Plastic bins - for fixing large specimens
f. Gloves masks and aprons

Safety Problem
The major safety issues for the staff and the visitors in the mortuary are :

a) Infection and
b) Injury

The best way to do a post-mortem examinaiton in relative bacteriological safe method would be to do it with
aseptic precautions, as strictly as those observed in surgical operation theatre. Total avoidance of risk from
instruments and equipment is a practically impossible. But it is absolutely essential for post-mortem
examination to be performed as neatly and tidily as possible. Instruments should not leave the table/sink until
these have been wiped and rinsed in clean running water. The concept of universal precaution are to be
followed meticulously. It is suggested that one should wear a proper garb. If the deceased has an active lesion
of tuberculosis, staphylococcal infection or hepatitis, extra precaution by way of proper mask, gloves and a
pair of spectacles is needed. Gloves and gown should be kept clean by sponging with clean water frequently.
The aim (desirable but not literally attainable) is that no micro-organism should leave the room except by way
of drain.
Anthrax may also pose a problem but is fortunately rare these days and does not create hindrance in safety
precaution.

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If it is suspected that the body is infected and which is likely to spread infection, it may be wraped in a bed
sheet soaked in 10.0 per cent Formalin or 5.0 per cent Phenol while awaiting disposal. Polythene bag or
P.V.C. bag for such body has increasingly being used, keeping infection control in mind.
Studies has shown that one of the most important carriers of infection in mourtary is telephone. It is better not
to have this apparatus in the post- mortem room at all. The ideal place for such an instrument is the
consultants’ room or the technicians’ room. However, at times, it becomes necessary to answer the telephone
while doing a dissection and in that situation. it is better to fit an extension handle to the shaft of the receiver
which can be detatched for cleaning purposes.

Miscellaneous Procedures:

Embalming :
This isa acceptable technique for preserving the body. Modern method of embalming usually do not involve
evisceration and consists of injection of preserving fluids into the soft tissues of the body through the blood
vessels.
Formaldehyde has been used for many years as a principal perserving agent in the majority of embalming
fluids. Since its inception in 1867, this item has been considered to be the principal non-metallic chemical
agent which is in vogue that would disinfect and preserve human tissues. The embalming is normally
undertaken by the Department of Anatomy in majority of Indian hospitals and does not fall within the
jurisdiction of Department of Forensic Medicine or Pathology, although there is common belief that this
procedure is undertaken in the mortuary. Embalming is an inescapable procedure before the body is carried
in an air-craft or in a train for any socio cultural reasons.

Exhumation:
This is the procedure of taking out the body from the grave for the purpose of carrying out further post mortem
investigation when a suspicion about the cause of death arises as in as criminal abortion, homicide, or
disputed cause of death or may be for the purpose of insurance claims etc.
Exhumation is carried out under the written orders of the District Magistrate or the Coroner. In India, there is
no time limit fixed for exhumation of the dead body. In France, it is limited to 10 years and in Germany it is 30
years. The body may be subjected to post-mortem examination after exhumation, if required. Such bodies are
highly decomposed and need all safety precautions before the post-mortem is conducted in the mortuary
complex.
In India, this procedure is not so common owing to the custom of cremating the dead bodies among Hindus
who contribute the largest portion of the population.

Mummification :
This term is applied to a peculiar dessication of a dead body where its soft parts shrivel up but retain the
natural appearance and even the features of the body. Mummification occurs in bodies buried in shallow
graves in the dry and sandy soils (desert) where the evaporation of the body fluids is very rapid owing to the
prevailing hot and dry wind. The artificial method of mummification of dead bodies was known and practiced
by the ancient Egyptians. This procedure has now been replaced by embalming.

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Legal Procedures in India in relation to the Dead
Out of the broad divisions of post-mortem examinations i.e. medico-legal and non-medico-legal, the latter
(also called pathological autopsy) involves relatively simple procedure and only a consent of the next of kin is
needed before the autopsy is carried out. In such cases, the initiative normally rests with the attending
physician. This is not the case with the medico-legal post-mortem examination and can be described as
follows :
Before medico-legal post-mortem examinations are contemplated, certain basic procedures are needed to be
carried out by the custodian of the law. In India, two types of medico-legal investigation systems are allowed,
namely, the police Inquest under section 174 Criminal Procedure Code (Act V of 1898) and the Coroners
Inquest under the Coroner Act (Act IV of 1871). The Police Inquest is followed throughout the country except
in the cities of Bombay and Calcutta where Coroners’s Inquest prevails In most of the Western countries, it is
however the corner who deals with medico-legal investigations.

Summary of the procedure to be followed for an effective Mortuary Services

In the event of death in a hospital ward, the doctor who is present at the time of event will declare that the
patient has died, however, the treating doctor should also sign the death certificate. It is better to isolate and
remove the dead body at the first instance and the body should be duly covered. As an immediate step, it is
better to remove the dead body and transfer it to a vaccant area in the ward. The following steps need to be
followed for a proper administrative and legal safeguard:
a) Identification mark : An adhesive plaster bearing the name of the patient in indelible ink should be put
up on the right wrist of the deceased. WHO approved International Death Certificate should be filled
in and signed by the treating medical officer.
b) Death Register : Death register should be maintained in admission office, where the certificate should
be sent for proper entry in the register and the body should be handed over to the relations after
taking the signatures of the close relatives or next of kin.
c) Placing of Body in Mortuary : Every hospital should maintain an air conditioned well maintained
mortuary as is described, and the dead body can be kept here for 4 to 5 days. Mortuary attendant are
to be assigned to hand over the body, after proper identification, to the claiment after proper
verification and taking due signature.

Mode of disposal of body in case there is no claiment :

Every hospital should try to contact the relation on phone or by sending a telegram followed by letter, and
should wait for atleast 48 hours, before initiating final disposal of the body.
Facility of embalming (preservation of the body)
Department of anatomy of forensic department should have the facilities for it. A charge should be fixed for it
as per the laid down policy.

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Medico-Legal
All hospitals like district sub-division or a teaching hospital earmarked for the medico legal responsibility
should work out the minimum standard for starting this facility. A police post can be had in a casualty
department, which can take care of all types of medico-legal cases.
(autopsies) :
As it is known fact that due to religious beliefs, values and customs, clinical autopsies are not common.
However, it is a internationally known fact that it is an important procedure to confirm the diagnosis made
before death, so as to learn from any mistake committed and to understand clinico-pathological correlations
and is practiced very widely.

Procedures In order to initiate this procedure :

i) From the very beginning all patients should sign a consent form as is being done in case of operation.
ii) After death the nearest relatives should be requested to give autopsy consent.
iii) The resident of pathology normally should be informed to come and conduct it.
iv) When all the arrangements are ready, then only the dead body should be wheeled into the mortuary
alongwith the following:
a) Autopsy consent form
b) Autopsy request form
c) Case-sheet

After autopsy, the dead body must be prepared in such a way so that there should not be any sign of mutation
and it is to ensure that all due respect to the deceased is given.

Medico-Legal cases :
Some part of medico-legal cases is discussed elsewhere in the text however in case of inpatient care.
Whether a given case “is” or “is not” a medico-legal case is to be recorded at the time ot admission itself on
the case-sheet. By mistake even if it is not declared, and the medical officer incharge comes to know the fact
while taking the history, then it is he, who should incorporate in the cace-sheet preferably with an rubber stamp
as MLC and the admission office also be informed. If an MLC case dies in the hospital, the dead body is to be
handed over to the police only for further action such as arrangement of legal documents for autopsy, but in
no circumstance, the body should be given to the relation without clearance from police.
The MLC for which the report has been prepared in some other hospital, if brought in to another hospital for
special treatment, the case should normally be admitted through casualty. At the casualty all the necessary
entries are to be made in the medico-legal register and then the case may be admitted and sent to the
respective ward. It is always advisable that admission office as well as casualty medical officers are informed
of all the discharges and deaths of the medico-legal cases, by the treating residents doctors, so that they can
inform the police immediately and make necessary entries in the medico-legal register. In no circumstance
death certificates from the ward should be given to the relatives in cases of medico-legal nature. It should be
given only to the police authority. The record of a medico-legal case must be kept under safe custody in
medical record department excepting the registers which are kept in emergency department.

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 HOUSEKEEPING

The hospital is an institution for the treatment of sick but has many attributes that of a school, hotel, cafeteria,
laboratory and also a factory. The patients admitted in the hospital do not get cured only by medical and
nursing care, drugs or surgical procedures. There are a combination of factors which contribute to the healing
process. Palatable food, clean linen, a congenial atmosphere and good interpersonal relationships have been
recognised to be essential in the recovery of the sick in the hospital. A patient coming to an alien environment
of the hospital gets tremendously influenced by its physical and social environmental hence, the aesthetics
and the cleanliness of the hospital premises have gradually been given more and more importance particularly
in modern corporate hospitals.
Housekeeping services in a hospital is entrusted with maintaining a hygienic and clean hospital environment
conducive to patient care.
The housekeeping services has its origin in the hotel industry and has developed along with the peoples’
expectations of a hygienically clean and aesthetically well maintained room for stay and rest. Later the
concept of housekeeping got incorporated as a hospital service also. However, there exists differences in
concept and practice between the housekeeping in hospitals and hotels. Whereas a hotel houses mostly the
healthy, a hospital takes care of the sick and the injured. Control and prevention of hospital infection is one of
the most vital functions of hospital housekeeping whereas, in a hotel the aesthetics receive the maximum
emphasis. In a hotel, economy forms the basis of room allottment whereas in a hospital the type and
seriousness of the illness are the main considerations in ward/bed allotment. In fact hospital housekeeping
services is an activity upon which the health care services of the hospital depend to a great extent.
The hospital housekeeping service comprises of the activities related to cleanliness, maintenance of hospital
environment and good sanitation services for keeping premises free from pollution.
Historically, the housekeping activities moved from a department under nursing service to a separate
department under the direction of an executive housekeeper. It is a function of the hospital and an all
pervasive activity which is performed in every department of the hospital.
Housekeeping services as indicated earlier has a direct effect on the health, comfort and morale of the
patients, staff and visitors hence, it is also an important public relations variable. As Eugene aptly points out
“Housekeeping - or rather the lack of it - strikes the first lasting blow to the concerned”.
Amongst the important functions of housekeeping services is to provide highest degree of efficiency and
effectiveness which would ensure patients, attendants and visitors to feel that they are welcome.

A flow chart of functions of good housekeeping can be depicted as :

Good Housekeeping
helps in

Prevention and Control

of Hospital infections

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 Reduces Reduces Reduces
Average Cost of Suffering
Length of Medical Care to patients
Stay

A good housekeeping service is an asset which no hospital can afford to neglect.

With the concept of levying user charges to patients in government owned and managed hospitals gaining
momentum, it is imperative that due emphasis is given to provide the patients with the optimal medical,
nursing and support services care.
An appropriate housekeeping service can reduce manhours, reduce costs and raise sanitation levels. L.
Broome has summed up the functions of the housekeeping services as “Anything that seriously has to do with
housekeeping is of social and economic consequence to everybody. In fact housekeeping is an important
variable in the provision of “Quality Assurance” of hospital care.
Scientific hospital houskeeping is still in its infancy but its identify and importance has begun to be recognised.
Tradition should not be the only criteria on which to base current procedures. Housekeeping routines should
be constantly reviewed in light of new scientific findings.
Although housekeeping is recognised to be an essential attribute of hospital care to patients, the budgetary
provision for such services gets lower precedence in the overall hospital budgeting system but while assessing
the outcome criteria of a housekeeping service this aspect gets highest priority from consumer point of view.

Components of housekeeping
Housekeeping services in a hospital is entrusted with maintaining a hygienic and clean hospital environment
condusive to patient care. It is an essential ingredient in the health care delivery system and acts as the
“eyes” and “ears” of the hospital.
The hospital housekeeping services comprises of the activities related to cleanliness, maintenance of hospital
environment and good sanitation services for keeping premises free from pollution. According to Rowland and
Rowland among the key responsibilities of the housekeeping services are to :
a. Clean floor
b. Clean furniture
c. Discharge cleaning
d. Remove garbage
e. Replace mattresses
f. Replace supplies in utility rooms
g. Clean housekeeping equipment
h. Clean rooms
i. Inservice training
j. Clean fixtures, walls and ceilings
k. Exterminate bugs and pests

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l. Clean curtains, windows and bath rooms

According to Branson and Kennox a housekeeper’s work may consist of some or allof the following :
a. Cooperation with other departments
b. Recruitment, dismissal and welfare of his/her staff
c. Supervision, control and training of his/her staff
d. Compilation of duty rosters and wage sheets
e. Checking the cleanliness of offices and rooms
f. Checking and reporting of all maintenance works
g. Control and supervision of the work of the linen room and possibly the laundry
h. Prevention of fire and other accidents in his/her department
i. Ordering and control of stores in the department
j. Keeping inventories and records of equipment redecoration

Malcolm T. MacEachern mentions apart from cleaning the following functions of the housekeeping services.
1. Control of linen supply
2. Control of noise
3. Saving of heat and electricity by turning off unnecessary lights and radiators when not
needed.
4. Economical use of supplies
5. Development of public goodwill by a courteous, cheerful but unobtrusive attitude
towards patients and visitors.
6. Promotion of safety measures by observing and reporting dangerous conditions
7. Development of harmonious relations with employees in other departments.

The housekeeping function is performed in every department of the hospital. The importance of good
housekeeping has grown with the knowledge on prevention and control of hospital infection in which the
housekeeping plays a major role. The prevention and control of infection reduces the average length of stay of
patient, reduces pharmaceutical costs, minimise suffering and maximises utilisation of beds.
Other Functions : These are not essentially nursing functions but help in the overall care of the patient e.g.
liason with other department and services e.g. Dietary Services, Pharmacy Services, Radiodiagnostic and
Laboratory Services, Social Services, Housekeeping, Laundry and Linen Services, Maintenance Services etc.
The role and functions of the housekeeping services has correspondingly increased over the years. It is a
service function of the hospital and an all pervasive activity which is performed in every department of the
hospital.

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Organisation of Housekeeping Services
In the United Kingdom the housekeeping services generally follow the organisation pattern as given below :
Domestic Services Manager

Assistant Domestic Services Manager

Domestic Supervisors
Ward Housekeepers

Domestic Assistants-Ward orderlies

Housekeeping Aids

Managerial posts are graded according to a points system which relates floor area at 1 point to every 500
square metres.

Designation Points

Domestic Services Manager 20 - 100 points

Asstt.Domestic Services Manager 10 - 20 points

Senior Housekeepers 03 - 100 points

Domestic supervisors are responsible for the direct supervision of the domestic work in the specific area
allotted to them. Generally they would supervise 10 - 20 domestic staff.

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Suggested Organisational Chart for small hospital

MANAGEMENT

MEDICAL SUPERINTENDENT

OTHER DEPTT. HEADS

OTHER DEPTT.HEADS

HOUSEKEEPER

SUPERVISORS SUPERVISORS
ATTENDANTS ATTENDANTS

Housekeeping staff

Bartan and Bella enunciate the principal factors that should dictate the size of the staff :
1. Architectural design and planning
2. Areas to be serviced
3. Type of service rendered
4. Frequency of service
5. Amount of traffic
6. Accessibility of work areas
7. Type and amount of equipment provided
8. Policies of the management
9. Housekeeping staff’s knowledge and skill

Generally all buildings are built with the aim of initial economy and requirement. Economy of management
through the years that follows does not receive adequate attention. The architectural “bugaboos” i.e. the
architectural problems associated with housekeeping services generally are as follows :

1. Floors :
a. Surfaces : Uneven surfaces require more effort and manpower for cleaning.
b. Different type of floors require different methods and mateirals for cleaning.
2. WallsDampness of walls leading to peeling of paint and difficulty in cleaning.

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3. Oversized/undersized windows :
Require expert and cautious cleaning. The approach/accessibility to windows may at times be difficult leading
to difficulties in cleaning.

4. Absence of Ramps :
Steps/stairs lead to difficulties in carrying supplies and equipment.

Areas to be serviced :
These include the private wards, general wards, emergency and accident department, outpatient department
and outdoors.

Traffic problems
If cleaning is being done during peak traffic movement hours e.g. visiting hours, doctors rounds there will be a
delay in the services which are being rendered. Other related factors are :
a. relation of waste receptacles to work units
b. relation of Janitors closet to work unit
c. availability of supplies and equipment at the right time and place

Size and type of service

In hospital cleaning is a round-the-clock performance. As has been aptly remarked by Barton “Day and night
service cannot be achieved on good intentions and air, it takes planning and plenty of money”.

Housekeeping personnel :

Manpower Planning : The methods used for manpower planning geneally select one or two factors (for
example from three areas of service like time, activity and patient progress) which influence the staffing and
study them in detail. The proposed methods are :

a. Time study
b. Activity study
c. Patient progress study

Work Load : The allottment of work area to a sanitary attendant depends upon the degree of cleanliness
required, type of hospital, whether it is a closed or an open area, the size of the rooms, kinds of drain
(open/close). Secondly, it depends upon whether the sweeper is assigned to the intensive care unit,
emergency, or general wards. A sanitary attendant should be employed one for 10 hospital beds or for a work
area of 1,200 to 1,500 square feet.
For a nursing unit one sweeper over 10 beds is recommended on the basis of round the clock services. More
sanitary attendants may be required for intensive care units/emergency wards.

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Very few hospitals have an adequate number of supervisors. The currently accepted basis for establishing the
number of supervisors is one supervisor to a floor or to a division. It is an inequitable and inconsistant pattern.
It is advisable to keep a thirty percent leave reserve. One supervisor for 10 sweepers is recommended.
Simply assigning sanitary attendants to a divison/ward which is the hospital’s per unit of measurement is not a
sound or accurate basis for estimating the number of personnel. The factors mentioned must be taken into
consideration.
As a general rule a maid can clean anywhere from 3000 to 6500 square feet per day. Experience and
research have shown that a minimum and maximum amount of floor area which a mopper can be expected to
cover ranges from 1800 to 4000 sq.ft. per man hour.

Time need for tasks

The effort should always be made to make a work schedule flexible and adaptable to each area in the
hospital. A schedule should not be so rigid that an emergency situation cannot be handled.
As per Silman and Mannhalter following may be taken as standards.
Time required per 1000 sq. ft.
Dust mopping 6 minutes
Wet mopping 12 minutes
Machine scrubbing 2 hours

Training programme
The training programme should include on the job and class room training. The contents of the class room
training should include :
a. Need for training
b. Benefits of training
c. Organisation of housekeeping department
d. Personnel and housekeeping policies
e. Use/care and cost of housekeeping equipment
f. Use of housekeeping supplies
h. Correct method of using mops
i. Safety in housekeeping

The head of the Housekeeping Department is generally titled as an Executive Housekeeper. She must be a
person with intelligence, tact and poise and one who has a clear concept of her duties. The following
qualifications and abilities are desirable :
1. A general education
2. An active interest in contributing to her profession
3. A knowledge of the technical aspects of cleaning
4. An ability to select, train and supervise personnel
5. A faculty for working with others
6. Neatness and orderliness
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7. An understanding of budgeting and record keeping
8. A knowledge of bacteriology and chemistry as they relate to housekeeping
9. An awareness of principles of organisation

Cleaning agents used in Housekeeping

Medical interest in hygiene and cleaning tends to be biomodally distributed with peaks in the zones
corresponding to obsession and to apathy and little in the central zone of reasonable and practical common
sense. As Wright and Greece state that contamination is important in a hospital and cleaning is a valuable
way of dealing with it, common sense will help to show when the former matters and how the latter may best
be performed. They further state that the major sources of iatrogenic infections in cleaning can be :
a. Bacterial growth in mop heads
b. Scrubbing machines

Dust being loose particles is comparatively easily removed by the use of various pieces of equipment; dirt,
however, owing to its adherance to surfaces by means of grease or moisture requires the use of cleaning
agents as well as equipment.
Water is the simplest cleaning agent but normally unless it is used in conjuction with some other agent e.g. a
detergent, it is not an effective cleanser.
Detergents are cleaning agents which when used in conjuction with water can loosen and remove dirt and
then hold it in suspension so that the dirst is not redeposited on the clean surface. There are three basic
properties which the detergents have :
a. Wetting power to lower the surface tension of the water and enable the surface of the article to be
thoroughly wetted.
b. Emulsifying power to break up the grease and enable the soiling to be loosened.
c. Suspending power to prevent redisposition of the soiling

Disinfectants are often misused and rationalization of their use in hospitals is desirable for control of both of
infection and costs. Infections may be caused by micro organisms which contaminate disinfectants during use
especially when objects such as mops are stored in disinfectants. Unnecessary use of disinfectants is not
only wasteful but may increase the microbiological hazard of the hospital environment.

Linen Services
Provision of clean linen forms an essential ingredient of efficient housekeeping services.
The importance of a clean environment and linen for proper patient care has been stressed since the
inception of hospitals. During the 12th century A.D. the famous hospital of Paris “Hotel Dien” had a separate
area called “Blanchissange” or laundry in the cellar of the hotel which opened on the river Seine. One sister
washed the linen and one sister was incharge of the laundry.
During the period 1300-1800 there was a deterioration in term of cleanliness of environment including linen.
There was a consequent increase in the incidence of hospital infection and high mortality especially in
operated cases.

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In 1854 during the Crimean War Florence Nightingale scientifically organised the laundry and linen service for
the sick and the wounded. This was a significant factor in reducing the mortality rate from 40% to 2% in
operative cases. In order to establish man’s victory over microbial organisms, importance of personal hygiene
and cleanliness of surroundings including linen cannot be over emphasised. Hospital aquired infections
tended to increase whenever the laundry and linen and other housekeepings services were inadequate.

Quality Assurance in Housekeeping Activities in Hospitals

The housekeeping department probably is the most underrated of all the hospital service departments. Many
hospitals now realise that in addition to quality of care, the factors that consumers consider in choosing a
hospital are location and appearances. It is essential that housekeeping services are of some “quality”. To
lend some form of specificity it is essential to define the term quality.
The Bureau of Indian Standards (BIS) defines quality as “The totality of features and characteristics of a
product or service that bear on its ability to satisfy stated or implied needs”.
Others have defined quality as “fitness for use” (Juran) and “Conformance to specifications (Crosby)”. The
quality objectives as enumerated by BIS include :
a. Customer satisfaction consistent with professional standards and ethics.
b. Continuous improvement of the service
c. Giving consideration to the requirements of society and the environment.
d. Efficiency in providing the service. Eight dimensions of quality have been enumerated.

1. Performance
2. Feature
3. Reliability
4. Conformance
5. Durability
6. Serviceability
7. Aesthetics
8. Perceived quality

Different people view quality differently. In the hospital setting the patients are the customers and they can be
different from the customers of other business establishments e.g. they can ask for services that are improper
and unnecessary. Quality is based not only on patients perception (a function of their attitudes based on
culture and experience) but also on the accurate synthesis of medical observations.
The Indian Hospital Association in their Quality Assurance Programme (QAP) have listed the following as
indication of quality of housekeeping services.
a. Degree of automation
b. Number of staff
c. Training programme for housekeeping staff
d. Team spirit amongst staff

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e. Checks on effectiveness of disinfectant carried out
f. Availability of incinerator

Application of the US Joint Commission on Accreditation of Health Care Organisation (JCAHO) ten step
quality assurance model to housekeeping services.

Delineate Scope

Identify important
aspects of housekeeping

Identify
Indicators

Establish standard for

Evaluation

Collect Data Corrective Action

for indicators

Compare Data Areas for

with standards improvement

Standard Standards
Attained not obtained

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 CHAPTER VI

COMMUNICATION SYSTEM IN HOSPITAL

Introduction :
Transfer of information is essential in every sphere of human activity. Communication is the basis of all such
activities in a society. In an organisation particularly a social organisation like hospital it is imperative to have a
system of sharing information for decision making or effective management through a good communication
network. It is required to link the members of the organisation and therapy, improve the interpersonal
relationship and unifies the activities of members to achieve the goal of the organisation.
Hospitals are complex organisations, and effective communication is the inevitable requirement to achieve the
goal of better patient care. Communication gaps in hospital result in avoidable inconvenience and difficulties
in patient care areas and activities.

Importance of Hospital Communication

The present day hospital is an organised complex system. As the hospital services are becoming highly
technical and specialised and the technicality of these services have to be understood and realised by the
recepient and at the same time it has to be specific, prompt and readily available to all types of beneficiaries.
The expectations of such beneficiaries are also to be gauged and disseminated to the providers of the
service. Hospital management has to see that heterogenous group of people working in a hospital with
different cultural, social, economic and educational backgrounds brought to a common platform. The gaps
that exist among staff in perceiving a problem and translating the services to meet the needs of the patients
and also of the administrator and clinical professionals can be minimised by an effective communication
system.
This heterogeneous group has to work together as a team to render a coordinated patient care service.
Coordination of activities, is necessary to integrate the hospital’s social system. Every employee of the hospital
therefore has to know in clear terms his role and the role of others in the set up and it is the administrator who
will have to shoulder the responsibility in this account.

Planning and Organisation

An effective communication system in the hospital is a major administrative responsibility well planned system
will enhance the coordination and team work of functionaries. Besides, it improves the hospital climate and
achieves cohesion among functionaries, by boosting their morale, motivation, and sense of belonging and
pride. The other major benefits of improved hospital communication are better public relations and improved
‘image’ of the hospital.

Classification of Hospital Communication System

Hospital communication system can be classified as :
1. Extramural, occuring between the hospital and the community
2. Intramural, occuring between the hospital staff and the beneficiaries within the hospital,
which includes the communication that occurs amongst the staff themselves.
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Extramural communication
The contact of the community and the hospital are through various channels, it could be personal, telephonic,
mail or mass media contact. The specific areas of the hospitals where such contact are very common are :

1. Enquiry Counter
2. Admission office
3. Administrative office
4. Public relations office
5. Telephone exchange
6. Service outside the hospital, like mobile hospital, relief camp and sub-centres or extended hospital
care through domicilliary service
7. Patient information booklet

Hospital Administrator needs to be aware of these vital areas of contact with the community and it is the
responsibility of the hospital management to improve communications and maintain a high standard to
enhance the image of the hospital. In the context of universal Primary Health Care and role of hospitals in this
respect and also modern day marketing strategy of the hospital, extramural communication assumes vital
importance.

Among functionaries and beneficiaries

Communication with the patient care beneficiaries occurs almost in all areas of the hospital, like administrative
department, clinical care area, supportive services and utility areas. Some of the important aspects of this type
of communication, which should attract the attention of the Administrator are, sign posting, guidance service,
information booklet, hospital atmosphere, public address system and audio visual aids.
Sign postings : These need to be located at strategic places to guide the beneficiaries and functionaries.
More than one language should be used for wider acceptability. The design should be eye catching, pleasing
and easily understood. Symbols used should confirm to the international standards. Colour coding system for
directional guidance will help the less educated beneficiaries.
Guidance Service : Commonly the Enquiry counter and the admission office of the hospital should provide
adequate guidance. Experience has shown the guidance provided by the functionaries of these places is
found to be inadequate and impolite and very casual in nature. To overcome this type of common short
comings, the incumbants in these areas are to be sensitised with periodic in service training and also
motivating by way of visit and exposure to some organisation which are functioning in other sectors like hotels
etc. Such personnel also require a course of instruction on interpersonal behaviour and politeness. Dealings
of these functionaries could make or break the image of the hospital. Larger hospitals could introduce a “May
I help you” service and located in strategic places to guide beneficiaries to their destination, without getting
lost. These guides could be part time workers or even volunteers from social service organisation or even
from neighbourhood association. They can serve the counters during the busy-periods of morning and visiting
hours.

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Information Book-let : An information booklet containing relevant information about the hospital set up, the
services provided, timings of different service areas will benefit the patients and relations visiting the hospital.
These could also be priced, if necesssary and these booklets could also be used as media for health
education.
Hospital Atmosphere : Cleanliness of the hospital, good seating arrangement and other utility services like
drinking water, toilet facility, good linen and dietary services communicate to the hospital users in a much
better ways, what other modes of communication cannot possibly achieve.
Public Address System : Use of Public Address System and other audio visual aids at the waiting areas will
enable the Administration to provide health education, during the period of waiting for consultation.
Films on health education and Family Planning and other care related subject may be screened during waiting
period, especially at the antenatal clinics. Closed circuit television (CCTV) may also be used in the wards for
entertainment and health education of hospitalised patients. These facilities of closed circuit TVs can always
be gainfully utilised for flashing out news to hospital personnel in the event of any fire and evacuation of
people and even in situation like requisition of doctors for emergency medical care need.
Suggestion system : A well organised suggestion system will enable the Administration to get feedback from
the patients. On the basis of these suggestions, improvements in services could be made, based on their felt
needs. A presently located and displayed suggestion box in strategic areas like OPD and other service areas
is a very effective system of receiving feed back from the service users. It is to be ensured that all such
suggestions are open and suggestions or grievances are responded to by a designated officer on a regular
basis.
Among functionaries and beneficiaries : The different media of communication used among the hospital
functionaries may be oral, written, electrical, telecommunication and electronic media and each of such media
are to be used depending on the target group or content of the message and nature and urgency of
communication.

Oral media : The commonly used devices are :

1. Informal talks to a group of employees
2. Meetings and conferences
3. Planned appointments, wherein the administrator meets different hospital staff in groups to review
their activities periodically.
4. Mass meetings enabling face to face contact with all employees at one time. The Administrator could
also make important announcements in these meetings. Suggestion regarding the hospital as a whole
could be received. Feed back and response to such meeting are to be followed up on the subsequent
meetings.
5. Informal employee contact occurs when the Administrator meets them during festivals or social
gatherings. This is a very effective way to improve interpersonal relationship.
6. Counselling is used for face to face problem solving by the senior functionaries at every tier of
hierarchy. It helps two way communication and lessons tension amongst the functionaries.

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Written media : Some of the various written media used in hospitals are :
1. Letters, memorandum, circulars, reports
2. Standing orders : These are required for each category of functionary and should be laid down in
writing in a clear unambiguous language.
3. Hand book : It should contain general information regarding hospital organisation and subjection of
organisation with its functions. Employment policy, service conditions, benefits and welfare measures
of the employees should be included in such a document.
4. Manual : Technical manuals should be published for each category of employee and made available
at the work station. It should contain details of policy and procedures adopted in the hospital and also
various steps for any standard procedures.
5. Hospital magazine : It enhances growth of informal organisation and improves morale of the
members. It should be published periodically and regularly, without discontinuity. It should also ensure
education and information balance to justify the publication, and entertainment balance to hold the
employees’ interest. The other criteria are reader balance (age, sex, education), content balance
(news, features, humor, illustrations)and length of article balance (long and short articles). Question
and answer section will evoke reader interest. Bi-lingual publication is necessary.
6. Bulletin Boards : These need to be located at strategic places, and where the employee contact is
maximum. Contents which are displayed should be current and outdated materials need to be
removed promptly. It could be gainfully used to display greetings to employees from the Administrator,
like “Happy New Year”, “Happy Diwali”, “Happy Christmas” and others.
7. Information Racks : Well informed employee is a reliable employee. Information racks, containing
reading material on general subjects; could be maintained in rest room, recreation room and tea club.
8. Pay insert : Hospital where pay is disbursed in “pay packets” could insert seasonal greetings, to
improve the morale of the employees.
9. Suggestion System : Reward oriented suggestion system will kindle the creativity and initiative
amongst employees. Suggestions found worthy, are to be implemented to motivate and employees
participation for organisational development.
10. Annual report : The larger hospitals should publish annual report indicating its scope and function
and plan of activities. It should publish annual report. It should incorporate activities and achievements
of the hospitals. It will enable the employee to know the role played by the individuals in these
achievements.

Electrical and Mechanical Media : The following devices are available for use in hospitals in present day set
up:

1. Public Address System : Centrally controlled public address system enable the administration to
make important announcements, especially during emergencies like fire or building collapse.
Selectively these can be used for car calling system from parking area and so on.
2. Audible codes : These are meaningful codes used to alert individuals or group of individuals like
cardiac team, emergency team etc. in emergencies or a disaster situation.

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3. Light Signalling system : Staff selection by use of lighted numerical displays can also be used to
contact a particular person or group of persons in emergencies in the hospital premises.
4. Movies : Inhouse produced or hired movies could be used for inservice training of hospital
employees, especially the lower category, to enable them to understand procedure of certain activities
and hospital ethics.
5. CCTV : Closed Circuit Television are increasingly being used for teaching, inservice training, health
education and security in the hospital.
6. Fire Alarm : Manually operated fire alarm needs to be located at vulnerable places of the hospital.
Automatic fire detection and alarm system should be incorporated in larger hospitals.

Telecommunication and Electronics Media : High tech electronic media including telephones, intercoms,
paging and EDP has established a niche in a modern hospital communication system.
Telephones : Far reaching advanes have been made in telecommunications in the recent years. From the
manually operated exchanges, we have now come to electronic and satelite beamed exchanges. However,
effective utilisation of this system in hospitals has been inadquate in most of Government and public sector
hospitals.
1. Public telephones : The larger hospitals should have more than one public telephone booth
particularly for the general public, the patients and their relations. Atleast one such telephone should
be located in such a way that a person on a wheelchair can use it, unaided. Maintenance of these
telephones, and provisioning of phone directory should be ensured.
2. Exchanges Switch board accommodation should be carefully chosen and made comfortable, since
the telephone operators will function better in congenial surroundings. It should be of adequate size,
well ventilated, and preferably sound and dust proof. Operation of switch board is a specialised task
and only trained people should be appointed. Many telephone calls to the hospital are from persons
who are nervous and worried. Such persons need to be handled with kindness and sympathy. Hence,
the operators should be polite, sympathetic and helpful. The operators should know about the hospital
set up and functioning, since they all act as enquiry counter in a hospital set up. Orientation and
refresher courses will enable them to be aware of what is happening in the hospital.
3. Functioning of Telephones : Installation of telephones does not mean efficient communication. The
sets should be functional round the clock. A system to check periodically the serviceability of
telephones should be advised. Some important telephones need to be checked every day particularly
for the designated medical officers for emergency care need. Faults detected during such checks and
faults reported by users should be rectified in the shortest possible time. All complaints should be
registered and timed so that an effective monitoring of the maintenance service is ensured.
Intercom : A survey conducted by one of the hospitals in USA revealed that 84.0% of telephone calls was
among 20% of functionaries. Introduction of intercoms relieved the exchange load by 84% and improved its
functioning both economically and also for easy maintenance.
Intercom system is used for inter-departmental and intra-departmental communication, independent of
telephone exchange.
Some of the important uses of intercom in hospitals are :
1. confidential communications

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2. group call facility
3. automatic connection, if the desired number is engaged.
4. point to point connection through the existing a/c electric lines.
5. Connection of incoming public call
6. Paging facility

Paging system Quick location of essential hospital staff during emergency is vital for prompt patient care.
Even during non-emergency period quick location of key hospital functionaries, will increase the efficiency of
hospital functioning. Most of the conventional staff locating systems resort to telephones, lighted displays,
audible codes and messenger service. Developoments in radio and electronic technology have improved staff
location system and are easily and economically installed in our hospitals.
Two types of paging systems, namely, magnetic loop paging and radio paging are currently in use.
Magnetic loop system consists of one or more loops of cables embedded in the structure of the building and
connected to a control centre. When a signal is initiated at the control centre, the current passes through the
cables, producing magnetic field around the loops. Pocket receiver responds to the particular signal, and
produces a continuous or intermittent high pitch tone or beep. This alerts the page holder, to contact the
control centre to receive the message. The range of magnetic loop is only 6 to 7 meteres. Double loop gives
better reception than single loop.
Radio paging system uses low, very high or ultra high frequency transmission. The range is 2 to 5 km. and
even more with newer technology boom in our country.

Success of the Paging System : Success of this depends on the following factors :
1. Cultivation of page culture among the page holders. The system should be taken as a tool for efficient
patient care, and not as an extra load. It is an emergency oriented system. “Page Boy” needs to be
carried by the page holder on his person, and not locked up in cupboard.
2. Page calls should be confirmed to the control centre and it has to be impressed upon the page holder
that the areas of functioning of the “Page Boy” lies with the page holder only.

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 CHAPTER VII

RECORD MANAGEMENT IN A HOSPITAL

Records management is a programme that involves the functions of creating, administering, retaining,
submitting and destroying record, Herbert Hoover has rightly mentioned the advantages of proper records
keeping when he says. “A business decision is only as good as the facts on which it is based.” Records are
the memory of the internal and external transactions of an organisation. By external transaction we mean the
correspondence between the organisation and its clients - beneficiaries as well as supporters. By internal
transaction is meant the dealings on external transactions by persons in the organisations at all levels.
Records contain a written evidence of the activities of an organisation in the form of letters, circulars, reports,
contracts, invoices, vouchers, minutes of meeting, books of accounts, etc. Thus, the records management is
concerned with the retaining, submitting and destroying of records. The proper maintenance of these records
in right quantity and quality is the essence of records management. The success of this record keeping would
be reflected in the timely availability of all the records. In the context of medical records, Dr. Mc.Gibony had
said “A cronicle of the pageentry of medical and scientific progress is found in the hospital records. There
may be found the running story, disconnected it is true, of the drama, the comedy, the mystery, the miracles of
medicines and hospital of the Twentieth century.
The medical record is a clinical, scientific, administrative and legal document relating to patient care in which
is recorded sufficient data written in sequence of events to justify the diagnosis and warrant the treatment and
end results.

Essentials of records management

1. Comprehensive : the records should be such as can be easily understood when retrieved back for
planning, policy-making and decison-making. The language used should be simple and
understandable.
2. Properly Planned : The records should be screened at regular intervals of time to weed out the
information not required for future. In this way we can reduce the paper work to twenty five percent.
This would indirectly help us in locating the desired information quickly.
3. Economical : We should manage the records economically so that we may achieve more with
minimum efforts.
4. Accurate : The records should be accurate otherwise its utility would be doubtful.
5. Timely : The time taken in retrieving the information should be as short as possible. Reducing
retrieval time is essential for effective materials management.
6. Classification : Records must be classified to be of practical use. The classification should be done
either on the basis of subjects or chronology.

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It should be :
1. Serve specific needs
2. Have specific objectives and purposes
3. Be kept to a minimum with respects to number, scope and content
4. Be designed for least expensive handling
5. Be upto-date
6. Be worth their cost
7. Be related directly to tabulations and reports that will stem from them
8. Be available when needed
9. Be considered valuable by supervisors and line management.

Contents of Medical Records

The medical record is a clear, concise and accurate history of the patients life and illness written from the
health and medical point of view. The story of the patients’ illness narrated by the patient, observations made
by nurses and the comments and treatment given by the doctors are recorded in the medical record. Thus,
the medical records comprises three general sections.
1. A general section covering administrative and personal data. The socio-economic record of the
patient includes, the name of the patient, father’s or husband’s name, age, sex, religion, income,
patient’s address and the address of nearest relative. Other administrative informations which are
included are the data of admission, the in-patient number, the name of the nursing unit and bed
number. This sheet is prepared in the Central Admitting office.
2. A nurses section where in are noted the observations of the trained nurses and the detail of treatment
administered. This part of the medical record consists of graphic charts relating to temperature, pulse,
respiration, blood pressure and any other observations maintained, intake output chart and medicine
administered;
3. A medical section containing statements on the studies, observations, conclusions and activities of the
attending doctors or of the intern or the resident working under him. The medical section of the record
consists of the entire medical history of the patient. It contains :

History sheet
Physical examination sheet
Provisonal diagnosis
All the investigations reports
Physicians orders sheet
Treatment, medical or surgical
Anaesthesia record
Operation record
Obstetric record
Consultancy report
Progress report

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 Final diagnosis
Discharge summary
If death-cause of death
Autopsy report

Classification
The classification of records would depend upon the nature or organisation. However, it would be useful to
classify records into the following four - fold classifications :

a. Vital records - Protected and preserved for a long time

b. Important records - Not currently in use but are of high value to retain
c. Useful records - Currently used correspondence
d. Transit record - Useful for only a short period till the subject is alive or active

Mechanism of Records Management

There are two basic instruments through which we create and maintain records, i.e. form and files. Let us
discuss in brief about these two mechanism.
Filing : Filing is the process of classifying, arranging and storing records systematically so that these can be
easily retrieved. Neuner and Hayaes defined filling as the systematic arrangement for keeping of business
correspondence and records so that these may be found and delivered quickly when needed for reference in
future. George R. Terry defines, filing is the placing of documents and paper in acceptable containers
according to some pre-determined arrangement so that any of these when required, may be located quickly
and conveniently.
Filing arrangement : The files can be arranged on any one or more of the following basis depending upon the
need of the organisation :

1. Alphabetical order
2. Numerical order
3. Geographic order
4. Chronological order
5. Subject-wise

Many variations and innovations in these five general systems of filing have been developed, e.g. the use of
colours, sound and special visual devices.
In the offices of the Government of India and State Governments, filing system is based on the subject
system. This system has many defects-lack of uniformity, lack of clear-cut demarcation and time-consuming
tracing process.
The question of filing system was examined by the Administration Reforms Commission and they
recommended the functional filing system. The proposed system can be elaborated as follows :

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a. The main subjects under the functions, say establishment, common office service, budget, are first
listed under functional group headings which are respectively identified by capital letters “A” “B” etc.
b. Each main subject or main head under each functional group is assigned a consecutive Arabic
numerals beginning with “I” which may go upto “99”.
c. Similarly, the sub-subjects or sub-heads under each main head are assigned consecutive, Arabic
numerals beginning with II which also could go upto “99”.
d. The identifying subject numerals and sub-subject numerals are separated by “O” refer the main head
while that to the right to its sub-head, topic or aspect.
e. Files opened under the same subject etc. are given serial number 1,2 and 3 and so on and separated
from the groups of numerals by an oblique.
f. The year in which the file is opened is shown separately from the file number by an oblique.
g. At the end of each file code number is to be indicated with the abbreviated form of a section or a unit.

File Indexing

File indexing is a key to locate the files. Index is a reference list used for locating a particular document in the
filing equipment. The following types of indexing may be used for locating.
Vertical card indexing
Visible card indexing
Visible book indexing
Loose leaf book indexing

Centralised and Decentralised filing system

Centralised filing system is one, where all the filing equipments and personnel are located in a single area of
the office, accessible to all departments by messengers, controlled by a centralised plan or index of the filing.
Decentralised filing system also called departmentalised filing system is one, where each organization makes
its own arrangement for filing.

Advantages
Advantages of centralised filing area :
1. It ensures uniformity and standardisation of the filing equipment and procedure which can help in easy
and quick location of records.
2. It eliminates the need of duplication and distribution to all concerned sections. It encourages
completeness of related documents.
3. It enhances economy of time for both file users and file personnel because there is only one place to
send material to be filed, and one place to find it.
4. Control is exercised more effectively since one person or group alone is responsible which minimises
oversights and loss of valuable records.
5. It promotes economy of filing equipment and floor space.

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To be most effective a compromise has to be struck between centralised and decentralised filing systems.
Decentralised filing should be kept to a minimum.

Advantage of records keeping

The records help the management in the following ways :
1. Help in sound decision making : Effective decison making depends to a great extent upon the
adequate information provided by the records and availablity of these records in time.
2. Effective channel of internal control : Records are very important to ensure internal control. Records
can help in minimising chance of error and prevent occurence of fraud and corruption.
3. Facilitate evaluation of Corporate Performance : The records can help in evaluating the performance
of an organisation during definite intervals of time and different periods. Besides, records can help in
comparing the performance of organisation in the same line.
4. Promotes efficiency of operations : The effective operations of an organisation depend to a great
extent upon the speed, and accuracy of the records. Records keep the wheels of the organisation
moving fast.
5. Fulfils Statutory requirement : Records are also kept in compliance with the provisions of different
statues, e.g. maintenance of statutory books under Indian Companies Act, 1956. Besides, records are
needed in the event of litigations, disputes or claims.
6. Futuristic Approach : Analysis of records help in ascertaining future and trends which can help in
better policy making and planning.
The fundamental reason for promoting maintenance of an adequate medical record is its utility to good patient
care, to the doctor, to the hospital and towards medical education and research. Besides, the legal
requirements of the hospital medical records are also to be completed.

USE OF HOSPITAL STATISTICS FOR MANAGEMENT

The Medical Records Department in a hospital is mainly responsible for the collection as well as analysis of
the data to ensure utilisation of the hospital for patient care. Such data has immense value for the day-to-day
management of the hospitals as well as future planning of the hospital services. Let us mention some of the
important information which is used by the hospital management to enhance the hospital functioning.

1. Death Rates : Hospital deaths include deaths of patients admitted to the hospital. Death are generally
classified into two categories, i.e. the Gross deaths and the net deaths. Gross deaths include all the deaths of
admitted patients while Net deaths exclude the patients dying within 48 hours of admission. Net deaths in a
hospital is a reflection of the working of the hospital. Net deaths rate is calculated as follows :

Number of net deaths during a period of time

Number of total discharge during that period of time x 100

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In an average net death rates range between 4 to 6 percent. Any gross variations from the normally expected
net death rate indicates an abnormal phenomenon which should be analysed by the hospital management.
Such deviation can either be due to natural causes or due to failure on the part of one of the service areas of
the hospital. In the case of later correctives need to be applied and death rate brought back to the normal
expected range.
The use of net rates for enhancing the efficiency of the hospiotal services is not limited to the overall net
death rates of various deparatments and units of the hospital. As such, the hospital management can keep a
track of the performance of each and every unit/department of the hospital by keeping a track of their net-
death rates. This is being practised in most of the teaching hospitals but not in district hospitals.

2. Average Length of Stay

The length of stay of patients is another important hospital indices. For purposes of calculations, the day of
admission of the patient is always taken into consideration and the date/day of discharge is always ignored
irrespective of the time of admission or the time of discharge. Through the process of discharge analysis, the
average length of stay of patients discharged during a particular period of time is worked out not only for the
whole hospital but also department-wise/unit-wise. The aim of this information is to locate the unnecessary
length of stay and to discourgage it. But reducing the unnecessary length of stay more patients, can be
admitted to the hospital and avail services. This information therefore, is not only important from the economic
point of view but is also important from the community services point of view. Average length of stay is
calculated as follows :

Total length of stay of discharged patients

during a period of time x 100
Total discharge during that period of time

3. Bed Turnover Rate

Bed turnover rate indicates the number of patients who have been given services per bed per year. It is
calculated as follows :

Total number of discharges during a year x 100

Total number of authorised beds

Bed turnover rate is determined by the Average Length of stay as well as the time intervals between one
discharge and successive admissions. This time interval is known as T-interval. Also bed turnover rate as well
as T-interval are important indicators of the planning utilisation of hospital resources.

4. Bed Occupancy Rate

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Bed Occupancy rate gives the relationship between the availability of facilities and their utilisation. Optimum
bed occupancy is treated to be between 85-90 per cent. An occupancy of over 90 percent means stress is on
one or another area of the hospital. When the bed occupancy rate is 100 or more than 100 percent, it is a
case of dilution of hospital facilities and lowering of efficiency. Bed occupancy rate can be worked out for the
whole hospital as well as for each discipline/unit of the hospital as under :

Average daily census during a period of time x 100 =

Number of authorised beds

ISSUES AND PROBLEMS OF RECORDS MANAGEMENT IN HOSPITAL

Based upon observation, discussion and analysis we give here the main problems faced by hospital
authorities in records management and suggest probable solutions.
A. Use of out-dated forms : Need of constant revision : At present, forms being used in most of the
hospitals are not in tune with the improvements in new technology and scientific developments. Some
of the columns in the forms are obsolete while many important columns are not available. It is thus
essential that forms must be revised constantly to keep them up-to-date. The ultimate purpose of
tabulating the data from forms becomes insignificant as the forms do not convey the desired
information. It must be statutory for every organisation to get their forms reviewed after every three
years either by the internal O & M cells or central O and M organisation.
B. Shortage of experienced personnel : Need of trained personnel: The hospital authorities do not
attach as much weightage to records management as it is done to other sources. This gives less
emphasis in terms of resources to this activity. There is generally shortage of trained personnel to
handle records. It is suggested that adequate experienced personnel may be appointed to take care
of records management.
C. Lack of Planning Storage of In-active records : Need of effective storage and control of inactive
records : Storage should be done at a proper place where proper conditions of temperature,
circulation of air and humidity are provided. Mostly, we find dirt and dust in this area. After storing the
records, indexing is necessary to locate the record for retrieval. We can reduce congestion and cost
through the control of inactive records. This would indirectly help in finding the relevant record
immediately. The Secretariat training school in its report on Work Study (III) suggested the following
improvements to make effective control of the inactive records.
a. Keep a table of the important contents of a file on the cover or a slip. This will facilitate location of
contents which the title of the file or its number may not help to locate speedily.
b. Keep documents like records, separately from the files. This will reduce the bulk of the files and assist
speedier location and use of documents not related to correspondence and notes.
c. Papers containing information may be carried in a third folder separately from notes and
correspondence.
d. Persons and dealing with “information” should compile the vital elements of information and keep it at
in cabinets for ready reference. Simple “Home made” devices can be invented to carry such
information and reduce dependence

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e. Keep a small alphabetical register of important files, cases reports and other documents in your
personal custody for more purposeful follow up, records location and speedier disposal.
f. Need of effective handling and processing of records
Handling and processing of records should be simple and should not consume much time and
personnel resources. The expert handling and processing of records would depend upon the design
of registry and its place in the office layout, rational and well laid out procedures and the training of the
personnel responsible for job.
g. Evaluation of records handling : There is a need to check the records frequently. A random checking
can be done with the help of the following two ratios.

1. Accuracy Ration : No. of reference not found

No. of reference found

2. Activity Ration : No. of references found

No. of documents filed

If the accuracy ratio is half or one percent, it is thought to be excellent. If it is three or more percent, it
is in a poor state.
If the activity ratio is below ten percent, it exhibits that there istoo much inactive material. If it is
between ten to twenty per cent, it means that there is a need of improvement while it is more than
twenty percent. It shows that the records are in bad shape. Such evaluations can help in improving the
records.
h. Need of Determination of Records Retention Period : There is no hard and fast rule that specific
records should be retained for specific period of time. The decision regarding the retention period
should be decided by the organisation basing on its needs, requirements and objectives. The records
which help in tracing the history of the organisation and help in policy-making should be kept for long.
The unwanted records should be destroyed to save time and resources.
i. Transfer of records :Transfer of records entail two stages i.e. (i) dating of unimportant records for
destruction and ultimate disposal, (ii) moving the records from active to inactive files and from there to
storage area. In a complex organisation we can make use of micro-films. Micro-films can help in
space saving, safe preservation and clean and easy handling. Besides, these reduce the risk of fire
hazards and chances of loosing document.

Need of improving quality of medical records : Quantitatively the system of medical records is fairly
satisfactory but qualitatively the medical records need lot of improvements. It is recommended that more
efforts should be made by the hospital management, all clinicians as well as medical records officer towards
improving the quality of medical records.

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MEDICAL RECORDS DEPARTMENT

In view of the character and complexity of the modern data gathered in study of the illness of the individual
and its management, every hospital needs to have a well organised Medical Record Department/Section.
1. The department should be headed by a trained Medical Record Officer.
2. Medical Record Committee for policy making body and also to draw regards to the method of case-
sheet writing, method of filling and maintenance, use of data, use of new technique. Any other policy
matter related with the type of form to be used (whether unit system or serial, unit system seriel has to
be used etc.) will be at the discretion of the committee.
3. The Medical Record Committee should be chaired by the Chief of the hospital. It should also be
represented by Senior Consultant from Medicine, Surgery, Gyndecololgy, Pathology Deptt. and Head
of Nursing Services. Rotation of the members can be introduced to bring new faces after a period of
2-3 years.
4. The Committee should meet once in month and review samples of the complete case-sheet to ensure
the quality of care provided in the Hospital. TheCommittee should also review the records of cases
who have died in the hospital which may be a starting point of long term goal of introducing “Medical
Audit” and a step towards quality assurance in the hospital.
Following are the areas of the hospital from where the Medical Records are initiated reception, outpatient
department casualty or emergency department, admission office, ward/ operation theatres/ labour room. In
view of these, facilities have to be made for stationaries, sufficient in numbers and standardised format of
different nature/ type so as to be added in case sheet. When computer terminals are available the
responsibility of feeding the information be also clearly assigned.

Operational Management
a) Medical Record Officer who is over all incharge of the department. He will be responsible to
implement the decision taken by medical record committee. All staff will work under him/ her
administrative control.
b) He will issue duty roaster, indicating shift of duty so that department funtions round the clock. It is also
desirable that his staff and the admission office Medical record technical staff should also be in
position to retrieve the old records of patients and also many other matters relating to medico legal
cases etc.
c) As mentioned earlier under heading, the function of the three sub-division of medical record
department are
c.1. Admission office : i) Reception and enquiry
ii) Reservation of beds in the hospital
iii) Preparation, identification of data
iv) Social data
v) Assignment of patients (to OPD or ward)
vi) Notification of disease to
public health authorities

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c.2 Ward or Nursing unit (following records are initiated)

i) History
ii) Examination report
iii) Diagnosis report
iv) Investigation form
v) Treatment given are recorded
vi) Progress notes are added every day
vii) Evaluations are mentioned
viii) Discharge/death report are filled
c.3 Record office: The case-sheet are to be collected from patient care areas after the discharge of
patient by medical record department at the earliest. The following are the flow of activities of the
medical records in the record office:

i) Assembling of record sheets (It should

be arranged as per order issued in
medical record mannual).
ii) Checking (Deficiency) in terms of
completion of the record etc.
iii) Incomplete record control (follow-up of
the completion record is very essential).
iv) Coding of all diagnosis according to
International classification of diseases.(ICD)
v) Discharge analysis and preparing
statistics for physician/medical record
committee.
vi) Reporting and notification of Hospital
Statistics to government/public health
authority.
vii) Issue of old records to physicians/wards
whenever required.
viii) Makes the record available for life
Insurance/health Insurance and to the
court.
ix) Filling/storage.

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OWNERSHIP/LEGAL ASPECT

a) Medical record is the property of hospital and medical record officer is the custodian of it. It is medico-
legal and also the administrative document. It should be kept as long as is required. However, due to
shortage of space, if there is need to dispose off the record, the following guidelines may be followed:

i) Retention period (10 year for Inpatients)

(5 year for outpatients)

ii) If the fund permits some important papers for medico legal and administrative purpose as
case-sheet and discharge summary etc. could be microfilmed, before destroying the inpatient files. In
case of OPD, only registration books may be kept for 10 years which will be helpful for verification of
OPD attendance by the patient in medico legal cases.
iii) In modern days the data are being increasingly stored in computer, which can be
used for teaching/research and treatment purpose. But it has got no legal significance due to
Consumer Protection Act as on now.
iv) Bradma system for printing of vital data for patients in some of the hospital which has
a captive clientale coming to the hospital regularly.

b) Personal Document

i) The medical record is a confidential and privilege communication between the Medical
professional and the patient so any of its contents can not be communicated without the patient’s
consent. There are few exception like, when court of law summon for it, and it can also be a part of
evidence.
ii) Life Insurance/Hospital Authority/ Health Insurance authority which can summon such
document for the settlement of dues etc. The hospital authority Director has a right to pass the
information needed which can fulfill such requirement.

Loss :
All medico-legal case sheet must be kept separately and in safe custody. The other records can be kept in
open-shelf. Any loss of medical records should always be promptly enquired and the matter should be
brought to the notice of the officer incharge for records for any other administrative action. As indicated the
Medical record is a very valuable document for patient care services. It helps the hospital administration by
generating administrative and clinical data and information. It is an idea for providing data/information. It is
therefore indispensible for medical education and research, so it is imperative that all clinical heads should
train the Junior doctors and senior residents how to write medical records. It is also equally important to
complete it and write in good hand-writing so that the records can be read easily and if possible the hospital
should try to introduce typing facilities for operation notes/reports, and details of the discharge summary. It will
go a long way in improving medical care.

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QUALITY OF PATIENT CARE (METHOD OF EVALUATION) :
There must be a built in system to evaluate the quality of service being rendered in the hospital. It is called
Medical audit and it is a part of medical record activities or in some places, it is called peer review. The
concept of medical audit implies the review of medical records of the patient so as to see that standard
medical treatment is followed. Such review may also point out lapses in clinical services or the efficiency of
hospital administration.
The introduction of such review system of medical records are increasingly felt by the hospital administration
to ensure quality care of patients in the hospital particularly as a safeguard against consumer protection
liabilities although ithas not been widely accepted by medical fraternity.
It should be introduced so that it gives satisfaction and guidance as how to increase productivity and maximise
the utilization of hospital resources, and at the same time it will highlight the adequacy of facilities which
contribute towards better patient care.
As a first step such review of patient care through medical records could be called patient care evaluation. The
medical record department should take the responsibility to develop the methodology depending on the type of
the hospital and its services.

Factors Influencing Hospital Care

General
There are number of factors which influence the quality of hospital care. The presence or absence of these
factors or extent to which a particular hospital tries to achieve better standards will indirectly reflect the quality
of hospital care. Some of the major attributes which needs to be assessed for quality of hospital care area are
as follows :
a) Hospital Staff
i) Hospital staff is the key element in the provision of patient care services. Quantitative adequacy and
their qualification with experience are of prime importance in any type of services, be it clinical care,
nursing care or functional efficiency of support and utility service areas. It is better to establish certain
standards regarding the number of doctors or nurses to that of number of patients or a technician for
so many tests etc. These numbers can be worked out with the help of methods like work study, time
and motion. Standards for Indian Hospitals about the number viz-a-viz the hospital bed strength has
been worked out by Bureau of India Standards and are published regularly. They should be assigned
jobs. The qualification and experience of staff are also to be laid down depending upon the
technicality required for each job. Better qualified and experienced personnel will increase the quality
and quantity of work output.
ii) A properly laid down system needs to be introduced to know the turn-over, absentism rate, etc. so as
to assess the satisfaction rate of the employees. Only motivated workers can produce good work
outputs and principle of personnel administration applied to in the organisation should be turned to
that direction.
iii) Training : There should be continuous on the job/ or in service training programme for all categories of
workers which has got important contribution for the efficiency and effectiveness of the workers.
There should be organised/structured training programme so that career developments of workers

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 can take palce in the right direction. It will bring discipline and satisfaction and keep the morale of the
hospital workers high.
b) Clinical and service facilities
Adequate and appropriate clinical facilities can only take care of all types of clinical problems. Better facilities
will improve the quality of medical care. The clinical units must be complimented adequately by diagnostic
and supporting departments like- Imaging unit, Pathology, Blood Bank, CSSD, Linen service and so on.
These department should not only be established, but also need to be well organised to provide effective
service to clinical areas. Thus, an evaluation will give information as regards how many times a operation has
been cancelled due to non-availability of linen or blood or other items and how many times treatment was
dalayed because of non-availability of reports or drugs and other supplies.
c) Use of facilities like Bed :
i) Bed occupancy Rate : The average percentage of occupancy of the hospital beds.
ii) Admission : Total number of admissions in a given year against the beds available.
iii) Performance budget: Comparision of performance or work output in relation to the budget
provided.

d) Quantum of Work
Work load also affects the quality of care and services. Augumentation of resources should therefore be in
accordance with the workload and projected according to trend of patient load.
The best datas required are:
i) OPD cases (old + new)
ii) Casualty cases (old + new)
iii) Number of operations performed (Minor + major)
iv) Number of Investigations carried out
v) Number of (Units of) Blood used.

e) MEDICAL CARE
Medical care rendered by clinical service can also only be evaluated in retrospect through analysis of clinical
records (medical audit). It is the review of quality of professional work or medical care rendered. It is as
important to a hospital as that of financial audit to business activities. As a business manager justifies the
financial expenditure, the physician should also be called upon to evaluate the clinical process which may
have led to deaths, complications and poor results like hospital infection or prolonged hospital stay etc. These
results are to be obtained from medical record, so emphasis has always been given for good medical record
which should be complete, accurate and adequate.

Planning and Organisation

Planning and organization of medical care evaluation is not so difficult as it consists of a complete or partial
review of medical records of discharged patients (including deaths). It needs systematic analysis to
determine:
i) The completeness and adequacy of record

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ii) The correctness and substantiation of final diagnosis
iii) The errors in diagnosis, treatment or judgement and
iv) The possible causes of complications and poor results.

METHOD
It may be practical or even desirable to examine the documents of each and every patient, so that specific
problems and any deviation of clinical care outcome of patients. These may be :
i) Long stay cases over 30 days
ii) Cases of increased incidence of a particular complication.
iii) Cases where post operative complications have arisen in more frequency
iv) All deaths beyond 48 hours. Some of important questions can be passed like :
1) Has summary of the case been recorded at the time of the discharge?
2) Do the clinical findings, laboratory and X-ray reports support the final diagnosis?
3) Was there any delay in initiating the treatment?
4) In case of death, whether it was expected, justified or not?

COMPILATION OF STATISTICS
Some statistical parameters commonly used for comparing the standard of work performed in different
hospitals, or the same hospital for different periods. Some of such figures shown can be taken as optimal
figures and attaining such figures in hospital speaks that the hospital services are relatively satisfactory. These
figures can also be worked out wardwise, unitwise, or even physician wise to keep constant which of efficiency
services.
i) Cross (Crude) death rate - 5%
ii) Net death rate - 2 to 4%
iii) Anaesthetic death rate - 1.5/3500
iv) Maternal death rate - 0.2%
v) Infant death rate - 1 to 2%
vi) Caesarian section rate - 4 to 5%
vii) Consultation rate - 15 to 20%
viii) Post operative infecton rate - 1%
ix) Occupancy rate - 80 to 90%
A proper, systematic evaluation gives value judgement on mainly interest of manpower.
Resources Used
Budget asked and fund provided in comparision to the services rendered can also highlight value based
information.

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 CHAPTER VIII

USE OF COMPUTER IN HOSPITALS

Introduction :
Comptuer technology is being used in applications ranging from guiding astronauts in space to monitoring
heart beats of patients. It is playing a major role as an aid to management in making available option that
never existed before. Computers have come to play an integral role in the daily operations of health care
facilities. Continuous development of software and hardware has fostered increasingly sophisticated use of
Electronic Data Processing (EDP) in health care institutions.
It is expected that sooner or later any modern hospital will be using computers and allied automatic eqipment
as basic tools in diagnosis, monitoring of patients conditions and as compilers and analysers of patient history
information.
As hospital administration involves a large number of activities directed towards patient care by heterogenous
people. It is a labour intensive organisation employing more than twice the number of beds. There is a change
in the clientale as well as their expectations. The utilisation of the hospital services has changed from curative
care to promotive, preventive and rehabilitative care. Cost of construction and maintenance have increased.
Personnel management has become a difficult task due to unionism. Under these circumstances, Hospital
Management has become a complex and demanding job. To achieve this, reliable, relevant and valid
information flow is necessary. Information flow in a hospital is direct information dealing with patient care and
indirect information dealing with administrative aspects. Automatic Data Processing (ADP) or Electronic Data
Processing (EDP) system is enescapable to manage the information explosion efficiently, to achieve the goal
of patient care. Now, it is a question of not “why” computers, but “how” computers could be used in hospitals.
Properly, planned, programmed and used, computer system will reduce cost of patient care and improve
patient management to a great extent.
Installations of computers in hospitals is not to be looked upon as a status symbol, but as a means of
promoting efficiency and quality of patient care. However, EDP is not a panacea for all ill, it is no substitute for
sound, and scientific administration.
The aim of introducing computers in hospital administration is to improve the quality of patient care procedures
and optimise the utilisation of resources.
Providing highly efficient medical care and improving the administrative machinery ensures optimisation of
resources utilisation which are the main objectives of introduction of computers in hospitals. Both these
objectives can be fulfilled if there is an efficient machinery for information handling, and its integration in the
organisation.
Application in Hospitals :

Gilbert (1967) recommended application of EDP in hospitals in the following four functions:
1. Administrative diagnosis and decision making (setting objectives, planning and organisation)

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2. Operational decision making and status reporting (assigning tasks, allocating and arranging for
physical distribution of non-medical and some medical resources, reporting and evaluating results)
3. Medical diagnosis and decision making
4. Medical research and decision making

The areas of application of EDP system in a hospital can be broadly classified into two major groups (Well,
1967).
1. Medical Functions :
a. Patient care requirements
b. Physiological monitoring (Patient to computer to nursing station)
2. Administrative functions :
a. Medical and hospital statistics
b. Business and related functions

The major areas of application of EDP system in administrative functions of a hospital are Decision Support
System. Information Resources Management, Micro-electronics and Networks (Pronti, 1983) and Human
Resources Management (Nelson, 1983).
Decision Support System : The Information currently available with Hospital Administration is inadequate
due to lack of a proper technique for integration of financial, statistical and clinical measures of peroformance.
Computers will help integrationof the information efficiently to improve decision making process.
Information Resource Management : Data and information are a valuable resource for hospital
administration. Information resource management encompasses the coordination and synthesis of many
varied functional activities of the hospital. The information resources in a hospital are all facilities, equipment,
personnel, supplies and other machinery needed to collect, store, process and disseminate, accurate, timely,
complete and relevant information to decision making and problem solving.

Micro electronics and Networks

Success of an organisation depends on its effective communication system. Electronic communication has
been found to be cheaper, quicker and more efficient than the present system which depends on voluminous
paper work.

Human Resources Management :

Sixty five per cent of hospital budget is spent on the personnel working in hospital. EDP helps in better
management of Human Resources, thereby saving time and money. Basic personnel data base, position
control, manpower planning, wage and salary administration, professional development, selection - promotion
- transfer decision support and productivity and analysis are some of the vital areas of computer application.
The level of computer support to hospital administration varies from the use of a single micro computer
recording to main-frame supporting many terminals at different departments recording bed status, outpatient
waiting list, patient master index, patient records, transfer, discharge, drug orders etc.

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During the past two decades, computer application in hospital administration has revolutionised patient care
activities. The information system has improved to provide uptodate and authentic information needed by the
Adminisrator, by integrating both Hospital Information System (HIS) and Medical Information System (MIS).
Pay rolls, financial transactions, personnel matters, stock accounting, inventory control, laundry and catering
services come under “HIS”. The two components of “HIS” are the administrative data of the patient and the
medical services data. Admission and discharge of patients, bed availability and utilisation, medical statistics,
medical records, cost benefit analysis, planning, education and research are the main components of
administrative data. Nursing services, central sterile supply department, scheduling of operations, drug
administration with minimum errors etc. are parts of medical services data. Besides, bedside monitoring and
compilation of investigation reports have lead to a dynamic process of evaluation and decision making for
management of the critically ill patient (Rindani, 1982)
Eighty basic applications for EDP system in hospitals have been identified by Thomas (1967). Some of the
latest developments in computer application in Hospital Administration are :

1. Admitting procedure:
a. Automated bed board capability
b. Real-time census capability
c. Generation of unoccupied bed list
d. Patient tracking capability
e. Enquiry capability

2. Patient Care Activity

a. Pre-admission data
b. Doctor’s orders
c. Nurses’ records
d. Outpatient result reporting
e. Census function
f. Service scheduling

3. Pharmacy Services
a. Producing patient medication profile
b. Monitoring of prescription for drug - drug interactions and therapeutic incompatibility
c. Unit - dose drug dispensing system
d. Perpetual inventory control
e. Complete material management procedure from demand estimation to controls

4. Appointment System
Total medical record (TMR) system allows variation in length of appointment time depending on the type of
case (new or old case). This system also helps a patient with or without preference for appointment (Herpok
et al 1983).

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5. Staffing Pattern
“Medicus System” is one of the latest developoments which automatically assesses the requirement of nursing
staff for wards depending on the condition of patients daily on a realistic manner (Gagnon, 1983).

6. Medical Records
a. Medical Record Abstract - Skeletal abstract by visual display
b. Delinquent Medical Record Control - keeps track of incomplete records and reminds the
clinicians
c. Patient Registration Data Base
d. On-line master patient index file - constant updating, in addition to giving new registration
number to old cases (Samuel, 1982)

Advantage of Computerisation :
Computers are used to collect pre-registration information ,schedule hospital visits, process clinical
information generated during hospital stay and produce abstracts of medical care delivered. This information
is stored for processing during subsequent visits, to decrease the time and effort required for initiating the
diagnostic and treatment procedure. Thus, more time and effort is made available to be directed to the actual
delivery of health care (Killingsworth, 1983).
The availability of disease and diagnosis related statistic, combined with those on the running of hospital, plus
the standard summaries make it easier to control medical documentation. The asserted information provided
by the computer facilitates research, thereby helping decision making. Laboratory results reach much faster
with quality control. Chronological control of radiological investigation avoids duplication, thus preventing
avoidable irradiation risk (Scherrer, 1983).
Computer data is used for management analysis. Hospital Administrators are developing new ways to identify
the products of their institutions - such as with case mix measures, and determining the resources consumed
in proportion of service rendered. In the personnel department, the computers helps in improving monitoring
and control of personnel costs, reduction in man hours spent in getting a particular assignment complete,
realistic forecasting in resource planning and better utilisation of staff (Nelson, 1983).
Computer terminals at nursing station have eliminated paper work, minimised medication errors and helped
the nursing staff to devote more time for patient care activities.

Methodology
Policy decision to introduce computer in hospitals should be taken at highest level. The planning should cater
to the unique objectives of the institution. The vital decision as to which aspect - patient care functions or
administrative functions - should be introduced first to be decided by the top planners. During the detailed
planning proceeds, the medical, nursing and ancillary staff should be taken into confidence by the
Administrator. Once the decision is made, a process of step by step introduction should be followed, learning
from experience. Selection of hardware (satellite terminals) and software should be done in consultation with
the technical team to suit our requirements and future expansion. The pre-use format of new forms to be

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introduced to facilitate computerisation should be done with utmost care and foresight, avoiding frequent and
adhoc changes.

Staff Resistance
For the uninformed, the computer is often a threat, the basis of threat varying from one category of staff to
another - the medical and nursing staff may consider it as a threat to status or authority; to the ancillary staff it
may be an impending threat to job. These threats should be dispelled to elicit the cooperation of the entire
hospital staff. Consequently, a programme of education, training and motivation is imperative to achieve
involvement and committment of all the staff members. The success of the system depends entirely on the
wholehearted invovlement of the hospital staff. Computerisation does not mean manpower replacement;
rather, it is added functions without any increase in manpower.

Role of Administrator vis-a-vis computer

Introduction of computer in hospitals does not mean that all problems will be solved by the computer. Even
though the computer could handle most of the routine and repetitive decisions, the Hospital Administrator will
still remain the vital decision maker on issues of vital importance and those that are non-repetitive. The
Administrator will not become obsolete. On the other hand, the continuing role of the Administrator will
become essential, since management will become more complex year by year, necessistating intricate
decision making.
Once the system is introduced, the Administration should be aware of, and avoid the common project failure
due to factors such as :
1. Data for input not available when required or not sufficiently accurate.
2. Laborious and slow data collection process
3. Frequent change in user requirement
4. Insufficiently used output
5. Resistance from staff

Conclusion :
In any document based system (like hospital information system), the document is always in some other place
than where one wants it to be (Barnett, 1977). The main aim of computerisation in the hospital is to ensure
that information is available whenever and wherever it is required in the quickest possible time.
The present manual (clerical) system of recording and record keeping in hospitals is a laborious and time
consuming process, resulting in non-availability of information in time - when needed most. Storage and
retrieval of records, admission procedure, patient location system, bed
occupancy status, bed vacancy status are the most common records needed on day to day practice which can
be retained. Another important benefit of computerisation in the use of internet facility used in leading
hospitals for reference materials and other information.

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