ER Service Standards

Emergency Department
Service Standards
For General Hospitals
Disclaimer
The authors views expressed in this publication do not necessarily
reflect the views of the United States Agency for International
Development or the United States Government.

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iii

ACKNOWLEDGMENTS
Emergency medicine focuses on the diagnosis and treatment of acute illnesses and trauma that
require immediate resuscitation and treatment. It is a field of practice based on the knowledge and
skills required for the prevention, diagnosis, and management of acute and urgent medical and
surgical cases.
Emergency physicians are tasked with seeing large number of patients, treating their illnesses and
referring them to the hospital as necessary. It requires a broad field of knowledge and advanced
procedural skills often including; trauma resuscitation, basic cardiac life support, and basic airway
management, etc
This series of documents and publications provides the necessary guidelines for specialists,
planners, managers, health providers, and those working with communities to improve the
provision of essential and lifesaving care for patients. This series covers four areas: clinical and
medical care, planning and management, community development.
We would like to thank the many dedicated people who have contributed to the development of
these materials. Through proper application of the principles, approaches, and actions incorporated
in this series, quality services can be made accessible and available to patients who need them
most.
It is my sincere hope that this series of documents will contribute to improving the health and well-
being of patients in our country.

v

CONTRIBUTORS
The Emergency Department Service Standards for General Hospitals was modified from the
original volume (Emergency Department Service Standards for Level II General Hospitals)
developed by the Ministry of Health and Population in Egypt under the Healthy Mother/Healthy
Child Project in collaboration with the United States Agency for International Development
(USAID) and its technical assistance contractor, John Snow, Inc. The technical working group
contributed to the original volume and adapted the material to suit the needs of Jordanian hospitals.
Ministry of Health Technical Working Group

Dr. Jamal Qunash
Director of Emergency Directorate at MOH

Dr. Basel Abu-Sabha
Director of Emergency Department at Al-Basheer Hospital

Dr. Ali Awwad
Emergency Medicine Specialist at Al-Basheer Hospital

Reviewers

Professor Sabry Hamza
Chief of Party / Health Systems Strengthening II (HSSII) Project

Dr. Anwar Al-Khasawneh
Emergency Task Manager / Health Systems Strengthening II (HSSII) Project

Formatting and Operational Assistance

Ms. Sarah Salaytah
Executive Assistant / Health Systems Strengthening II (HSSII) Project

Emergency Department Service Standards for General Hospitals
vii

TABLE OF CONTENTS
FOREWORD.................................................................................................................................................... I
ACKNOWLEDGMENTS ............................................................................................................................ III
CONTRIBUTORS ..........................................................................................................................................V
TABLE OF CONTENTS ........................................................................................................................... VII
TABLE OF FIGURES .................................................................................................................................. XI
ABBREVIATIONS AND ACRONYMS .................................................................................................. XIII
INTRODUTION ........................................................................................................................................ XIII
CHAPTER 1: UNDERSTANDING EMERGENCY DEPARTMENTS IN GENERAL HOSPITALS .. 3
1. UNDERSTANDING EMERGENCY DEPARTMENT ...................................................................... 3
2. HISTORY ............................................................................................................................................ 3
3. DEPARTMENT LAYOUT ................................................................................................................. 3
4. SIGNAGE ............................................................................................................................................ 4
5. CRITICAL CONDITIONS HANDLED ............................................................................................. 4
6. NON-EMERGENCY USE .................................................................................................................. 5
7. SCHEMATIC DESIGN/ FUNCTIONAL REQUIREMENTS ........................................................... 6
CHAPTER 2: EMERGENCY SERVICE STANDARDS FOR GENERAL HOSPITALS ................... 13
1. INTRODUCTION ............................................................................................................................. 13
2. EMERGENCY DEPARTMENT ENTRY......................................................................................... 13
3. WAITING HALL .............................................................................................................................. 13
4. RECEPTION/REGISTRATION ....................................................................................................... 13
5. RECEPTION AND REGISTRATION OFFICE ............................................................................... 13
6. PUBLIC RELATIONS ...................................................................................................................... 15
7. PHARMACY ..................................................................................................................................... 15
8. ACCOUNTING ................................................................................................................................. 15
9. PUBLIC TOILETS ............................................................................................................................ 15
10. STORE (STRETCHERS & WHEELCHAIRS) ................................................................................ 15
11. POLICE ............................................................................................................................................. 15
12. TRIAGE ROOM ................................................................................................................................ 15
13. RESUSCITATION ROOM, EQUIPPED FOR LIFESAVING PROCEDURES (FOR ADULTS
AND PEDIATRICS) ......................................................................................................................... 19
14. EXAMINATION ROOM .................................................................................................................. 27
15. OBSERVATION ROOM .................................................................................................................. 31
16. OPERATING ROOM (FOR MINOR SURGERY) ........................................................................... 35
17. PLASTER ROOM ............................................................................................................................. 39
Table of Contents
viii

18. ISOLATION ...................................................................................................................................... 42
19. CLEAN UTILITY ............................................................................................................................. 44
20. DIRTY UTILITY............................................................................................................................... 44
21. STORE ROOM .................................................................................................................................. 44
22. NURSING STATION ........................................................................................................................ 46
23. PHYSICIANS OFFICE .................................................................................................................... 46
24. NURSES OFFICE ............................................................................................................................ 48
25. STAFF REST ..................................................................................................................................... 49
26. DOCTOR ON CALL ......................................................................................................................... 49
27. STAFF CHANGE .............................................................................................................................. 50
28. PERSONNEL .................................................................................................................................... 50
29. DEPARTMENT ADMINISTRATION ............................................................................................. 53
30. INFECTION CONTROL PROCEDURES ........................................................................................ 54
31. BEHAVIORAL ASPECTS OF EMERGENCY CARE .................................................................... 55
32. CLINICAL PROCEDURE ................................................................................................................ 58
33. PATIENT TRANSFER ..................................................................................................................... 61
34. CRASH CART .................................................................................................................................. 61
CHAPTER 3: QUALITY ASSURANCE MONITORING SYSTEM ...................................................... 67
1. INTRODUCTION ............................................................................................................................. 67
2. ASSESSING COMPLIANCE WITH STANDARDS ....................................................................... 68
3. SUPERVISORY TEAMS AT THE HOSPITAL DIRECTORATE (HD) AND QUALITY
DIRECTORATE (QD) LEVELS ...................................................................................................... 68
4. SERVICE STANDARDS MONITORING CHECKLISTS .............................................................. 68
5. CONDUCTING EMERGENCY DEPARTMENT ASSESSMENTS ............................................... 69
6. EMERGENCY DEPARTMENT SELF-ASSESSMENTS................................................................ 69
7. HOSPITAL /QUALITY DIRECTORATE ASSESSMENTS ........................................................... 70
8. VERIFYING EMERGENCY DEPARTMENT ASSESSMENT SCORES ...................................... 70
9. SOLVING COMPLIANCE PROBLEMS ......................................................................................... 71
10. WRITING RECOMMENDATIONS FOR IMPROVEMENT .......................................................... 72
11. QUARTERLY REPORTS ON EMERGENCY DEPARTMENT COMPLIANCE SCORES ......... 72
12. PRESENTATION OF EMERGENCY DEPARTMENT COMPLIANCE SCORES ....................... 73
CHAPTER 4: EMERGENCY DEPARTMENT MONITORING CHECKLISTS FOR GENERAL
HOSPITALS .................................................................................................................................................. 77
1. SERVICE STANDARDS FOR TRIAGE ROOM ............................................................................. 77
2. SERVICE STANDARDS FOR RESUSCITATION ROOM, EQUIPPED FOR LIFESAVING
PROCEDURES (FOR ADULTS AND PEDIATRICS) .................................................................... 79
3. SERVICE STANDARDS FOR OBSERVATION ROOM ............................................................... 83
4. SERVICE STANDARDS FOR OPERATING ROOM (FOR MINOR SURGERY) ....................... 86
5. SERVICE STANDARDS FOR PHYSICIANS OFFICE ................................................................. 90
6. SERVICE STANDARDS FOR NURSES OFFICE ......................................................................... 91
7. SERVICE STANDARDS FOR RECEPTION /REGISTRATION OFFICE .................................... 92
ix

8. SERVICE STANDARDS FOR STOCK ROOM .............................................................................. 93
9. SERVICE STANDARDS FOR PERSONNEL ................................................................................. 95
10. SERVICE STANDARDS FOR DEPARTMENT ADMINISTRATION .......................................... 98
11. SERVICE STANDARDS FOR INFECTION CONTROL PROCEDURES .................................... 99
12. SERVICE STANDARDS FOR BEHAVIORAL ASPECTS OF EMERGENCY CARE ............... 100
13. SERVICE STANDARDS FOR CLINICAL PROCEDURES ......................................................... 103
14. CRASH CART ................................................................................................................................ 107
CHAPTER 5: EMERGENCY DEPARTMENT MONITORING CHECKLISTS FOR GENERAL
HOSPITALS - CRITICAL SERVICE STANDARDS ONLY ................................................................ 111
1. SERVICE STANDARDS FOR TRIAGE ROOM ........................................................................... 111
2. SERVICE STANDARDS FOR RESUSCITATION ROOM, EQUIPPED FOR LIFESAVING
PROCEDURES (FOR ADULTS AND PEDIATRICS) .................................................................. 112
3. SERVICE STANDARDS FOR OBSERVATION ROOM ............................................................. 115
4. SERVICE STANDARDS FOR OPERATING ROOM (FOR MINOR SURGERY) ..................... 116
5. SERVICE STANDARDS FOR PERSONNEL ............................................................................... 118
6. SERVICE STANDARDS FOR CLINICAL PROCEDURES ......................................................... 120
7. SERVICE STANDARDS FOR CRASH CART ............................................................................. 122
CHAPTER 6: CLINICAL PERFORMANCE MONITORING ............................................................. 125
1. CLINICAL INDICATORS MONITORING CHECKLIST ............................................................ 127
2. CLINICAL PRACTICE INDICATORS FOR EMERGENCY MEDICAL SERVICES ................ 130
3. EMERGENCY DEPARTMENT SERVICE STANDARDS COLLECTIVE CHECKLIST FOR
GENERAL HOSPITALS ................................................................................................................ 131
4. EMERGENCY DEPARTMENT SERVICE STANDARDS COLLECTIVE CHECKLIST FOR
GENERAL HOSPITALS CRITICAL ........................................................................................... 135
5. PERCENTAGE COMPLIANCE ACTUAL SCORE FOR GENERAL HOSPITALS ................... 137
6. PERCENTAGE COMPLIANCE ACTUAL SCORE FOR GENERAL HOSPITALS -
CRITICAL ........................................................................................................................................ 138
7. EMERGENCY DEPARTMENT SERVICE STANDARDS RECOMMENDATIONS FOR
IMPROVEMENT ............................................................................................................................ 139

xi

TABLE OF FIGURES

FIGURE 1: EMERGENCY DEPARTMENT ................................................................................ 7
FIGURE 2: ZONE 1 ......................................................................................................................... 8
FIGURE 3: ZONE 2 ......................................................................................................................... 9
FIGURE 4: ZONE 3 ....................................................................................................................... 10
FIGURE 5: CRASH CART ........................................................................................................... 63

xiii

ABBREVIATIONS AND ACRONYMS
A

ABG Arterial Blood Gas
ACLS Advanced Cardiac Life Support
AIA American Institute Of Architects
ARI Acute Respiratory Infection
ASAP As Soon As Possible
ATLS Advanced Trauma Life Support
B

BCLS Basic Cardiac Life Support
BEOC Basic Essential Obstetric Care
BLS Basic Life Support
BP Blood Pressure
C

CBT Competency-Based Training
COPD Chronic Obstructive Pulmonary Disease
CPR Cardiopulmonary Resuscitation
CQIS Continuous Quality Improvement System
CT Computed Tomography
CVP Central Venous Pressure
E

ECG Electrocardiogram
ED Emergency Department
EMS Emergency Medical Services
EMT Emergency Medical Technician
EOC Essential Obstetric Care
ET Endotracheal
F

FP Financial Planner
G

GP General Practitioner

Acronyms and Abbreviations
xiv

H

H
2
Hydrogen
HIS Health Information System
HM/HC Healthy Mother/Healthy Child
I

ICU Intensive Care Unit
IU International Unit
IV Intravenous
IVF Intravenous Fluid
M

MCH Maternal And Child Health
MD Medical Doctor
Mg Magnesium
MgSO
4
Magnesium Sulfate
MOHP Ministry Of Health And Population
N

NSAID Nonsteroidal Anti-Inflammatory Drug
O

O
2
Oxygen
P

PHC Primary Health Care
PRO Patient Relations Officer
Q

QA Quality Assurance
R

RR Respiratory Rate
U
U/S Ultrasound
xv

INTRODUCTION
Over the past decade, Jordan was able to achieve and maintain remarkable outcomes in improving
the health status of all Jordanians.
Emergency medicine focuses on the diagnosis and treatment of acute illnesses and trauma that
require immediate resuscitation and treatment. It is a field of practice based on the knowledge and
skills required for the diagnosis, and management of urgent and acute medical and surgical cases.
Emergency physicians are tasked with seeing large number of patients, treating their illnesses, and
referring them to the hospital as necessary. It requires a broad field of knowledge, training, and
advanced skills often including; basic cardiac life support, basic airway management, and trauma
resuscitation, etc.
Across Jordan, emergency medical services face many challenges; mainly the quality of services,
shortage of trained staff, and infrastructure challenges (size, and design).
Due to increasing number of population, and increasing number of casualties resulting from high
incidence of road traffic accidents, the ministry of health (MOH) is taking active steps to improve
the status of infrastructure and staff working in the emergency departments(ED) of MOH hospitals.
This publication is intended to serve as a convenient reference, a guide for service delivery, and a
tool to support performance improvement. This will improve the MOH potentials to get
accreditation for the emergency departments at the government hospitals across Jordan.
This series of documents and publications provides the necessary guidelines for specialists,
planners, managers, and health providers to improve the provision of essential and lifesaving care
for patients.
This publication covers six areas: understanding ED, emergency services standards, quality
assurance monitoring system, ED monitoring checklists, and clinical performance monitoring.
It is our sincere hope that this series of documents will contribute to improving the health and well
being of patients in Jordan.
1

Chapter 1:
Understanding Emergency
Departments in
General Hospitals

3

CHAPTER 1: UNDERSTANDING EMERGENCY DEPARTMENTS IN
GENERAL HOSPITALS
1. UNDERSTANDING EMERGENCY DEPARTMENT
The emergency department (ED), sometimes termed the emergency room (ER), emergency ward
(EW), accident & emergency (A&E) department or casualty department is a hospital or primary
care department that provides initial treatment to patients with a broad spectrum of illnesses and
injuries, some of which may be life threatening and require immediate attention.
2. HISTORY
The first specialized trauma care center in the world was opened in 1911 in the United States at the
University of Louisville Hospital in Louisville, Kentucky.
3. DEPARTMENT LAYOUT
A typical emergency department has several different areas; each specialized for patients with
particular severities or types of illness.
Upon arrival to the ED, an individual typically undergoes a brief triage (sorting) interview to help
determine the nature and severity of their illness or injury. Individuals with serious illnesses or
injuries are then seen by a physician more rapidly than those with less severe symptoms or injuries.
After initial assessment and treatment, patients are admitted to the hospital, stabilized and
transferred to another hospital, or discharged.
In the triage area, patients are seen by a triage physician/nurse, who completes a preliminary
evaluation, before they are transferred to another area of the ED or a different department in the
hospital. Patients with life- or limb-threatening conditions may bypass triage and may be seen
directly by a physician.
The resuscitation area is a key area of an emergency department. It usually contains several
individual resuscitation bays, usually with one specially equipped for pediatric resuscitation.
Each bay is equipped with a crash cart (defibrillator, airway equipment, oxygen, intravenous lines
and fluids, and emergency drugs). Resuscitation areas also have monitor, ECG machines, and often
limited X-ray facilities to perform chest, skull, and pelvis films. Other equipment may include non-
invasive ventilation (NIV) and portable-ultrasound devices.
The general medical area is for stable patients who still need to be confined to bed (note that a
"bed" in the ED context is almost always a trolley rather than a full hospital bed). This area is often
very busy, filled with many patients with a wide range of medical and surgical problems. Many will
require further investigation and possible admission.
Patients who are not in need of immediate treatment are sent to the minors area. Such patients may
still have been found to have significant problems, including fractures, dislocations, and lacerations
requiring suturing.
A pediatric area for the treatment of children has recently become standard, to dedicate separate
waiting areas and facilities for children. Some departments employ a play therapist whose job is to
put children at ease to reduce the anxiety caused by visiting the emergency department, as well as
provide distraction therapy for simple procedures.
Chapter 1: Understanding Emergency Departments in General Hospitals
4
Contemporary EDs typically do not maintain a dedicated area for obstetrics. Such patients who
present to the ED are sent to the obstetrics/maternity ward or the Labor and Delivery suite, unless
there is another medical condition that requires treatment first.
Many hospitals have a separate area for evaluation of psychiatric problems. These are often staffed
by psychiatrics and mental health nurses and social workers. There is typically at least one room for
people who are actively a risk to themselves or others (e.g. suicidal).
4. SIGNAGE
A hospital with an emergency department usually has prominent signage reading Emergency or
Accident and Emergency (often in white text on a red background) and an arrow to indicate where
patients should proceed.
5. CRITICAL CONDITIONS HANDLED
5.1 Cardiac Arrest
Cardiac arrest may occur in the ED/A&E or a patient may be transported by ambulance to the
emergency department already in this state. Treatment is basic life support and advanced.
Life support as taught in advanced life support and advanced cardiac life support courses. This is an
immediately life-threatening condition which requires immediate action in salvageable cases.
5.2 Heart Attack
Patients arriving to the emergency department with a myocardial (heart attack) are likely to be
triaged to the resuscitation area. They will receive oxygen and monitoring and have an early ECG:
aspirin will be given if not contraindicated or not already administered by the ambulance team;
morphine or diamorphine will be given for pain; sublingual (under the tongue) or buckle (between
cheek and upper gum glycerin trinitate (nitroglycerine) (GTN or NTG) will be given, unless
contraindicated by the presence of other drugs, such as drugs that treat erectile dysfunction.
An ECG that reveals ST segment elevation or new left bundle branch block suggests complete
blockage of one of the main coronary arteries. These patients require immediate reperfusion (re-
opening) of the occluded vessel. This can be achieved in two ways: thrombolytic (clot-busting
medication) or percutaneous transluminal coronary angioplasty (PTCA). Both of these are effective
in reducing significantly the mortality of myocardial infarction. Many centers are now moving to
the use of PTCA as it is somewhat more effective than thrombolytic if it can be administered early.
This may involve transfer to a nearby facility with facilities for angioplasty.
5.3 Trauma
Major trauma, the term for patients with multiple injuries, often from a road traffic accident or a
fall, is treated by a trauma team who have been trained using the principles taught in the
internationally recognized advanced trauma life support (ATLS) course of the American college for
surgeons. Some other international training bodies have started to run similar courses based on the
same principles.
The services that are provided in an emergency department can range from simple x-rays and the
setting of broken bones to those of a full-scale trauma center. A patient's chance of survival is
greatly improved if the patient receives definitive treatment (i.e. surgery or reperfusion) within one
5

hour of an accident (such as a car accident) or onset of acute illness (such as a heart attack). This
critical time frame is commonly known as the "golden hour."
Some emergency departments in smaller hospitals are located near a helipad which is used by
helicopters to transport a patient to a trauma center. This inter-hospital transfer is often done when
a patient requires advanced medical care unavailable at the local facility. In such cases the
emergency department can only stabilize the patient for transport.
5.4 Mental Illness
Some patients arrive at an emergency department for a complaint of mental illness. In many
jurisdictions (including many U.S. states), patients who appear to be mentally ill and to present a
danger to themselves or others may be brought against their will to an emergency department by
law enforcement officers for psychiatric examination. From the emergency department, patients
thought to be mentally ill may be transferred to a psychiatric unit (in many cases involuntarily).
5.5 Asthma and COPD
Acute exacerbations of chronic respiratory diseases, mainly asthma and chronic obstructive
pulmonary disease (COPD), are assessed as emergencies and treated with oxygen therapy,
bronchodilators, steroids or thyophilline, have an urgent chest x-ray and arterial blood gases and are
referred for intensive care if necessary. Non invasive ventilation in the ED has reduced the
requirement for intubations in many cases of severe exacerbations of COPD.
6. NON-EMERGENCY USE
Emergency departments around the world are increasingly being used for non-emergency care
because of overburdened healthcare systems. Many people, afflicted by minor injuries or illnesses
late at night or at times when their doctor's office is closed, reforced to resort to attending the ED.
This is especially true for conditions with distressing symptoms, such as a child's ear infection.
People in lower socioeconomic classes are more likely to use the ED for primary care services, as
they typically find it inconvenient or impossible to miss work for a visit to the General Practitioner
(GP), or who may be unable to afford an office visit (where a physician or clinic may refuse
treatment for inability to pay).
In the United Kingdom, it has become more popular to visit the A&E since it became mandatory
for patients to be fully treated and discharged from the department within four hours of arrival.
Also, the introduction of the new contract for primary care doctors in that country decreased the
accessibility of GP services. Under this contract GPs can opt out of on-call cover, and patients
sometimes present instead to the A&E.
Patients attending the ED for minor complaints do not contribute significantly to the overall
workload of the department. (Despite the level of complaints in the general public and by health
staff). Studies, in Australia at least, have shown that improved after-hours GP access has no effect
on ED workload or waiting times.
In the United States, and many other countries, hospitals are beginning to create areas in their
emergency rooms for people with minor injuries. These are commonly referred as Fast Track or
Minor Care units. These units are for people with non life-threatening injuries. The use of these
units within a department has been shown to significantly improve the flow of patients through a
department and to reduce waiting times. Urgent Care clinics are another alternative, where patients
can go to receive immediate care for non-life-threatening conditions.
6
7. SCHEMATIC DESIGN/ FUNCTIONAL REQUIREMENTS
Based on international standards, AIA standards, and proper medical planning, the schematic
design for the ED was made to meet the functional requirements of the ED. See (figure1).
The emergency department schematic design cover the level of services specific to the Emergency
Department, including:
ED entry
Waiting area
Reception and registration office
Public relations
Police room
Triage room
Resuscitation room
Examination/treatment room
Observation area ( male and female)
Operating room
Isolation/decontamination room
Ultrasound
Clean utility
Dirty utility
Laboratory
Radiology
Pharmacy
Physicians office
Nursing station
Plaster room
Head office
Nurses office
Staff rest
Stock rooms
Staff change
Department administration
Infection control procedures
Behavioral aspects of emergency care
Clinical procedures
Patient transfer
Each item will be discussed in relation to its physical structure, furniture, equipment, supplies and
medications, whenever it is relevant.


7

Figure 1: Emergency Department

Observation Area

Wards
(male/female)
Isolation
Nursing station
Utilities

Entry / Public Area
Pedestrian / relatives entry
Waiting area
Reception / registration
Accounting
Pharmacy
Police
(PRO) Counseling
Stretchers / wheelchairs
Public toilets
Direct access to triage
Treatment Area
Triage
Exam / treatment
Isolation
Decontamination
Resuscitation
Ultrasound
Dirty utility
Clean utility
Storage
Nursing station
Medical Supporting
Services Area
Operating theater
Plaster room
X-Ray
Lab
Equipment store
Supporting Services
Staff rest
Doctor on call
Head office
Staff change
Communication
Patient walk in Ambulant Entry
Discharge or
Admission to Hospital
Discharge or
Discharge or
Zone 1 Zone 2 Zone 3
8

Figure 2: Zone 1

Entry / Public Area
Pedestrian / relatives entry
Waiting area
Reception / registration
Accounting
Pharmacy
(PRO) Counseling
Stretchers / wheelchairs
Police
Public toilets
Direct access to triage
Walk in Entry
9

Figure 3: Zone 2

Treatment Area
Triage
Exam / treatment
Isolation
Decontamination
Resuscitation
Ultrasound
Dirty utility
Clean utility
Storage
Nursing station

Medical Supporting
Services Area
Operating theater
Plaster room
X-Ray
Lab
Equipment store
Discharge or Admission
to Hospital
Ambulant Entry
Discharge or Admission to
Hospital
10

Figure 4: Zone 3
Observation Area

Wards (male/female)
Isolation
Nursing station
Utilities
Discharge or Admission to
Hospital
11

Chapter 2:
Emergency Service Standards
for General Hospitals


13

CHAPTER 2: EMERGENCY SERVICE STANDARDS FOR
GENERAL HOSPITALS
1. INTRODUCTION
The service standards are the criteria for the procedures, supplies, and conditions essential for
quality health care services. Each standard is considered to be essential for full, effective provision
of the services. The Emergency Department Service Standards are based upon nationally-approved
clinical protocols for the diagnosis, management and prevention of common health problems. This
document includes Protocols for Emergency Department Teams.
These clinical protocols and service standards were developed from international research on the
most medically effective and cost-efficient practices. If followed correctly by health providers, the
number of deaths from major medical, surgical and child emergencies can be reduced by a
significant estimated percentage.
The Emergency Department Service Standards are organized into the three levels of care (as
shown in Table 1) that are provided within a medium size general hospital. (NOTE: Not all
facilities provide the full range of services as listed below for each level of care, some facilities
may provide more and some facilities provide fewer services.) A "generic" organizational structure
for (General Hospitals), Emergency Department is illustrated in Figure 1.
2. EMERGENCY DEPARTMENT ENTRY
Patient Entry (Walk in)
Ambulant Entry
3. WAITING HALL
Adequate waiting space
4. RECEPTION/REGISTRATION
Adequate space
5. RECEPTION AND REGISTRATION OFFICE
Forms used:
Out-Patient Form
The form must include:
Patient's personal data
Patient's complaint
Diagnosis
Treatment

Chapter 2: Emergency Service Standards for General Hospitals
14
Observation Form
Patient's diagnosis
Patient's vital signs
Patient's physical examination
Fluid chart
Medication chart
Investigations (laboratory, radiology, blood bank requests)
Consultation request
Register for Inpatient Admission
Diagnosis in Emergency Department
Service to which patient is admitted
Name of attending specialist/consultant
Patient's documents and investigation results
Patient's condition upon transfer:
o Stable
o Unstable
o Critical
Patient's transfer from Emergency Department done by:
o Porter
o Nurse
o Doctor
Consultation Form
Name, position, specialty of requester physician and requested physician
Diagnosis
Reason for consultation
Urgency of consultation (urgent, ASAP, routine)
Reply
Mortality Register
This must include:
Date and time of admission
Date and time of death
Diagnosis
Treatment
Investigations
Cause of death
15

6. PUBLIC RELATIONS
Adequate space
7. PHARMACY
Adequate space
8. ACCOUNTING
Adequate space
9. PUBLIC TOILETS
Adequate number for Males and Females
10. STORE (STRETCHERS & WHEELCHAIRS)
Adequate space
11. POLICE
Adequate space
12. TRIAGE ROOM
The goal of triage is to rapidly assess and identify life, or limb threatening emergencies. All
patients who present to the Emergency Department (ED) for care will be seen by a physician.
Expected Activities
To establish priorities for patient care, classify patients into emergent, urgent and non-
urgent.
To respond quickly to possible life threatening illness or injuries and escort them
immediately to the resuscitation room with an ongoing appropriate care.
To provide access for all people seeking medical care.
To provide a safe, assuring environment while awaiting therapeutic interventions for minor
complaints.
12.1 Physical Structure
12.1.1 Room Specifications
o One room (at least) should be available to be used as triage room.
o The room should not be less than 20 m2.
o Floors must be covered by porcelain tiles or plastic tiles.
o Walls must be painted with a washable paint.
o Paint and/or ceramic tiles must be light in color to facilitate observation of cleanliness.

16
12.1.2 Cleanliness
The room must be observed to be clean (no observable dust, dirt, trash, hospital wastes or
spider webs), including:
o Floors
o Furniture
o Equipment
o Instrument
o Doors and Windows
o Walls
o Lighting Fixtures
o Ceilings
12.1.3 Illumination
o Sufficient lights must be available, considering room area, including natural light
(windows with screens to keep insects out).
o Electric lights must be in good condition (all bulbs/tubes functioning, securely fixed,
with safe wiring and switches).
12.1.4 Ventilation
o Adequate ventilation considering room area, including natural sources (e.g. windows)
must be available.
o Electrical fans or air conditioners must be in good condition.
12.1.5 Electrical Sockets
o Three sockets (at least) must be available, appropriately distributed in the room
considering placement of equipment, and in good condition (i.e. securely fixed and
without hazards).
12.1.6 Sink
o Hand washing facilities must be available.
o Adequate drainage of the basin must be observed.
12.2 Furniture
The furniture listed below must be present in the triage room in the indicated minimum
quantities. The following conditions must be observed:
o All furniture must be clean (free of dirt, dust, stains, fluids, etc.).
o All plastic or cloth fabric must be intact (no holes or tears).
o Metal surfaces must be free of rust or stains.
o All furniture must be in sturdy condition (no loose or unstable parts).
o Painted surfaces must be intact and free of major scratches.
o If furniture has wheels, the wheels must be present and in working condition.
17

12.2.1. Examination Table (Adult)
o Two-Three examination tables
o Each table must be allocated at least 7.4 square meters of room area.
o The table must be covered with foam and plastic sheet without any tears.
o The table must be covered with a clean sheet.
12.2.2. Privacy Screens
o One privacy screen for each bed in the room must be available.
12.2.3. Waste Receptacles
o One waste receptacle for each bed in the room must be available.
o Plastic liner must be in the receptacle.
o One waste receptacle for medical waste.
12.2.4. Instrument Cabinet
o One cabinet at least must be available. Glass panel and shelves must be free of cracks.
12.3 Equipment
The equipment listed below must be present in the triage room in the indicated minimum
o All equipment must be clean (free of dirt, dust, stains, fluids, etc.).
o All equipment must be in sturdy condition (no loose or unstable parts).
o On equipment with wheels, the wheels must be present and in working condition.
o Instruments ready for use must be sterilized.
o All electrical equipment must be observed to be properly operational, with working
switches, safe wiring and secure plugs.
12.3.1. One Ambo Bag With Adult And Pediatric Size Masks
12.3.2. Central Suction System
12.3.3. Central Oxygen Supply System
12.3.4. One Sphygmomanometer, Adult And Pediatric Cuffs
12.3.5. One Stethoscope, adult
12.3.6. One Stethoscope, Pediatric
12.3.7. Thermometers

18
12.3.8. ENT Examination Set
12.3.9. One X-Ray Viewer
12.4 Supplies
12.4.1. Disposable Plastic Syringes
12.4.2. Disposable Latex Gloves
12.4.3. Wooden Tongue Depressors
12.4.4. Antiseptics (Betadine Alcohol)
12.4.5. Medicated Cotton
12.4.6. Adhesive Surgical Tape (Plaster)
12.4.7. Strong Plastic Bags for Garbage
12.4.8. Soap (Sterilium)
12.4.9. K-Y Jelly
12.4.10. Torch
12.5 Standing Orders
12.5.1. Patient complaints, vital signs, and level of consciousness are recorded by the
nurse within 5 minutes.
12.5.2. Emergency department residents assess the case within 10 minutes and triage
cases into A, B, C according to urgency and severity of the case:
o Emergent (A): (A) cases will be shifted to resuscitation room.
o Urgent (B): (B) Cases will go either to observation room or be treated in the treatment
room.
o Non-urgent (C): (C) Cases will be treated in the treatment room.
12.5.3. Emergency department specialist will assess all (A) cases in the resuscitation room
within 5 minutes.
12.5.4. Emergency department specialist will see (B) and (C) cases on request of the
resident within 10 minutes.
12.5.5. All pregnant women will be send to the obstetric room to be seen by the resident &
or specialist within 5 minutes.

19

12.5.6. Urgent cases will be shifted to resuscitation room and will be managed by
emergency department resident and specialist within 5 minutes.
12.5.7. Timing of consultation will be recorded in every room in a log book.
13. RESUSCITATION ROOM, EQUIPPED FOR LIFESAVING PROCEDURES (FOR
ADULTS AND PEDIATRICS)
Expected Activities
Perform resuscitation procedures for all life threatening illnesses or injuries for adults and
pediatrics.
13.1. Physical Structure
13.1.1. Room Specifications
o Two rooms, one for Trauma Emergencies, The other for Medical Emergencies.
o The room must be at least 24 m2.
o Additional space with cubicle curtains for privacy may be provided to accommodate
more than one patient at a time in the trauma room.
o The room must be used exclusively for resuscitation.
o Walls must be painted with a washable paint or covered by ceramic tiles.
o Paint and ceramic tiles must be light in color to facilitate observation of cleanliness.
13.1.2. Cleanliness
o Floors
o Furniture
o Equipment
o Instrument
o Doors and Windows
o Walls
o Lighting Fixtures
o Ceilings
13.1.3. Illumination
o Sufficient light must be available, considering room area, including natural light
o Ceiling mounted operation light with good range mobility and adequate power to allow
the different interventional procedures (other ceiling light of adequate power may be
used).
20
13.1.4. Ventilation
o Adequate air conditioning must be available, considering room area.
o The air conditioner must be in good working order with observed ability to adequately
cool the resuscitation room.
o To maximize the efficiency of the air conditioner, doors and windows in the
resuscitation room must be able to be securely closed.
13.1.5. Electrical Sockets
o Six sockets (at least) must be available, appropriately distributed in the room
considering placement of equipment, capable of handling required electrical loads of
equipment in the resuscitation room, and in good condition (i.e. securely fixed and
without hazards).
13.1.6. Basin
o A basin with hot and cold water, soap, and clean towel must be available in the room.
o The faucet levers must be capable of being turned off with the elbow.
13.2. Furniture
The furniture listed below must be present in the resuscitation room in the indicated
minimum quantities. The following conditions must be observed:
13.2.1. Operating Table (or ICU bed)
o The table must have adjustable height.
o The table must take Trendelenburgs and reverse Trendelenburgs positions.
o The table must have two arm pieces to support patient's arms in abduction.
o The table must provide free access to patient from all sides.
13.2.2. Two Instrument Cabinets
o Glass panels and shelves must be free of cracks.
13.2.3. One Drawer Cabinet
13.2.4. Two Instrument Tables (Mayo Stands)
13.2.5. Two IV Stands
o Some of them may be part of resuscitation table.
21

13.2.6. One Examination Lamp
13.2.7. Two Waste Receptacle
o The receptacle must have a lid.
13.2.8. Crash Cart
It must contain adequate number of drawers for:
o One drawer for emergency medications.
o One drawer for airway management (Ambo Bag, O2 masks, nasal cannulae, oral and
nasal airway, ET tubes, Stylet, laryngoscopes [adult and pediatric blades]).
o One drawer for IV cannulae and transfusion set.
o One drawer for catheters (urinary, suction, CVP).
o One drawer for IV fluids.
o It must have:
Resuscitation board attached.
Portable O
2
cylinder attached.
A space to carry a defibrillator and ECG monitor.
Wheels in good working conditions.
13.2.9. Counter Space
13.3. Equipment
The equipment listed below must be present in the resuscitation room in the indicated
13.3.1. One Ambo Bag With Anatomical Masks - Adult Size, Pediatric Size
13.3.2. Two Suction Devices (Central & Mobile)
13.3.3. Two Laryngoscopes, Adult, Pediatric
o With blades of different sizes.
o One spare bulb must be available.
o If operated by disposable batteries, a spare set of batteries must be available.
22
13.3.4. Stylet for ET tubes
13.3.5. Complete Central Oxygen Supply System (Pipe, O
2
Regulator, Wrenches, O
2
Mask
and Cannula)
o Spare cylinder must be completely full.
o Must indicate that the cylinder to which it is attached is at least partially full.
o One open end wrench for attaching regulator to cylinder.
o One special wrench for opening and closing oxygen cylinder valve.
13.3.6. Defibrillator
o Must have adult and pediatric pedals.
o Automated, or manual.
13.3.7. ECG Monitor
13.3.8. Pulse Oximeter
13.3.9. Two Infusion Pumps
13.3.10. One Sphygmomanometer with Different Cuff Sizes for Adult And Pediatric
13.3.11. Stethoscope, Adult
13.3.12. Stethoscope, Pediatric
13.3.13. Two Thermometers
13.3.14. Glucometer
13.3.15. Hammer
13.3.16. Torch
13.3.17. One Handling Forceps
13.3.18. Trauma Scissors
13.3.19. ENT Examination Set
13.3.20. Instrument Set Pack
o Stitching pack
Scalpel and blade size 11 and 15
One needle holder
One toothed forceps
One stitch scissors
Sterile drapes (perforated towel)
Sterile gauze swabs
Xylocaine 1-2%
23

o Venous cut down pack
Small artery forceps, 2 pairs
Small dissecting scissors, 1 pair
Stitch scissors, 1 pair
One small toothed forceps
One small non-toothed forceps
One needle holder
Two pair narrow skin retractors (langenbeck)
Prolene3/0 on cutting needle
Vicryl3/0 on round needle
Antiseptic solution
Sterile gauze swabs
One small kidney dish
Adhesive tape
Xylocaine 1-2%
Syringes 5ml, 10ml
Sterile drapes (perforated towels)
Sterile gloves, 1 pair
o Chest tube insertion pack
Large artery forceps, 2 pairs
Long dissecting scissors, 1 pair
Stitch scissors, 1 pair
One small toothed forceps
One small non-toothed forceps
One needle holder
Two pair narrow skin retractors (langenbeck)
Silk 2/0 on cutting needle
Vicryl 3/0 on round needle
Antiseptic solution
Sterile gauze swabs
One small kidney dish
Adhesive tape
Xylocaine 1-2%
Syringe 2ml, 5ml
Sterile gloves 1 pair

24
o Central venous pressure line (CVP) pack
One needle holder
One toothed forceps
One stitch scissors
Four sterile drapes (towels)
Sterile gauze swabs
Xylocaine 1-2%
Syringe 5ml, 10ml (with needle)
Antiseptic solution
Silk 2/0 cutting needle
Central venous pressure catheter
Central venous pressure manometer
Three way stop-cock
o Intubation set
Magill forceps
Stylet
Endotracheal tubes different sizes
Laryngoscope adult
Laryngoscope pediatric
Batteries
Bulbs
Suction catheters, different sizes
Oral airway, different sizes
K-Y jelly
The instruments in the kit which are ready for use must be sterilized.

25

13.4. Supplies
The supplies listed below must be available in adequate quantities, considering the utilization level
of the facility.

Item No. Item Unit
13.4.1. IV Cannula, Different Sizes (Pediatric and Adult) Each
13.4.2. Infusion Set Each
13.4.3. Disposable Syringe, (Different Sizes) Each
13.4.4. Suction Catheter, Different Sizes Each
13.4.5. Yanker Suction Each
13.4.6. Foley Catheters, Different Sizes Each
13.4.7. Urine Collecting Bag Each
13.4.8. Urine Test Stick Container
13.4.9. Chest Tubes, All Sizes Each
13.4.10. Cvp Catheters, Different Sizes Each
13.4.11. Peritoneal Lavage Catheter Each
13.4.12. O
2
Masks Each
13.4.13. O
2
Nasal Cannulae Each
13.4.14. Examination Gloves Each
13.4.15. Surgical Gloves, Different Sizes Pair
13.4.16. Silk Sutures, Different Sizes Pack
13.4.17. Prolene, Different Sizes Pack
13.4.18. Vicryl, Different Sizes Pack
13.4.19. Cutting And Round Needles Each
13.4.20. Disinfectant - Alcohol, Betadine Container
13.4.21. Gauze Swabs And Bandage Roll
13.4.22. Surgical Tape, 2.5, 7.5 Cm Roll
13.4.23. Cervical Collar (Different Sizes) Each
13.4.24. Hair Cover Each
13.4.25. Surgeon's Mask Each
13.4.26. Shoe Covers (Medium & Large) Each
13.4.27. Tongue Depressors Box
13.4.28. Glucometer Strips Box
13.4.29. Soap, Hand Washing, Sterilium Each
13.4.30. Plastic Bag, Medical & None-Medical Waste Receptacle Each
13.5. Medications
The medications listed below must be available in adequate quantities, considering the utilization
level of the facility:

26
Item No. Item Unit
13.5.1. Aminophylline Ampoule
13.5.2. Salbutamol Inhaler
13.5.3. Suitable Antibiotics Ampoule
13.5.4. Antihistamine Ampoule
13.5.5. Calcium Gluconate Ampoule
13.5.6. Dextrose 10% Or 25% IV Bag
13.5.7. Dextrose 5% IV Bag
13.5.8. Normal Saline Solution IV Bag
13.5.9. Ringers Lactate IV Bag
13.5.10. Diazepam Ampoule
13.5.11. Epinephrine Ampoule
13.5.12. Heparin Ampoule
13.5.13. Hydrocortisone Ampoule
13.5.14. Insulin, Soluble Vial
13.5.15. Magnesium Sulfate Ampoule
13.5.16. Erythromycin Eye Drops Bottle
13.5.17. Morphine Ampoule
13.5.18. Nifedipine Capsule
13.5.19. Naloxone Ampoule
13.5.20. Pethidine Ampoule
13.5.21. Protamine Sulfate Ampoule
13.5.22. Sodium Bicarbonate 8.4% IV Bag
13.5.23. Vitamin K( 1 Mg Or 10 Mg) Ampoule
13.5.24. Xylocaine 1%, Or 2% Vial
13.5.25. Dopamine Ampoule
13.5.26. Dobutamine Ampoule
13.5.27. Antiemetic Ampoule
13.5.28. Suitable Non-Steroidal Anti-Inflammatory Nsaid Injection Ampoule
13.5.29. Atropine Ampoule
13.5.30. Antispasmodic Injection Ampoule
13.5.31. H
2
Receptor Antagonist Ampoule
13.5.32. Amiodorone Ampoule
13.5.33. Rapid Sequence Induction (RSI) Drugs Ampoule
13.6. Standing Orders
13.6.1. ABCs of resuscitation are started immediately by the resident and nurse.
27

13.6.2. Emergency department specialist or surgeon will lead the resuscitation within 5
minutes.
13.6.3. Two wide bore IV lines must be started within 5 minutes; blood sample is sent for
type and save then IV line is run with normal saline or lactated ringer.
13.6.4. O2 administration by an appropriate method will be started within 5 minutes if
indicated.
13.6.5. Vital signs are recorded within 10 minutes.
13.6.6. Blood must be available within 30 minutes, upon request.
14. EXAMINATION ROOM
Expected Activities
Examining patients
Recording Vital Signs
Give treatment to minor cases
o Two rooms at least must be available; One for males, the other for females.
o The room area must be not less than 30 m2.(7.4m2 for each bed )
Each patient bed area shall have space at each bedside for visitors, and provision for
visual privacy from casual observation by other patients and visitors.
Hand-washing stations Shall be provided for each four treatment cubicles.
Toilet room. One toilet room shall be provided for each eight treatment cubicles.
Shower room. One shower room shall be provided for each sixteen cubicles. May be
combined with the toilet room.
Nourishment area. It shall include a sink, work counter, refrigerator, storage
cabinets, and equipment for hot and cold nourishment between meals.
14.1.2. Cleanliness
o Floors
o Furniture
o Equipment
o Instrument
28
o Doors and Windows
o Walls
o Lighting Fixtures
o Ceilings
o Electric lights must be in good condition (all bulbs/tubes functioning securely fixed,
14.1.4. Ventilation
must be available.
o Electrical fans or air conditioners, if available, must be in good condition.
o Six sockets (at least) must be available appropriately distributed in the room considering
placement of equipment, capable of handling required electrical loads of equipment, and
in good condition (i.e. securely fixed and without hazards).
14.2. Furniture
The furniture listed below must be present in the observation room in the indicated
14.2.1. Six (or More) Beds
o The bed must be furnished with mattress, linens, Macintosh oilcloth, and pillowed bed
cover.
14.2.2. One Desk
14.2.3. Chair
14.2.4. One or two Instrument Cabinets
14.2.5. Three Or More Instrument Tables
29

14.2.7. Five Or More Privacy Screens
14.2.8. Six Waste Receptacle
14.2.9. IV Stand
o At least one for each bed.
14.3. Equipment
The equipment listed below must be present in the Treatment room in the indicated
14.3.1. Six Sphygmomanometers (Fixed at Each Bed), Adult
14.3.2. Two Sphygmomanometers Pediatric Cuffs
14.3.3. One Stethoscope, Adult and Pediatric
14.3.4. Central Suction System (at Each Bed)
14.3.5. Twelve Lead ECG Machine
14.3.6. Medical Thermometers
14.3.7. Central Oxygen Supply System (Pipe, O
2
2
Mask and
Cannula ) at Each Bed
14.4. Supplies
14.4.1. Disposable Plastic Syringes (Different Sizes)
14.4.2. Disposable Examination Gloves
14.4.3. Sterile Surgical Gloves
14.4.4. Cannulae (Different Sizes)
30
14.4.5. Infusion Sets
14.4.6. Disposable Urinary Catheters (Different Sizes)
14.4.7. Urine Collection Bags
14.4.9. Strips to Detect Sugar, Acetone, Albumin in Urine
14.4.10. Antiseptics (Betadine - Alcohol)
14.4.12. Adhesive Surgical Tape
NOTE: The above items may be present in a nearby room and readily accessible. Supplies for one
week must be available, according to hospital consumption.
14.5. Medications
Item No. Item Unit
14.5.1. Antipyretic Ampule or Suppository
14.5.5. Lasix Ampoule
14.5.8. Soluble Insulin Vial
14.5.9. Adrenaline Ampoule
14.5.11. Normal Saline IV Bag
14.5.12. Glucose 5% IV Bag
14.5.13. Ringers Lactate Solution IV Bag

31

14.6.1. Vital signs will be recorded by the nurse within 5 minutes.
14.6.2. The emergency department resident will assess the case, and whenever is
necessary.
14.6.3. The emergency department specialist (If available) will assess the case on
request.
14.6.4. The relevant specialist will see the case on request.
14.6.5. Timing of consultation will be recorded in a logbook.
15. OBSERVATION ROOM
Expected Activities
Observation of patients for whom further assessment is needed.
Give treatment during observation period.
o Two rooms must be available, male & female.
o The room area must not be less than 30 m2.
Each patient bed area shall have space at each bedside for visitors, and provision for
visual privacy from casual observation by other patients and visitors.
Hand-washing stations shall be provided for each four treatment cubicles.
Toilet room. One toilet room shall be provided for each eight treatment cubicles.
Shower room. One shower room shall be provided for each sixteen cubicles. May be
combined with the toilet room.
Nourishment area. It shall include a sink, work counter, refrigerator, storage
cabinets, and equipment for hot and cold nourishment between meals.
15.1.2. Cleanliness
o Floors
o Furniture
o Equipment
o Instrument
o Doors and Windows
32
o Walls
o Lighting Fixtures
o Ceilings
o Electric lights must be in good condition (all bulbs/tubes functioning securely fixed,
15.1.4. Ventilation
must be available.
o Five sockets (at least) must be available appropriately distributed in the room
equipment, and in good condition (i.e. securely fixed and without hazards).
15.2. Furniture
The furniture listed below must be present in the observation room in the indicated
15.2.1. Four (or More) Beds
cover.
15.2.2. One Desk
15.2.3. Chair
15.2.4. One Instrument Cabinet
15.2.5. One Instrument Table
33

15.2.7. Three or more Privacy Screens
15.2.8. Four Waste Receptacle
15.2.9. IV Stand
o At least one for each bed.
15.3. Equipment
The equipment listed below must be present in the observation room in the indicated
15.3.1. One Sphygmomanometer, Adult and Pediatric Cuffs
15.3.2. One Stethoscope, Adult and Pediatric
15.3.3. Central Suction System
15.3.4. Twelve Lead ECG Machine
2
2
Mask and
Cannula)
15.4. Supplies
15.4.1. Disposable Plastic Syringes (Different Sizes)
15.4.2. Disposable Examination Gloves
15.4.3. Sterile Surgical Gloves
15.4.4. Cannulae (Different Sizes)
15.4.5. Infusion Sets
15.4.6. Disposable Urinary Catheters (Different Sizes)
34
15.4.9. Strips to Detect Sugar, Acetone, Albumin in Urine
15.4.10. Antiseptics (Betadine - Alcohol)
15.5. Medications
Item No. Item Unit
15.5.1. Antipyretic Ampoule or Suppository
15.5.5. Lasix Ampoule
15.5.8. Soluble Insulin Vial
15.5.9. Adrenaline Ampoule
15.5.11. Ringers Lactate Solution IV Bag
15.5.12. Glucose 5% IV Bag
15.5.13. Normal Saline IV Bag

35

15.6.1. Vital signs will be recorded by the nurse within 5 minutes then every 30 minutes,
or as needed.
15.6.2. The emergency department resident will assess the case every 30 minutes and
whenever is necessary.
15.6.3. The emergency department specialist (If available) will assess the case on
request.
15.6.4. The relevant specialist will see the case within 30 minutes on request.
16. OPERATING ROOM (FOR MINOR SURGERY)
Expected Activities
Perform minor interventional procedures for stable non-emergent patients who suffer no
obvious life threatening conditions.
o The room must be at least 5m x 7m (35 m2).
o The room must be used exclusively for minor surgery.
o Walls must be painted with a washable paint or covered by ceramic tiles.
o Paint and ceramic tiles must be light in color to facilitate observation of cleanliness.
16.1.2. Cleanliness
o Floors
o Furniture
o Equipment
o Instrument
o Doors and Windows
o Walls
o Lighting Fixtures
o Ceilings

36
16.1.4. Ventilation
o Adequate air conditioning or fans must be available, considering room area.
o The air conditioner must be in good working order with observed ability to adequately
cool the delivery room.
o To maximize the efficiency of the air conditioner, doors and windows in the delivery
room must be able to be securely closed.
o Five sockets (at least) must be available, appropriately distributed in the room
equipment in the delivery room, and in good condition (i.e. securely fixed and without
hazards).
16.1.6. Basin
o A basin with hot and cold water, soap, and clean towel must be available in the room
o The faucet levers must be capable of being turned off with the elbow.
16.2. Furniture
The furniture listed below must be present in the operating room in the indicated minimum
16.2.1. One Operating Table

37

o One table for sterilized instruments.
o One table for contaminated instruments.
16.2.5. Two IV Stands
o May be part of operating table.
16.2.7. Good Ceiling Light (Operation)
16.2.8. One Swivel Stool
16.2.9. One Step Stool
16.2.10. One Wheel Chair
16.2.11. One X-ray viewer
16.2.12. Two Waste Receptacle
16.3. Equipment
The equipment listed below must be present in the operating room in the indicated
16.3.1. Central &Mobile Suction Device
2
2
Mask and
Cannula)
o Spare cylinder must be completely full.
o Must indicate that the cylinder to which it is attached is at least partially full.
16.3.3. One Sphygmomanometer, Adult and Pediatric Cuffs
16.3.4. One Stethoscope, Adult
38
16.3.5. One Stethoscope, Pediatric
16.3.7. Instrument Set Packs
o Stitching packs
One needle holder
One toothed forceps
One stitch scissors
Four sterile drapes (towels)
Sterile gauze swabs
16.4. Supplies
The supplies listed below must be available in the indicated quantities, considering the utilization
Item No. Item Unit
16.4.1. IV Cannula, Different Sizes Each
16.4.2. Infusion Set Each
16.4.3. Disposable Syringe, Different Sizes Each
16.4.4. Suction Catheter, Different Sizes Each
16.4.5. Nasogastric Tube, Different Sizes Each
16.4.6. Urinary Catheters, Different Sizes Each
16.4.7. Urine Collecting Bag Each
16.4.8. Prolene , Different Sizes, Cutting Needle Pack
16.4.9. Vicryl , Different Sizes, Cutting and Round Needles Pack
16.4.10. Disinfectant - Alcohol, Betadine Container
16.4.12. Surgical Gloves, Different Sizes Pair
16.4.13. Gauze Swabs And Bandage Roll
16.4.14. Medicated Cotton Roll
16.4.15. Surgical Tape, 2.5, 7.5cm Roll
16.4.16. Hair Cover Each
16.4.17. Surgeon's Mask Each
16.4.18. Shoe Covers (Medium and Large) Each
16.4.19. Tongue Depressors Box
16.4.20. Torch Each
16.4.21. K-Y Jelly Each
16.4.23. Plastic Bag, Large Waste Receptacle Each
39

16.5. Medications
The medications listed below must be available in adequate quantities, considering the utilization
level of the facility. The medications may be presented in a nearby room and readily accessible.
Item No. Item Unit
16.5.2. Suitable Antibiotics Ampoule
16.5.4. Calcium Gluconate Ampoule
16.5.5. Dextrose 10% or 25% IV Bag
16.5.6. Dextrose 5% IV Bag
16.5.7. Ringer Lactate
16.5.8. Normal Saline Solution IV Bag
16.5.9. Epinephrine Ampoule
16.5.11. Insulin, Soluble Vial
16.5.13. Naloxone Ampoule
16.5.14. Natural Vitamin K 10 mg Ampoule
16.5.15. Xylocaine 1% or 2% Vial
16.5.16. Suitable Non-Steroidal Anti-Inflammatory NSAID Injection Ampoule
16.5.17. Atropine Ampoule
16.5.18. Antispasmodic Injection Ampoule
16.5.19. H
2
Receptor Antagonist Ampoule
17. PLASTER ROOM
Expected Activity
Application of different types of casts
17.1.1. Room specifications
o Room area must not be less than 3mx4m (12m2).
o Floor must be covered with porcelain tiles and plastic tiles.

40
17.1.2. Cleanliness
o Floors
o Furniture
o Equipment
o Instruments
o Doors and Windows
o Walls
o Lighting Fixtures
o Ceilings
o Electric lights must be in good condition (all bulbs/tubes functioning, securely fixed and
17.1.4. Ventilation
must be available.
o Electrical fans or air conditioners, if available, must be in a good working condition.
o Two sockets (at least) must be available, appropriately distributed in the room
considering placement of equipment and in good condition (i.e. securely fixed and
without hazards).
17.1.6. Telephone
o A telephone (internal line) must be available in a good working condition.
17.2. Furniture
The furniture listed below must be present in the plaster room in the indicated minimum

41

17.2.1. One (or More) Beds (Couch)
cover.
17.2.2. One Desk
17.2.3. Chair
17.2.4. Two Side Chairs
17.2.6. One Or More Privacy Screens
17.2.8. IV Stand
17.2.9. One or More Drawer Cabinets
17.2.11. Good Ceiling Light
17.2.15. One X-ray viewer
17.3. Equipment
The equipment listed below must be present in the Cast room in the indicated minimum
42
17.3.1. Electrical Saw
17.3.2. Two Medium Sizes Basins
17.3.3. One Plaster Scissors
17.4. Supplies
The supplies listed below must be available in the indicated quantities, considering the utilization
Item No. Item Unit
17.4.1. Plaster, Different sizes Each
17.4.3. Gauze Swabs and Bandage Roll
17.4.4. Medicated Cotton Roll
17.4.5. Surgical Tape, 2.5, 7.5 cm Roll
17.4.7. Soft ban, and or Stochonet Roll
17.4.8. Plastic Bag, Large Waste Receptacle Each
18. ISOLATION
Expected Activity
Examination of patients( Special cases)
o Room area must not be less than 3mx4m (12m2).
o Floor must be covered with porcelain tiles and plastic tiles.
18.1.2. Cleanliness
o Floors
o Furniture
o Equipment
o Instruments
o Doors and Windows
43

o Walls
o Lighting Fixtures
o Ceilings
18.1.4. Ventilation
must be available.
without hazards).
18.1.6. Telephone
18.2. Furniture
The furniture listed below must be present in the seclusion room in the indicated minimum
18.2.1. One bed
cover.
18.2.3. One Privacy Screen
18.2.4. One Waste Receptacle
44
18.2.5. IV Stand
18.2.6. Good Ceiling Light
18.3. Equipment
The equipment listed below must be present in the Cast room in the indicated minimum
19. CLEAN UTILITY
Adequate size
20. DIRTY UTILITY
Adequate Size
21. STORE ROOM
Expected Activity
Storage of materials and supplies for emergency department use.
Provide enough materials and supplies in case of mass accidents or disasters.
o Room area must not be less than 4m x 4m (or 16 m2).
o Floors must be covered with porcelain tiles or plastic tiles.
21.1.2. Cleanliness
o Floors
o Furniture
o Equipment
45

o Instruments
o Doors and Windows
o Walls
o Lighting Fixtures
o Ceilings
21.1.4. Ventilation
must be available.
o Three sockets (at least) must be available, appropriately distributed in the room
without hazards).
21.2. Furniture
The following furniture must be present in the storage room in the indicated minimum
21.2.1. Shelving Cabinet
o Adequate shelf heights.
o Easy accessibility.
o Enough shelves.
21.2.2. One Filing Cabinet
21.2.3. Two Waste Receptacle (Small)
46
21.3. Equipment
21.3.1. One Refrigerator
o Fourteen cubic feet (at least).
o Both refrigerator and freezer compartments should be in good working order.
Extra stock of the following should be available.
21.3.2. IV Stands
21.3.3. Sphygmomanometers
21.3.4. Sphygmomanometer Cuffs, Different Sizes
21.3.5. Thermometers
21.3.6. Wheel Chairs and Trolleys
21.4. Supplies
22.4.1. Stock supply of one week must be available in the stock room at all times
22.4.2. Enough stock supply to deal with mass accidents and disasters must be present
22. NURSING STATION
Adequate space
23. PHYSICIANS OFFICE
Expected Activity
Administrative work of staff physicians.
o Floors must be covered with porcelain tiles and plastic tiles.
23.1.2. Cleanliness
o Floors
o Furniture
o Equipment
47

o Instruments
o Doors and Windows
o Walls
o Lighting Fixtures
o Ceilings
23.1.4. Ventilation
must be available.
without hazards).
23.1.6. Telephone
23.2. Furniture
The following furniture must be present in the physicians office in the indicated minimum
23.2.1. One Desk
23.2.2. One Desk Chair
23.2.4. One Waste Receptacle (Small)
48
23.3. Equipment
23.3.1. One X-ray Viewer
o All electrical lamps in viewer must be working.
24. NURSES OFFICE
Expected Activity
Administrative work of staff nurses.
o Floors must be covered with porcelain tiles or plastic tiles.
24.1.2. Cleanliness
o Floors
o Furniture
o Equipment
o Instruments
o Doors and Windows
o Walls
o Lighting Fixtures
o Ceilings
24.1.4. Ventilation
must be available.

49

without hazards).
24.1.6. Telephone
o A telephone (internal line) must be available in good condition
24.2. Furniture
The following furniture must be present in the Nurses office in the indicated minimum
24.2.1. One Desk
24.2.5. One Waste Receptacle (small)
24.3. Equipment
o Fourteen cubic feet (at least).
o Both refrigerator and freezer compartments should be in good working order.
25. STAFF REST
Adequate space
26. DOCTOR ON CALL
Adequate space
50
27. STAFF CHANGE
Two rooms; Male & Female
Adequate space
28. PERSONNEL
28.1. Physicians
28.1.1. 24 hours coverage is provided by residents on duty in the emergency room (at
least one at each shift); all residents (specialists) carrying out emergency room duties will
be trained in:
o BCLS (pediatric and adult).
o ABCs of trauma (pediatric and adult).
28.1.2. In hospital specialist coverage for at least obstetric, pediatrics, anesthesia,
surgery, medicine is provided 24 hours.
28.1.3. The emergency room director is a qualified emergency, physician/surgeon of an
appropriate specialty connected to the management of emergency patients. S/he is
currently certified in:
o ACLS (pediatric and adult).
o ATLS (pediatric and adult).
28.1.4. The emergency room director is readily available on request. His duties include:
o Organize and train personnel.
o Maintain and upgrade equipment.
o Maintain service standards.
o Apply protocols and guidelines.

28.1.5. Full time emergency room director
28.1.6. Emergency room specialist on shift basis (If available)
28.1.7. Consultation by a specialist is available within 15 to 30 minutes in emergencies
28.2. Nurses
28.2.1. Emergency Room Head Nurse
o At least five years postgraduate experience.
o At least three years of experience in emergency room.
o Certified in BLS.
o Responsible for organizing nursing work, training of nurses, check equipment, applying
policies and procedures protocols, QA service standards.
51

28.2.2. Nursing Staff in Adequate Number
o Sufficient number of staff according to size of service and patient load.
o Trained in CPR.
o Trained in use of lifesaving devices.
28.2.3. In charge nurse is present in each shift. Takes the responsibility of the head
nurse in her absence.
28.3. Other Emergency Room Staff
28.3.1. Porters and/or Security
28.3.2. Cleaners
All are trained on their job duties.
28.4. Personnel Requirements
The following minimum personnel available to provide services are required to be present at the
facility:

52
No.
Staff
Category
Staff Position
Number Required
Critical
1
Essential
2

1
.

T
r
i
a
g
e

R
o
o
m

2
.

R
e
s
u
s
c
i
t
a
t
i
o
n

R
o
o
m

3
.

O
b
s
e
r
v
a
t
i
o
n

R
o
o
m

4
.

O
b
s
t
e
t
r
i
c

R
o
o
m

5
.

O
p
e
r
a
t
i
n
g

R
o
o
m

8
.

R
e
g
i
s
t
r
a
t
i
o
n

9
.

S
t
o
c
k

R
o
o
m

1
.

T
r
i
a
g
e

R
o
o
m

2
.

R
e
s
u
s
c
i
t
a
t
i
o
n

R
o
o
m

3
.

O
b
s
e
r
v
a
t
i
o
n

R
o
o
m

4
.

O
b
s
t
e
t
r
i
c

R
o
o
m

5
.

O
p
e
r
a
t
i
n
g

R
o
o
m

8
.

R
e
g
i
s
t
r
a
t
i
o
n

9
.

S
t
o
c
k

R
o
o
m

28.4.1. Managing MD ED Director 1 1
28.4.2. Service MD Specialist 5 10
28.4.3. Service MD Resident 5 12
28.4.4. Nurse ED Head Nurse 1 1
28.4.5. Nurse Staff Nurse 6 4
28.4.6. Nurse Associate Nurse 6 4
28.4.7. Technician EMT 3 4
28.4.8. Support staff
Registrar & Patient
Relations Officer
(PRO)
3 2
28.4.9. Support staff Cleaner & Porter 4 8
28.4.10. Support staff Security & Porter 3 4
1
Critical = required minimum for launching improved services.
2
Essential = required minimum for 100% compliance with QA Service Standards.
28.5. Training
The following personnel must have the following minimum required competencies:
Staff Position
A
.

O
r
i
e
n
t
a
t
i
o
n

B
.

L
e
a
d
e
r
s
h
i
p
,

T
e
a
m

B
l
d
g

P
r
o
b
l
e
m

S
o
l
v
i
n
g

C
.

Q
A

S
e
r
v
i
c
e

S
t
a
n
d
a
r
d

D
.

C
l
i
n
i
c
a
l

s
k
i
l
l
s

E
.

N
u
r
s
i
n
g

s
k
i
l
l
s

F
.

P
a
t
i
e
n
t

T
r
a
n
s
p
o
r
t

G
.

P
a
t
i
e
n
t
/
F
a
m
i
l
y

R
e
l
a
t
i
o
n
s

H
.

R
e
g
i
s
t
e
r
s

&

R
e
p
o
r
t
s

I
.

I
n
f
e
c
t
i
o
n

C
o
n
t
r
o
l

J
.

I
n
t
e
r
p
e
r
s
o
n
a
l

C
o
m
m
u
n
i
c
a
t
i
o
n

28.5.1. ED Director
28.5.2. Senior Specialist
28.5.3. Resident
28.5.4. ED Head Nurse
28.5.5. Staff Nurse
28.5.6. Associate Nurse
28.5.7. EMT
28.5.8.
Registrar & Patient Relations
Officer (PRO)

28.5.9. Cleaner & Porter
28.5.10. Security
53

29. DEPARTMENT ADMINISTRATION
29.1. References
One copy (at least) of the following booklets should be available in emergency department:
Emergency department clinical practice guidelines.
Emergency Nursing Procedures
Emergency department clinical protocols.
Staff job descriptions.
29.2. Job Descriptions
All staff should keep a copy of their job description.
Performance evaluation of staff should be according to the job description.
29.3. Facility Maintenance Procedures of the Department
Members of emergency department should be able to explain the existing system that is
used in maintaining the emergency department.
29.4. Preventive Maintenance Procedures for Equipment
Members of emergency department should be able to explain the existing system that is
used in preventive maintenance of emergency department equipment.
29.5. Logs and Registers
The following logs and registers should be available in the emergency department:
o Emergency department log
o Admission log
o Mortality log
One extra log (at least) should be available in stock.
All logs should be completed in accordance with instructions.
29.6. Forms
The following forms should be available in the Emergency Department:
o Admission (outpatient) form
o Observation form
o Consultation form
Sufficient number of forms for one month use at the hospital.
29.7. Monthly Reports
A copy of the monthly reports sent to the directorate should be kept in a special file.
Forms should be completed properly according to instructions.
Reports should be sent on time each month.
54
29.8. Utilization of Forms and Statistics
Emergency department staff should benefit from available information as follows:
o Developing special department plans.
o Supervision of services.
29.9. Organizational Structure
Organizational structure of the emergency department is diagramed and posted in the
director's office.
30. INFECTION CONTROL PROCEDURES
30.1. Cleaning and Disinfection of Rooms, Halls, and Corridors
After each case: disinfect operating table with antiseptic.
Daily: disinfect floors, toilets, washing basins and waste receptacles with antiseptic.
Weekly: clean furniture, doors, and windows with soap and water.
30.2. Hand Washing Procedures
Physicians and nurses must wash their hands before and after the following procedures:
o Before examining patient, putting on gloves and giving injections.
o After examining each patient, taking off gloves, giving injections and touching any
discharges or body fluids.
30.3. Wearing Examination Gloves
Physicians and nurses must wear examination gloves in the following conditions:
o Performing medical/local examinations.
o Handling contaminated instruments.
30.4. Wearing Surgical Gloves
Physicians and nurses must wear surgical gloves in the following conditions:
o Performing surgical procedures.
o Performing invasive procedures.
30.5. Wearing Gowns
Physicians and nurses must wear gowns in the following conditions:
o Attending multiple traumas.
o Performing surgical/invasive procedures.
30.6. Skin Disinfection
Physicians and nurses must disinfect appropriate areas of the patients skin before taking
blood samples, giving injections, performing invasive procedures.
55

30.7. Cleaning, Disinfecting and Sterilizing Equipment and Instruments
Equipment, instrument, and machines must be cleaned and sterilized as follows:
o Equipment:
Metallic parts: sterilize in hot air oven or autoclave.
Glass parts: wash with soap and water and disinfect.
Rubber parts: sterilize in autoclave or sterilize chemically.
o Instruments: sterilize in autoclave or hot air oven.
30.8. Waste Disposal
Wastes including human tissues, gloves, syringes, cotton, etc., must be disposed of in the
waste receptacle after each intervention.
Waste receptacles must be emptied every day, or when full, by discarding the plastic liner.
Wastes collected by the facility must be disposed of in an approved manner.
31. BEHAVIORAL ASPECTS OF EMERGENCY CARE
There is no place where behavioral aspects can affect the quality and results of medical care like the
situation of emergency.
31.1. Presence of Physician
The presence of a physician at all times in the emergency department is a necessity. The following
conditions have to be fulfilled:
Proper training (knowledge, skills)
Senior supervision and guidance
Back-up from different specialties at appropriate timing
The emergency department physician is responsible for implementing the following:
31.1.1. Comply with the department policies and procedures and follow approved clinical
protocols and guidelines. Deviation from policies and protocols should be justified.
31.1.2. Complete medical records of clinically relevant data.
o Documentation of history, examination, investigation, diagnosis, and treatment.
o Physician progress notes.
o Consultation request.
31.1.3. Timing: Patients are attended by the emergency department physician according
to a properly applied triage plan.
o Time of patient's arrival and examination is recorded.
o Time of consultation request and reply is recorded.
o Time of request for supportive services (laboratory, blood bank and radiology) and their
arrival is recorded.

56
31.1.4. Explaining to Family and Relatives of Patients
o A member of medical staff should talk to patient's family or relatives about the clinical
situation and respond to their questions. The patient relations officer takes over this
action until a medical staff member is available.
31.2. Presence of Nursing Staff
Adequate number
Adequate training (knowledge, skills)
The emergency department nurse is responsible for:
31.2.1. Clinical Duties
o Recording clinical observation notes as per department policy.
o Check equipment and have them always available and ready for use.
o Check supplies and ensure availability in the sufficient quantities as per department
policy.
31.2.2. Administrative Duties
o Supervise and maintain the cleanliness and organization of the department
o Reporting to supervisors or department head deficiencies and shortages
31.2.3. Dealing with patient's relatives and friends in a professional manner (and
according to hospital policy).
31.2.4. Supervise paramedical staff such as porters, cleaners, security, patient relations
officer, etc.
31.2.5. Ensure safe and prompt transport of patients between departments.
31.2.6. Attend to patient needs, including privacy, comfort, and special requests.
31.3. Staff Punctuality, Assignment and Communication
31.3.1. No commitment to other hospital duties at the same time
31.3.2. Adequate motivation, incentives and supervision
Doctors and nurses are required to conduct:
31.3.3. Doctors and nurses are required to conduct proper endorsement, physician to
physician and nurse to nurse concerning:
o Patient's clinical data
o Equipment status
o Supplies status
o Other department issues

57

31.4. Good Team Work
Supervision reflects a supportive rather than punitive attitude
Staffs are encouraged to ask and learn about clinical issues. The rationale for protocols is
explained on a routine basis (not just the need for compliance). Staff should be encouraged
to report situations objectively (including their mistakes recognize limitations and seek
help) in order to learn from them.
Staff have required skills and knowledge to perform their duties
Tasks are coordinated among different staff members, there is good communication and a
high level of trust between different staff members
Roles of each team member are identified (Staff know the role of each team member)
Policies and procedures guidelines both at administrative axis and clinical axis
Shared goals and objectives with general understanding that success of the place is a
success for each individual
Feedback of individual and team: is a valuable way of evaluating the efficiency of the
system and designing corrective interventions. Feedback mechanisms are in place for
individual actions and team performance. Individual feedback includes: team performance
indicators include review of cases, near miss audits.
31.5. Factors Determining Performance
People (inside and outside the facility)
Influence of peers, colleagues and administration:
o Supportive Management accessible to staff
o Supportive and collaborative behavior among peers
o Compliance with protocols is encouraged among peers (positive peer pressure), and
noncompliance (malpractice, negative behavior) is discouraged. This can have positive
effect if the good practice spreads to new groups of people. It may have negative effect
if the malpractice is allowed to gradually displace the proper procedures and guidelines.
People outside the facility e.g. community and patient's satisfaction can encourage
performance through recognition and appreciation of staff efforts. (How can this be
measured?)
31.6. Internal Factors
Staff feels that they have the ability to perform their jobs to their own satisfaction and
communicate problems to someone who can take appropriate action.
Staff feel that their efforts are rewarded
Staff feel that negative behaviors are discouraged
31.7. Problem Solving Team Meeting (Held Weekly)
31.7.1. Case Reviews Conducted
31.7.2. Needs/Issues Identified
31.7.3. Interventions Planned
58
31.7.4. Interventions Implemented
31.7.5. Feedback Studied
o Mechanism in place to solicit feedback from all levels of staff
32. CLINICAL PROCEDURE
32.1. Proper Patient Triage
32.1.1. Patient complaints, vital signs, and conscious level are recorded by the nurse
within 5 minutes.
32.1.2. Emergency department residents assess the case within 10 minutes and triage the
cases into A, B, C according to urgency and severity of the case: emergent (A), urgent
(B), non-urgent (C). (A) Cases will be shifted to resuscitation room. (B) Cases will go
either to observation room or be treated in the treatment room. (C) Cases will be treated
in the treatment room.
32.1.3. Emergency department specialist will assess all cases in the resuscitation room
(A cases) within 5 minutes.
32.1.4. Emergency department specialist will see (B) and (C) cases on request of the
resident within 10 minutes.
32.1.5. All pregnant women will be seen in the obstetric department by the resident
within 5 minutes.
32.1.6. Timing of consultation will be recorded in every room in a log book.
32.2. Resuscitation Procedures
32.2.1. Proper adult resuscitation according to priorities
o ABCs of resuscitation are started immediately by the resident and the nurse.
A. Airway is opened and cleared with cervical spine control.
B. Breathing assessment and start ventilation if required. O2 administration by an
appropriate method will be started within 5 minutes if indicated.
C. Circulation assessment with external bleeding control. Two wide bore IV Lines
must be started within 5 minutes, blood sample is sent for type and save, then IV
Line is run with lactated ringer or saline.
o Vital signs are recorded within 10 minutes.
o Blood must be available within 30 minutes upon request.
o Emergency department specialist will lead the resuscitation within 5 minutes.

59

32.3. Procedures for Patients under Observation
32.3.1. Vital signs will be recorded by the nurse within 5 minutes then every 30 minutes.
32.3.2. The emergency department resident will assess the case every 30 minutes and
whenever is necessary.
32.3.3. The emergency department specialist will assess the case on request.
32.3.4. The relevant specialist will see the case within 30 minutes on request.
32.3.6. Treatment is given according to written physician orders.
32.3.7. Investigations are performed according to written physician orders.
32.3.8. Patient is monitored and physician is notified with progress of his patient and
results of the requested investigations.
32.3.9. If acute deterioration in condition of a patient under observation is noticed,
transfer to the resuscitation room will be immediately considered.
32.4. Minor Surgical Procedures
32.4.1. Minor surgical procedures like wound suturing, wound dressing, urinary
catheterization, etc., are done in this room.
32.4.2. Serious multiple trauma and unstable patients are not managed in this room.
They are managed in the resuscitation room.
32.4.3. Sound surgical technique must be followed:
o Proper skin preparation
o Proper draping of surgical field
o Use of sterile instruments and sutures
o Use of appropriate size needles and sutures
32.4.4. Infection control procedures must be observed.
32.4.5. Patients must not be denied local anesthesia when indicated. However, close
patient's observation is required during this procedure.
32.4.6. Proper positioning of patients during procedures must be observed to guard
against vaso-vagal syncope.

60
32.5. Patient Transfer
32.5.1. Safe Transportation inside the Hospital
o The patient must be stabilized.
o Adequate care of patient's position during transportation if spinal injury is suspected.
Adequate number of personnel must be available if help is required.
o Ongoing resuscitation procedures must be maintained during transportation as needed.
o Patient must be accompanied by an appropriate level of staff, according to his condition.
o Patient's management responsibility must be properly handed over to the receiving
department.
32.5.2. Safe Patient Referral (to Another Facility)
Referral of patients to the hospital and referral of patients to another hospital are done
according to an approved plan at regional level:
o Indications, procedures and communications are established.
o Acceptance of the receiving hospital is obtained.
o Stabilization before and during transfer is ensured.
o Patient is accompanied by an appropriate level of staff.
o Medical records are provided to the receiving hospital.
o Ambulances should be equipped with resuscitation devices.
32.6. Ancillary Services
32.6.1. Blood Bank
o Proper request is filled
o Urgency of request is marked
o Timing of request and timing of arrival of blood are recorded
32.6.2. Laboratory
o Proper request is filled
o Urgency of request is marked
o Timing of request and timing of arrival of the result are recorded
32.6.3. Radiology
o Transportation procedures are followed (see previous section)
o Reports by radiologist must be provided when requested
o Functional program. Equipment and space shall be as necessary to accommodate the
functional program. The imaging department provides diagnostic procedures. It includes
radiology, fluoroscopy, Ultrasound, CT Scanning, MRI, and similar techniques
o Radiation protection requirements shall be incorporated into the specifications and the
building plans.
61

33. PATIENT TRANSFER
33.1. Safe Transportation inside the Hospital
33.1.1. The patient must be stabilized.
33.1.2. Adequate care of patient's position during transportation if spinal injury is
suspected. Adequate number of personnel must be available if help is required.
33.1.3. Ongoing resuscitation procedures must be maintained during transportation as
needed.
33.1.4. Patient must be accompanied by an appropriate level of staff, according to his
condition.
33.1.5. Patient's management responsibility must be properly handed over to the
receiving department.
33.2. Safe Patient Referral (To Another Facility)
Referral of patients to the hospital and referral of patients to another hospital are done
according to an approved plan at regional level:
33.2.1. Indications, procedures and communications are established.
33.2.2. Acceptance of the receiving hospital is obtained.
33.2.3. Stabilization before and during transfer is ensured.
33.2.4. Patient is accompanied by an appropriate level of staff.
33.2.5. Medical records are provided to the receiving hospital.
33.2.6. Ambulances should be equipped with resuscitation devices.
34. CRASH CART
The crash cart must include all equipment and medications used in cardiopulmonary
resuscitation (CPR) and emergency situations.
All emergency department nurses must be aware of the crash cart contents and its organization.
They must be trained in CPR and the proper use of lifesaving equipment.
The crash cart contents must be reviewed and the charge nurse should sign the checklist every
shift.

62
34.1. Crash Cart Contents
The crash cart is composed of three parts in addition to the two sides.
34.1.1. The Upper Part (top)
o Large sized equipment (defibrillator and ECG monitor), and Ambo bag are placed on
the top surface.
34.1.2. Drawers
o First drawer: contains all drugs used in cardiopulmonary resuscitation or emergency
situations (see drug checklist).
o Second drawer: contains IV items, i.e. infusion sets, syringes, bandages, adhesive tapes,
IV cannulae, ECG monitor leads and tongue depressors.
o Third drawer: contains items used in airway management and endotracheal intubation:
Oral and nasopharyngeal airways (different sizes)
Endotracheal tubes (different sizes)
Laryngoscopes with different blade sizes (functioning batteries and bulbs)
Magill forceps
K-Y jelly
o Fourth drawer: contains instrument set packs used in emergency situations:
Central venous pressure (CVP) pack
Venous cut down pack
Intubation pack
All instrument set packs must be sterile.
o Fifth drawer: contains all tubes and catheters used in emergency situations:
Suction catheters
Nasogastric tubes
Urinary catheters
Chest tubes
Different sizes must be available
34.1.3. The Lower Part
o Contains IV solutions used in emergency situations addition to different sized
sphygmomanometer cuffs.
34.1.4. Sides
o Cardiopulmonary resuscitation board is attached to one side and a portable oxygen
cylinder is attached to the other side.
o The crash cart wheels must be in good working condition.

63

34.2. Drug Checklist
Item No. Drug Number
34.2.1. Adrenaline 20
34.2.2. Atropine 20
34.2.3. Sodium Bicarbonate 40
34.2.4. Xylocaine 10
34.2.5. Calcium Chloride 10
34.2.6. Dopamine 3
34.2.7. Dobutamine 3
34.2.8. Nitroglycerine 3
34.2.9. Lanoxin 5
34.2.10. Lasix 20
34.2.11. Aminophylline 20
34.2.12. Dextrose 50% 10
34.2.13. Magnesium Sulfate 20

Figure 5: Crash Cart

Ambu bag
CPR board
IV solutions and tubing, blood
pressure cuff, procedure trays

Nasogastric tube,
suction catheters
indwelling (Foley)
catheter
ABG kits, CVP lines
O
2
cylinder
Intubation equipment
IV supplies,
syringes, needles

Drugs
Defibrillator / monitor
65

Chapter 3:
Quality Assurance Monitoring
System

67
CHAPTER 3: QUALITY ASSURANCE MONITORING SYSTEM
1. INTRODUCTION
The service standards are the criteria for the procedures, supplies, and conditions essential for
quality health care services. Each standard is considered to be essential for full, effective provision
of the services. The Emergency Department Service Standards are based upon nationally-approved
clinical protocols for the diagnosis, management and prevention of common health problems. This
document includes Protocols for Emergency Department Teams.
These clinical protocols and service standards were developed from international research on the
most medically effective and cost-efficient practices. If followed correctly by health providers, the
number of deaths from major medical, surgical and child emergencies can be reduced by a
significant estimated percentage.
The Emergency Department Service Standards are organized into the three levels of care (as
shown in Table 1) that are provided within a medium size general hospital. (NOTE: Not all
facilities provide the full range of services as listed below for each level of care, some facilities
may provide more and some facilities provide fewer services.) A "generic" organizational structure
for (General Hospitals), Emergency Department is illustrated in Figure 1.
The Emergency Department Service Standards cover the level of services specific to the
Emergency Department, including:
Triage room
Resuscitation room
Examination/treatment room
Observation area ( male and female)
Operating room
Laboratory
Radiology
Pharmacy
Physicians office
Plaster room
Nurses office
Stock rooms
Reception/registration office
Department administration
Infection control procedures
Behavioral aspects of emergency care
Clinical procedures
Patient transfer
Each item will be discussed in relation to its physical structure, furniture, equipment, supplies and
medications, whenever it is relevant.
Chapter 3: Quality Assurance Monitoring System
68
2. ASSESSING COMPLIANCE WITH STANDARDS
The main purpose of establishing the Emergency Department Service Standards is to acquire
compliance with these basic standards to ensure that each Emergency Department is providing an
acceptable level of services. An Emergency Department complies with a standard when it satisfies
all of the specific requirements for that standard. Each standard has an explanatory description that
provides an adequate amount of information to judge whether an Emergency Department is
complying with the requirements for that standard. For example, the box below shows the standard
for a pediatric laryngoscope:
Pediatric Laryngoscope
With two straight blades sizes 0 and 1.
One spare bulb must be available.
If operated by disposable batteries, a set of batteries must be available.
Each specific requirement is described in detail. An Emergency Department must meet all of these
requirements before it complies with standard 2.3.4. If one item is missing (e.g. there is no spare
bulb) the facility does not comply with that standard.
The Emergency Department Service Standards are designed to be:
Simple
Scientific
Measurable
Acceptable
Appropriate
Effective
Practical
Feasible
Reliable
Client-friendly
3. SUPERVISORY TEAMS AT THE HOSPITAL DIRECTORATE (HD) AND QUALITY
DIRECTORATE (QD) LEVELS
Most, but not all, of the members of HD, and QD teams have supervisory functions. Management
Teams, who have supervisory responsibilities, form the supervision teams who will participate
directly in monitoring compliance to the E D Services.
4. SERVICE STANDARDS MONITORING CHECKLISTS
This checklist covers the full range of ED services. The checklists are organized to reflect different
combinations of services offered by the ED.
It will take approximately one day to properly assess an ED every quarter. It makes sense to divide
up the responsibilities for supervision.
69
Some team members will be responsible for assessing the clinical skills of ED staff while others
will be responsible for managerial and administrative aspects. All team members will have problem
solving and reporting responsibilities.
Table 3.1: Monitoring Checklist for General Hospitals Emergency Department
to be used to assess General Hospital Emergency Department.
Emergency
Department
Checklist
Components
Responsible Governorate
Supervision Team Members
Triage Room
Resuscitation Room
Observation Room
Obstetric Room
Operating Room
Physicians Office
Nurses Office
Registration information
office
Laboratory
Blood Bank
General Service Standards
Infection Control
Emergency Transport
Physical Structure
Furniture
Equipment
Supplies
Medications
General Service Standards
Registers and Reports
Clinical Procedures

Emergency Management
Services Director
Chief Nursing Supervisor

The checklists are designed to be used along with the Emergency Department Service Standards.
The order of categories and items within the categories follow the service standards. This makes it
easy for Hospital Managers and Supervisors (Hospital Management Teams) to use during their
assessments, using the service standards as the detailed reference book while marking the scores in
the checklist.
5. CONDUCTING EMERGENCY DEPARTMENT ASSESSMENTS
The monitoring checklists are designed to keep record of two sets of scores: Emergency
Department Assessments and Hospital Directorate (HD) or Quality Directorate (QD) Assessments.
Each level will maintain their own checklists in which they record their assessment scores.
6. EMERGENCY DEPARTMENT SELF-ASSESSMENTS
Each Emergency Department team will be given their own checklists to record the results of their
Self-Assessments. There is a space to record scores from four assessments. If Self-Assessments are
completed once a month, the same checklist may be used for four months. When four Self-
Assessments have been conducted and the checklist is full, the Emergency Department team will
start a new one, but they will keep the completed checklists for later review.
70
During the last week of each month, the staff at the Emergency Department will perform their Self-
Assessment. The following steps should be followed to perform a Self-Assessment:
Staff should be assigned to assess and fill out the sections of the checklist for which they are
responsible.
The staff will then use the checklist and service standards to assess each standard, checking
"yes", "no" or writing "NR" (not required) on the form for each standard. Notes should be taken
for each standard which is scored as "no".
Once all categories of the checklist have been completed, the Emergency Department Director
should review it to make sure the checklist has been accurately and completely filled in. The
director should calculate a compliance score for each section and then the total Emergency
Department compliance score. The formula is: Total Actual Score/Total Required Score x 100.
An example is shown below.

1. Triage Room 15 September 2010 30 September 2010 15 November 2010
Actual Score: 11
= 0.26 x 100 = 26%
17
= 0.60 x 100 = 60%
25
= 0.80 x 100 = 80%
Required Score: 35 35 35

The compliance scores should then be discussed by the staff in a meeting where they could
discuss the following questions:
What service standard categories have the highest scores?
Which categories have the lowest scores?
What problems stand in the way of the Emergency Department obtaining a 100%
compliance score?
What can be done by the Emergency Department staff themselves to improve the scores?
Who in the staff should do it and when?
The staff should then make an action plan to solve these problems and assign people to carry
the plan out.
If low compliance scores are due to problems which are not within the control of the
Emergency Department staff, the staff should identify and write up what they think needs to be
done by the Hospital Directorate Supervisors.
7. HOSPITAL / QUALITY DIRECTORATE ASSESSMENTS
H/Q Teams are responsible for two types of supervisory assessments:
Verifying Emergency Department assessment scores.
Conducting Quarterly Emergency Department Assessments
8. VERIFYING EMERGENCY DEPARTMENT ASSESSMENT SCORES
It is the responsibility of the HD/QD Team Supervisors to determine whether the Emergency
Department assessments made by the Emergency Department Team are complete, accurate and a
true representation of an Emergency Departments compliance to the service standards. The
HD/QD Team will receive the quarterly Emergency Department Service Standards monitoring
report (described later) within 10 days of the end of each quarter. They should first review the
report to see if all Emergency Departments have been assessed during that quarter.
71
Secondly, they should visit the Emergency Department in order to verify, or double-check, the
Emergency Department Team assessments.

Important Principles of the Monitoring System

There are several important principles that need to be followed by the HD Teams when they are
making their Emergency Department assessments:
Avoid careless compliance assessment and recording by any team member, which is unfair to
facility staff, other supervision team members and, ultimately, the well being of the Emergency
Department clients. The monitoring system provides a structured, objective approach to
supervision, where all Emergency Departments are assessed by the same criteria.
The checklist should always be used with the Emergency Department Service Standards. Each
member of the supervisory team should have a copy with them and refer to it when they are
doing their assessments. Only in this way can the supervisor accurately and systematically judge
compliance to a service standard.
Only medically qualified supervisors should assess Emergency clinical procedures. Observations
of health provider-client interactions should be done quietly (no interference or comments from
the supervisor) and in a manner that is respectful of the clients right to privacy and
confidentiality. If the client does not want to be observed by a third person, for example during a
physical examination, this is their right and the supervisor should leave the room. Assessment of
Emergency clinical procedures must always be done by following the clinical sections of the
service standards and the monitoring checklist together.
Discussions between Emergency Department staff and supervisors should focus on solving
problems, not on finding blame. Solving problems will often require Emergency Department,
hospital and governorate personnel to work together to take action. It is counterproductive to
blame people for problems that, in the great majority of cases, are with the system in which the
people work, rather than with the people in the system.
9. SOLVING COMPLIANCE PROBLEMS
9.1. Identifying the Level of Responsibility for Non-compliance
Part of the supervisors assessment of compliance/non-compliance is the need to identify the level
of responsibility for non-compliance. It is essential to distinguish this from assigning blame for
things that do not work blaming others creates defensiveness, inhibits initiative, and is usually
counterproductive. Rather, for each standard where non-compliance is observed, supervisors should
ask first, Which level of the system bears the major responsibility for this non-compliance? Is it at
the Emergency Department, hospital, regional or central level? Is it a combination of all or some
levels?
Once the level of responsibility is identified, then the person or persons best qualified to correct the
problem can be called into action. For example, if there is a lack of drugs at the Emergency
Department, it must be determined whether the responsibility for non-compliance is at the hospital
level. Did the Emergency Department and hospital staff correctly order the drugs on time? If they
did not, the Emergency Department Director, Hospital Director and Pharmacist need to be given
better instructions about how and when to order drugs.
72
If the HD level did not correctly process the Hospitals order and distribute them properly, then the
HD Director and Pharmacist need to review the way they handle such orders. Did the governorate
correctly order the drugs from the central level? If they did not, they need to review their
procedures as something is wrong with the system.
10. WRITING RECOMMENDATIONS FOR IMPROVEMENT
On the Recommendations Log, supervisors will write recommendations for actions to be taken in
improving each standard which scores a no on the checklist. These recommendations do not need
to be elaborate, but they should conform to the following requirements:
Each recommendation should identify the level of responsibility for the problem that has
created the non-compliance. This can be stated as Emergency Department, hospital, HD, etc.
The person or persons who need to take action to correct the problem should be identified.
A clear description of the specific action to be taken needs to be written.
And finally, a clear description of the action that was taken to solve the problem needs to be
recorded.
The following are some examples of how the recommendations should be written:
The Emergency Department Director must ensure that monthly reports are submitted on time
by writing the dates they are due to be sent to the Hospital Director on a large wall calendar.
The Hospital Director will talk to the hospital storekeeper to find out why drugs for the
Emergency Department are not being correctly sent to the facility.
The Hospital Pharmacist must keep drug inventories and records up to date.
The Emergency Department Cleaners must clean each room after each patient is referred or
discharged.
The HD Director will find out why the hospitals request, two months ago, to procure a "crash
cart" was not carried out. The HD Director will send someone to procure the "crash cart" in
three days.
To complete the recommendations for the improvement form:
Write the Emergency Department name, month and year at the top of the form.
Write in the number of the standard which scored a no (Example: 2.1.2).
Write a brief description of the problem and the cause of the problem. (Example: The
Resuscitation Room is not clean since the facility does not have a supply of cleaning products
because they did not order them from the HD last month).
Write in the recommendation, identifying level of responsibility, action to be taken and the
person who will take the action.
11. QUARTERLY REPORTS ON EMERGENCY DEPARTMENT COMPLIANCE
SCORES
When the HD Team finishes their Emergency Department assessments, the completed monitoring
checklists will be submitted to the MOH Information Center so the scores can be entered into the
computer database. The checklists to be submitted include all of those completed by the
Governorate Management Team Supervisors.
73
Emergency Department Self-Assessment scores will not be entered into the database. Emergency
Department Self-Assessment scores will remain in the Emergency Department itself for review by
the HD Team. The Facility Manager should copy the scores of the Governorate Management Team
into their own checklists. For the Emergency Department Team, this will serve as a record and
reminder of their service standard compliance and which service standards need to be improved.
Each quarter the Hospital Directorate Team is responsible for preparing a report on the compliance
scores of the Emergency Department they assessed during that quarter. The report is designed to
provide a picture of the problems and strengths in compliance of Emergency Department services
standards within the Governorate. The report will present high level summaries as well as more
detailed summaries of Emergency Department compliance. The different presentations are
discussed as follows.
12. PRESENTATION OF EMERGENCY DEPARTMENT COMPLIANCE SCORES
The different aspects of Emergency Services which have the greatest impact on the quality of
patient care are the focus of monitoring and evaluation activities. For this reason, the HSS11
Project has developed some indicators. Each indicator is a measurable dimension that is considered
an important aspect of care.
The goal of selecting these indicators was to choose events that cover a broad range of activities
and address important aspects of care. Additionally, it is an important mechanism for identifying
problem areas in the provision of medical care and monitoring improvements in availability.
Results can be compared with the required compliance scores in a way that deviations from the
norm can be readily recognized. The indicators included in this manual have been designed to
allow monitoring on a continuous basis and from several different perspectives.
75

Chapter 4:
Monitoring Checklists for
General Hospitals

77
CHAPTER 4: EMERGENCY DEPARTMENT MONITORING CHECKLISTS
FOR GENERAL HOSPITALS
1. SERVICE STANDARDS FOR TRIAGE ROOM
Facility Name:
Year:

C
r
i
t
i
c
a
l

Month Month Month Month
Yes No Yes No Yes No Yes No
1.1.2. Cleanliness
1.1.3. Illumination
1.1.4. Ventilation
1.1.6. Sink
Facility-Level Assessment
Date:
Actual Score
Required Score 6 6 6 6
Directorate-Level Assessment
Date:
Actual Score

1.2. Furniture
C
r
i
t
i
c
a
l

1.2.1. Examination Table, Adult
1.2.2. Privacy Screens
1.2.3. Waste Receptacles
1.2.4. Instrument Cabinet
Date:
Actual score
Required score 4 4 4 4
Date:
Actual score

Chapter 4: Emergency Department Monitoring Checklists for General Hospitals

78
1.3. Equipment
C
r
i
t
i
c
a
l

1.3.1.
One Ambo bag with adult and pediatric
size masks

1.3.2. Central/One Suction Device
1.3.3.
Central/Complete Oxygen Supply
System (Cylinder or pipe, O
2
regulator,
wrenches, O
2
mask and cannula)

1.3.4.
One Sphygmomanometer, adult and
pediatric cuffs

1.3.6.
One Stethoscope, pediatric (preferably
neonatal)

1.3.7. Thermometers
Date:
Actual score
Date:
Actual score

1.4. Supplies
C
r
i
t
i
c
a
l

1.4.1. Disposable Plastic Syringes
1.4.4. Antiseptics (Betadine Alcohol )
1.4.6. Adhesive Surgical Tape (plaster)
1.4.8. Soap
1.4.9. K-Y Jelly
1.4.10. Torch
Date:
Actual score
Date:
Actual score

Completed By: Date:
79
2. SERVICE STANDARDS FOR RESUSCITATION ROOM, EQUIPPED FOR
LIFESAVING PROCEDURES (FOR ADULTS AND PEDIATRICS)
Facility Name:
Year:

C
r
i
t
i
c
a
l

2.1.2. Cleanliness
2.1.3. Illumination
2.1.4. Ventilation
2.1.6. Basin
Date:
Actual Score
Date:
Actual Score

2.2. Furniture
C
r
i
t
i
c
a
l

2.2.1. Operating Table (or ICU bed)
2.2.2. Two Instrument Cabinets
2.2.5. Four IV Stands
Date:
Required Score
Actual Score 7 7 7 7
Date:
Required Score
Actual Score 7 7 7 7


80
2.3. Equipment
C
r
i
t
i
c
a
l

2.3.1.
One Ambo Bag with Anatomical
Neonatal Mask

2.3.2.
One Ambo Bag with Anatomical
Masks, adult size, pediatric size

2.3.3.
Two Suction Devices (Central &
Mobile)

2.3.4. Two Laryngoscopes, adult, pediatric
2.3.5. Stylet for ET tubes
2.3.6.
Central / Complete Oxygen Supply
2

regulator, wrenches, O
2
mask and
cannula)

2.3.8. ECG Monitor
2.3.9. Pulse oximeter
2.3.10.
One Sphygmomanometer with
different cuff sizes for adult and
pediatric

2.3.11. Stethoscope, adult
2.3.12. Stethoscope, pediatric
2.3.13. Two Thermometers
2.3.14. Glucometer
2.3.15. Hammer
2.3.16. Torch
2.3.18. Trauma scissors
2.3.19. Nebulizer
2.3.20. Instrument Set Pack
Date:
Actual Score
Date:
Actual Score

81
2.4. Supplies
C
r
i
t
i
c
a
l

2.4.1.
I.V Cannula, different sizes (pediatric and
adult)

2.4.2. Infusion Set
2.4.3. Disposable Syringe, different sizes
2.4.4. Suction Catheter, different sizes
2.4.5. Yanker Suction
2.4.6. Urinary Catheters, different sizes
2.4.7. Urine collection bag
2.4.8. Urine Test Stick
2.4.9. Chest tubes, All Sizes
2.4.10. CVP Catheters, All Sizes
2.4.11. Peritoneal Lavage Catheter
2.4.12. O
2
Masks
2.4.13. O
2
Nasal Cannula
2.4.14. Examination Gloves
2.4.15. Surgical Gloves, All Sizes
2.4.16. Silk Sutures, Size 3/0, 2/0, 0
2.4.17. Prolene, Size 5/0, 4/0, 3/0, 2/0
2.4.18. Vicryl, Size 4/0, 3/0, 2/0
2.4.19. Cutting and Round Needles
2.4.20. Disinfectant - Alcohol, Betadine
2.4.21. Gauze Swabs and Bandage
2.4.22. Surgical Tape, 2.5, 7.5 cm
2.4.23. Cervical collar (different sizes)
2.4.24. Hair Cover
2.4.25. Surgeon's Mask
2.4.26. Shoe Covers
2.4.27. Tongue Depressors
2.4.28. Glucometer Strips
2.4.29. Soap, Hand Washing
2.4.30. Plastic Bag, Waste Receptacle
Date:
Actual Score
Date:
Actual Score


82
2.5. Medications
C
r
i
t
i
c
a
l

2.5.1. Aminophylline
2.5.2. Salbutamol inhaler
2.5.3. Suitable Antibiotics
2.5.4. Antihistamine
2.5.5. Calcium Gluconate
2.5.6. Dextrose 10% or 25%
2.5.7. Dextrose 5%
2.5.8. Normal Saline Solution
2.5.9. Ringers Lactate
2.5.10. Diazepam
2.5.11. Epinephrine
2.5.12. Heparin
2.5.13. Hydrocortisone
2.5.14. Insulin, Soluble
2.5.15. Magnesium Sulfate
2.5.16. Erythromycin Eye Drops
2.5.17. Morphine
2.5.18. Nifedipine
2.5.19. Naloxone
2.5.20. Pethidine
2.5.21. Protamine Sulfate
2.5.22. Sodium Bicarbonate 8.4%
2.5.23. Vitamin K( 1 or 10 mg)
2.5.24. Xylocaine 1%, or 2%
2.5.25. Dopamine
2.5.26. Dobutamine
2.5.27. Antiemetic
2.5.28.
Suitable non-steroidal anti-inflammatory
NSAID injection

2.5.29. Atropine
2.5.30. Antispasmodic injection
2.5.31. H
2
receptor antagonist
Date:
Actual Score
Date:
Actual Score

Completed By: Date:
83
3. SERVICE STANDARDS FOR OBSERVATION ROOM
Facility Name:
Year:

C
r
i
t
i
c
a
l

3.1.2. Cleanliness
3.1.3. Illumination
3.1.4. Ventilation
Date:
Actual Score
Date:
Actual Score

3.2. Furniture
C
r
i
t
i
c
a
l

3.2.1. One (or more) Examination bed
3.2.2. One Desk
3.2.3. Chair
3.2.5. One Instrument Table
3.2.6. One Privacy Screen
3.2.8. IV Stand
Date:
Actual Score
Date:
Actual Score


84
3.3. Equipment
C
r
i
t
i
c
a
l

3.3.1.
pediatric cuffs

3.3.2. One Stethoscope, adult and pediatric
3.3.3. Central Suction Device
3.3.4. Twelve lead ECG machine
3.3.6.
2
regulator,
wrenches, O
2
mask and cannula)

Date:
Actual Score
Date:
Actual Score

3.4. Supplies
C
r
i
t
i
c
a
l

3.4.1.
Disposable Plastic Syringes
(different sizes)

3.4.3. Sterile surgical gloves
3.4.4. Cannula (different sizes)
3.4.5. Infusion Set
3.4.6.
Disposable Urinary Catheters
(different sizes)

3.4.9.
Strips to Detect Sugar, Acetone,
Albumin in Urine

3.4.10. Antiseptics (Betadine -Alcohol)
Date:
Actual Score
Date:
Actual Score
85
3.5. Medications
C
r
i
t
i
c
a
l

3.5.1. Antipyretic injections / Suppositories
3.5.2. Antihistamine injections
3.5.3. Magnesium Sulfate injections
3.5.4. Aminophylline injections
3.5.5. Lasix injections
3.5.6. Hydrocortisone injections
3.5.7. Nifedipine
3.5.8. Soluble Insulin
3.5.9. Adrenaline
3.5.10. Antiemetic
3.5.11. Ringers Lactate Solution
3.5.12. Glucose 5%
3.5.13. Normal Saline
Date:
Actual Score
Date:
Actual Score

Completed By: Date:


86
4. SERVICE STANDARDS FOR OPERATING ROOM (FOR MINOR SURGERY)
Facility Name:
Year:

C
r
i
t
i
c
a
l

4.1.2. Cleanliness
4.1.3. Illumination
4.1.4. Ventilation
4.1.6. Basin
Date:
Actual Score
Date:
Actual Score

4.2. Furniture
C
r
i
t
i
c
a
l

4.2.1. One Operating Table
4.2.5. One IV Stand
4.2.7. One Ceiling Operating Light
Date:
Actual Score
Date:
Actual Score

87
4.3. Equipment
C
r
i
t
i
c
a
l

4.3.2.
2
regulator,
wrenches, O
2
mask and cannula)

4.3.3.
pediatric cuffs

4.3.5.
One Stethoscope, pediatric (preferably
neonatal)

4.3.7. Instrument Set Packs
Date:
Actual Score
Date:
Actual Score


88
4.4.Supplies
C
r
i
t
i
c
a
l

4.4.1. Cannula, I.V, different sizes
4.4.2. Infusion Set
4.4.4. Suction Catheters, All Sizes
4.4.5. Nasogastric Tube, All Sizes
4.4.6. Urinary Catheters, All Sizes
4.4.7. Urine Collecting Bag
4.4.8.
Silk/ Prolene cutting needle, different
sizes

4.4.9.
Vicryl 3/0, 4/0, 2/0 cutting and round
needles

4.4.10. Disinfectant - Alcohol, Betadine
4.4.11. Examination Gloves
4.4.12. Surgical Gloves, All Sizes
4.4.13. Gauze Swabs and Bandage
4.4.15. Surgical Tape, 2.5, 7.5 cm
4.4.16. Hair Cover
4.4.17. Surgeon's Mask
4.4.18. Shoe Covers
4.4.19. Tongue Depressors
4.4.20. Torch
4.4.21. K-Y Jelly
4.4.22. Soap, Hand Washing
4.4.23. Plastic Bag, Large Waste Receptacle
Date:
Actual Score
Date:
Actual Score

89
4.5. Medications
C
r
i
t
i
c
a
l

4.5.5. Dextrose 10% or 25%
4.5.6. Dextrose 5%
4.5.8. Epinephrine
4.5.11. Nifedipine
4.5.12. Naloxone
4.5.13. Vitamin K 10 mg
4.5.14. Xylocaine 1% or 2%
4.5.15.
Suitable non-steroidal anti-
inflammatory NSAID injection

4.5.16. Atropine
4.5.18. H
2
receptor antagonist
Date:
Actual Score
Date:
Actual Score

Completed By: Date:


90
5. SERVICE STANDARDS FOR PHYSICIANS OFFICE
Facility Name:
Year:

C
r
i
t
i
c
a
l

5.1.2. Cleanliness
5.1.3. Illumination
5.1.4. Ventilation
5.1.6. Telephone
Date:
Actual Score
Date:
Actual Score

5.2. Furniture
C
r
i
t
i
c
a
l

5.2.1. One Desk

Date:
Actual Score
Date:
Actual Score

5.3. Equipment
C
r
i
t
i
c
a
l

5.3.1. One X-ray Viewer

Date:
Actual Score
Date:
Actual Score

Completed By: Date:
91
6. SERVICE STANDARDS FOR NURSES OFFICE
Facility Name:
Year:

C
r
i
t
i
c
a
l

6.1.2. Cleanliness
6.1.3. Illumination
6.1.4. Ventilation
6.1.6. Telephone
Date:
Actual Score
Date:
Actual Score

6.2. Furniture
C
r
i
t
i
c
a
l

6.2.1. One Desk
Date:
Actual Score
Date:
Actual Score

6.3. Equipment
C
r
i
t
i
c
a
l


Date:
Actual Score
Date:
Actual Score

Completed By: Date:

92
7. SERVICE STANDARDS FOR RECEPTION /REGISTRATION OFFICE
Facility Name:
Year:

7.1. Registration Information Office
C
r
i
t
i
c
a
l

7.1.1. Out-patient Form
7.1.2. Observation Form
7.1.3. Register for in-patient admission
7.1.4. Consultation Form
7.1.5. Mortality Register
7.1.6. Transfer Form
Date:
Actual Score
Date:
Actual Score

Completed By: Date:
93
8. SERVICE STANDARDS FOR STOCK ROOM
Facility Name:
Year:

C
r
i
t
i
c
a
l

8.1.2. Cleanliness
8.1.3. Illumination
8.1.4. Ventilation
Date:
Actual Score
Date:
Actual Score

8.2. Furniture
C
r
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t
i
c
a
l

8.2.1. Shelving Cabinet
Date:
Actual Score
Date:
Actual Score

8.3. Equipment
C
r
i
t
i
c
a
l

8.3.2. IV Stands
8.3.3. Sphygmomanometers
8.3.4.
Sphygmomanometer cuffs, different
sizes

8.3.5. Thermometers
8.3.6. Wheel Chairs and Trolleys
Date:
Actual Score
Date:
Actual Score

94

8.4. Supplies
C
r
i
t
i
c
a
l

8.4.1.
Stock supply of one week must be
available in the stock room at all times

8.4.2.
Enough stock supply to deal with mass
accidents and disasters must be present

Date:
Actual Score
Date:
Actual Score

Completed By: Date:
95
9. SERVICE STANDARDS FOR PERSONNEL
Facility Name:
Year:

9.1. Physicians
C
r
i
t
i
c
a
l

9.1.1. 24 hour coverage by residents
9.1.2.
In hospital specialist coverage for at
least Obstetric, Pediatrics, Anesthesia,
Surgery, medicine is provided 24 hours

9.1.3.
The emergency room director is a
qualified emergency/physician/ surgeon
of an appropriate specialty connected to
the management of emergency patients

9.1.4.
The emergency room director is readily
available on request

9.1.6.
Consultation by a specialist is available
within 15 to 30 minutes in emergencies

Date:
Actual Score
Date:
Actual Score

9.2. Nurses
C
r
i
t
i
c
a
l

9.2.1. Emergency room head nurse
9.2.2. Nursing staff in adequate number
9.2.3.
In charge nurse is present in each shift.
Takes the responsibility of the head
nurse in her absence.

Date:
Actual Score
Date:
Actual Score


96
9.3. Emergency Medical Technician
(EMT)
C
r
i
t
i
c
a
l

9.3.1.
Ambulance staff who handle patients in
the pre-hospital phase are trained in
CPR, ABCs of resuscitation, rules of
patient transportation and use of
ambulance devices

Date:
Actual Score
Date:
Actual Score

9.4. Other Emergency Room Staff
C
r
i
t
i
c
a
l

9.4.1. Porters and/or security
9.4.2. Cleaners
Date:
Actual Score
Date:
Actual Score

9.5. Personnel Requirement
C
r
i
t
i
c
a
l

9.5.1. Managing MD (ED Director) 1
9.5.2. Service MD (Specialist) 5
9.5.3. Service MD (Resident) 5
9.5.4. Nurse (ED Head Nurse) 1
9.5.5. Nurse (Staff Nurse) 3
9.5.6. Nurse (Associate Nurse) 6
9.5.7. Technician (EMT) 3
9.5.8.
Support staff (Registrar & Patient
Relations Officer [PRO]) 3

9.5.9. Support staff (Cleaner & Porter) 3
9.5.10. Support staff (Security & Porter) 3
Date:
Actual Score
Date:
Actual Score

97
9.6. Training
C
r
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t
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c
a
l

9.6.1. ED Director
9.6.2. Specialist
9.6.3. Resident
9.6.4. ED Head Nurse
9.6.5. Charge Nurse
9.6.6. Assistant Nurse
9.6.7. EMT
9.6.8.
Registrar & Patient Relations Officer
(PRO)

9.6.9. Cleaner & Porter
9.6.10. Security
Date:
Actual Score
Date:
Actual Score

Completed By: Date:

98
10. SERVICE STANDARDS FOR DEPARTMENT ADMINISTRATION
Facility Name:
Year:

10.1. Department Administration
C
r
i
t
i
c
a
l

10.1.1. References
10.1.2. Job Descriptions
10.1.3.
Facility Maintenance Procedures of the
Department

10.1.4.
Preventive Maintenance Procedures
for Equipment

10.1.5. Logs and Registers
10.1.6. Forms
10.1.7. Monthly Reports
10.1.8. Utilization of Forms and Statistics
10.1.9. Organizational structure
Date:
Actual Score
Date:
Actual Score

Completed By: Date:

99
11. SERVICE STANDARDS FOR INFECTION CONTROL PROCEDURES
Facility Name:
Year:

11.1. Infection Control Procedures
C
r
i
t
i
c
a
l

11.1.1.
Cleaning and Disinfection of Rooms,
Halls and Corridors

11.1.2. Hand Washing Procedures
11.1.3. Wearing Examination Gloves
11.1.4. Wearing Surgical Gloves
11.1.5. Wearing Gowns
11.1.6. Skin Disinfection
11.1.7.
Cleaning, Disinfecting and Sterilizing
Equipment and Instruments

11.1.8. Waste Disposal
Date:
Actual score
Date:
Actual score

Completed By: Date:


100
12. SERVICE STANDARDS FOR BEHAVIORAL ASPECTS OF EMERGENCY CARE
Facility Name:
Year:

12.1. Presence of Physician
C
r
i
t
i
c
a
l

12.1.1.
Comply with the department policies
and procedures and follow approved
clinical protocols

12.1.2.
Complete medical records of clinically
relevant data

12.1.3. Timing

Time of patient's arrival and
examination is recorded

Time of consultation request and
reply is recorded

Time of request for supportive
services and their arrival is recorded

12.1.4.
Explaining to family and relatives of
patients

Date:
Actual Score
Directorate Level Assessment
Date:
Actual Score
101
12.2. Presence of Nursing Staff
C
r
i
t
i
c
a
l

12.2.1. Clinical duties
Recording clinical observation notes
Check equipment
Check supplies
12.2.2. Administrative duties

Supervise and maintain the
cleanliness and organization of the
department

Reporting to supervisors or
department head deficiencies and
shortages

12.2.3.
Dealing with patient's relatives and
friends in a professional manner

12.2.4. Supervise paramedical staff
12.2.5.
Ensure safe and prompt transport of
patients between departments

12.2.6.
Attend to patient needs, including
privacy, comfort and special request

Date:
Actual score
Date:
Actual score

12.3. Staff Punctuality, Assignment
and Communication
C
r
i
t
i
c
a
l

12.3.1.
No commitment to other hospital
duties at the same time

12.3.2.
Adequate motivation and
incentives and supervision

12.3.3. Proper endorsement
Patient's clinical data
Equipment status
Supplies status
Other department issues
Date:
Actual score
Date:
Actual score


102
12.4. Problem Solving Team Meeting
(held weekly)
C
r
i
t
i
c
a
l

12.4.1. Case reviews conducted
12.4.2. Needs / issues identified
12.4.3. Interventions planned
12.4.4. Interventions implemented
12.4.5. Feedback studied
Date:
Actual score
Date:
Actual score

Completed By: Date:
103
13. SERVICE STANDARDS FOR CLINICAL PROCEDURES
Facility Name:
Year:

C
r
i
t
i
c
a
l

13.1.1.
Patient complaints, vital signs, and conscious
level are recorded by the nurse within 5
minutes

13.1.2.
Emergency department residents assess the
case within 10 minutes and triage the cases
into A, B, C

13.1.3.
Emergency department specialist will assess
all (A) cases in the resuscitation room within
5 minutes

13.1.4.
Emergency department specialist will see B
and C cases on request of the resident within
10 minutes

13.1.5.
Ob/Gyn specialist will see cases in obstetric
department on request within 30 minutes. He
will attend obstetric cases in resuscitation
room within 15 minutes

13.1.6.
Timing of consultation will be recorded in
every room in a log book

Date:
Actual Score
Date:
Actual Score

C
r
i
t
i
c
a
l

13.2.1.
Proper adult resuscitation according to
priorities

13.2.2.
Proper neonatal resuscitation according to
priorities

Date:
Actual Score
Date:
Actual Score


104
13.3. Procedures for Patients under
Observation
C
r
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t
i
c
a
l

13.3.1.
Vital Signs will be recorded by the nurse
within 5 minutes then every 30 minutes

13.3.2.
The emergency department resident will
assess the case every 30 minutes and
whenever is necessary

13.3.3.
The emergency department specialist will
assess the case on request

13.3.4.
The relevant specialist will see the case
within 30 minutes on request

13.3.5.
Timing of consultation will be recorded in a
logbook

13.3.6.
Treatment is given according to written
physician orders

13.3.7.
Investigations are performed according to
written physician orders

13.3.8.
Patient is monitored and physician is
notified with progress of his patient and
results of the requested investigations

13.3.9.
If acute deterioration in condition of a
patient under observation is noticed, transfer
to the resuscitation room will be
immediately considered

Date:
Actual Score
Date:
Actual Score
105
C
r
i
t
i
c
a
l

13.4.1.
Minor surgical procedures like wound
suturing, wound dressing, urinary
catheterization, etc. are done in this room

13.4.2.
Serious multiple trauma and unstable
patients are not managed in this room. They
are managed in the resuscitation room

13.4.3. Sound surgical technique must be followed
13.4.4.
Infection control procedures must be
observed

13.4.5.
Patients must not be denied local anesthesia
when indicated. However, close patient's
observation is required during this
procedure

13.4.6.
Proper positioning of patients during
procedures must be observed to guard
against vaso-vagal syncope

Date:
Actual Score
Date:
Actual Score

C
r
i
t
i
c
a
l

13.5.1. Safe transportation inside the hospital
13.5.2. Safe Patient Referral (to another facility)
Date:
Actual Score
Date:
Actual Score


106
13.6. Ancillary Services
C
r
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t
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c
a
l

13.6.1. Blood Bank
13.6.1.1. Proper request is filled
13.6.1.2. Urgency of request is marked
13.6.1.3.
Timing of request and timing of arrival of
blood are recorded

13.6.2. Laboratory
13.6.2.1. Proper request is filled
13.6.2.2. Urgency of request is marked
13.6.2.3.
Timing of request and timing of arrival of
the result are recorded

13.6.3. Radiology
13.6.3.1. Transportation procedures are followed
13.6.3.2.
Reports by radiologist must be provided if
requested

Date:
Actual Score
Date:
Actual Score

Completed By: Date:
107
14. CRASH CART
Facility Name:
Year:

C
r
i
t
i
c
a
l

14.1.1. The upper part (top)
14.1.2. Drawers
14.1.3. The lower part
14.1.4. Sides
Date:
Actual Score
Date:
Actual Score

14.2. Drug Checklist
C
r
i
t
i
c
a
l

14.2.1. Adrenaline
14.2.2. Atropine
14.2.3. Sodium Bicarbonate
14.2.4. Xylocaine
14.2.5. Calcium Chloride
14.2.6. Dopamine
14.2.7. Dobutamine
14.2.8. Nitroglycerine
14.2.9. Lanoxin
14.2.10. Lasix
14.2.12. Dextrose 50%
Date:
Actual Score
Date:
Actual Score

Completed By: Date:
109

Chapter 5:
Monitoring Checklists for
General Hospitals Critical
Service Standards Only

111
CHAPTER 5: EMERGENCY DEPARTMENT MONITORING CHECKLISTS
FOR GENERAL HOSPITALS - CRITICAL SERVICE STANDARDS ONLY
1. SERVICE STANDARDS FOR TRIAGE ROOM
Facility Name:
Year:

1.1. Equipment
C
r
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t
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a
l

1.1.1.
One Ambo Bag with adult and pediatric
size masks

1.1.2. One Central/Mobile Suction Device
1.1.3.
System (O
2
regulator, wrenches, O
2

mask and cannula)

1.1.4.
pediatric cuffs

Date:
Actual score
Date:
Actual score

Completed By: Date:
Chapter 5: Emergency Department Monitoring Checklist for General Hospitals
Critical Service Standards Only

112
2. SERVICE STANDARDS FOR RESUSCITATION ROOM, EQUIPPED FOR
LIFESAVING PROCEDURES (FOR ADULTS AND PEDIATRICS)
Facility Name:
Year:

2.1. Furniture
C
r
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t
i
c
a
l

2.1.1. Four IV Stands
Date:
Actual Score
Date:
Actual Score

2.2. Equipment
C
r
i
t
i
c
a
l

2.2.1.
One Ambo Bag with Anatomical Adult
Mask

2.2.2.
One Ambo Bag with Anatomical Masks
adult size, pediatric size

2.2.3. Two Central Suction Devices
2.2.4. Two Laryngoscopes, adult, pediatric
2.2.5.
Two Central/Complete Oxygen Supply
2
regulator,
wrenches, O
2
mask and cannula)

2.2.7. ECG Monitor
2.2.8.
One Sphygmomanometer with different
cuff sizes for adult and pediatric

Date:
Actual Score
Date:
Actual Score

113
2.3. Supplies
C
r
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t
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c
a
l

2.3.1.
I.V Cannula, different sizes (pediatric and
adult)

2.3.2. Infusion Set
2.3.4. Chest tubes, Sizes
2.3.5. O
2
Masks
Date:
Actual Score
Date:
Actual Score


114
2.4. Medications
C
r
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t
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c
a
l

2.4.2. Salbutamol inhaler
2.4.6. Dextrose 10% or 25%
2.4.7. Dextrose 5%
2.4.9. Ringers Lactate
2.4.10. Diazepam
2.4.11. Epinephrine
2.4.15. Morphine
2.4.16. Nifedipine
2.4.17. Naloxone
2.4.18. Protamine Sulfate
2.4.19. Sodium Bicarbonate 8.4%
2.4.20. Vitamin K (1 or 10 mg)
2.4.21. Xylocaine 1%, or 2%
2.4.22. Dopamine
2.4.23. Dobutamine
2.4.24. Atropine
Date:
Actual Score
Date:
Actual Score

Completed By: Date:
115
3. SERVICE STANDARDS FOR OBSERVATION ROOM
Facility Name:
Year:

3.1. Supplies
C
r
i
t
i
c
a
l

3.1.1. Cannula (different sizes)
3.1.2. Infusion Set
Date:
Actual Score
Date:
Actual Score

3.2. Medications
C
r
i
t
i
c
a
l

3.2.1. Antihistamine Ampoules
3.2.2. Magnesium Sulfate Ampoules
3.2.3. Aminophylline Ampoules
3.2.4. Lasix Ampoules
3.2.5. Hydrocortisone Ampoules
3.2.6. Nifedipine (sublingual)
3.2.7. Soluble Insulin
3.2.8. Normal Saline
3.2.9. Glucose 5%
3.2.10. Ringers Lactate Solution
Date:
Actual Score
Date:
Actual Score

Completed By: Date:


116
4. SERVICE STANDARDS FOR OPERATING ROOM (FOR MINOR SURGERY)
Facility Name:
Year:

4.1. Equipment
C
r
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t
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c
a
l


4.1.2.
pediatric cuffs


4.1.4.
2
regulator,
wrenches, O
2
mask and cannula)

Date:
Actual Score
Date:
Actual Score

4.2. Supplies
C
r
i
t
i
c
a
l

4.2.1. Cannula, I.V, different sizes

4.2.2. Infusion Set

Date:
Actual Score
Date:
Actual Score

117
4.3. Medications
C
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4.3.5. Dextrose 10% or 25%

4.3.6. Dextrose 5%


4.3.8. Epinephrine



4.3.11. Nifedipine

4.3.12. Vitamin K 10 mg

4.3.13. Xylocaine 1% or 2%

4.3.14.
Suitable non-steroidal anti-inflammatory
NSAID injection

4.3.15. Atropine


Date:
Actual Score
Date:
Actual Score

Completed By: Date:


118
5. SERVICE STANDARDS FOR PERSONNEL
Facility Name:
Year:

5.1. Physicians
C
r
i
t
i
c
a
l

5.1.1. 24 hour coverage by residents

5.1.2.
In hospital specialist coverage for at
least Obstetric, Pediatrics, Anesthesia,
Surgery, medicine is provided 24
hours


5.1.4.
Emergency room resident/Specialist on
shift basis

5.1.5.
Consultation by a specialist is
available within 15 to 30 minutes in
emergencies

Date:
Actual Score
Date:
Actual Score

5.2. Nurses
C
r
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l

5.2.1. Emergency room head nurse

5.2.2. Nursing staff in adequate number

Date:
Actual Score
Date:
Actual Score

119
5.3. Emergency Medical Technician
(EMT)
C
r
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t
i
c
a
l

5.3.1.
Ambulance staff who handle patients in
the pre-hospital phase are trained in
CPR, ABCs of resuscitation, rules of
patient transportation and use of
ambulance devices

Date:
Actual Score
Date:
Actual Score

5.4. Personnel Requirements
C
r
i
t
i
c
a
l

5.4.1. Managing MD (ED Director) 1

5.4.2. Service MD (Specialist) Adequate

5.4.3. Service MD (Resident) Adequate

5.4.4. Nurse (ED Head Nurse) 1

5.4.5. Nurse (Charge Nurse) Adequate

5.4.6. Nurse (Assistant Nurse) Adequate

Date:
Actual Score
Date:
Actual Score

Completed By: Date:

120
6. SERVICE STANDARDS FOR CLINICAL PROCEDURES
Facility Name:
Year:

C
r
i
t
i
c
a
l

6.1.1.
Emergency department residents assess the case
within 10 minutes and triage the cases into A,
B, C

6.1.2.
Emergency department specialist/specialist will
assess all (A) cases in the resuscitation room
within 5 minutes

Date:
Actual Score
Date:
Actual Score

C
r
i
t
i
c
a
l

6.2.1.
Proper adult resuscitation according to
priorities

Date:
Actual Score
Date:
Actual Score

6.3. Procedures for Patients under
Observation
C
r
i
t
i
c
a
l

6.3.1.
If acute deterioration in condition of a patient
under observation is noticed, transfer to the
resuscitation room will be immediately
considered

Date:
Actual Score
Date:
Actual Score

121
C
r
i
t
i
c
a
l

6.4.1.
Serious multiple trauma and unstable patients
are not managed in this room. They are
managed in the resuscitation room

Date:
Actual Score
Date:
Actual Score

C
r
i
t
i
c
a
l

6.5.1. Safe transportation inside the hospital

6.5.2. Safe Patient Referral (to another facility)

Date:
Actual Score
Date:
Actual Score

Completed By: Date:


122
7. SERVICE STANDARDS FOR CRASH CART
Facility Name:
Year:

C
r
i
t
i
c
a
l

7.1.1. The upper part (top)

7.1.2. Drawers

7.1.3. The lower part

7.1.4. Sides

Date:
Actual Score
Date:
Actual Score

7.2. Drug Checklist
C
r
i
t
i
c
a
l

7.2.1.
Adrenaline

7.2.2.
Atropine

7.2.3.
Sodium Bicarbonate

7.2.4.
Xylocaine

7.2.5.
Calcium Chloride

7.2.6.
Dopamine

7.2.7.
Dobutamine

7.2.8.
Nitroglycerine

7.2.9.
Lanoxin

7.2.10.
Lasix

7.2.11.
Aminophylline

7.2.12.
Dextrose 50%

7.2.13.
Magnesium Sulfate

Date:
Actual Score
Date:
Actual Score

Completed By: Date:
123

Chapter 6:
Clinical Performance
Monitoring

125
CHAPTER 6: CLINICAL PERFORMANCE MONITORING
The overall goal of clinical performance monitoring is to ensure that the emergency medical care
provided in general hospitals meet high quality standards. This document describes the system that
will be used for clinical performance monitoring. The system establishes and maintains
mechanisms to continuously collect analyze feedback, report and use information on the level of
compliance with clinical standards. This is in order to continuously reduce quality gaps through the
use of quality improvement methods.
Each indicator is a measurable dimension that can be used to determine the degree of adherence to
a standard of an important aspect of care. Indicators are intended to translate a qualitative statement
(as expressed by EMS standards) into a quantitative one.
The different aspects of emergency care, which have the greatest impact on patient mortality, are
the focus of monitoring and evaluation activities. For this reason, some indicators have been
developed to monitor the implementation of EMS clinical protocols in emergency departments. The
indicators are designed to be used at the facility level (Facility Level Emergency Indicators).
In order for the indicators to be appropriate, the indicators were assessed to be:
Measurable: when it is expressed as a number.
Valid: truly measures the desired result of the standard.
Reliable: the same result is obtained each time it is computed under the circumstances it has
been designed for.
Clear: understood by everyone concerned and is not subject to distortion or misinterpretation.
Realistic: when the information necessary to make the measurement is available and the
resources required to collect the data are within the means of the organization.
The objective of these indicators is to develop a monitoring system and a matrix of indicators at the
department level, which can be used by managers to monitor clinical performance on a continuous
basis and from several different perspectives. The managers will be able to supervise management
of life threatening cases (near misses) and evaluate the effectiveness of interventions within their
departments. The indicators will also enable health officials to monitor improvements, availability,
and quality of care, identify problem areas, analyze and solve problems and make plans. Results
can be compared with the required compliance scores in a way that deviations from the EMS
protocols can be readily recognized.
Each indicator in this module is defined, along with its purpose for collection. A summary of the
data collection methodology is provided and the method for computing and presenting the results
are summarized. In addition, the indicator, the indicator reporting frequency, target, and
performance objective and indicator interpretation is described.
The goal of selecting these indicators was to choose events that are life threatening and address
important aspects of care. For this reason, clinical indicators were developed to cover the following
seven essential aspects of emergency care:
Triage process
Resuscitation process
Patient observation

Chapter 6: Clinical Performance Monitoring

126
Safe transfer
Documentation
Continuous medical education
Ancillary services
127
1. CLINICAL INDICATORS MONITORING CHECKLIST
Governorate
Facility

Assessment Type (): Facility (Self-assessment) Directorate Central

Clinical Practice Indicators
1.1.Triage Process
Case Case Case Case Case
Yes No Yes No Yes No Yes No Yes No
1.1.1. Patient seen by nurse in 5 minutes

1.1.2. Patient seen by doctor in 10 minutes

1.1.3.
Vital signs recorded (blood pressure, pulse, temperature,
respiratory rate)

1.1.4. Provisional diagnosis made

1.1.5.
Grading of cases: A, B and C (emergent, urgent and non-
urgent)

Actual Score
Required Score 5 5 5 5 5
Total Percent

1.2. Resuscitation Process
1.2.1. Airway (opened, cleared and maintained)
1.2.2. Breathing: respiratory rate measured
1.2.3. Breathing: auscultation finding recorded
1.2.4. Breathing: O
2
supplement given
1.2.5.
Circulation: adequate IV cannula
(size number)

1.2.6. Circulation: adequate IVF rate
1.2.7. Circulation: blood sample drawn
1.2.8. Monitoring urine output
1.2.9. Monitoring blood pressure
1.2.10. Monitoring pulse
1.2.11. Monitoring O
2
saturation
Actual Score
Total Percent

128
1.3.Patient Observation
1.3.1. Nurses note completed
1.3.2. ED doctors note completed
1.3.3.
Specialists note completed (when a specialist is
asked to assess the case)

1.3.4. Duration of ED stay recorded
Actual Score
Total Percent

1.4. Safe Transfer
1.4.1. Pre-transfer assessment and stabilization
1.4.2. Proper patient transportation
1.4.3. Monitoring during transfer
1.4.4. Receiving hospital contacted
1.4.5.
Accompanying medical staff (doctor, nurse,
EMT - compatible with patients condition)

Actual Score
Total Percent

1.5. Documentation
1.5.1.
Outpatient form (used for outpatient
management)

1.5.2.
Inpatient form (used for patients under
observation or patients requiring resuscitation)

1.5.3.
Consultation form (used for cases requiring
consultations)

1.5.4. Mortality form (used for all mortality cases)
Actual Score
Total Percent
129
1.6. Continuous Medical Education
1.6.1.
Mortality and morbidity review completed
periodically

1.6.2. Monthly scientific meeting
1.6.3. Periodic workshops conducted
Actual Score
Total Percent

1.7. Ancillary Service
1.7.1. Blood Bank: Blood groups available
1.7.2.
Blood Bank: Preparation of blood units is
completed according to the indicated urgency

1.7.3.
Laboratory: 24 hour lab tests available
according to service standards

1.7.4.
Laboratory: Results are reported according to
the indicated urgency

1.7.5. Radiology: X-ray 24 hour service available
1.7.6. Radiology: U/S 24 hour service available
1.7.7. Radiology: CT 24 hour service available
1.7.8.
Radiology: Reporting is completed according
to indicated urgency

Actual Score
Total Percent


130
2. CLINICAL PRACTICE INDICATORS FOR EMERGENCY MEDICAL SERVICES
Triage Process
Timing Vital signs recorded
Provisional
Diagnosis
Grading of Cases
Seen by nurse in 5
minutes
Seen by doctor in 10
minutes
Blood pressure
Pulse
Temperature
Respiratory rate
Completed A - emergent
B - urgent
C - non-urgent
Resuscitation
Process
Airway Breathing Circulation Monitoring
Opened
Cleared
Maintained
Respiratory rate
measured
Auscultation finding
recorded
O
2
supplement
given
Adequate IV
cannula (size
number)
Adequate IVF rate
Blood sample drawn
Blood pressure
Pulse
O
2
Saturation
Urine output

Patient
Observation
Nurses note ED doctors note Specialists note Duration of ED stay
Completed Completed Completed when a
specialist is asked to
assess the case.
Recorded
Safe Transfer
Pre-transfer
assessment and
stabilization
Monitoring during
transfer
Receiving hospital
Accompanying
medical staff
Proper patient
transportation
Contacted Doctor
Nurse
EMT
Document
Outpatient form used
for outpatient
management
Inpatient form used
for patients under
observation or patients
requiring resuscitation
Consultation form
used for cases
requiring
consultations
Mortality form used
for all mortality cases
Continuous
Medical
Education
Mortality and morbidity
review done periodically
Monthly scientific meeting Periodic workshops done
Ancillary
Service
Blood Bank Laboratory Radiology
Blood groups available
Preparation of blood units is
completed according to the
indicated urgency
24 hour lab tests available
according to service
standards
Results are reported
according to the indicated
urgency
X-ray: 24 hour service
available
U/S: 24 hour service
available
CT: 24 hour service
available
Reporting is completed
according to indicated
urgency

131
3. EMERGENCY DEPARTMENT SERVICE STANDARDS COLLECTIVE CHECKLIST
FOR GENERAL HOSPITALS
Facility Name:

Year:

Facility-level
Assessment

Hospital Directorate-level
Assessment

3.1. Service Standards for
Triage Room
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.1.1. Physical Structure 6 6 6 6
3.1.2. Furniture 4 4 4 4
3.1.3. Equipment 7 7 7 7
3.1.4. Supplies 10 10 10 10
Total 27 27 27 27
Percentage Compliance % % % %

Resuscitation Room
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.2.2. Furniture 7 7 7 7
3.2.3. Equipment 20 20 20 20
3.2.4. Supplies 30 30 30 30
3.2.5. Medication 31 31 31 31
Total 94 94 94 94

Observation Room
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.3.2. Furniture 8 8 8 8
3.3.3. Equipment 6 6 6 6
3.3.4. Supplies 13 13 13 13
3.3.5. Medication 13 13 13 13
Total 45 45 45 45

132
Operating Room
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.4.2. Furniture 11 11 11 11
3.4.3. Equipment 7 7 7 7
3.4.4. Supplies 23 23 23 23
3.4.5. Medication 18 18 18 18
Total 65 65 65 65

Physicians Office
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.5.2. Furniture 4 4 4 4
3.5.3. Equipment 1 1 1 1
Total 11 11 11 11

Nurses Office
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.6.2. Furniture 5 5 5 5
3.6.3. Equipment 1 1 1 1
Total 12 12 12 12

Registration
Information Office
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.7.1.
Registration Information
Office
6 6 6 6
Total 6 6 6 6

133
Stock Room
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.8.2. Furniture 3 3 3 3
3.8.3. Equipment 6 6 6 6
3.8.4. Supplies 2 2 2 2
Total 16 16 16 16

Personnel
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.9.1. Doctors 6 6 6 6
3.9.2. Nurses 3 3 3 3
3.9.3.
Emergency Medical
Technician (EMT)
1 1 1 1
3.9.4.
Other Emergency Room
Staff
2 2 2 2
3.9.5. Personnel Requirements 10 10 10 10
3.9.6. Training 10 10 10 10
Total 32 32 32 32

Department
Administration
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.10.1. Department Administration 9 9 9 9
Total 9 9 9 9

Infection Control
Procedures
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.11.1.
Infection Control
Procedures
8 8 8 8
Total 8 8 8 8


134
Behavioral Aspects of
Emergency Care
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.12.1. Presence of physician 4 4 4 4
3.12.2. Presence of nursing staff 6 6 6 6
3.12.3.
Staff punctuality,
assignment and
communication
3 3 3 3
3.12.4.
Problem solving team
meeting (held weekly)
5 5 5 5
Total 18 18 18 18

Clinical Procedures
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.13.1. Proper Patient Triage 6 6 6 6
3.13.2. Resuscitation Procedures 2 2 2 2
3.13.3.
Procedures for Patients
Under Observation
9 9 9 9
3.13.4. Minor Surgical Procedures 6 6 6 6
3.13.5. Patient Transfer 2 2 2 2
3.13.6. Ancillary Services 8 8 8 8
Total 33 33 33 33

Crash Cart
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
3.14.1. Crash Cart Contents 4 4 4 4
3.14.2. Drug Checklist 13 13 13 13
Total 17 17 17 17

135
4. EMERGENCY DEPARTMENT SERVICE STANDARDS COLLECTIVE CHECKLIST
FOR GENERAL HOSPITALS CRITICAL
Facility Name:
Year:

Facility-level
Assessment

Directorate-level
Assessment

Triage Room
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
4.1.1. Equipment 5 5 5 5
Total 5 5 5 5

Resuscitation Room
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
4.2.1. Furniture 1 1 1 1
4.2.2. Equipment 8 8 8 8
4.2.3. Supplies 5 5 5 5
4.2.4. Medication 25 25 25 25
Total 39 39 39 39

Observation Room
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
4.3.1. Supplies 2 2 2 2
4.3.2. Medication 10 10 10 10
Total 12 12 12 12

Operating Room
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
4.4.1. Equipment 4 4 4 4
4.4.2. Supplies 2 2 2 2
4.4.3. Medication 16 16 16 16
Total 22 22 22 22

136
Personnel
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
4.5.1. Doctors 5 5 5 5
4.5.2. Nurses 2 2 2 2
4.5.3.
Emergency Medical
Technician (EMT)
1 1 1 1
4.5.4. Personnel Requirements 6 6 6 6
Total 14 14 14 14

Clinical Procedures
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
4.6.1. Proper Patient Triage 2 2 2 2
4.6.2. Resuscitation Procedures 1 1 1 1
4.6.3.
Procedures for Patients
Under Observation
1 1 1 1
4.6.4. Minor Surgical Procedures 1 1 1 1
4.6.5. Patient Transfer 2 2 2 2
Total 7 7 7 7

Crash Cart
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
Actual
Score
Required
Score
4.7.1. Crash Cart Contents 4 4 4 4
4.7.2. Drug Checklist 13 13 13 13
Total 17 17 17 17

137
5. PERCENTAGE COMPLIANCE ACTUAL SCORE FOR GENERAL HOSPITALS
Service Standards
Month Percentage Compliance
Actual
Score
Required
Score

Actual Score

= x 100
Required Score

1 Service Standards for Triage Room 27 %
2
Service Standards for Resuscitation
Room
94 %
3 Service Standards for Observation Room 45 %
4 Service Standards for Operating Room 65 %
5 Service Standards for Physicians Office 11 %
6 Service Standards for Nurses Office 12 %
7
Service Standards for Registration
Information Office
6 %
8 Service Standards for Stock Room 16 %
9 Service Standards for Personnel 32 %
10
Service Standards for Department
Administration
9 %
11
Service Standards for Infection Control
Procedures
8 %
12
Service Standards for Behavioral Aspects
of Emergency Care
18 %
13
Service Standards for
Clinical Procedures
33 %
14 Service Standards for Crash Cart 17 %
Total 393 %

Remarks:

Completed By: Date:

138
6. PERCENTAGE COMPLIANCE ACTUAL SCORE FOR GENERAL HOSPITALS -
CRITICAL
Service Standards
Month Percentage Compliance
Actual
Score
Required
Score

Actual Score

= x 100
Required Score

1 Service Standards for Triage Room 5 %
2
Service Standards for Resuscitation
Room
39 %
3
Service Standards for Observation
Room
12 %
4 Service Standards for Operating Room 22 %
5 Service Standards for Personnel 14 %
6
Service Standards for Clinical
Procedures
7 %
7 Service Standards for Crash Cart 17 %
Total 116 %

Remarks:

Completed By: Date:

139
7. EMERGENCY DEPARTMENT SERVICE STANDARDS RECOMMENDATIONS
FOR IMPROVEMENT
Governorate Facility

Assessment Type (): Facility (Self-assessment) Directorate
Assessor(s): Date of Assessment:

Number
Description of problem causing
non-compliance
Recommended action
(including level of responsibility and
person(s) to take action)
Part Standard

ER Service Standards

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