Hospital Wide Policies including Disaster Management

Departmental Policies and Procedures

Emergency Codes: Dial Intercom No. 33

  • Code Blue – Medical Emergency
  • Code Red – Fire
  • Code Pink – Infant/ Child Abduction
  • Code Yellow – External/ Internal Disaster
  • Code Violet – Violence

Patient and Family Rights

  • To receive high quality care appropriate to the Patient’s needs and consistent with the scope of the hospital.
  • To know the name of the Physician who has the primary responsibility for coordinating care.
  • To be educated in a language and format that they can understand and also be educated about preventing Healthcare Associated Infection.
  • To have the right to multidisciplinary counseling and education on various pain management techniques where appropriate and determine what information regarding their care would be provided to self and family.
  • To receive considerate care regardless of race, gender, ethnicity, religious belief so age while respecting their values and special preferences including cultural, spiritual needs and dietary preferences.
  • To be treated with personal dignity, privacy and confidentiality during examination, procedures and treatment
  • As and when appropriate, to be educated about the medication, potential side effects of medication, diet and nutrition, food – drug interactions, immunizations, organ donation, preventive strategies like lifestyle modification and other aspects of the disease process, including unanticipated outcome.
  • To have protection from physical abuse or neglect.
  • The patient and/or family members are explained about the results of diagnostic tests and the diagnosis and any change in the patient’s condition in a timely manner.
  • The patients and/or family members are explained about the proposed care including the risks, benefits, complications, alternatives and the expected results.
  • To have information on plan of care, progress and information on their healthcare needs.
  • To be able to raise a complaint/feedback and be made aware of the process of raising the complaint/feedback and it’s redressal.
  • To receive counseling regarding the estimated cost of treatment and payment schedule at the time of admission and whenever there is a change in care plan.
  • To give informed consent before transfusion of blood and blood products, anesthesia, surgery, initiation of any research protocol and any other invasive/High risk procedures/treatment.
  • The care plan is prepared and modified in consultation with family members incorporating patient and family members concerns and requests
  • The patients or their family member’s special educational needs are identified and addressed.
  • The Patient can refuse a recommended treatment to the extent permitted by law, and be informed about the medical consequences of the refusal.
  • The Patient can request a second opinion about the diagnosis or treatment plan.
  • The Patient has right to access his or her Medical Records any time and is assured of the confidentiality of medical records and has the opportunity to approve or refuse the release of such information.

Patient and Family Responsibilities

  • To provide complete and accurate information including full name, address, home telephone number, date of birth, insurance details and employer details whenever necessary.
  • To provide accurate and complete information concerning present complaints, past medical history, hospitalizations, medications and other matters relating to the Patient’s health.
  • To follow the treatment plan advised by the Physician, including the instructions of nurses and other health professionals as they carry out the Physician’s orders.
  • To make it known whether the Patient understands the course of the medical treatment and seeks clarifications if required.
  • To treat hospital staff and other Patients with dignity and respect and not to conduct any activity that will disrupt the work of the hospital.
  • To be respectful of the privacy of others and the property of the hospital.
  • Do not bring alcohol, unauthorized drugs or weapons in the hospital, ever.
  • To respect that the hospital is a no smoking zone.
  • To follow visiting hours of the hospital.
  • Leave valuables at home and bring only those items necessary during hospital stay.
  • Assure that the financial obligations of Patient’s care are fulfilled as per the hospital policy.
  • The patients are responsible for their own actions should they refuse treatment or their treating consultant’s advice.

Vulnerable Patient:

The Organization has identified and clearly defined those patients coming under the vulnerable categories. These are mentioned as below

  • Children below the age of 12 years
  • Adults above the age of 70 years
  • Physically/ mentally challenged persons
  • Patient with language barrier (Foreigner)
  • Patients who cannot perform ADL (acts of daily living)

The Organization has appropriate Policy and Procedures for treating Vulnerable Patients, Consent: General consent is taken at the time of patient’s admission. Apart from this, at the time of a surgery/ procedure/ investigation an informed consent is needed if a patient is going for the same.

Hospital Infection Control

At Hospital, we follow the standard precautions (earlier known as universal precautions) and have made policies and procedures regarding precautionary measures to minimize the risk of transmission of blood borne pathogens. These policies are to protect employees and are expected to be followed by all. When in contact with blood or internal body fluid, wear gloves. Dispose of needles, sharps and all other medical waste in the proper containers. When splashing of body fluid is anticipated, gown, mask and protective eye gear must be worn. Additional precautions may be required in specific situations or on specific units. Questions regarding the transmission of blood borne pathogens should be addressed immediately to your immediate supervisors.

Essential Elements in Hospital Infection Control:

Hand Hygiene/Hand Wash 40-60 sec. / Hand Rub-30 sec.

WHO five moments :

  • Before touching a patient.
  • Before clean / aseptic procedure.
  • After body fluid exposure risk.
  • After touching a patient
  • After touching a patient surroundings.

Personnel Protective Equipments (PPE)

  • Gloves, Gown/Apron
  • Mask including surgical and N95
  • Cap, Goggles/Face Shield
  • Gum Boots / Shoe Cover

Safe Handling and Disposal of Sharps

  • Do not recap needles/avoid pass from hand to hand.
  • To ensure that the needles are not broken or bent before use.
  • To ensure that sharps are disposed at the point of use in puncture proof sharp containers.
  • To ensure that not more than two-third of the sharps containers are filled.
  • Follow needle stick injury protocol.

Safe Handling and Disposal of Wastes

  • Segregate the wastes at source
  • Know the policies and protocols or the Hospital as per Biomedical Rules 2016
  • Safe disposal and Safe handling of spillage
  • Covid waste should be collected in double layered biodegradable bags.

Managing Blood and Body Fluids

  • Spillage management as per policy
  • Safe handling of specimen during collection, labeling and transport.

Disinfection of the Equipments

  • Proper cleaning of the equipments and subsequent disinfection as per policy.
  • Follow written policies and protocols

Immunization

  • Hepatitis B, Tetanus and Covid Vaccination will be provided to all the employees of the Hospital. In addition, Typhoid and Hepatitis A vaccines will be provided to all Kitchen staff.

Isolation

  • Isolate patients with transmissible diseases and use standard and transmission based precaution.


Management of Sharp (needle stick) Injury

  • Do not suck the injury site.
  • Wash with soap and water or irrigate the exposed mucous membrane.
  • Contact supervisor or Infection control nurse for further management.
  • Complete the incident report

Handling soiled Linen

  • Any linen soiled with body fluids of a patient is to be treated as contaminated linen.
  • Soiled linen must be bagged in the Yellow Bag at the bedside, never shaken or allowed to touch the floor.
  • Linen are held away from the body to prevent contamination.
  • Bag must be less than 2/3rd full.
  • The Yellow Bag must be appropriately labelled contents, ward, date and send to the laundry.
  • At laundry, there is a special procedure for cleaning and disinfecting of soiled linen, before sending it back for regular washing and then on floors.

Handling Contaminated Files

  • If any body fluid is spilled on paper, that paper is to be treated as contaminated and following needs to be done:
  • Place the Paper in a plastic impervious yellow bag.
  • Fill up an incident form.
  • The nurse has to send the file to MRD where it will be photocopied, attested and photocopied file will be sent back to the floor.
  • The paper which has been contaminated will be discarded as per Bio Medical Waste rules.
  • All of us need to be equally concerned with infection control in the hospital.
  • Hands should be washed before and after patient contact, bathroom use, and handling patient files. Be sure to wash your hands before entering and after coming out of the intensive care areas.
  • An Infection Control Committee has been constituted, which serves as an advisory body. An infection control manual has been complied and is available with all departments and with members of the infection control committee and on all computer systems.

Bio Medical Waste Management involves:

  • Segregation
  • Collection
  • Storage
  • Final Disposal
  • Pre-Treatment
  • On-site Transportation
  • Off-siteTransportation

Always follow the color-coding as given by the infection control committee:

S.No. Bag Color Waste Description Disposal/ Treatment Area Of Collection
1 Yellow Human Tissues/blood & Body Fluids/Animal Waste / Soiled Waste, Expired Medicine Incineration All
         
2 Red Tubing, bottles, intravenous tubes & sets, catheters, urine bags, syringes (without needles and fixed needle syringes) & vaccutainers and gloves, (Infected Plastic waste) Autoclaving or Microwaving All
         
3 Blue Unbroken/Broken Glassware/vials metallic body implants Autoclaving/shredding/ Micro-Waving/Chemical Treatment & Destruction All
         
4 >White Translucent/ Puncture Proof/ Containers Needles/Sharps/Scalpels Blades/Waste Sharps/ Fixed Needle Syringes Autoclaving/shredding/ Micro-Waving/Chemical Treatment & Destruction All
         
5 Yellow Cytotoxic waste Return back to manufacturer or incineration All

# General Waste: 

  • Green color: Organic Waste  
  • Blue color: Recyclable waste

* Covid-19 Waste:

  • Should be disposed in double layer medical waste bag and labelled as “COVID-19 Waste” and Sprayed 1% hypo over the bins

8. Hazardous Materials

Hazardous materials that contain ingredients those are harmful to health. These include materials that are lethal and non-lethal, corrosive, toxic, irritant, sensitizing, mutagenic, teratogenic or carcinogenic. The concentration level of each ingredient in a mixture is taken into account in determining whether the mixture as a whole is determined to be hazardous.

Purpose

In the event of a spill, competent and prompt action is necessary for immediate clean up to reduce and eliminate the hazards present. The handling, storage and use of hazardous materials (HAZMAT) are controlled and hazardous waste is disposed off safely

 
Responsibility for Spill Management “It is the responsibility of person who had done the spill to manage it. All spills large (>10ml) or small (<10ml) must be reported to hospital infection control nurse (ICN) immediately”

Steps of Spill Management for Small Spill (<10ml)

  • Make nearby people aware about the spill
  • Cordon off the area, if possible
  • Identify the nearest spill kit available
  • Wear PPE and heavy duty gloves
  • Draw a line of demarcation around twice the size of spill using the marker pen provided in the kit and mention the date and time of spill
  • Put soaking paper (tissue paper/newspaper/ paper towels) over the spill.
  • Take out 10% Sodium hypochlorite solution provided in the spill kit (shelf life 1 month).
  • Prepare 1000ml fresh dilution of 1% Sodium hypochlorite (use a part of 10% Hypo and one part of tap water) using the graduated mug available in the kit
  • Pour this freshly prepared solution over the spill, covering it completely.
  • Leave for a contact time of 20 minutes.
  • After contact time, use the plastic dustpan and wiper provided in the kit to collect the soaked paper and put a yellow bag, labeled as “Blood spill” with date, time and place of spill and discard in yellow bin.
  • In case the spill contains any broken pieces of glass or other sharps, discard all spill contents in a sharp discarding container.
  • Clean the area with appropriate disinfectant (D-256 / 1% Hypo).
  • Remove the PPE and discard appropriately
  • Perform hand washing with soap and water
  • Report the spill in incident reporting form and contact your supervisor and the infection control team.
  • It is the duty of the supervisor to ensure that spill kit components are restocked after use and that daily checking of spill kit contents is updated in the spill log book.

Steps of Spill Management for Large Spill (>10ml)

In case of large spill of blood and body fluids, inform housekeeping department (6020,6022) and ICN immediately.

  • Make nearby people aware about the spill
  • Cordon off the area, if possible
  • Use the main housekeeping spill / HAZMAT kit to manage such spills.
  • Wear PPE and heavy duty gloves.
  • Draw a line of demarcation around twice the size of spill using the marker pen provided in the kit and mention the date and time of spill
  • Put large size soaking pads (tissue paper/newspaper/ paper towels) over the spill.
  • Take out 10% Sodium hypochlorite solution provided in the spill kit (shelf life 1 month).
  • Prepare 1000ml (or more if needed) fresh dilution of 1% Sodium hypochlorite (use a parts of 10% hypochlorite and one part of tap water) using the graduated mug available in the kit
  • Pour this freshly prepared solution over the spill, covering it completely.
  • Leave for a contact time of 20 minutes.
  • After contact time, use the plastic dustpan and wiper provided in the kit to collect the soaked paper and put a yellow bag, labeled as “Blood spill”. Discard this yellow bag.
  • In case the spill contains any broken pieces of glass or other sharps, discard all spill contents in a sharp discarding container.
  • Clean the area with appropriate disinfectant (D-256 / 1% Hypo).
  • Remove the PPE and discard appropriately
  • Perform hand washing with soap and water
  • Report the spill in incident reporting form and contact your supervisor and the infection control team.
  • It is the duty of the housekeeping supervisor to ensure that spill kit components are restocked after use and that daily checking of spill kit contents is updated in the spill log book.

Patient Exposure to Blood/body Fluids

  • Accidental exposure to blood/body fluid has to be treated the same way as a needle sticks injury is treated.
  • Send appropriate samples for examination.
  • Inform the infection control officer/casualty medical officer and get medically examined.
  • Fill up an incident form


Yashoda Super Speciality Hospital, Kaushambi is “Mercury Free”

9. Sentinel Event

A sentinel event is an occurrence that has resulted in unanticipated death or major permanent loss of function not related to the natural course of the patient’s illness, or underlying condition. Followings are The Sentinel Events as Identified by the Hospital.

Definition:

An unexpected incident, related to system or process deficiencies, which leads to death or major and enduring loss of function* for a recipient of health care services.

* Major and enduring loss of function refers to sensory, motor, physiological, or psychological impairment not present at the time services were sought or begun. The impairment lasts for a minimum period of two weeks and is not related to an underlying condition.

Event type description
 

  • Surgical events
    • Surgery performed on the wrong body part
    • Surgery performed on the wrong patient
    • Wrong surgical procedure performed on the wrong patient
    • Retained instruments in patient discovered after surgery/procedure
    • Patient death during or immediately post surgical procedure
    • Anesthesia related event
  • Device or product events Patient death or serious disability associated with:
    • the use of contaminated drugs, devices, products supplied by the organization
    • the use or function of a device in a manner other than the device’s intended use
    • the failure or breakdown of a device or medical equipment
    • intravascular air embolism
  • Patient protection events
    • Discharge of an infant to the wrong person
    • Patient death or serious disability associated with elopement from the health care facility
    • Patient suicide, attempted suicide, or deliberate self-harm resulting in serious disability
    • Intentional injury to a patient by a staff member, another patient, visitor, or other
    • Any incident in which a line designated for oxygen or other came to be delivered to a patient and contains the wrong gas or is contaminated by toxic substances
    • Nosocomial infection or disease causing patient death or serious disability
  • Environmental events Patient death or serious disability while being cared for in a health care facility associated with:
    • a burn incurred from any source
    • a slip, trip, or fall
    • an electric shock
    • Failure in the use of restraints or bedrails
  • Care management events
    • Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products
    • Maternal death or serious disability associated with labor or delivery in a low-risk pregnancy
    • Medication error leading to the death or serious disability of patient due to incorrect administration of drugs, for example:
      • omission error
      • dosage error
      • dose preparation error
      • wrong time error
      • wrong rate of administration error
      • wrong administrative technique error
      • wrong patient error
    • Patient death or serious disability associated with an avoidable delay in treatment or response to abnormal test results.
  • Criminal Events
    • Any instance of care ordered by or provided by an individual impersonating a clinical member of staff
    • Abduction of a patient
    • Sexual assault on a patient within or on the grounds of the health care facility
    • Death or significant injury of a patient or staff member resulting from a physical assault or other crime that occurs within or on the grounds of the health care facility

Any instance of care ordered by or provided by an individual impersonating a clinical member of staff.

When a sentinel event occurs, it should be reported immediately to the appropriate individuals so that assessment and understanding of the causes that immediately/remotely caused the event can be made; and appropriate changes in the organization’s systems and processes are brought about to reduce the probability of such an event in the future.

10. International Patient Safety Goals

i. Identify Patients Correctly
ii. Improve Effective Communication
iii. Improve the Safety of High-Alert Medications
iv. Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery
v. Reduce the Risk of Health Care–Associated Infections
vi. Reduce the Risk of Patient Harm Resulting from Falls

11. Commandments for Doctors

  • Write Medication in Order and in legible clear Capital Letters.
  • Document your visit with notes duly signed with the date, time signature and name.
  • Avoid verbal orders.
  • Use alcohol hand rub before and after each patient examination and after touching patient’s surroundings.
  • Make a habit patient and family education as part of care.
  • Ensure informed consent for all procedures.
  • Assess and re-assess patient as per hospital policy
  • Prepare /and counter sign discharge summaries and talk to patient regarding discharge instructions, follow-up and care at home.
  • Prescribe as per hospital formulary and follow the antibiotic policy.
  • Have formal meetings / briefings with the other specialties when more than one doctors is treating the patient.

12. Commandments for Nurses

  • Thou shall care for patient’s needs; no other job shall come before this.
  • Thou shall keep patients safe, secure and free from harm or injury at all times.
  • Thou shall keep the patients clean and well groomed at all times and sure that they are never hungry, thirsty or cold
  • Thou shall speak to patients, families and each other with respect and compassion.
  • Thou shall act with kindness, gentleness and understanding.
  • Thou shall attend to the patients and families’ complaints and requests with speed and persistence until they are satisfied.
  • Thou shall provide privacy when delivering personal care, toileting and bathing.
  • Thou shall help the patients control their lives by providing as much assistance as necessary.
  • Thou shall give of yourself and your love and be blessed with love in return.
  • In laughter and in joy, thou shall work to share the tear and the smile and count each day as precious.
  • Nurses will administer the medicines after cross checking;
    • Right patient
    • Right dose
    • Right route
    • Right documentation
    • Right education
    • Never leave medicines unattended in the open. Lock them in bedside cabinets.
    • Label all open, in use vials.
    • Right drug
    • Right time
    • Right purpose
    • Right to refuse
    • Right education
    • Right evaluation