Bisidimo General Hospital EBC Manual of Operations for

Emergency Department
2015 EFY

2015, Ethiopian Fiscal Year

Bisidimo General Hospital EBC Manual of Operations for Emergency Department

2015, EFY
Purpose: To provide guideline instructions for the provision of immediate relief
to and management of the patients arriving at the hospital with acute
medical and surgical emergencies with any injuries by accidents,
sudden attacks of illness, head trauma, Physical abuse, poisoning,
burns and rape cases etc without any discrimination

Scope: Scope of services of the ED range from providing episodic, primary,

acute (comprehensive) care to referrals.
 Triage all incoming patients.
 Have patients assessed by qualified individuals.
 Diagnose, treat, admit and provide appropriate referral and follow
up.
 Ensure critically ill patients receive the top priority care as
determined by triage guidelines.
 Initiate lifesaving treatment.

Responsibility: Emergency Medical Officer, Emergency staff Nurse and Emergency

Pharmacist and other supportive staff

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Organizational Structure

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Job Descriptions

ER Team Coordinator
 He/she is responsible for all activities conducted in Emergency Services
including: Patient triage, Case management, and Laboratory, pharmacy and
diagnostic services.
 The Director of Emergency Services is responsible for managing all department
staff and should ensure that equipment and supplies are available for the patient
load.
 Ensure proper care for patients are given as per the standards;
 Ensure proper utilizations of materials, supplies and medical equipments in the
unit;
 Ensure proper implementations of all hospital reforms;
 Ensure implementations of quality improvement projects in ER Department;
 Actively involved in different committee activities at Hospital Level;
 Fill performance evaluations of their respective employees;
 Do other activities given by chief clinical Officer(Medical Director).

General Medical Practitioner (GP)

 Provide skilled health assessment, diagnosis and treatment services to patients;
 Order diagnostic tests and investigations, communicates the results to the client and
prescribe appropriate treatment including medications;
 Monitor patients' conditions and progress and reevaluates treatments as necessary;
 Perform minor operations including safe delivery;
 Counsel patients on diet, hygiene and preventative health care;
 Perform surgical emergencies in obstetrics and general surgery (instrumental
delivery, caesarean section and appendectomy for uncomplicated cases);
 Admit patients into and discharge them from Wards;
 Plan, implement, or administer health programs in hospitals or communities for
prevention and treatment of injuries or illnesses;
 Participate in disease prevention and health promotion programs;
 Participate in epidemic investigation and management programs;
 Participate in teaching of health science students and operational researches;
 Document all care provided and education/information given to patients;
 Participate in hospital-based quality audits.
 Ensure proper utilizations of materials, supplies and medical equipments in the unit;

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  Ensure proper implementations of all hospital reforms;
 Ensure implementations of quality improvement projects in their Department;
 Actively involved in different committee activities at Hospital Level;
 Do other activities given by chief clinical Officer and ER Coordinator.
ER Head Nurses/Coordinator

Duties and Responsibilities

 Head nurses manage all the administrative duties of the departments which they are
assigned to work in
 They schedule shifts for the nurses and assign duties to them
 They collect work reports from all the nurses regarding their day-to-day activities and
maintains a record of them
 They present the records collected from all the nurses to the respective doctors who
are handling cases of those patients
 They assist and conduct training programs for the nurses who are new and need help
 They also solve any issues related to the patients
 Head nurses also come in direct contact with the patients and diagnose their health
problems
 Inventory management is also one of the responsibilities of the head nurses
 They maintain a log of the entries of the patients and their health reports
 Promote and maintain good working and inter-personal relationships with
Management / patients / staff / visitors / doctors and colleagues
 Co-ordinate nursing service activities with other departments
 They are responsible for caring for the patient and getting them prepared for the next
steps in their treatment
 Ensures Implementation of all hospital policies with respect to IPPS and cleanness of
rooms and make sure that the patients are provided with enough facilities and
entertain all types of complaints from the patients
 Ensures patients are properly triaged and got necessary treatments

 Fill efficiency of nurses responsible to them

 Do other activities given by ER Coordinator and Matron

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  Administratively responsible to Hospital Matron.

ER Staff Nurses

Duties and responsibilities include

 Initiate appropriate triage assessment

 Make a decision on the level of patient acuity (Red, Orange, Yellow, Green and
Black) using the standardized triage format and supportive guidelines.
 Dispose patients according their level of acuity to the resuscitation, examination or
waiting area.
 Initiate appropriate nursing interventions when necessary.
 Re-triage, reassure and make very important investigations for patients waiting in the
waiting area.
 Secure the safety of patients and staff of the department.
 Maintain patient privacy.
 Provide patient and public education where appropriate to facilitate.
 Act as liaison for members of the public and other health care Professionals.
 Make sure that the triage sheet is completed and attached to patient triage.
 Deliver the complete nursing care
 Record all patient diagnosis in to HMIS register
 Ensure timely submissions of reports
 Organize and prioritize delegated nursing care effectively;
 Do other activities given by ER Head Nurses and/or Matron

Administrative staff
 Administrative staff job descriptions are given in detail in HR Manual

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Emergency Department (ED) Staffing
1. The Emergency Department of Bisidimo Hospital offers comprehensive emergency
care 24 hrs a day.
2. Physicians, Nurses, Lab and Pharmacy staff and other supportive staff are assigned in
this department;
3. During peak hours , the consultants of all medical services are available in the
hospital and can be reached immediately incase of any need.
4. During non peak hours the consultants from each clinical department are available on
call basis.
5. In case of Accidents involving numerous individuals at a time all consultants and
staff members responsible to provide critical care can be called as per the
requirement.
6. Nurse staff allocation shall be according to Nursing policies and procedures.

Emergency Care Services

 The ED service covers evaluation, resuscitation and treatment of all the emergency
conditions; it involves both pre-hospital and in-hospital emergency services of the
following types: Cardio-pulmonary emergencies; Surgical Emergencies; Trauma
Related Emergencies; Medico Legal Emergencies; Endocrinal Emergencies;
Obstetrics & Gynecological Emergencies; Infectious Emergencies and Ambulance
Services

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Triage Policy and Procedures
 Emergency Department patients will receive prompt initial assessment by a registered
nurse and will have emergency care initiated according to their level of acuity.

 The desired outcome of the triage process is that all Emergency Department patients
will receive expedient treatment according to established priorities.

 Emergent patients requiring immediate intervention are transferred to the appropriate

bed station in the ED to initiate the patient assessment & care process.

 The registrations of patients will be assisted by runners;

 The registration process of the patient is also initiated in the ED if the patient
condition permits. In case of limb and life threatening situations the registration and
consent process are postponed so as to facilitate the initiation of appropriate
emergency care;

 Patient triage shall be made by the approved formats and attached to patient medical
Record. The Format is given in this manual.

 Patient Triage shall be made as per hospital protocols and National ER Patient triage
guidelines.

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Triage Decisions

Patient brought to the ER

Initial assessment done by EMO& nurse. Initial assessment

to be done by 10mins
Initial assessment includes Level of consciousness, temp, BP,
PR, RR, Spo2 to be checked

Stable Unstable Brought in dead

Treated and Patient is made fit for MLC initiated

sent home transfer. ABC secured Body handed over to
morgue and other
concerned Bodies

Consultant Admit under Refer to

reference Consultant if higher/other
facilities to treat center if facilities
the patient are are not available
available

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Ambulance Services
 Please refer to the Ambulance Services Document in line with Liason service
documents;
 Ambulance should be equipped with basic medical equipments;

Medical Records (Registers and Documents maintained)

 Medical Record Management should be according to Hospital Medical Record
management Policy;

Patient Admissions, Referral and discharges

 Admission, discharges and referral of patients should be in line with Hospital
protocol for this purposes;

MLC (Medico Legal cases)

1.Brought Dead
i. Take past history – HTN / DM / IHD etc.,

ii. Look for / Ask about any suspicious signs:

 Poisoning – Smell

 Strangulation – Ligature mark around neck / abnormal sings

 Any external injuries

 Expose the body completely and look for any sings

 Palpate the head and look for any haematoma, etc which may be missed.

iii. If a female, ask history of married life and if it is less than 7 years register it as MLC,
- it is mandatory.

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 iv. Register all brought dead cases as medico-legal case if death has occurred
unexpectedly or from an unexplained cause.

v. On arrival, the Emergency Medical officer should examine the patient thoroughly. He
/ She should go into the history in detail and look for signs of homicide, suicide,
violence, external injuries to rule out any suspicious cause for the death. In case of
female patient, marital history should be elicited and if EMO feels suspicious cause
for the death, Medico Legal Case has to be registered.

vi. After complete examination and confirmation by clinical evaluation death & is
confirmed, the individual should be declared as Brought in Dead (BID) and the
accompanying relatives/friends must be explained and informed about the probable
cause of death and they are given only a Brought Dead Certificate until the cause of
death is confirmed.

vii. The local police should be informed immediately in case suspicion or foul play. The
police will do the further disposal of the dead body after inquest. The Emergency
Medical Officer will render necessary assistance.

Death on Arrival:
 If a patient has sudden Cardio-Respiratory Arrest on arrival at the Emergency Room,
the patient has to be resuscitated as per Hospital protocols.
 Once death is confirmed the case should be treated as death on arrival, and necessary
documentation should be done.
 EMO should go into the detailed history of the patient and arrive at the probable
cause of death. On the basis of this, death certificate should be issued and
arrangements for release of the body are taken after settlement of hospital dues.

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Handling of Death & Release of Dead Body
 See Hospital Protocol for management of Deaths and Care for the deceased;

Death Certificate:
 ER Coordinator and/or GP should certify the cause of death in the Death Certificate
after careful and thorough examinations of the patient after discussing with the
concerned consultant.
 Death certificate is initiated if the death occurs within the hospital, unless there are
grounds and evidence to the contrary.
 The cause of death should be well documented and a copy of the Death certificate
should be filed along with the medical documents of the deceased patient.

Storage of Medicines in Emergency Department

1. All Emergency medications will be available 24 hrs in the ER ( refer list of emergency
medication)
2. All Emergency medications will be replenished by the nurse/pharmacist on duty with
each case and on daily basis. This should be done on daily Medicine and medical
equipment handover procedures and registers.
3. Medication inventory / Crash cart will be checked by the nurse on duty with each shift
change, to detect loss or theft.
4. Narcotics drugs will be kept in the narcotics box and will be under the supervision of the
nurse in Charge.
5. Narcotic drugs will be released only on the signed requisition of the consultant/MO.
6. Working condition of the ER equipments will be checked by the nurse on duty with each
change In shift.
7. Any Malfunction /nonfunctioning of the equipment will be brought to the notice of the
nurse in charge and the Chief clinical officer and work order is raised.

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Laboratory Services
 Laboratory samples should be obtained within the emergency department and
analysed either within the department or at the central laboratory, depending on the
test requested.

 At a minimum the following tests should be provided in the Emergency Department:

Haemoglobin, Haematocrit, Blood film, Blood group and cross match, Total cell
count, Random blood sugar, Urinalysis, Stool examination, and Pregnancy test.

 More complex tests may be performed in the Central Laboratory.

 If the sample is to be tested in the central laboratory then a runner should take the
specimen to the laboratory and collect the result.

Radiology Services

 A runner should transport the patient to the X-Ray department where the test will be
conducted. Results should be taken back to the Emergency Department by a runner.

 A cashier service should be available within the emergency department for the
payment of all emergency room treatments, investigations, drugs and consumables.

 Runners should assist the patient and/or caregiver with making payment.

Emergency Department Equipment

 Minimum Lists of Needed equipments in ER Unit are given in the annex unit.

Appointment and Referral Procedures

 This shall be according to Hospital Appointment and Referral protocols.
Refer to this protocol.
Handover of Clinical Care

 Refer Clinical Shift Handover Protocol.

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Patient Communication
 Communication in general and patient communication in particular are
document in hospital Communication guideline. Please refer for this
guideline for additional information.
Infection Control In ER Department
 Infection prevention activities shall be according to hospital protocols
and National IPPS Manual. Please refer for this Manuals.
Emergency Preparedness Plan (Disaster preparedness plan)
Response Time
 All patients will come to the ED for emergency medical evaluation or treatment will
receive care by qualified personnel in a timely manner consistent with the acuity of
their illness.
 Bisidimo Hospital has a policy to attend to the patients arriving in the ED
immediately. The Nurse assessment at the triage is done immediately.
 All patients arriving in the ED are examined and attended by doctors without delay.
 The Consultants of respective specialty are called & they attend to the patient
immediately during the regular hours of operations of the OPD.
 During after hours, Consultants on call are contacted immediately upon need.
 Treatment to patients who are critical is initiated immediately without any delay for
the purpose of documentation and consent.
 Procedures and responses for likely emergencies and incidents are managed as per
Bisidimo Hospital Major incident policy and procedures.

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 Bisidimo Hospital Emergency Department
Patient Triage and Waiting Monitoring Card

Date Total Numbe Number of Number of Reasons for the gas

Patient r of Patients Patients
s Seen Patients Triage > 5 Stayed > 24
Triage Minutes Hours in
<5 the ER Bed
Minutes

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 General minimum Equipment, Supply and Drug Needs for
Emergency unit/departments
Equipment and Supply Needs for Emergency Services
Equipment and Furniture Supplies
Stretcher Emergency Drugs
Wheel chair Cleansing agents/chemicals
Office furniture Antiseptics/Disinfectants
Screen Dressing materials
Diagnostic kits Stationary
Resuscitation tools –adult/paediatric Personal Protective Equipment
Examination beds
Short stay beds
Refrigerator
Weighing scale
IV stand
Procedure kits
Lab equipment
Mobile X ray
Ultrasound
Monitoring machines
Electrocardiogram
Oxygen cylinder with accessories
High power mobile lamps
Telephone
Computer
Wall clock

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Crush cart drug and supplies list that has to be available all times 24hrs, 365 days a year
S.N Item
Drugs
1 Adrenalin
2 Atropine
3 Dopamine
4 Ventolin puff
5 Hydrocortisone
6. Anti-histamine
7 Diazepam
8 Analgesics
9 IV fluids
10 40% glucose
11 Regular insulin
Supplies
1 Oral airway different size
2 O2 administration nasal cannula
3 O2 administration face mask different size
4 Ambu bag diff. size with 3 diff. size masks
5 O2 concentrator and o2 full cylinder
6 IV cannula
7 Glucometer with adequate sticks
8 Pulseoximetre
9 Suction machine functional with suction tubes
10 Dressing and suturing materials

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