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KHYBER MEDICAL INSTITUTE PESHAWAR PAKISTAN

Standard Operating Procedures 2010

STANDING OPERATING PROCEDURES, KHYBER TEACHING HOSPITAL PESHAWAR

By: P&D-M&E

SOPs KTH 2010P&D Cell-M&E 2


Table Of ContentsDEPARTMENT OF MEDICINE..............................................................................................................................................6

SOPS FOR EMERGENCY TRAY...............................................................................................................................................6Emergency Tray Equipment..............................................................................................................................................6Emergency Medicines.......................................................................................................................................................7

SOPS FOR PRESCRIPTION OF DRUGS......................................................................................................................................8General Principles for Prescribing of Drugs...................................................................................................................8Administering intravenous drugs......................................................................................................................................8Administering Oral Drugs................................................................................................................................................8

SOPS FOR ADMISSION TO IN PATIENT CARE ON THE WARD.................................................................................................9Who Can Admit.................................................................................................................................................................9

SOPS FOR DISCHARGING THE PATIENTS.............................................................................................................................10In patient Consultation Between Different Units of the Hospital...................................................................................10

SOP FOR PRIVATE ROOMS...................................................................................................................................................11Admission Criteria..........................................................................................................................................................11Admission Process..........................................................................................................................................................11Private Rooms Services..................................................................................................................................................11

SOPS FOR CONSULTANT OPD.............................................................................................................................................11SOPS FOR WARD ROUND....................................................................................................................................................12SOPS FOR G.I. ENDOSCOPIES..............................................................................................................................................12

DEPARTMENT OF SURGERY..........................................................................................................................................12

INTRODUCTION...........................................................................................................................................................13ATTENDANCE, PUNCTUALITY AND LEAVE:............................................................................................................13Admission to Surgical units:...........................................................................................................................................13Admission to Private Rooms...........................................................................................................................................14History Sheets.................................................................................................................................................................14Duty Rotas.......................................................................................................................................................................14Academic Activities:.......................................................................................................................................................14Emergency Patients........................................................................................................................................................14Patient Preparation for Surgeries;.................................................................................................................................15OPD................................................................................................................................................................................15OPERATION THEATRE:...............................................................................................................................................17MINOR OT:....................................................................................................................................................................17WARD ROUNDS:...........................................................................................................................................................17DURG ADMINISTRATION:...........................................................................................................................................18INDENT BOOK:.............................................................................................................................................................18SAFETY MEASURES:....................................................................................................................................................18WARD CLEANLINESS AND MAINTAINANCE:...........................................................................................................18

DEPARTMENT OF GYNAE &OBSTETRIC....................................................................................................................19

INTRODUCTION...........................................................................................................................................................19ATTENDANCE, PUNCTUALITY AND LEAVE:............................................................................................................19Admission to Gynae Units & Labour Room:..................................................................................................................19Admission to Private Rooms...........................................................................................................................................20History Sheets.................................................................................................................................................................20Duty Rotas.......................................................................................................................................................................20Academic Activities:.......................................................................................................................................................20Emergency Patients........................................................................................................................................................21Patient Preparation for Surgeries;.................................................................................................................................21Postoperative Care:........................................................................................................................................................22OPD & ANC:..................................................................................................................................................................22OPERATION THEATRE:...............................................................................................................................................22WARD ROUNDS:...........................................................................................................................................................22DURG ADMINISTRATION:...........................................................................................................................................24



DISCHARGE:.................................................................................................................................................................24Labour Room..................................................................................................................................................................24CLINICAL AUDIT:.........................................................................................................................................................25DOCUMENTATION:......................................................................................................................................................25INDENT BOOK:.............................................................................................................................................................25SAFETY MEASURES:....................................................................................................................................................25WARD CLEANLINESS AND MAINTAINANCE:...........................................................................................................25RESEARCH AND CLINICAL TRIALS:..........................................................................................................................26

DEPARTMENT OF OTO-RHINO-LARYNGOLOGY (ENT).........................................................................................27

ATTENDANCE, PUNCTUALITY AND LEAVE:............................................................................................................27Admission to ENT units:.................................................................................................................................................27Admission to Private Rooms...........................................................................................................................................28History Sheets.................................................................................................................................................................28Duty Rotas.......................................................................................................................................................................28Academic Activities:.......................................................................................................................................................28Emergency Patients........................................................................................................................................................28Patient Preparation for Surgeries..................................................................................................................................29OPD................................................................................................................................................................................29OPERATION THEATRE:...............................................................................................................................................29WARD ROUNDS:...........................................................................................................................................................30DURG ADMINISTRATION:...........................................................................................................................................31INDENT BOOK:.............................................................................................................................................................31SAFETY MEASURES:....................................................................................................................................................31WARD CLEANLINESS AND MAINTAINANCE:...........................................................................................................31

DEPARTMENT OF OPHTHALMOLOGY.......................................................................................................................32

INTRODUCTION...........................................................................................................................................................32ATTENDANCE, PUNCTUALITY AND LEAVE:............................................................................................................32Admission to units...........................................................................................................................................................33Admission to Private Rooms...........................................................................................................................................33History Sheets.................................................................................................................................................................33Duty Rotas.......................................................................................................................................................................33Academic Activities.........................................................................................................................................................33Emergency Patients........................................................................................................................................................34Patient Preparation for Surgeries..................................................................................................................................34OPD................................................................................................................................................................................35OPERATION THEATRE.................................................................................................................................................35WARD ROUNDS.............................................................................................................................................................35DURG ADMINISTRATION............................................................................................................................................36INDENT BOOK:.............................................................................................................................................................36SAFETY MEASURES:....................................................................................................................................................36WARD CLEANLINESS AND MAINTAINANCE:...........................................................................................................36

DEPARTMENT OF PEDIATRICS & CHILD HEALTH.................................................................................................37

Admission Policy.............................................................................................................................................................37Ward Discharge Policy...................................................................................................................................................37Ward Round Policy.........................................................................................................................................................38Patients Investigations & Procedures Policy.................................................................................................................38Inject able Drug Policy...................................................................................................................................................38Ward Referral Policy......................................................................................................................................................38Ward Emergency Policy.................................................................................................................................................38

ACCIDENT & EMERGENCY SERVICES DEPARTMENT..........................................................................................40

Standard Operative Procedures.....................................................................................................................................40Dog Bite..........................................................................................................................................................................40



STANDARD OPERATIVE PROCEDURES..................................................................................................................................41General Instructions:......................................................................................................................................................41Medicines in casualty:....................................................................................................................................................41

STANDARD OPERATIVE PROCEDURES..................................................................................................................................42Trauma/Fire arm injury/Road traffic accident...............................................................................................................42Airway.............................................................................................................................................................................42Breathing:.......................................................................................................................................................................42Circulation:.....................................................................................................................................................................42Disability and deformity:................................................................................................................................................43AVPU System..................................................................................................................................................................43

Glasgow Coma Scale......................................................................................................................................................................43Exposure and Environment.............................................................................................................................................44Adjuncts..........................................................................................................................................................................44Vital signs.......................................................................................................................................................................44

MASS EMERGENCIES/BOMB BLAST INJURY/TERRORIST ACTIVITIES..................................................................................45

CCU CARDIOENT OF ACUTE MYOSPITAL - SOPS....................................................................................................46

GATE PASS SOPS..............................................................................................................................................................46I/V LINE..........................................................................................................................................................................46Management of Acute Myocardial Infarction Admitted to CCU....................................................................................47

SOPS FOR SURGICAL ICU................................................................................................................................................49

ADMISSION CRITERIA...........................................................................................................................................................49ON ARRIVAL IN SICU..........................................................................................................................................................49MORNING ROUNDS...............................................................................................................................................................49EVENING ROUNDS................................................................................................................................................................50INFECTION CONTROL............................................................................................................................................................50

I/V LINE..........................................................................................................................................................................50GATE PASS SOPS..............................................................................................................................................................50

SOPS FOR MEDICAL ICU..................................................................................................................................................51

Hierarchy........................................................................................................................................................................51Criteria for admission in MICU.....................................................................................................................................51Documentation................................................................................................................................................................51

GATE PASS SOPS.................................................................................................................................................................52Infection Control.............................................................................................................................................................52IV line..............................................................................................................................................................................52

PULMONOLOGY UNIT......................................................................................................................................................53

STANDING OPERATING PROCEDURE FOR BRONCHOSCOPY..................................................................................................53Duties of Bronchoscopy Technician/Reg/TMO..............................................................................................................53

STANDING OPERATING PROCEDURE FORASPIRATION & BIOPSY.........................................................................................54Duties of Technician, Reg/TMO/MO..............................................................................................................................54

STANDARD OPERATING PROCEDURE FOR CHEST INTUBATION.....................................................................54

Duties of Technician, Reg TMO/MO..............................................................................................................................54

STANDARD OPERATING PROCEDURES......................................................................................................................56

PATIENT’S HISTORY, MANAGEMENT AND TRAINING OF JUNIOR DOCTORS..............................................56

SOPS FOR ANESTHESIA DOCTORS...............................................................................................................................57

Checking Anesthesia Equipments...................................................................................................................................58Anesthetizing a Patient...................................................................................................................................................58Documentation / Record Keeping...................................................................................................................................58

SOP’S FOR UTILIZATION OF ZAKAT FUND...............................................................................................................59



Investigations:.................................................................................................................................................................59DECISIONS........................................................................................................................................................................62

DISASTER …………………BE PREPARED -A GENERAL REVIEW..................................................................................................63Steps to be taken.............................................................................................................................................................64

1. Nomination of a focal person...............................................................................................................................................642. Formation of Disaster Management Groups (DMGs).........................................................................................................643. Medicines.............................................................................................................................................................................644. Equipments..........................................................................................................................................................................645. Blood....................................................................................................................................................................................656. Instruments...........................................................................................................................................................................657. Ambulances.........................................................................................................................................................................65

Crisis Management Team (CMT)...................................................................................................................................66Objective.........................................................................................................................................................................66Group of Surgeons / Anesthetist.....................................................................................................................................67Doctors to be present at site of Mass Emergency...........................................................................................................69Diagnostic Services Management Group.......................................................................................................................70Medicine and Surgical Disposable Management Group................................................................................................70DMG-6 Information and Registration Group...........................................................................................................70

MASS EMERGENCY AREAS (RED ZONES)......................................................................................................................................71Logistics..........................................................................................................................................................................71TELEPHONE NUMBERS OF PROFESSORS...............................................................................................................72Introduction....................................................................................................................................................................74Guidelines for the patients..............................................................................................................................................74Ultrasound......................................................................................................................................................................74X-ray...............................................................................................................................................................................74CT Scan...........................................................................................................................................................................74MRI.................................................................................................................................................................................74Staff.................................................................................................................................................................................74Revenue...........................................................................................................................................................................75Duty Rota........................................................................................................................................................................75Cleanliness......................................................................................................................................................................75



DEPARTMENT OF MEDICINE

SOPS FOR EMERGENCY TRAY Every unit should have an emergency medical tray with purpose built portable trolley. Medical emergency tray be kept in an accessible & should be routinely monitored by staff

nurse to ensure that all supplies are replaced & weekly checked by registrar & monthly by hospital inspection team

All the equipment should be in working condition & emergency life saving drugs should be up to date.

EMERGENCY TRAY EQUIPMENT

Following equipment should be present in working condition all the time. Ambu bag at least two checked for physical integrity once a week. Masks of different types & sizes Flash light with extra batteries Portable small size oxygen cylinders with proper gauge & masks BD syringes of various sizes Swabs, sponges, cotton & adhesive taps Gloves Stethoscope, blood pressure set of good quality Laryngoscope Disposable oral airways of various sizes Scissors IV canulas of different sizes Catheters & naso gastric tubes of various sizes CVP lines Lumber puncture needles of different sizes Cat gut, silk & artery forceps Small portable sucker machine Defibrillator(01) ECG machine (01) Nebulizers(02) Chest tube with under water seal(03) Glucometer with strips Ophthalmoscope



EMERGENCY MEDICINES

S.NO Medicine Quantity1. Adrenaline of different strength 52. Antihistamine like Avil injection 103. Atropine Sulphate 54. Hypertonic 105. Soda bicarbonate & Calcium gluconate vial 5 each6. Injection Dobutrex & Dopamine 5 each7. Inj. Solucortef of different strength 10 each8. Inj. Decadron 109. Inj.Lignocaine 510. Inj. Diazepam 511. Tab. Inderal, thyroxine & lanoxin12. Tab. Asprin13. Angesid ( Sublingual nitrate tab.)14. Inj. Lasix 1015. Inj. Nalaxone 1016. Inj. Flumazanil 0317. Activated Charcoal 1018. Drips 0519. Potassium Chloride 0520. Isoket Inj. 0521. Inj. Vitamin K 1022. Inj. Zantac 0523. Inj. Transamine 0524. Ventoline Solution 0525. Atem nebulas 0526. Inj. Aminophyline 250 mg 0527. Humalin Regular. 70/30 0328. Anti snake venoms 2029. Inj. Sandostatin 1030. Kleen enema 0531. Inf. Hemacell 10



SOPS FOR PRESCRIPTION OF DRUGS GENERAL PRINCIPLES FOR PRESCRIBING OF DRUGS

To prescribe a drug is to take responsibility to relive ( or otherwise) the suffering of a patient by a doctor

Prescription should be written in clear hand writing & capital letters preferably ( write for others than your own self). Poor hand writing can result in lethal mistakes. The doctor should sign each prescription with his/ her name written beneath his/her signature.

The drug advised should be easily available, economical & effective. The word effective means that the drug is considered effective by the institution or the Deptt. or the unit

The doctor should be well versed with the use, interactions & side effects of the drug prescribed

The strength of drug , dosage, mode of administration & duration of use should be clearly mentioned in English/ universal technical language on in patient treatment sheet. For out patient prescription, preferably, local language/ urdu should be used.

A leading zero may be used( eg. 0.5 mg as 5mg may be read as 5 mg). Avoid using trailing zero which may be misread ( eg. 5.0mg may be read as 50 mg)

The doctor should know the cost of medicine prescribed & tailor it according to the socio- economic status of the patient as it may be the only cause of non-compliance.

Drugs available in hospital pharmacy should be given priority. If a drug is not available in the hospital pharmacy then drugs available at endowment fund

pharmacy should be prescribed Drugs from outside the hospital should only be prescribed when utterly necessary after

discussion with the team

ADMINISTERING INTRAVENOUS DRUGS First dose of IV drug should be given by the doctor on duty with attention of the following

Identify the patient Ask the patient about history of adverse reaction to the drug being given Check the name , strength & expiry date of the vial with a team member( Doctor Or Nurse) Intradermal test dose Make sure adrenaline, hydrocortisone & antihistamine injections are at hand Document that 1st. dose was given (time, date, doctor name with designation & signature)

with no adverse reaction. In case of adverse reaction, a detail account must be documented. If a drug needs to be given frequently after the 1st. dose( on the same admission) it should be

given by a nurse who should follow step 1.4 & document in the nursing note/ treatment sheet If an IV line is blocked, the nurse on duty should inform SHO/TMO to replace it so that the

patient can be given prescribed drug.

ADMINISTERING ORAL DRUGS Nurse should administer oral drugs with attention to the following points

Identify the patient Ask the patient about history of adverse reaction to the drug being given Check the name, strength & expiry date of the drug with a team member (nurse)



SOPS FOR ADMISSION TO IN PATIENT CARE ON THE WARD WHO CAN ADMIT

o Admission from OPD should be done by the registrar & aboveo Admission through casualty should be done by on call member of the team( SHO/ TMO) after

proper referral from CMO ( Pt should receive emergency treatment in the casualty, stabilized & only then referred to ward on call

1. If SHO/ TMO believe there is sufficient reason. he can admit the patient2. If SHO/ TMO can not make a decision he can put the patient under observation & call

the registrar & seniors while starting requisite treatment of the patiento Casualty can not be used as OPD. Non- emergency patients using casualty as portal of

admission to ward on call should pay executive admission feeo Admission after 2 Pm from consultants private clinic should be direct to ward on call with out

going through ( executive admission fee may be levieved)o Referral from other hospitals should be admitted via casualtyo On admission , detail history should be taken by the house officer on arrival, followed by a

summary of the patient by the TMO on dutyo For medico-legal cases proper official referral & presence of police is mandatoryo Proof of identity should be must for every patiento Afghans with out registration cards should be separately markedo RMO must accompany un accompanied & with out identity patients ( Lawaris patient) to the

ward for admission & should arrange all the necessary arrangements for management.



SOPS FOR DISCHARGING THE PATIENTS

o Patient should be discharged by senior registrar or aboveo The decision of discharging the patient should be taken a day earlier with intimation to patient

& his/ her relativeso Discharge summary should be prepared by the SHO & checked by TMOO/ Junior registrar/ SR

with particular attention to the following details1. Patient name2. Admission number3. Date of admission4. Date of discharge5. Diagnosis6. Details of investigations & treatment given7. Details of intra or interdepartmental consultation8. Details of treatment to be taken at home9. Details of follow up

IN PATIENT CONSULTATION BETWEEN DIFFERENT UNITS OF THE HOSPITAL o Call for consultation to other units be sent before 11 AMo Call in emergency or off hours should be directed to JR/SRo Each call should be properly written with clearly identified purpose of consultation along with

all investigationso During working hours, SR/ Asstt. Prof. should write call to VS, VP Or VG and then follow it up to

ensure that calls are appropriately written & attended to with desired help to the patiento After working hours, the concerned 3rd. year post graduate trainee, JR/SR will write the call &

follow it upo The consultant/SR of the call receiving unit shall attend the call. In case of their non

availability the JR/ MO/TMO shall attend the call with information to the consultant/SR latero Once a unit has taken over a patient through a call then they should follow that patient

through out his stay in the hospital & later on through OPD when necessary



SOP FOR PRIVATE ROOMS ADMISSION CRITERIA o Patient should be hemodynamicaly stableo Patient does not require frequent monitoring( monitory devices)o Patient does not have violence issues/ suicidal thoughts)

ADMISSION PROCESS o Private Room admission should be done on single occupancy basiso Consultant/ SR, can admit patients in private room directly via CMOo Consultant/ SR, JR can admit in patients from the ward to private roomo After admission , MO of private room should take history, send investigations & start

treatment as directed by the admitting doctor

PRIVATE ROOMS SERVICES o There should be one registrar for each side of private roomso One MO should be present in each duty shift in each side of private roomso One staff nurse should be present in each duty shift on each side of private room o Registrar of respective side of private rooms should conduct the morning & evening roundso 24 hours laboratory & radiological services should be availableo Each room should be connected to nursing station via telecom serviceso Each section should have emergency trolleys fully equipped with emergency medicines &

instruments & placed at an accessible area of the nursing station.o The consultant/ SRs are authorized to shift the patient from private room to respective ward if

needed.o The consultant /SRs of the respective medical unit will conduct the morning round of the

respective patients in private room & the JR of the respective medical unit will conduct the evening round.

SOPS FOR CONSULTANT OPD o Patient properly evaluated at general OPD be referred to consultant OPDo Record of referral be kept at general OPD & a copy sent to consultant OPDo Patient should be given time & date to see a consultant with intimation to the consultanto Investigations advised by consultant should be reported upon before 1.0 PM so that patient

does not have to come back the second time to get treatment.



SOPS FOR WARD ROUND o Medical staff up to SR level would start seeing patients at the start of their working

hours(8.0AM)o Consultant along with the whole team would start ward round at 9.0 AMo Senior most consultant ( Prof. / I/C of unit) in the team would conduct the ward roundo Other consultant of the team would extend help in the management by giving their opinion on

the signs & symptoms of the patiento Evening ward round would be conducted at 8 PMo Evening ward round would be conducted by Asstt. Prof. alternating with Assoc. Prof. with SR

presento In the evening ward round, the following will be ensured

1. Instruction in the morning ward round are carried out2. In the light of new findings, does the treatment to be changed on emergency basis or it

can wait till next morning when the whole team is around3. If the patient has improved & ready to be discharged , instruction regarding discharge

given so that discharge summary is ready in the morning

SOPS FOR G.I. ENDOSCOPIES o Patient to be reviewed by consultant/SR for the need for endoscopyo If indicated, Registrar/ TMO/ concerned HO to make arrangements for the endoscopy.o A written / informed consent to be taken from the patient/relativeo Screening for Hepatitis B, C & HIV must be doneo Any preparation required to be given as advised by the consultant/SRo Any pre medication required to be given as advised by the consultant/ SR.o On the morning of the endoscopy, the patient should be shifted to endoscopy suit with an IV

access.o The responsibility of shifting to Endoscopy suit lies with the concerned HO/TMO/ Registrar.o The endosopist should review the patient’s condition and the need for Endoscopy again at the

Endoscopy suit & make sure that the patient is fully prepared with a written consent, screening done & pre- medication given before proceeding with the endoscopy

o Endoscopy finding should be clearly written on the patient chart & biopsy if any taken, should be properly labelled & processed.

o Any post-procedure orders should be clearly written on the charto The post-procedure care if any advised by the endoscopist, is the responsibility of the

concerned HO/TMO/Registrar, who should receive the patient in the unit after the procedure & go through the endoscopy findings & instructions.

DEPARTMENT OF SURGERY



INTRODUCTION The Deptt. Of Surgery, KMC Peshawar consists of five General Surgical Units, Orthopedic & Trauma Unit, Casualty, Plastic Surgery & burn unit, SICU & a Pediatric Unit. Each unit has 46 beds. Patient care means that the doctors & ancillary staff are not only doing so in the wards but also are using the OPDs, major OT for doing so. It may be mentioned that the major OT not only has operating rooms but also a recovery room & endoscopy suite besides other areas such as staff rooms. Managing patients does not only mean treating disease but involves making sure that this is done in a way which comfortable both for the patients and relatives, ethical, logical & cost effective. It must be kept in mind that all medical personnel are part of a team each having their own roles in patient care. In dealing with patients & relatives medical personnel should be polite at all times. White coat, name tags & a professional turnout is emphasized for all doctors. A concerted effort is needed to prevent errors. Standardized systems are needed to minimize the need to rely on human nature, which is rather imperfect. Legal issues can come up in patient management. Following a set protocol can go a long way in protecting medical personnel from a legal view point. The following are some guidelines that should be followed by the Medical personnel while managing patients:

ATTENDANCE, PUNCTUALITY AND LEAVE: o Senior Registrar should maintain an attendance register of the House Officers, Medical Officers

and Registraro The Registrar must ensure the presence of nursing staff, dispensers and auxiliary staff.o Habitual late comers or absenteeism should be reported by the SR to the MS who should warn

such doctors and later on after the recommendation of the Professor in charge either be transferred of his/her services terminated. The Dean PGMI should additionally be informed in case trainees.

o Leave if needed should be applied for two days in advance. This should be signed by a substitute and Registrar and forwarded by the SR to the MS. Leave for unforeseen emergencies must be communicated to the Registrar.

o A House Officer is allowed a total of ten days leave during a six month period. A trainee is allowed days per year. A Medical Officer is allowed 25 casual leaves per year. A House Officer and Trainee is allowed days per year. A Medical Officer is allowed 25 casual leaves per year. A House Officer and Trainee will have to compensate by leaves per year. A House Officer and Trainee will have to compensate by additional days in their training should their leave exceed the allotted number of days aloe\wed.

1. The leave Register must be maintained by the SR.

ADMISSION TO SURGICAL UNITS: o All patient needing admission should be offered admission irrespective of whether they have

been seen in a private clinic or in OPD. Emergency patients will take priority as well as those needling urgent surgery eg. Cancer patients.



o Elective admission should be done after the patient is seen by a person of SR level and above. The admission should be justifiable

o Should a consultant see a patient in his / her private clinic & refer him/her to the casualty as an emergency case, the patient should be managed accordingly whether the particular consultant belongs to that ward or not. The patient may be shifted to the ward the consultant belongs to , only if he/she has requested to

ADMISSION TO PRIVATE ROOMS o Medico legal cases & emergency cases should not be admitted to private roomso No patient should be admitted to the private room without the approval of a member of the

teaching staff of the wardo Patients with cardiopulmonary problems, if admitted to private rooms should stay in the ward

for at least 24 hours post op

HISTORY SHEETS o Patient clerking must be done by the house officer at the earliest possible time following

admission. This should include proper examination of relevant systems & a note of chest findings, BP, Pulse

o TMO notes & plans in writing are mandatory, especially in emergency cases. However resuscitation of the patient will take priority

o Daily morning & evening progress report should be recorded by the HO & TMO

DUTY ROTAS o These should be made by the SR or Assistant Professor of the ward & should include duties in

minor OT, recovery room & wardo The doctors on duty have to be physically present in the wardo The HO & TMO can leave the ward after their duty is over only when the next doctor on duty

has arrived. However doctors on duty in the afternoon & night shift should all be present in the evening round.

1. Doctors should communicate with each other at the time of change of duty ie they should inform the next doctor on duty the status of serious patients etc

ACADEMIC ACTIVITIES: o The SR will prepare a list of academic activities to be held on “free days” in liaison with the

professor of the unito The HO & TMO must attend classes & demonstrations/ seminars being held in the ward

EMERGENCY PATIENTS o The registrar should ensure that the emergency drugs, disposables & equipments is available

at all times & in working conditiono Emergency patients should be promptly attended by the HO & TMO. The registrar should see

all emergency admission & record important observations. Should he/she be busy in OT, he/ she should be informed.

o Every effort should be made to resuscitate patients if indicated according to ABC protocol



o Emergency patients should be closely monitored & findings recorded & dealt with.o Only stable patients can be shifted out of the ward for important investigations.o Important surgical interventions should be done on the same day if the condition of the pt

permitso TMOs can perform emergency surgeries according to their year of training only under the

supervision of the registrar SR. Should the SR face difficulty he/she should call his next senior.

PATIENT PREPARATION FOR SURGERIES; o A written , informed consent is a must, duly signed by the pt. his/her immediate relative & the

HO or MOo Certain aspect must be made in writing , for eg amputations, mastectomy, the need for

permanent stoma etc.o Common complications should also be mentioned in the consent formo Should the patient refuse surgery this should be in writing in the presence of a relative &

signed by the pt , relative & doctor.o The side to be operated upon should be marked.o The nurse should make sure that the site to be operated on is shaved, jewelry & dentures

removed & all valuables left to a relative. She should know which patients are due for surgery & that they are shifted to the OT in time. All pre medications & investigations such as fasting blood sugar & early morning KUB should be positively done & sent with patients. The HO concerned should make sure that the patient are prepared properly. The HO staying in the ward on OT day should be present early in the ward & make sure that all these steps are carried out.

o During the evening round before the OT day, the registrar should make sure that the patient has the necessary requirements for surgery and calls to any department made if necessary.

o Ideally a copy of the OT list should be intimated to the OT after OPD and one of the anesthetists concerned with the ward, should carry out a round on the day before surgery, so that necessary requirements are fulfilled. The anesthetist should ideally carry out his round with the registrar at a time convenient to all.

o All preoperative investigations including hepatitis and HIV screening should be carried out before the patient is admitted so that they are ready for timely intervention if needed. They would prevent unnecessary delays, and wastage of time as well as resentment on the part of patients for having to be admitted only to be deferred or have a delay.

o Containers for specimens should be available with patients and should be properly marked beforehand by the House Officer concerned showing the name, bed number, ward and specimen name.

OPD o All doctors should be available in the OPD.o The Dispenser should make sure that the OPD is clean, the instruments sterilized, disposables

available and all equipment and lights etc in working order.o The staff should make sure that patients are asked to wait for their turn to prevent

unnecessary chaos.o Relevant information should be written on the OPD chit and signed.



o All patients due for surgery should be assessed for co morbid conditions, their BP and pulse noted and chest examined. They should be referred for an assessment for fitness if needed. Two or three doctors can use a separate room in the OPD for patient workup etc.

o All patients due for surgery should be advised investigations before admission. These should be seen and corrected if possible, before the patient is admitted.

o A waiting list should be maintained by each ward ideally mentioning the patients contact number and address. Unforeseen delays should preferably be communicated to the patient.



OPERATION THEATRE: o All OT notes should be complete and then recorded in an OT register.o The House Officers should ensure that all specimens are sent and received in the ward.o The chief OT tech is responsible for the cleanliness and discipline of the OT.o Swab count should be maintained at all times by one member of the operating team and the

same nurse of OT tech. ideally this should be written on a board.o A House Officer and Trainee of the ward should be present in the recovery room and ward to

respond to unforeseen mishaps.o All post op patients should be monitored.o Patients with Hepatitis B or C should be operated according to set protocol which should be

developed by the Surgical Department and the administration.

MINOR OT: o Two trainees should be present in the minor OT on OPD days to carry out minor procedures

like biopsies, nail avulsions etc.

WARD ROUNDS: o All morning rounds must be done by a consultant at a set time, preferably starting before 9 am

so as to have time for carrying out orders like investigations, calls etc.o The evening round must be done daily by the Registrar and important entries made.o The post of and emergency evening round should be done by the senior registrar/Assistant

professor with the registrars, medical officers and house officers.o The nurse and dispenser should be present in the round.o The Head Nurse should make sure that the ward is cleaned and the bedding done before the

round. The nurse should make sure that ward decorum is maintained 24 hours. The attendants should be asked to leave. One attendant must be present the patient who needs one.

o The Registrar should ensure that all orders of the senior teaching staff regarding patients have been carried out including referrals to medical and other related specialties.



DURG ADMINISTRATION: o Nurse should make sure that proper drug is given, through proper route at proper time, after

test dose if needed. Expiry dates must be checked. Entries in writing should be made as well as any reason for not administering the drug. Any confusion, any delays in administering the drug should be communicated to the Medical Officer or Registrar.

o The House Officer and Medical Officer concerned should make sure that the drugs are properly and timely administered.

INDENT BOOK: o The Registrar shall sign the indent book and check all the drugs and IV fluids supplied to the

ward.

SAFETY MEASURES: o At no time shall any anaesthetic drug be either kept with the other drugs or emergency drugs.

They should preferably be available in the OT and if need to be bough by the patient should be kept separately.

o All used syringes and IV fluid bottles should be immediately destroyed by the nurse. The Head Nurse and Registrar should be vigilant about this issue.

WARD CLEANLINESS AND MAINTAINANCE: o The Head Nurse should make sure that the ward is kept clean at all times. This includes the

floors, windows, beds, toilets, galleries, cupboards, side tables etc. The Registrar should ensure that this done.

o All equipment or lights etc that needs replacement must be immediately reported to the Registrar by the Head Nurse and Dispenser.

This protocol should be reviewed every six months and changes/additions made accordingly.



DEPARTMENT OF GYNAE &OBSTETRIC

INTRODUCTION The Department of Gynecology/Obstetric KMC Peshawar consists of 3 Gynae Units and a Labour Room. Each Unit has 40 beds, Labour Room has 20 beds & gives 24hrs emergency cover.Managing patients does not only mean treating disease but involves a coordinated approach to diagnosis, treatment & care services of all patients. This should be done in such a way which is comfortable both for the patients and relatives and is ethical, logical & cost effective. It must be kept in mind that all medical personnel are part of a team each having their own roles in patient care. In dealing with patients & relatives medical personnel should be polite at all times and should have professional attitude. White coat, name tags & a professional turnout is emphasized for all doctors.A concerted effort is needed to prevent errors. Standardized systems are needed to minimize the need to rely on human nature, which is rather imperfect. Legal issues can come up in patient management. Following a set evidence based protocols will protect medical personnel from medico legal issues.The following are some guidelines that should be followed by the Medical personnel while managing patients:



such doctors and later on after the recommendation of the Professor In-charge either be transferred or his/her services terminated. The Dean PGMI should additionally be informed in case of trainees.


o A House Officer is allowed a total of ten days leave during a six month period. A trainee is allowed days per year. A Medical Officer is allowed 25 casual leaves per year. A House Officer and Trainee will have to compensate by additional days in their training should their leave exceed the allotted number of days aloe\wed.

o The leave Register must be maintained by the SR.

ADMISSION TO GYNAE UNITS & LABOUR ROOM: o All patient needing admission should be offered admission irrespective of whether they have

been seen in a private clinic or in OPD. Emergency patients will take priority as well as those requiring urgent surgery eg. C-Section & Gynae emergency.




o Patients who have undergone major surgery should stay in ward for 24hrs postoperative, before being shifted to private room.

o Should a consultant see a patient in his / her private clinic & refer him/her to the casualty as an emergency case, the patient should be managed accordingly whether the particular consultant belongs to that ward or not. The patient may be shifted to the ward the consultant belongs to, only if he/she has requested to shift that patient.

ADMISSION TO PRIVATE ROOMS o Medico legal cases & emergency cases should not be admitted to private rooms.o No patient should be admitted to the private room without the approval of a member of the

teaching staff of the ward.o Patients with cardiopulmonary problems, if admitted to private rooms should stay in the ward

for at least 24 hours post op.


admission. This should include proper examination of relevant systems, Obstetric & Gynecological examination



DUTY ROTAS o These should be made by the Registrar/SR or Assistant Professor of the ward & should include

duties in Ward, Labour Room, O.T, OPD, ANCo The doctors on duty have to be physically present in the wardo The HO & TMO can leave the ward after their duty is over only when the next doctor on duty


o Doctors should not only communicate, with each other at the time of change of duty ie they should inform the next doctor on duty the status of serious patients etc but should also maintain a hand over & take over register


professor of the unito The HO & TMO must attend classes & demonstrations/seminars /journal club/ long cases

being held in the wardo Regular rehearsal drill of obstetric and Gynaecological emergencies should be done in ward by

the TMO, H.O and supervised by registrar.

EMERGENCY PATIENTS o The registrar should ensure that the emergency drugs, disposables & equipments are available

at all times & in working condition



o Emergency tray should be regularly updated & maintained by the registraro Emergency patients should be promptly attended by the HO & TMO. The registrar should see


o Every effort should be made to resuscitate patients if indicated according to ABC protocolo Emergency patients should be closely monitored & findings recorded & dealt with.o Only stable patients can be shifted out of the ward for important investigations.o Important surgical interventions should be done on the same day if the condition of the pt



PATIENT PREPARATION FOR SURGERIES; o A written , informed consent is a must, duly signed by the pt. his/her immediate relative & the

HO or MOo Certain aspect must be made in writing, eg tubal ligation, high risk consent etc.o Common complications should also be mentioned in the consent formo Should the patient refuse surgery this should be in writing in the presence of a relative &

signed by the pt , relative & doctor.o The site to be operated upon should be marked.o The nurse should make sure that the site to be operated on is shaved, jewelry & dentures

removed & all valuables & mobiles left to a relative. She should know which patients are due for surgery & that they are shifted to the OT in time. All pre medications & investigations such as fasting blood sugar should be positively done & sent with patients. The HO concerned should make sure that the patients are prepared properly. The HO staying in the ward on OT day should be present early in the ward & make sure that all these steps are carried out.

o During the evening round before the OT day, the registrar should make sure that the patient has the necessary requirements for surgery and calls to any department made if necessary.

o Ideally a copy of the OT list should be intimated to the OT after OPD and one of the anaesthetists concerned with the ward, should carry out a round on the day before surgery, so that necessary requirements are fulfilled. The anaesthetist should ideally carry out his round with the registrar at a time convenient to all.


o Containers for specimens should be available with patients and should be properly marked beforehand by the House Officer concerned showing the name, bed number, and ward and specimen name.

POSTOPERATIVE CARE: o One house officer and TMO must be available in the ward 24hrs a day for care of the patient.o The TMO Batch on call must come after O.T for postoperative round.o The registrar on call should do a postoperative round after O.T.



o Postoperative round must be documented with date and time by H.O /T.M.O , registrar & consultant on call.

o There must be protocol for resuscitation in case of any complication & immediate contact of senior as per protocol.

OPD & ANC: o All doctors should be available in the OPD.o The Dispenser & Khala should make sure that the OPD is clean, the instruments sterilized,

disposables available and all equipment and lights etc in working order.o The staff should make sure that patients are asked to wait for their turn to prevent

unnecessary chaos.o Relevant information should be written on the OPD chit and signed.o All patients due for surgery should be assessed for co morbid conditions, their BP and pulse

noted and chest examined. They should be referred for an assessment for fitness if needed. Two or three doctors can use a separate room in the OPD for patient workup etc.



OPERATION THEATRE: o All OT notes should be complete and then recorded in an OT register.o The House Officers should ensure that all specimens are sent and received in the ward.o The chief OT tech is responsible for the cleanliness and discipline of the OT.o Swab count should be maintained at all times by one member of the operating team and the

same nurse or O.T tech. Ideally this should be written on a board.o A House Officer should be present in the recovery room and ward to respond to unforeseen

mishaps.o All post op patients should be monitored.o Patients with Hepatitis B or C should be operated according to set protocol which should be

developed by the Gynae Department and the administration.


so as to have time for carrying out orders like investigations, calls etc.o The evening round must be done daily by the Registrar and important entries made.o The post and emergency evening round should be done by the senior registrar/Assistant


round. The nurse should make sure that ward decorum is maintained 24 hours. The attendants should be asked to leave. One attendant must be present the patient who needs it.







DISCHARGE: o The discharge slip should be prepared a day before the expected discharge of the patient by

the H.O & checked & counter signed by T.M.O, so that undue delay and discomfort of the patient is avoided.

o Decision of discharge should be done by the registrar, S.R or Consultant.

LABOUR ROOM o 3rd year TMO & House officer Batch on call will do labour room round at 8:00am along with

Registrar. 1st year PG and H.O batch will stay in the labour room from 8:00am ––– 2:00pm. A 4th year PG along with her batch on call will do round at 1:00pm along with the Registrar

o A 1st year PG along with H.O’s will stay in the labour room and 3rd year / 4th year PG will do round at 6:00pm. The Registrar /S.R and assistant Prof will do round at 7:00pm on emergencies & will be on call at night.

o The decision of surgery should be taken only after discussion with registrar.o All high risk patients should be discussed with the consultant on call.o The consultant on call should also inform about the progress of high risk patient.o The Head nurse should make sure that the labour room is clean all the times as it is a place of

quick patient turn over. This includes the delivery rooms, instruments, Autoclave, Drugs, linens, floors, beds, toilets etc. The registrars of the three units should work in collaboration for maintenance and cleanliness of the labour room.

o The Head nurse and the registrar of the Gynae unit on call should make sure that the emergency tray in the labour room is completed and updated all the times in order to face any sort of emergency.



CLINICAL AUDIT: o Statistical record of the ward should be maintained and regularly checked by the registrar /

S.R.o Fortnightly or monthly clinical audit meeting should be conducted in the ward & supervised by

the Professor in charge of the ward.o Adverse events & near miss events should be discussed in no blame environment to improve

patient outcome & should be notified to the administration.o Protocols for Obstetric & Gynaecological emergencies should be displayed in the Gynae Units

& Labour rooms & regularly updated.

DOCUMENTATION: o Adequate documentation should be maintained in the charts. All findings & orders should be

legibly written & signed with date & time. This should be regularly checked by the registrar on call.


ward.

SAFETY MEASURES: o At no time shall any anaesthetic drug be either kept with the other drugs or emergency drugs.

They should preferably be available in the OT and if need to be bought by the patient should be kept separately.







RESEARCH AND CLINICAL TRIALS: o Research projects will be allowed to the PGs and the teaching staff after being permitted by

the In-charge of the unit and after fulfilling ethical issues.o There must be at least three research project going on in each gynaecology ward

This protocol should be reviewed every six months and changes/additions made accordingly.

.



DEPARTMENT OF OTO-RHINO-LARYNGOLOGY (ENT)







ADMISSION TO ENT UNITS: o All patient needing admission should be offered admission irrespective of whether they have

been seen in a private clinic or in OPD. Emergency patients will take priority as well as those needling urgent surgery eg. Cancer patients.


o Should a consultant see a patient in his / her private clinic & refer him/her to the casualty as an emergency case, the patient should be managed accordingly whether the particular consultant belongs to that ward or not. The patient may be shifted to the ward the consultant belongs to , only if he/she has requested to




teaching staff of the wardo Patients with cardiopulmonary problems, if admitted to private rooms should stay in the ward

for at least 24 hours post op


admission. This should include proper examination of relevant systems & a note of chest findings, BP, Pulse




minor OT, recovery room & wardo The doctors on duty have to be physically present in the wardo The HO & TMO can leave the ward after their duty is over only when the next doctor on duty


o Doctors should communicate with each other at the time of change of duty ie they should inform the next doctor on duty the status of serious patients etc






o Every effort should be made to resuscitate patients if indicated according to ABC protocolo Emergency patients should be closely monitored & findings recorded & dealt with.o Only stable patients can be shifted out of the ward for important investigations.o Important surgical interventions should be done on the same day if the condition of the pt

permits



o TMOs can perform emergency surgeries according to their year of training only under the supervision of the registrar SR. Should the SR face difficulty he/she should call his next senior.

PATIENT PREPARATION FOR SURGERIES o A written , informed consent is a must, duly signed by the pt. his/her immediate relative & the

HO or MO.o Common complications should also be mentioned in the consent formo Should the patient refuse surgery this should be in writing in the presence of a relative &

signed by the pt , relative & doctor.o The side to be operated upon should be marked.o During the evening round before the OT day, the registrar should make sure that the patient

has the necessary requirements for surgery and calls to any department made if necessary.o Ideally a copy of the OT list should be intimated to the OT after OPD and one of the

anesthetists concerned with the ward, should carry out a round on the day before surgery, so that necessary requirements are fulfilled. The anesthetist should ideally carry out his round with the registrar at a time convenient to all.


o Containers for specimens should be available with patients and should be properly marked beforehand by the House Officer concerned showing the name, bed number, ward and specimen name.

OPD o All doctors should be available in the OPD.o The Dispenser should make sure that the OPD is clean, the instruments sterilized, disposables


unnecessary chaos.o Relevant information should be written on the OPD chit and signed.o All patients due for surgery should be assessed for co morbid conditions, their BP and pulse




OPERATION THEATRE: o All OT notes should be complete and then recorded in an OT register.o The House Officers should ensure that all specimens are sent and received in the ward.o The chief OT tech is responsible for the cleanliness and discipline of the OT.



o Swab count should be maintained at all times by one member of the operating team and the same nurse of OT tech. ideally this should be written on a board.

o A House Officer and Trainee of the ward should be present in the recovery room and ward to respond to unforeseen mishaps.

o All post op patients should be monitored.o Patients with Hepatitis B or C should be operated according to set protocol which should be



so as to have time for carrying out orders like investigations, calls etc.o The evening round must be done daily by the Registrar and important entries made.o The post of and emergency evening round should be done by the senior registrar/Assistant










ward.

SAFETY MEASURES: o At no time shall any anesthetic drug be either kept with the other drugs or emergency drugs.






Note: This protocol should be reviewed every six months and changes/additions made accordingly.



DEPARTMENT OF OPHTHALMOLOGY

INTRODUCTION The Deptt. Of Ophthalmology, KTH Peshawar consists of 2 units. Each unit has 46 beds. Patient care means that the doctors & ancillary staff are not only doing so in the wards but also are using the OPDs, major OT for doing so. It may be mentioned that the major OT not only has operating rooms but also a recovery room besides other areas such as staff rooms.Managing patients does not only mean treating disease but involves making sure that this is done in a way which comfortable both for the patients and relatives, ethical, logical & cost effective. It must be kept in mind that all medical personnel are part of a team each having their own roles in patient care. In dealing with patients & relatives medical personnel should be polite at all times. White coat, name tags & a professional turnout is emphasized for all doctors.A concerted effort is needed to prevent errors. Standardized systems are needed to minimize the need to rely on human nature, which is rather imperfect. Legal issues can come up in patient management. Following a set protocol can go a long way in protecting medical personnel from a legal view point.The following are some guidelines that should be followed by the Medical personnel while managing patients:







ADMISSION TO UNITS o All patient needing admission should be offered admission irrespective of whether they have

been seen in a private clinic or in OPD. Emergency patients will take priority as well as those needling urgent surgery eg. Trauma etc..





teaching staff of the ward


admission. This should include proper examination of ophthalmic system & a note of chest findings, BP, Pulse

o TMO notes & plans in writing are mandatoryo Daily morning & evening progress report should be recorded by the HO & TMO & should be

checked by SRo All emergency cases admitted should have arrival report by TMO & duty with plans of

management


OPD, OT,& wardo The doctors on duty have to be physically present in the wardo The HO & TMO can leave the ward after their duty is over only when the next doctor on duty


o Doctors should communicate with each other at the time of change of duty ie they should inform the next doctor on duty the status of serious patients etc

ACADEMIC ACTIVITIES o The SR will prepare a list of academic activities to be held on “free days” in liaison with the






all emergency admission & record important observations. Should he/she be busy in OT, he/ she should be informed. SR should be on call on every emergency day, if JR feels any difficulty he can call SR any time.

o Emergency patients should be closely monitored & findings recorded & dealt with.o Only stable patients can be shifted out of the ward for important investigations.o Important surgical interventions should be done on the same day if the condition of the pt



PATIENT PREPARATION FOR SURGERIES o A written , informed consent is a must, duly signed by the pt. his/her immediate relative & the

HO or MOo Certain aspect must be made in writing , for eg enucleation, evisceration, exentration & should

be explained to patient & relatives.o Common complications should also be mentioned in the consent formo Should the patient refuse surgery this should be in writing in the presence of a relative &

signed by the pt , relative & doctor.o The side to be operated upon should be marked.o The nurse should make sure that the site to be operated on is shaved, jewelry & dentures

removed & all valuables left to a relative. She should know which patients are due for surgery & that they are shifted to the OT in time. All pre medications & investigations such as fasting blood sugar & early morning KUB should be positively done & sent with patients. The HO concerned should make sure that the patient are prepared properly. The HO staying in the ward on OT day should be present early in the ward & make sure that all these steps are carried out.

o Any patient who is absent from bed or have no medicines/ IOL etc. shall be dropped from list.o During the evening round before the OT day, the registrar should make sure that the patient

has the necessary requirements for surgery and calls to any department made if necessary. SR shall supervise all these on pre op evening round

o Ideally a copy of the OT list should be intimated to the OT after OPD and one of the anesthetists concerned with the ward, should carry out a round on the day before surgery, so that necessary requirements are fulfilled. The anesthetist should ideally carry out his round with the registrar at a time convenient to all.




o Containers for specimens should be available with patients and should be properly marked beforehand by the House Officer concerned showing the name, bed number, ward and specimen name in case of biopsy, AC tape for C/S & corneal scraping for microscopy & C/S.

OPD o One doctor preferably JR should start OPD at 9.00 AMo All doctors should be available in the OPD.o The teaching staff (SR & above) on duty along with the HOs/TMOs etc. should be present in

their respective rooms till end of OPD timingo The technician should make sure that the OPD is clean, the instruments sterilized, disposables


unnecessary chaos.o Relevant information should be written on the OPD chit and signed with clearly written name

of doctorso All patients due for surgery should be assessed for co morbid conditions, their BP and pulse



o A waiting list should be maintained by each ward ideally mentioning the patients contact number and address. Unforeseen delays should preferably be communicated to the patient. This process should be supervised by SR

OPERATION THEATRE o All doctors should be present in concerned OT room as per duty rotao All OT notes should be complete and then recorded in an OT register.o The House Officers should ensure that all specimens are sent and received in the ward.o The chief OT tech is responsible for the cleanliness and discipline of the OT.o All post op patients should be monitored.o EUA will be done by consultant who has seen the patient before.o Surgery of a particular case will be given to particular trainee according to his seniority & level

of competence.o Patients with Hepatitis B or C should be operated according to set protocol which should be


WARD ROUNDS o All morning rounds must be done by a consultant at a set time, preferably starting at 8.30 am

so as to have time for carrying out orders like investigations, calls etc. except on Wednesday which should be at 9 am(Hospital CPC day)

o The evening round must be done daily by the Registrar and important entries made & pre op it should be supervised by SR.

o The post op and emergency evening round should be done by the senior registrar/Assistant professor with the registrars, medical officers and house officers.



o The nurse and dispenser should be present in the round.o The Head Nurse should make sure that the ward is cleaned and the bedding done before the



DURG ADMINISTRATION o Nurse should make sure that proper drug is given, through proper route at proper time, after




ward. He will also check all the maintenance items supplied & used/ installed in the ward.

SAFETY MEASURES: o At no time shall any anesthetic drug be either kept with the other drugs or emergency drugs.






o This protocol should be reviewed every six months and changes/additions made accordingly.



DEPARTMENT OF PEDIATRICS & CHILD HEALTH

ADMISSION POLICY o There will be alternate emergency cover of each unito Patients will be admitted from 9 AM to 2 Pm from OPD while emergency admission through

emergency pediatric services will be open for 24 hourso Two trainee MOs & 4 HOs will be on duty in such a manner that at any given time , one TMO &

2 HOs have to be present in the wardo One SR & 2 JRs will be on call for 24 hours for the Department of Pediatrics covering both

units. Evening round on every emergency day will be done by consultant on call .o Patients will be admitted on assurance that only one female attendants will be allowed in the

ward & the compliance will be checked by staff nurse on dutyo All histories should be completed & signed by the HO on duty, & the arrival rep[ort with full

assessment has to be taken immediately & signed by the TMOs/Mo on dutyo SR & consultant on duty will be informed depending on the nature of the illness if the child

needs to be seen before ward roundso Admission can be decided by the MO on duty in all urgent caseso When the pediatric unit on call becomes full, the EPS beds can be utilized by the unit on call

for every admission except for very sick patients. ( This is done to prevent doubling in the unit)

WARD DISCHARGE POLICY o Patients only be discharged after consultation of SR & above levelo All patients data is entered in to the ward computerized database by the concerned HOo All patients on discharge are issued discharge slipso Every discharge slip is countersigned by a consultant before handing over to the patientso Hospital computerized data form is filled for every patients & entered into the data base by

computer operator



WARD ROUND POLICY o Beds are not distributed per professor/ Assoc. Prof/ Asstt. Prof etc. All these cadres of

consultants do the rounds based on rota & equally distributed. Consultants are required to write their clinical findings & decisions in the notes or at least dictate it to the MO

o MO or HO of the respective bed present the patiento Round book is kept to write in the ‘jobs” & for hand over purposeo Printed history note books are designed & issued for patients recordso On call cover is provided by a single consultant out of routine duty hours to peads A/B units &

SCBU, assisted by a senior registraro Continuous notes are written & even reporting is the principle. Once or twice daily DPR is

discouraged. All instruction about the patient care must be given in writing. Doctors/ nurses must write their names in block letters & just signatures are not acceptable

PATIENTS INVESTIGATIONS & PROCEDURES POLICY o Where applicable & appropriate all tests must be sent to the hospital laboratory. Tests not

available in hospital are sent to recognized private laboratories. o Lumber puncture is done by MO or by senior house officer under supervision of the MO.

Lumber puncture is deferred & always done in the morning . CSF will be sent to by the ward lab. Technician

o Other invasive procedures e.g. chest drainage is carried by consultant or MO under supervision

o All procedures shall be recorded in the notes.

INJECT ABLE DRUG POLICY o Only recognized brands of the drugs agreed upon in the unit are allowed to be prescribed.

Junior doctors & consultants are not allowed to prescribe other than authorized trade names. Head Nurse is expected to counter check the inject able given by inspecting the empty the empty vials daily

o IV valium , IV KCL & other drugs like digoxin should be checked by the house officer & nurse together

WARD REFERRAL POLICY o Inter unit referral & inter hospital referral is always done through the consultant. Head of the

Department sets the example by personally writing the referral notes. It is expected that the counterpart unit consultant or at least SR should respond in writing. Patient suitability for transport to other hospital must be taken in to account. Any medical need e.g Oxygen /IV fluids/ ambulance arrangement must be met

WARD EMERGENCY POLICY o There is written plan present for all common emergencies which is available round the clock

on ward counter. Doctors on duty are required to follow these plans.o Consultant on call must be notified & advised taken for critically ill children.



o Emergency drugs are placed in emergency cupboard with all necessary life saving drugs available round the clock

o Emergency drugs used have to be constantly replenished either through indent from A&E Services or by patient attendants

o Resuscitation Equipment is daily checked & kept in emergency cupboard.o Proper hand over/ take over of emergency cupboard is done every day under supervision of

registraro Resuscitation equipment is daily checked & kept in emergency cupboard.



ACCIDENT & EMERGENCY SERVICES DEPARTMENT

STANDARD OPERATIVE PROCEDURES

DOG BITE o Wound should be washed with copious amount of saline and antiseptic solution.o Wound should not be sutured.o Tetanus prophylaxis should be given accordingly.

1. TiG (Tetanus immunoglobulin 250 units) in non immunized patients and 0.5 ml Tetanus Toxoid at separate sites with separate syringes.

2. Tetanus Toxoid only in previously immunized patients.

o Wound is classified as under:Category 1: touching or feeding suspect animals, but skin is intactCategory 2: minor scratches without bleeding from contact, or licks on unbroken skinCategory 3: one or more bites, scratches, licks on broken skin, or other contact that breaks the skin; or exposure to bats

o Post-exposure care to prevent rabies includes cleaning and disinfecting a wound, or point of contact, and then administering anti-rabies immunizations as soon as possible. Anti-rabies vaccine is given for Category 2 and 3 exposures. Anti-rabies immunoglobin, or antibody, should be given for Category 3 contact in non-immunized patient, or to people with weaker immune systems.

o If possible, the full dose of Anti-rabies immunoglobin should be infiltrated around any wound(s) and any remaining volume should be administered IM at an anatomical site distant from vaccine administration. Also, RIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of antibody, no more than the recommended dose should be given.

Dosage of Lyssovac (Berna) post exposure 0-3-7-14—48(booster) ---1.0 ml I/M

Only first dose of Anti Rabies vaccine (ARV) will be issued from hospital for dog bite cases provided the patient:o Has an evident puncture wound.o Presents within 24 hours of dog bite.o Did not receive any other ARV after dog bile.o Belongs to the area allocated to Khyber Teaching Hospital.o Submits photocopy of his computerized national identity card.

The dose will be issued with permission of I/C Casualty, shift DMS and RMO. It will be administered in the casualty and record be maintained. The site will be marked and documented by the CMO to prevent mis-use of vaccines.



STANDARD OPERATIVE PROCEDURES GENERAL INSTRUCTIONS:

o All patients coming to emergency will be attended by the CMO.o Record of medico legal patients will be maintained in MLC register.o Elective patients coming to emergency department by mistake or intention will be politely

directed to the concerned Outpatient department.o Chief complaints and provisional diagnosis of the patients should be clearly mentioned on the

prescription chit and vital signs recorded on the same.o Medicines prescribed and administered in the casualty should be recorded on the chit.o After initial treatment and resuscitation, all patients will be shifted to the concerned unit for

definitive care when the vital signs are stabilized.o In case of serious emergencies when the patient is not stable enough for shifting, the doctor

from concerned unit will be called for opinion.o In case of any ambiguity or administrative problem I/C Casualty or shift DMS will be

immediately informed.o All drugs in the casualty will be prescribed by the CMO and will be administered in the casualty

and record be maintained.o Carbon copy of the prescription chit will be retained in Casualty for record.o No drugs will be given to the patient for administration/use elsewhere.o Doctors on duty in casualty should refrain from prescribing unregistered drugs, drugs not

meant for the sign symptoms and provisional diagnosis of the patient or drugs on patient preference not indicated otherwise.

o All the medical claims and bills will be dully checked and signed by the I/C Casualty.

MEDICINES IN CASUALTY: o Victims of bomb blast and terrorist activities will be provided all medicines including

implants from hospital.o Red patients (i.e. serious emergencies needing admission) will be provided with fee medicines

excluding implants, from hospital for first 24 hours subjected to availability.o Yellow patients (sub acute emergencies needing observation only) will be provided with some

of medicines from hospital subjected to availability.o Green patients (outpatients) will be provided with free consultation only.

STANDARD OPERATIVE PROCEDURES TRAUMA/FIRE ARM INJURY/ROAD TRAFFIC ACCIDENT

o Patients presenting with major trauma should be given priority in management and primary survey of the patient with treatment should start immediately at arrival without wasting time in taking long histories.

o The standard treatment protocols should be followed according to ATLS/ESS-BLSPTC programs i.e. ABCDE.

1. A for Airway and Cervical spine.2. B for Breathing and ventilation.



3. C for Circulation.4. D for Disability and Deformity.5. E for Exposure, Environment and Evacuation.

AIRWAY o Talk to the patient to assess his airway, breathing and consciousness at the same time.o Start with chin lift and jaw thrust manoeuvre if not responding.o Oral cavity is examined for foreign bodies and secretions.o Gödel’s airway of appropriate size should be passed and suction done.o ETT and tracheotomy/ cricothyroidotomy are reserved for cases unable to maintain their

airway like unconscious patients or GCS less than 8.o Cervical spines should be immobilized with spine board or hard collar if the slightest double of

spinal injury exists.

BREATHING: o All trauma patients should be given supplemental oxygen by face mask till confirmed to have

adequate peripheral oxygen saturation.o Chest should be auscultated bilaterally.

CIRCULATION: o Two wide bore canolas should be passed in accessible veins in arms or fore arm. (Like 18 G n

adults, 20 G in adolescents and 22 G in children).o Venous cut down, central venous lines or interosseus lines can be used wherever indicated by

the attending physician.o Ring lactate is the fluid of choice for initial resuscitation.o Blood pressure and pulse rate should be regularly checked and properly recorded.o Any evident bleeding should be stopped with pressure dressing.



DISABILITY AND DEFORMITY:

o Patients should be properly exposed for examination preventing hypothermia and over-exposure.

o All suspected fractures should be simply splinted and open wounds washed and dressed.o Neurological status of the patient should be assessed according to AVPU or GCS.

AVPU SYSTEM o A Alerto V Responds to verbal commando P Responds to pain onlyo U Unresponsive

Glasgow Coma Scale

1 2 3 4 5 6Eyes Does not

Open eyesOpens eyes Response toPainful stimuli

Opens eyes in response to voice

Opens eyes spontaneously

N/A N/A

Verbal Makes no sounds

IncomprehensibleSounds

Utters inappropriate words

Confused,disoriented

Oriented, converses normally

N/A

Motor Makes no movements

Extension toPainful stimuli

Abnormal flexion to painful stimuli

Flexion/Withdrawal to painful stimuli

Localizes painful stimuli

Obeys commands



EXPOSURE AND ENVIRONMENT o After initial treatment and resuscitation, all patients will be shifted to the concerned unit for

definitive care when the vital signs are stabilized.o The relevant documents should accompany the patient and the doctor in concerned

department should be priory informed to make necessary arrangements.o In case of serious emergencies when the patients are not stable enough for shifting, the

doctor from concerned unit will be called for opinion.o The environment and temperature should be conductive for the patient.

ADJUNCTS o Following investigations should be generously utilized where ever needed:-

1. Radiographs lf chest and pelvis and cross table lateral view of cervical spines2. ECG3. FAST (Focal assessment sonography in trauma)4. CT Scan for Head injury5. Pulse oximetry6. DPL (Diagnostic peritoneal lavage)

o Nasogastric tube and urinary catheter help in preventing aspiration of gastric contents and measuring urinary output and should be used

o After completing primary survey the doctor should start secondary survey only if the vital signs of the patient are within normal limits.

o At this stage AMPLE history should be recorded as following

A Allergies (Whether allergic to any medicines?)M Medication (Was taking any medicine?)P Past illnesses/pregnancy L Last MealE Events/Environment leading to injury

VITAL SIGNS include the heart beat, breathing rate, temperature, and blood pressure. These signs may be watched, measured, and monitored to check and individual level of physical functioning. Normal vital signs change with age, sex, weight, exercise and condition.Normal ranges for the average healthy adult vital signs are:

o Blood Pressure: 120/80 mm/Hgo Breathing: 12-18 beats per minute (at rest)o Temperature: 97.8-99.1 degrees Fahrenheit / average 98.6 degrees Fahrenheit.

MASS EMERGENCIES/BOMB BLAST INJURY/TERRORIST ACTIVITIES



o The mass emergencies will be dealt according to the revised Disaster Management Plan already published.

o Patients will be received and shifted after resuscitation as mentioned on page 2-3 of Disaster Management Plan.

o The Medical Superintendent will be the focal person for dealing with Media, VIP’s/visitors and Relatives of the patient.

o In absence of Medical Superintendent the DMS (Admin) and DMS (P&D) will be the focal person respectively.

o The senior most surgeon available at the scene will triage the patient and label them with tags as under for further management.

Grey Dead or InsolvagableRed Patient with Life threatening injuries Yellow Patient with Non-life threatening major injuries.Green Walking wounded patients with minor injuries

o Patients will be treated according to ATLS protocols as simplified above for Poly-trauma patients.



CCU CARDIOENT OF ACUTE MYOSPITAL - SOPS

GATE PASS SOPS o Visitor pass must be issued to the attendant accompanying patients admitted in the CCU.o Rupees 100 (refundable) deposited for each pass with the charge nurse and document in the

registero Visitor pass collected by charge nurse when patient is discharged,o Refund Gate pass fee of Rs 100 and clearly document in the register.

1. INFECTION CONTROL:-

I/V LINE 1. Wash hands2. Pass by staff nurse/4th year nurse3. Explain procedure to the patient4. Take consent5. Clean area with spirit swab6. Share the area if needed7. Spread plastic sheet8. Pass I/V line in sterilized way, check with saline and stabilize with nichban sticking9. Change after three days



MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION ADMITTED TO CCU

Tasks TimeDuration

Written order ActionBy

Comfortable position Maintain IV line 02 inhalation

IMMEDIATE Rx Aspirin 300m Chew orally Clopidogral 300mg Orally Inj.Morphine+Metchlorpromide I/V ß-Blocker if BP is high Nitrates (Exclude Contra Ind.) Consider Thrombolytic therapy1). Consent from the patient2). Exclude Contraindications Preparation of streptokinase

Within 5MinDo

Do

Do

Consider Within15m

MO/TMO/SMO/Cons

Do

Do

Do

H.ONurse

StaffNurse

MO

(See SOP).

(Immediate Rx (Continued)

3). Monitoring4). Prognosis

MOStaffNurse

MOMO

Documentation Arrival report BP record chart Risk factor Rx chart Nursing entry sheet ECG pasting

Within20-30 minutes

HO/TMO/MO/SMO/ConsultantMOMOHO/NMO/HONurseNurse



Investigation

Baseline (see app) Post St. Kinase ECG Documentation of any

Adverse events Post SK notes Treatment adjustment Reassurance to patients &

relatives

Within20-30 minutes

MO/TMO/SMO

DoDoDo

DoDoDo

Staff Nurse

Staff Nurse

MOMOMO



SOPS FOR SURGICAL ICUADMISSION CRITERIA

o Pre-post of patient in shock (Hypovolumic &Shock)o For total parental nutritiono Post of major surgery e.g. total colostomies, Esophegectomies, gastrectomyo Patient with multiple injuries (e.g. FAI)o DICo Delay recovery from GAo Ventilator support

ON ARRIVAL IN SICU o Patient will be examined by both HO and M.O.o Documentation by the HO,M.O separately encompassing time of arrival in the SICU,o History of illness/injuries/surgery, Past History, drug allergies, drug history, family history,

clinical findings, investigations required and management plan.o To discuss the new admissions with the Registrar and senior registrar.o To follow the treatment plans according to the treatment protocols and guidelines.o To start the management ASAP but not later than 15 minute after the arrival of the patients.o Ensure to utilize the hospital resources a much as possible and to send all investigations to the

hospital laboratory if available.o To counsel/inform relatives/attendants of patient and take proper detailed consent with

explanation of any possible procedures if needed as part of the patient’s management.

MORNING ROUNDS o The HO,MOs and TMOs working (inclusive of those on rotation) will take daily progress report

of the patient after proper examination of the patients and proper documentation with time and date written clearly.

o The morning round will be supervised by the Sr. Reg. and M.O will present beds, if beds are allotted then MOs will present their respective beds. HO should be encouraged to present beds and supervised.

o During rounds The patient, his relatives attendants should be properly informed about the disease, state/ condition of the patient and prognosis

o If a procedure or referral is planned during the round it must be explained to the patient or his relatives.



EVENING ROUNDS o Evening round to be done on regularly basis irrespective of any holidays.o Senior Rg. must supervise the evening round.o HO and MO on duty must be present in the evening round and present their respective

patients per SICU protocols.o All orders, examination findings, unusual findings and treatment plans must be clearly

documented and singed. Name of the responsible doctor should be written clearly under the signature.

o Any new development or change of plans must be explained to the patient or his relatives.o Proper handover and take over to be undertaken with clear documentation on the chart of the

patient. This applies to doctors and nursing staff.o Any defaulters from the rounds must be report per protocol of the hospital.

INFECTION CONTROL o All entering the SICU must take off their shoes and over alls before entering the SICU.o Wash hands before examining patients and relatives must wash hands before touching their

patients.o After examination and procedure, all health care providers must wash their hands.o Relatives and attendants accompanying the patients must be discouraged and clearly told not

to bring any unnecessary personnel belongings to the SICU.o Hospital timings regarding visiting hours and rounds must be observed.

I/V LINE 1. Wash hands2. Pass by staff nurse/4th year nurse3. Explain procedure to the patient4. Take consent5. Clean area with spirit swab6. Share the area if needed7. Spread plastic sheet8. Pass I/V line in sterilized way, check with saline and stabilize with nichiban sticking9. Change after three days

GATE PASS SOPS

o Visitor pass must be issued to the attendant accompanying patients admitted in the SICU.o Rupees 100 (refundable) deposited for each pass with the charge nurse and document in the

register.o Visitor pass collected by charge nurse when patient is discharged o Refund Gate pass fee of Rs 100 and clearly document in the register.



SOPS FOR MEDICAL ICU

10 bedded ICU for most serious patients of the hospital, subject to availability of beds

HIERARCHY o Senior Registraro Registraro 6 Medical Officerso 2 House officers on rotation from medical wardso 2 staff nurses in each shifto One student nurse

CRITERIA FOR ADMISSION IN MICU o Patient requiring mechanical support e.g. ventilator, dialysiso Patient with metabolic crisis or electrolyte imbalance, organ failure, shock(septicemia,

hypovolumic)o Comatose Patients, CVA, Infections, Meningitis, Encephalitis, Poisoning etc.o 2 beds for tetanus patients

1. The patients are admitted in MICU from medical & allied as well as surgical & allied wards with medical problems

2. In MICU the staff present on duty is responsible for all the orders given for medication & nursing care

DOCUMENTATION o As soon as the patient is shifted to the MICU, the MO on duty reviews the treatment of the

patient, fully understands the purpose of the patient admission in the ICU and along with the HO present on duty documents the patient( history taking by the HO while the MO writes the arrival reports clearly) with in the 30 minutes of the patients arrival

o If already prescribed with any investigations & treatment, the orders must be carried out as soon as possible. HO being on the front line is fully supervised by the MO & registrar. If the SR is present then he must supervise all the staff present in MICU and review all the work done by the staff junior to him

o When a doctor/ consultant from the parent ward visits the ICU , the MO & the HO must present & discuss the relevant patient in detail with the visiting doctor & properly document their notes.

o A proper treatment plan to be notified on the chart of the patient, so as to elaborate the line of action

o Proper , clear, compassionate explanation of what is being done for the patient should be communicated by the HO/ MO/ Registrar/ SR to the patient after as per protocol of the MICU & the prognosis dicussed with the relatives with in the ethical limits.



o While changing shifts the doctors, nurses & other staff must ensure proper well documented hand over & take over

GATE PASS SOPS o Visitor pass must be issued to the attendanto accompanying the patient admitted in MICUo Rs 100 ( refundable) deposited for each pass with the o charge nurse & document in the registero Visitor pass collected by charge nurse when patient is dischargedo Refund gate pass fee of Rs 100 & clearly document in register

INFECTION CONTROL

IV LINE a. Wash handsb. Pass by staff nurse/ 4th year student nursec. Explain procedure to the patientd. Take consente. Clean area with spirit swabf. Shave the area if neededg. Spread plastic sheeth. Pass IV line in sterilized way, check with saline & stabilize with nichiban stickingi. Change after 3 days



PULMONOLOGY UNIT

STANDING OPERATING PROCEDURE FOR BRONCHOSCOPY

DUTIES OF BRONCHOSCOPY TECHNICIAN/REG/TMO o Patient should be NBM for at least 4-6 hrs.o Check P.T. It should not be more than 3 sec from control.o Check, document & share B.P, PULSE, SaO2, and any ECG abnormality. Patient o Hemodynamically stable and SaO2 at least >90%.o Check procedure items. (Technician & MO/TMO on duty)o Explain procedure to the patient. (Duty of MO/TMO responsible for bed in case of admitted

patient and also TMO on duty in OPD cases).o Take written informed consent from patient/relative.o Ensure patient / working i/v access (Cannula).o Re-confirm the indication for bronchoscopy and side of pathology.o Recheck working oxygen cylinder, oxygen gauge and new/sterilized nasal cannula.o Properly operating suctioning machine and sterilized bronchoscope confirmed before each

bronchoscopy.o Re- confirms the availability & expiry date of all possible medications in the resuscitation

trolley.o Must always checked sputum for AFB result (if available) before bronchoscopy.o Identify the name, CXR, check relevant investigations and correlate clinically.o Hand over the valuable of patient like watch, gold rings, bangles etc. to relative.o Particularly, remove nose ring or clip in female patient.o Perform procedure in accordance with guidelines.o Operator must be SR or above to perform procedure independently.o Specimen must be labeled legibly before handing it over to the patient.o Document procedure notes.o Re-check and document post procedure BP, Pulse & SaO2.o In case of TBB obtain CXR (PA view) & exclude pneumothorax.o Bronchoscopy call must be discussed with the consultant before giving date and then

animate the date to the bronchoscopy technician well in time to enable him to prepare list.



STANDING OPERATING PROCEDURE FOR ASPIRATION & BIOPSY

DUTIES OF TECHNICIAN, REG/TMO/MO o Check procedure items. (Technician & MO/TMO assistant).o Check and document B.P, PULSE, SaO2 and any ECG abnormality. Patient hemodynamically

stable and SaO2 at Least > 90%.o Take written informed consent from patient / relative.o Explain procedure to the patient. o Re- Confirm patient I/V access.o Hand over the valuables of patient like watch, gold rings, bangles etc. to relative.o Correlate clinical findings and site of pathology with latest CXR/CT scan/Chest U/S.o Identify the name & date on CXR.o If TMO is main operator, he must have authorization from SR/AP/Prof. All others must do

under supervision of consultant/ year 3 trainee of Pulmonology.o Perform procedure in accordance with the guidelines.o Send pleural fluid for R/E and Pleural biopsy for H/P.o Specimen must be labeled before handing it over to the patient.o Send the specimen only to hospital/specified laboratory.o Document procedure notes and any specific order.o Check chest X-ray post procedure.o Presence of close relative/ female staff should be ensured if procedure is undertaken on

female patient.o OPD cases should be admitted for proper care.

STANDARD OPERATING PROCEDURE FOR CHEST INTUBATION

DUTIES OF TECHNICIAN, REG TMO/MO o Check procedure disposables sterilized equipments & other required items.o Check and document B.P, pulse & SaO2.o Take consent from patient/relative.o Explain procedure to the patient.o Correlate clinical findings and site of pathology with latest CXR/CT scan /Chest U/S.o Identify the name & date on CXR.o Re – confirm identification for chest intubations & document authorization.o Re – confirm patient IV access (IV line).o If TMO is main operator, he must have authorization from SR/AP/Prof. All others must do

under supervision of consultant /year 3 trainee of Pulmonology.o Perform procedure in accordance with the guidelines.o Re – check proper working of chest tube, all connections and under water seal bottle.o Check Chest X- ray post procedure.o Document all the procedure notes and any specific order.



o Explain precautions regarding tube care to the patient &/attendant as well.o Re – check & document post procedure BP, Pulse & SaO2.o Presence of close relative/female staff should be ensured if procedure is undertaken on female

patient.o OPD case should be admitted for proper care.



STANDARD OPERATING PROCEDURES

PATIENT’S HISTORY, MANAGEMENT AND TRAINING OF JUNIOR DOCTORS.

The following rules should be observed and followed. (Duty of Registrar, TMO/MO will look after to continue implementation).

o Time of arrival and treatment should be written on the treatment charts (Reg /TMO/MO on duty).

o Patient should get admission number within an hour of arrival (duty of staff nurse and ward technician) but this should not delay the treatment.

o Medical officers should write medication within half and hour and arrival reports within one hour of receiving the patient.

o House Officers should write detailed history of the patients within three hours of admission and all the histories must be completed till 2.00 pm.

o Medical Officers and House Officers on Evening Duty should write Arrival Reports and Detailed histories of all the patients admitted through Casualty.

o Any medication written on Treatment Charts should be in clear and eligible writing with name of the advising doctor mentioned.

M or Dr.Mukhtiar Zaman AfridiS for Dr. Saadia AshrafR for Dr Rukhsana FarooqiRest all should write their full names.

o Generic Names of drugs should also be written in Capital Letters.o First dose of all I/V antibiotics must be given by the TMO/MO/ on duty and properly

document.o All the required information should be entered in appropriate pages & ensure all pages

including investigation pages should be duly filled in by the discharge of the patient. (Duty of HO/TMO/MO).

o All CXR of the patients should be labeled and dated serially.o All orders/ investigations ordered in morning round must be fulfilled till 1.00 pm and delay

should be noted in notes & communicated to the next on call team.o All investigations received back should be checked by respective MO/TMO, signed & any

action arising should be taken & documented on history sheet. If needed, discuss with senior and take appropriate action but document properly.

o Three samples of sputum must be sent for patients having suspicion of Pulm TB. (Duty by MO/TMO’s).

o Evening Rounds should be documented in the Register by the nurse, signed by the MO and report should be written in the evening round register and separate report submitted the Dr.Mukhtiar Zaman Afridi.



o All investigations advised must be sent to the lab on the register and sign should be taken from the appropriate person from lab. (MEMO needs to go from management of ward to lab for cooperation.)

o Beds allotted to each HO/TMO/Rotation TMO must be properly displayed on the beside (duty of registrar) and all needs to be aware of the case and DPR.

o Registrar should ensure that DPR and ward is ready before starting morning round.o All HO’s should bring their own stethoscope and BP apparatus.o All patients’ diagnosis and their ICD 10 coding must be clearly written on their history sheets

as well as on their discharge cards.o It is the duty of the Reg /MO/TMO to ensure patient is getting all medications as prescribed.o No discharge card is given to the patient unless it is checked and duly signed by the chest ward

permanent TMO/MO & /Registrar.o On OPD days chest ward TMO/MO who’s duty is in ward is supposed to see and manage

admitted patients and prepare them for post OPD round.o Bed numbers and important orders of all serious patients should be clearly written on the

lounge notice board (duty by relevant MO/Registrar).o Call from other wards should be noted and attended by Reg /Senior MO/TMO and if needed

consult the senior on duty. Call specifically written for the consultant should be noted and timely informed to the consultant on call. Call register should be maintained by Reg /MO on duty.

o Bronchoscopy call must be discussed with the consultant before giving date and then intimate the date to the bronchoscopy technician well in time to enable him to prepare list.

o All MO/TMO should perform their duties in respective places in accordance with the duty Rota displayed in the ward and doctor’s lounge.

o Monthly morbidity and mortality meetings will be held in last week of the month (SR duty) and doctors should present all respective cases. List of cases will be developed during the month.

o All TMO’s should keep their log book updated and get it signed within 1 week of the activity.o All MO’s keep a record of the procedures performed and their outcome and report will be

presented in the monthly meeting along with record of short cases, long cases and CPC presented or attended. Etc.

o Any new appointee should go through induction, orientation programme within 1 week of arrival & all protocols & guidelines will be shared ( duty 0f SR & JR).

SOPS FOR ANESTHESIA DOCTORSPRE OPERATIVE EVALUATION / ASSESSMENT

(BOTH ELECTIVE & EMERGENCY CASES)

o To anticipate potential risk involved by taking a thorough history, physical examination & laboratory investigations

o To ensure that the patient is prepared to decrease the risk of adverse outcome



o To provide appropriate information to the patient & to obtain consent for a planned anesthetic technique.

o To prescribe pre medication and prophylactic measure if required.o To provide satisfactory pre operative careo Consultation with relevant professional & seniors where required.

CHECKING ANESTHESIA EQUIPMENTS o Checking anesthesia machine, oxygen supply, anesthesia circuits, laryngoscope, suction

machine, monitors etc.o Labeling syringes of anesthesia drugso Stand-by supply of oxygen cylinder, emergency drugs, ambu bag, defibrillator etc.

ANESTHETIZING A PATIENT o Setting I/V line & starting I/V fluidso Setting monitors-SpO2, BP, ECG etc.o Pre medicationo Induction & maintenance of anesthesia as plannedo Recovery of patiento Shifting the patient from the recovery to ward or ICU according to the patient clinical statuso Consultation with seniors in difficult situation/complication

DOCUMENTATION / RECORD KEEPING o Pre operative assessment recordo Anesthesia plan.( GA or regional technique)o Intra operative events & monitoring: Blood loss, IV fluid & drug giveno Record vital signso Signs of recovery noted



SOP’S FOR UTILIZATION OF ZAKAT FUND

o Budget to be distributed (Month wise)o Medicine to be issued to;

1. Indoor patient (Valid Istehqaq from whole province)2. Out door patient (Valid Istehqaq, Pesh. Distt: & referred cases only)

INVESTIGATIONS: o MRI, CT-Scan to indoor patient on the sign of the consultant only.o Routine investigations to Zakat patient (free)

1. Ailments i.e. diabetic, Asthmatics, HTN, osteoporosis, Thalecemic etc.o OPD patient, from KTH surrounding area properly referred by district Zakat officer will be

entertained.o Medicine received must be defaced before issue and sign/thumb impression taken in the LP

ledger for Zakat.o Zakat indent must be signed & stamped by a consultant;o Three days dose will be issued to indoor patients and 7-15 days dose to be issued to o Outdoor patients as per short/long illness in the allowed allocation to ensure o judicious utilization for effective therapy & quick disposal o Brand of common drugs will be selected to avoid complications/ ensure judicious utilization of

funds for effective therapy and quick disposal.

a). 60% of total budget will be used for Bulk purpose of some common drugs to facilitate the patients

b) 20% of total budget will be for investigations. c) 30% of total budget will be for outdoor patients. d) 50% of total budget will be for indoor patients.



DISASTER/ CRISIS MANAGEMENT FLOW CHART

SOPs KTH 2010P&D Cell-M&E

Casualty KTH

Reception + Resuscitation

Neurosurgery + Cardiothoracic

Trauma unit near Orthopedic

Minor Injuries

Lady Reading Hospital Peshawar

Resuscitation

Casualty O.T Minor O.T

Major Injuries

Main O.T

Transfer to Surgical/ Orthopedic Wards etc

60


SOPs KTH 2010P&D Cell-M&E

IBP Block

Reception

Resuscitation

Major OperationsIn Main O.T

Minor Operations in IBP Block O.T

Transfer to Surgical/ Orthopedic etc

61


DECISIONS

1. PROTOCOL FOR RECEIVING INJURED/SERIOUS PATIENTS.

The Disaster management team which comprises the doctors to be present on the premises in Casualty KTH and Trauma Unit adjacent to Orthopaedic ward will assess and proceed to treat the patient. Patient requiring resuscitation will be resuscitated in Casualty and Trauma area. Patients requiring any minor surgical procedure shall be shifted to the Minor O.T which has been upgraded with facilities for anaesthesia and sterilization. Patients requiring major surgical procedure shall be shifted to the Main O.T and the surgeons present at the site shall operate. ENT and Eye cases will be taken care of by the respective. These patients after having been operated and treated will be admitted back to the units on call. If the unit on call has become full with patients the other units should be used for admitting the patients and the staff of that unit will be responsible for their care and further management of complications.

PETCOT building will be developed as soon as possible to become the designated area for Emergency reception and treatment. However till such time that PETCOT is not functional

the above protocol mentioned shall be in vogue. PETCOT is being developed for mass emergency so as to exclude the main hospital as much as possible from the influx of attendants and public coming with the injured patients. An area for reception of emergency will be designated in Petcot, and a resuscitation area will also be designated. The team of doctors and paramedics designated for being present at the site of emergency shall then function in this area.

The theatre in Petcot will be fully developed with anaesthesia cover and all minor and major cases which can be operated there will be taken care of in this operation theatre. The cases of serious nature requiring major surgery will be operated in the Main O.T of KTH. These patients will then be shifted to the wards on call and if their numbers increase will go to the other allied wards.

2. One TMO from the surgical wards and Medical Wards should be posted to the casualty on daily basis from the unit on call.

3. The provision of all necessary items like Oxygen Cylinders, masks, suckers, I/C Canulas, I/V Fluids emergency drug shall be present at the site of emergency resuscitation and these shall be checked by the focal person i.e the Medical Superintendent. 4. Bulk Store in the basement with resuscitation material for fifty patients shall be present at all times and will be checked by the focal person.

5. The Operation Theatre in Casualty shall be fully functional.

6. Resuscitation items for at least twenty patients shall be available in the Casualty of KTH and the focal person shall check its availability.



DISASTER ………………… BE PREPARED -A GENERAL REVIEW

Disaster is a sudden great incidence causing massive destruction and casualties like Bomb blast, Road Side Accidents, Fire Arm Injuries, Riots and violence, Building Collapse and out break of epidemic diseases.

Disasters have been classified as natural and man made. There is a complex relationship between the two.

In order to cope with all sorts of emergencies effectively, all health care institutions must devise an institutional disaster plan of action. Because in the crisis situation, the failure of the authority to warn people adequately and of people to respond promptly can contribute to the increase loss of life and damages. Therefore a plan of action should be worked out to effectively manage crisis situation. Every health care institution must be prepared and ready to tackle the crisis situation developing as a result of the disaster in its area. The hospital administration must anticipate the crisis. It can save death and misery. The sudden increase in demand on the services of the health care must be met. Absence of a plan will add to chaos and confusion, which come on when ever large numbers of people are affected. That will paralyze the services to be provided by the institution- what would have been possible ordinarily would be come almost impossible. All the concerned people, the hospital administration, doctors, nurses and other paramedical staff, the victims, the relatives and the public become frustrated. Lives may be lost unnecessarily because of lack of preparedness.



STEPS TO BE TAKEN 1. Nomination of a focal person

In all kind of crisis situation there is need for a unified authority. One focal person should be identified, who will issue instructions. These instructions must be followed otherwise there will be confusion and conflict.

It is also necessary to decide before hand who will be the next focal person in the absence of the designated focal person. The focal person should be available at the control room always. His duty is to coordinate and supervise the activities, ensuring that the plan is being carried out efficiently. He should be available to give advice and instructions. The focal person motivates and encourages the crisis team to give their best.

The focal person should ensure that there is proper communication: Between the members of the team With the anxious relatives of the victims With the public With the authority and With the media The Focal person will submit the daily situation report to the Chief Coordinator for onward

submission to the higher authorities.

2. Formation of Disaster Management Groups (DMGs)The hospital administration must develop disaster management groups. The members of the groups, consisting of doctors, nurses, paramedical and other supportive staff should be carefully selected and trained. Each one must be aware of his / her responsibilities, what to do and whom to contact, should they need assistance.

These groups should be capable of being assembled quickly, at any time of day or night, hence, in he selection of people, priority should be given to those who are available easily and live close by in the campus, in the neighbor hood , having telephone connections and own transport.

3. Medicines All kind of life saving drugs should always be made available in the accident and emergency department insufficient quantity to provide emergency care to a maximum of 500 patients.

4. Equipments Certain equipments and materials should be earmarked for dealing with disasters. They must

be checked periodically. It must be ensured that they can be used without any delay.



5. Blood About 500 bags of screened blood should be made available in the blood bank all the time. A

donor list of people willing to donate blood at short notice be ready, with their correct address and telephone numbers. Formation of donors desk in the hour of need . 6. Instruments

To ensure the availability of sterile instruments for mass emergency use.7. Ambulances

Ambulances must be well equipped with emergency drugs , equipments and trained medical staff.

8. Establishment of information and Registration Desks at Accident and Emergency Department

9. During Natural calamities, the tele-communication system is usually disrupted. It is therefore necessary for every mega health institution to establish its own wireless system for the purpose.

10. Arrangements for preservation of unknown dead bodies.

11. The focal person who is the Medical Superintendent should check the medicines and relevant equipment on weekly basis to be ready for emergency situations.



CRISIS MANAGEMENT TEAM (CMT)

OBJECTIVE

To ensure timely organized Trauma care in order to decrease mortality, morbidity & disability due to injury.

-CMT will hold regular meetings to check the preparations of the hospital in order to cope with all sorts of emergencies effectively.1. Dr. Mohammad Zafar Chief Coordinator

Chief Executive KTH/KMC/KCD Office: 091-9216362Resident: 091-5861627Cell No. 0300-5949517

2. Dr. Khizar Hayat Khan Medical Superintendent Focal Person

Office: 9216832 Residence: 9211196Cell No. 03339155129

3. Dr. Farman Ali Coordinator DMGsDMS (P&D)Office: 1208 Mobile: 0333-9166402

4. Dr. Mohammad Zafar AfridiDy: Medical Superintendent (Admn) Coordinator DMGs Office: 2003 Mobile:03339120753

4. Dr. Ghulam Rasool Main Operation Theatre CoordinatorOffice No. Cell No. 03219093747

6. Dr. S.MujtabaResident Medical Officer Member Office: 2004 Mobile 0300-5940821

7. Dr. S. Asad Maroof MemberSenior Registrar Casualty/TraumaOffice No. 2042

8. Dr. Akbar ShahI/C A & E Deptt. Member Contact # Office: 9216363Mobile: 03465114449

9. Mr. Jalil Anwar Member Chief Pharmacist

Contact #0333913878410. Mrs. Naseem Himayat Member

Chief Nursing Supdt: Office No. 2167



GROUP OF SURGEONS / ANESTHETIST S. No. Name of Group Leaders Contact Numbers1. Assoc. Prof. Dr. Atta Ur Rehman 033391067672. Assoc. Prof. Dr. Rooh Ul Muqim 03005974985SNo Name of Surgeon/Supervisors Contact No1 Prof. Mia Asadullah Jan 033391687812 Prof. Attaullah Jan 58128603 Prof Zafar Durrani 5841800-030085828384 Prof. Parhaizgar 0333-5974985

S. No. Name of Doctors to be present at site of mass Emergency

Contact Numbers

1. Prof. Dr. Mustafa Iqbal Supervisor 030059575282. Assoc. Prof. Dr. Mushtaq 033391431303. Assoc. Prof. Dr. Attaur Rahman 5844501 / 0303-78669274. Assoc. Prof. Dr. Ijaz Ahmad 272817 / 0300-5908006

5. Assoc. Prof. Dr. Zahid Askar 5843457 6. Assoc. Prof. Dr. Inayat 0300-59204928. Assoc. Prof. Dr. Zakir Ullah 5860561/033391693669. Assoc. Prof. Dr. Hashimuddin Azam 0300594992010. Assoc. Prof. Dr. Hamza Khan 0300901271011. Assist. Prof. Dr. Qutbi Alam 5704519 / 0333-912582912. Assist. Prof. Dr. Abid Haleem 81171613. Assist. Prof. Dr. Zareen SR 851640 / 0300-5980301

S.No. Name of Anesthetists to be present in O.T in case of mass emergency

Contact Numbers

1. Asstt:Prof. Dr. Tahira Hakim Shah 5812582/033496724472. Assist. Prof. Dr. Nighat Aziz 033391562213. Dr. Asmatullah 58253094 Dr. Neelam 033491452295 Dr. Aniqa 58118316 Dr. Zarmina Javed 0300-9598319 / 8401947 Dr. Ghulam Rasool

Department Coordinator5815466

8 Dr. Nirgus 58126329 Dr. Talat 5851007 / 0333-9113680

S.No. Name of Nurses Contact Numbers 1. Mrs. Shaheena Rehmat 58500723 Mrs. Akhter Shah 58407384 Mrs. Sabia Bukhari 57035105 Mrs. Robina Sultan6 Mrs. Aqila Shaheen 58426368 Mrs. Gul Naz



S.No. Name of OTAs Contact Numbers 1 Mr.Liaqat Khan 2573708 / 0333-91654532 Waheed Ahmad 0300-59295843 Qayum Jan 0921- 6452514 Irshad Ali 22112415 Ibrahim Khan 22853746 Rashid Khan 0333-91509177 Khair Ul Bashar8 Younis Khan 0333-91277489 Jehanzeb 299030410. Subhan S.No. Name of Anaesthesia Technicians Contact Numbers 1 Saleem Shah 241549 / 0300-59839382 Khan Sher3 Muslim Khan 0300-59772294 Safiullah 25728285 Ikhtiar Alam 0333-91224376 Mujahid Azam 0300-59738797 Nishad Ali 6114188 Shabir 0300-59390889 Khan Said 0300-5727031S.No. Name of Ward orderlies Contact Numbers 1 Viqar Khan 0300-59757652 Hidayat Ullah 5700880 3 Mukhtiar Khan 57029444 Attaullah Shah5 Riaz Khan 8700916 Misal Khan7 Gul Bahar8 Azad Khan9 Samin Jan 83346310 Javed 5702079



DOCTORS TO BE PRESENT AT SITE OF MASS EMERGENCY

S.No. Name of Surgeons / Doctors Contact Numbers 1. Assoc. Prof. Dr. Ibrar Eye 845550 / 0300-5864732

2. Assist. Prof. Dr.Tariq Waheed 0300-5940788

3. Assist. Prof. Dr. Inayat E.N.T 0333-9115307

4. Dr. Awal Hakim Orthopedic Ext: 2235

5. Dr. Zahid Khan

6. Dr. Jamshed Ext: 2117

7. Dr. Ajmal Registrar 03339146350

8. Dr. Azhar Shah Registrar 03005928386

9. Dr. Sayed Asif Shah S.R Burn 0321-9046656

10. Assist. Prof. Dr. Attaullah 03339143511

11. Assist. Prof. Dr. Qutbe Alam

12. Assist. Prof. Dr. Tariq Saeed 03025524826

13. Assist. Prof. Dr. Zarin 03339414477

14. Assist. Prof. Dr. Abid Haleem

15. Assoc. Prof. Dr. Zahid Askar

16. Assoc. Prof. Dr. Ayaz 03005933101

17. Assist. Prof. Dr. Wazir Mohammad

18. Assist. Prof. Dr. Jamila Javed Shah 03005937571

19. Dr. Muslim Senior Registrar SBW Resident Supervising Coordinator



DIAGNOSTIC SERVICES MANAGEMENT GROUP This group will manage the affairs of Blood Bank, the Clinical Laboratory, Radiology Deptt: and ECG .

The Blood Bank of KTH has a capacity to store 500 bags of blood.

S.No. Name of Doctor Contact Numbers 1 Dr. Azeem Afridi2 Dr. Fayaz Naeem Assoc. Prof.

Radiology3 Dr. Inam Pathologist 570190945 Mr. Hanif Chief Blood Bank Tech: 2670044 / 0300-5943981

MEDICINE AND SURGICAL DISPOSABLE MANAGEMENT GROUP

All the emergency drugs have been stocked in the Casualty Satellite pharmacy. These are sufficient to provide health care to a maximum of 500 patients. (List of medicine is given below):

S.No. Name of Pharmacist / Store keeper Contact Numbers 1 Jalil Anwar Chief Pharmacist

Coordinator 0333-9138784

2 Mr.Javed Senior Pharmacist 034692185093 Badri Zaman Store Keeper 8426874 Zahir Ali Dispenser 0300-5962257

DMG-6 INFORMATION AND REGISTRATION GROUP

S.No. Name of officers /officials Contact Numbers

1 :Mr. Farhad Khan PRO 03339109847

2 Mr. Mumtaz Khan Protocol Officer 03219009657

3 Safdar Khan 9216363

4 Ayub Khan Head Ward orderly 0333-9166288



MASS EMERGENCY AREAS (RED ZONES)

Disaster Cell in Trauma unit ------- 30 beds Casualty Department ------- 12 beds Eye A & B , ENT A&B units ------ 184 beds Surgical Wards A,B,C&D ------- 184 beds Surgical ICU ------- 8 beds

Total ------- 418 beds

All these areas have been equipped with beds, linens, staff, emergency trays and medicines.

LOGISTICS In case of power failure alternate mechanisms have been ensured working in collaboration

with WAPDA authorities. Stand by diesel generators along with sufficient diesel for emergency ensured. Provision for continuous supply of water. Fire extinguishers to all vulnerable areas. Emergency Nos have been provided to the telephone operators. Hot line No. 9216348 communicated to Police and DCO Peshawar. Measures taken to ensure that the hotline is not kept busy. Six Ambulances have been equipped for Primary Care with sufficient Diesel and round the

clock provision of drivers. At least ten trolleys and Ten Wheel Chairs are available for patient transport. Blood Bank Officer and Social Welfare Officer are working in close liaison with Social welfare

society of KMC to ensure sufficient blood.



TELEPHONE NUMBERS OF PROFESSORS

S.NO NAME OF PROFESSOR OFFICE RESIDENCE MOBILE1. Prof. Mia Asadullah Jan 2212 5841894 0333-91687812. Prof.Dr.Sultan Mahmood 2216 5841628 0333-91662203. Prof. Balqis afridi 2205 5841894 0300-59224724. Prof.Sadeeq U Rahman 2197 5813092 0300-59499515. Prof. Attaullah Jan 2187 5812860 0333-91233916. Prof. Inayat Shah Roghani 2236 5828011 0304-90064477. Prof.Zafar Hayat 2186 5815651 0300-59801598. Prof.Niamatullah Kundi 2184 5844561 0300-59204639. Prof. Nadeem Khawar 2199 5817773 0345-904389210. Prof.Zafar Durani 2188 5841800 0300858283811. Prof. Azer Rashid 2182 5276747 0300-594241812. Prof.Shah-e-Din 2201 581251313. Prof. M. Aziz Wazir 0333-910388714. Prof. Nisar Anwar 2174 576326 0300-859555115. Prof. Dr. Noor Ul Iman 0333913132216. Prof. Dr. M. Hamayun 0300595602717. Prof. Dr. Mukhtiar Zaman 0333913531618. Prof. Mehmud Aurangzeb 0333914111419. Prof.Dr. Mustafa Iqbal 03005957528

0333925909120. Assoc. Prof. Atta Ur Rehman 5844501 0333910676721. Assist. Prof. Dr.Arif Raza 2126 5836199

58258612573042

0333-9167305

SOPS FOR LABORATORY INVESTIGATIONS



All the samples must be properly labeled All the routine/ baseline investigations which do not need the orders of the Professor I/C of

the concerned unit ( like blood complete, urine exam, blood urea, blood sugar etc.), may be sent in time to the laboratory before 10.00 am

Specialized investigations or any other test advised may be sent to the laboratory up to 12. 0 Noon. These investigations will be completed & reported up to 2. PM

Emergency investigations will be entertained any time up to 2 PM in the morning shift & round the clock afterwards

All the pre operative patients must be screened by Elisa . The ICT quick method may be utilized only for dire emergencies.

Samples for Elisa tests must reach laboratory from 9 AM -- 4 PM Blood for P.T/ APTT must be sent in citrated tube in proper volume in the ratio of 0.2 ml

reagent & 1.8 ml blood Patient for fasting blood sugar must have 12 hrs fasting & random glucose checked after lunch/

dinner

DEPARTMENT OF RADIOLOGY



INTRODUCTION Radiology department is now changed into an imaging department and gives services round the clock.Department has facilities of conventional X-ray, fluoroscopic examinations, ultrasound and Doppler studies. The endowment fund has provided CT and MRI.

GUIDELINES FOR THE PATIENTS Patient coming to radiology department has investigation forms duly filled in and advised by treating physician, gets his examination form registered at the counters manned/controlled by MS KTH along with the payment of dues and gets receipt. A few examination services are on appointment bases, where the patient is given date by the clerk in room No 6. the money so collected is deposited with the almoner of the hospital by the respective data entry operator.

ULTRASOUND Department runs in three shifts. Morning: 8am to 1pm. It is for all cold cases of the OPD, wards and also for emergency cases. Ward cases are by appointment. Evening: 1pm to 8pm. Night: 8pm to 8am.Evening and night shifts provide cover to casualty and ward emergency cases.

X-RAY X-ray are done round the clock and the shifts are the same as for the ultrasound.

CT SCAN CT scan is done up to 3pm and reported daily. After this the emergency services are provided round the clock.

MRI MRI is done daily up to 3pm and reported on the same day except few cases kept for teaching purpose.

STAFF There are different cadres of staff working in the department, the included are

KMC teaching staff. Provincial Health Services Doctors. Provincial Health Services Paramedics. Clerical and supporting services of dais ward orderlys, sanitary. Doctors of all cadres work under the supervision of head of radiology department, who is

Professor of KMC. JR/SR is designated staff of MS KTH and is responsible for liaison between department and administration of KTH. They are the administrative local heads.

Doctors perform all the procedures and examinations of patients and report the images of different modalities.

Paramedics mostly the X-ray, CT and MRI technicians responsible for acquiring images. A few minor procedures of general radiology are also performed by paramedics. Dais are present in ultrasound section and responsible for assisting the doctors on duty in

handling the female patients and also fulfill the requirement of female attendant at the time



of examination

REVENUE Radiology department is also the earning hand of the institution. Most of the services provided are on charge basis.The revenue then generated is deposited with the Almoner of KTH. Revenue generated from CT and MRI is deposited in the account of Endowment fund project and later distributed between Provincial Endowment fund, KTH and staff of radiology department.

DUTY ROTA Duty Rota is made by registrar in consultation with the head of department. The doctor on duty has to be present in the department. House officers and TMO’s also perform the duties on rotation bases. Duties are assigned in three shifts. Registers are maintained in the department by senior technician and supervised by JR/SR along with head of department.

CLEANLINESS Department cleanliness and maintenance is checked daily.


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