DHA Standards For Day Surgical Centres

STANDARDS FOR DAY
SURGERY CENTERS
Health Policies and Standards Department
Health Regulation Sector (2019)

INTRODUCTION
Health Regulation Sector (HRS) is an integral part of Dubai Health Authority (DHA) and has been
established to regulate, license and monitor health facilities and healthcare professionals in the Emirate
of Dubai. The Standard was developed to improve the quality and safety of Day Surgical Centre
Services (DSCS) under DHA jurisdiction. The Standard for Day Surgical Centre aims to fulfil the
following overarching DHA Strategic objectives set out in the Dubai Health Strategy (2016–2021).
Objective #1: Position Dubai as a global medical destination by introducing a value-based,
comprehensive, integrated and high-quality service delivery system.
Objective #2: Direct resources to ensure happy, healthy and safe environment for Dubai population.
Objective #3: Promote public and private collaboration in healthcare.
Objective #4: Foster innovation across the continuum of care.
ACKNOWLEDGMENT
The Health Policy and Standards Department (HPSD) developed this document in collaboration with
Subject Matter Experts. HPSD would like to acknowledge and thank the subject matter experts for
their contribution and dedication toward improving the quality and safety of healthcare services.
Health Regulation Sector
Dubai Health Authority
Standards for Day Surgery Centres Page 2 of 103 Ref. No. HRS/HPSD/DSC/2/2019
TABLE OF CONTENTS
INTRODUCTION ............................................................................................................................ 1
ACKNOWLEDGMENT .................................................................................................................... 2
EXECUTIVE SUMMARY ................................................................................................................. 5
DEFINITIONS ................................................................................................................................. 6
ABBREVIATIONS ......................................................................................................................... 12
1. BACKGROUND ..................................................................................................................... 14
2. PURPOSE.............................................................................................................................. 15
3. SCOPE .................................................................................................................................. 15
4. APPLICABILITY .................................................................................................................... 15
5. STANDARD ONE: REGISTRATION AND LICENSURE PROCEDURES ................................... 15
6. STANDARD TWO: HEALTH FACILITY REQUIREMENTS ..................................................... 18
7. STANDARD THREE: STAFFING AND HUMAN RESOURCE REQUIREMENTS ...................... 22
8. STANDARD FOUR: PRE-OP ASSESSMENT, PATIENT CARE AND ANESTHESIA ................ 26
9. STANDARD FIVE: PATIENT SAFETY ................................................................................... 31
10. STANDARD SIX: PATIENT MONITORING AND DISCHARGE ............................................... 33
11. STANDARD SEVEN: MEDICATION MANAGEMENT AND PHARMACY .............................. 36
12. STANDARD EIGHT: CRITICAL CARE SERVICES AND EMERGENCY MANAGEMENT........... 39
13. STANDARD NINE: SUPPORT SERVICES .............................................................................. 44
14. STANDARD TEN: MEDICAL RECORD AND HEALTH INFORMATION MANAGEMENT ....... 46
15. STANDARD ELEVEN: ADMINISTRATIVE REPORTING ........................................................ 48
16. STANDARD TWELVE: FACILITY MANAGEMENT ................................................................ 50
17. STANDARD THIRTEEN: INFECTION PREVENTION AND CONTROL ................................... 58
18. STANDARD FOURTEEN: PATIENT RIGHTS AND RESPONSIBILITIES ................................. 63
REFERENCES................................................................................................................................ 65
APPENDICES ................................................................................................................................ 70
APPENDIX 1: DSC CLASSIFICATION (ANESTHESIA, SEDATION AND PATIENT SAFETY) ......... 70
APPENDIX 2: DSC CLASSIFICATION AND PERMITTED MEDICATIONS ...................................... 73
APPENDIX 3: LIST OF PERMITTED PROCEDURES BY DAY SURGICAL CENTRE CLASSIFICATION77
APPENDIX 4: DAY SURGICAL CENTRE CARE PATHWAY............................................................ 84
APPENDIX 5: MINIMUM REQUIREMENTS FOR INFORMED CONSENT FORM............................ 85
APPENDIX 6: SURGICAL SAFTEY CHECKLIST ............................................................................. 88
APPENDIX 7: CONSCIOUS SEDATION COMPETENCY ................................................................ 89
AND DUTIES TRAINING OF PERSONNEL AND GENERAL CONSIDERATIONS ............................ 89
APPENDIX 8: MODERATE SEDATION/ANALGESIA .................................................................... 91
APPENDIX 9: ALDRETH’S SCORING SYSTEM FOR RECOVERY & DISCHARGE FROM THE ........ 97
RECOVERY ROOM ........................................................................................................................ 97
APPENDIX 10: CRITERIA FOR HOME–READINESS ..................................................................... 98
APPENDIX 11: MINIMUM EMERGENCY MEDICATION (CLASS A, B and CM) ........................... 100
APPENDIX 12: MINIMUM EMERGENCY MEDICATION (CLASS C) ............................................ 101
APPENDIX 13: HEALTHCARE PROFESSIONAL VACCINATION AND ........................................ 103
IMMUNISATION REQUIREMENTS ............................................................................................. 103
EXECUTIVE SUMMARY
The purpose of this document is to assure provision of the highest levels of safety and quality Day
Surgical Centres Services (DSCS) at all times. The standards have been developed to align with the
evolving healthcare needs and international best practice. The standards include various aspects
required to provide effective, efficient, safe and high quality Day Surgical Services. It includes the health
facility and healthcare professional requirements, staffing requirements, permitted sedation levels,
permitted patient acuity, emergency management and transfer of patients, sedation and procedure
requirements. Various aspects of patient care and safety including set up, pre-assessment, diagnostics,
informed consent, equipment use and maintenance, medication management, records management,
infection control, quality control, reporting of key performance data and patient rights and
responsibilities are also included.
A Day Surgical Standalone Centre is a freestanding surgical centre that provides low complexity
surgical and diagnostic procedures and services for healthy patients or patients with mild diseases only
without substantive functional limitations who do not require hospitalization or overnight stay beyond
midnight (12.00 a.m.). A Day Surgical Standalone Centre may include several surgical units to
accommodate different procedures by the respective surgical team. Day Surgical Centres are
Consultant or Specialist Led services supported by a surgical team who are trained, competent,
experienced and privileged by the Medical Director to perform specified surgical procedures within the
confinements of permitted licensure, specialisation (and procedure), patient acuity and sedation levels.
DEFINITIONS
Adverse Event: is an unanticipated, unintended, undesirable or potentially dangerous
occurrence/injury in a Healthcare organization.
Analgesia: means the reduction or elimination of pain. It is usually induced by drugs that act locally (by
interfering with nerve conduction) or generally (by depressing pain perception in the central nervous
system.
Consultant/Specialist Led Service: is a service where a consultant or specialist physician or dentist
retains overall clinical responsibility for the service, care professional team or treatment. The
consultant or specialist is not necessarily be physically present for each healthcare activity but takes
clinical responsibility for the overall patient care and is the lead for the surgical procedure.
Cooling off period: is the point from when a patient has a pre-op assessment to the point of surgery.
Day Surgery Centre: is an independent Health Facility, which provides Day Surgical Services and is not
located within or adjoining a hospital. It has an operating theatre and provides low complexity surgical
and diagnostic procedures and services for healthy patients or patients with mild diseases only without
substantive functional limitations who do not require hospitalization or overnight stay beyond midnight
(12am). A Day Surgical Centre may include several surgical units to accommodate different procedures
by the respective surgical teams. Day Surgical Centres are Consultant or Specialist led services
supported by a surgical team who are trained, competent, experienced and privileged by the Medical
Director to perform specified surgical procedures within the confinements of the permitted licensure,
specialisation, patient acuity and sedation levels.
Dissociative Drugs: is an alter perception of pain and sight and elicit feelings of
detachment/dissociation from the environment and self.
Healthcare professional: shall mean a natural person who is authorized and licensed by the Dubai
Health Authority (DHA), to practice any of healthcare professions as per the unified prequalification’s
requirements for the United Arab Emirates.
Informed Consent: refers to an agreement and permission accompanied by full information on the
nature, risks and alternatives of a surgical or interventional procedure. Informed consent for surgical
procedures under anesthesia is a two-step process i.e. consent at the point of pre-op assessment and
consent on the day of the procedure. At both points, consent is taken in a written form.
Never Events: are defined as Serious Incidents/Preventable Adverse Events that are wholly
preventable because guidance or safety recommendations that provide strong systemic protective
barriers are available at Dubai or Federal level have not been implemented by the healthcare provider.
Operating Room (OR): is defined as a room in the surgical suite that meets the requirements of a
restricted area and is designated and equipped for performing surgical operations or other invasive
procedures that require an aseptic field. Different form of anesthesia may be administered in an OR as
long as appropriate anesthesia gas administration devices and exhaust systems are provided. A hybrid
operating room is an operating room that has permanently installed equipment to enable diagnostic
imaging before, during, and after surgical procedures (use of portable imaging technology does not
make an OR a hybrid operating room).
Patient: is any individual who receives medical attention, care, treatment or therapy by a DHA licensed
healthcare professional in a DHA licensed health facility.
Procedures: are surgical interventions, which require Informed Consent from the patients or next of
kin/ legal guardian, as per UAE Federal Laws.
Procedure Room: is a room for the performance of medical procedures that do not require an aseptic
field but may require use of sterile instruments or supplies. Procedure rooms are considered
unrestricted areas. Local anesthesia and minimal and moderate sedation may be administered in a
procedure room, but anesthetic agents used in procedure rooms do not require special ventilation or
scavenging equipment.
Recovery Area: means a room/area dedicated to providing medical services to patients recovering
from Surgery or Sedation/Anesthesia.
Restricted Area: is a surgical suite is a designated space that can only be accessed through a semi-
restricted area in order to achieve a high level of asepsis control. Traffic in the restricted area is limited
to authorized personnel and patients, and personnel are required to wear surgical attire and cover head
and facial hair. Masks are required where open sterile supplies or scrubbed persons may be located.
Risk Management: is defined as ’a logical and systematic method of establishing the context,
identifying, analysing, evaluating, treating, monitoring and communicating risks associated with any
activity, function or process in a way that enables the organization to minimize losses and maximize
opportunities.
Safety: means the condition of being protected against physical, psychological, or other types or
consequences of failure, error, or harm, which could be considered non-desirable. This can take the
form of being protected from the event or from exposure to something that causes health losses, for
example, the use of a drug, or a procedure, or risk in the care environment.
Sedation: The administration of a sedative agent or drug to induce a state of calm, restfulness, or
drowsiness. The sedative agent or drug depresses activity of the central nervous system, reduces
anxiety, and induces sleep. There are four levels of sedation however, given that sedation is a
continuum, it is not always possible to predict how an individual patient will respond and the patient
may progress to a level of sedation that is beyond the scope of practice of staff without specific
anaesthesia training:
a. Minimal Sedation (Anxiolysis) is a drug-induced state to reduce patient anxiety during in which
the patient responds normally to verbal commands (technically awake). In this stage, the following
shall be present:
 Normal respirations
 Normal eye movements
 Intact protective reflexes
 Amnesia may or may not be present
Refer to CLASS A CENTRE (Appendix 1).
b. Moderate Sedation/Analgesia (Conscious Sedation) is a drug-induced depression of
consciousness during which the patient tolerates unpleasant therapeutic or diagnostic procedure,
responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation
while maintaining cardio-respiratory function. This commonly involves intravenous administration
of drugs with anxiolytic, hypnotic, analgesic, and amnesic properties either alone or as a supplement
to a local or regional anesthetic. Moderate sedation is a medically controlled state of drug induced
depressed consciousness that:
 Allows protective reflexes to be maintained
 Retains the patient's ability to maintain a patent airway independently and continuously;
 Permits appropriate response by the patient to physical stimulation or verbal command, for
example, "open your eyes."
 The drugs, doses, and techniques used are not intended to produce a loss of consciousness.
Refer to CLASS B CENTRE (Appendix 1).
c. Deep Sedation/Analgesia is a drug-induced depression of consciousness or unconsciousness
during which patients cannot be easily aroused and respond purposefully following repeated or
painful stimulation or verbal command. The ability to independently maintain ventilatory function
may be impaired thus; patients may require assistance in maintaining a patent airway and
spontaneous ventilation. Cardiovascular function is usually maintained.
Refer to CLASS CM CENTRE (Appendix 1).
d. General Anesthesia is a controlled state of drug-induced unconsciousness state accompanied by a
loss of protective reflexes, including loss of the ability to maintain a patent airway independently
or to respond purposefully to physical stimulation or verbal command. Cardiovascular function may
be impaired and positive pressure ventilation may be required because of depressed spontaneous
ventilation or drug-induced depression of neuromuscular function.
Refer to CLASS C CENTRE (Appendix 1).
Semi-restricted Area: comprises the peripheral support areas surrounding the restricted area of a
surgical suite. These support areas include facilities such as storage areas for clean and sterile supplies,
sterile processing rooms, work areas for storage and processing of instruments, scrub sink areas,
corridors leading to the restricted area, and pump rooms.
Sentinel Event: is defined as an unanticipated occurrence involving death or major permanent loss of
function unrelated to the nature course of the patient illness or underlying condition.
Spinal Anesthesia: is a single injection with a thin needle that puts the local anesthetic close to the
nerves, within the Cerebrospinal Fluid (CSF) that surrounds the spinal cord.
Topical Anesthesia: means the application of an anesthetic agent directly or by spray to the skin or
mucous membranes, intended to produce a transient and reversible loss of sensation to a circumscribed
area.
ABBREVIATIONS
ACLS : Advanced Cardiac Life Support
ALS : Advanced Life Support
ARD : Antibiotic Removal Device
ART : Assisted Reproductive Techniques
ASA : American Society of Anaesthesiologists
BLS : Basic Life Support
BMI : Body Mass Index
CAD : Coronary Artery Disease
CDC : Centre for Disease Control and Prevention
CHF : Congestive Heart Failure
COPD : Chronic Obstructive Pulmonary Disease
DAMA : Discharge Against Medical Advice
DHA : Dubai Health Authority
DIC : Disseminated Intravascular Coagulation
DM : Diabetes Mellitus
DSC : Day Surgical Centre
DSS : Day Surgical Services
DVT : Deep Vein Thromboembolism
ESRD : End Stage Renal Disease
GIFT : Gamete Intra-fallopian Transfer
HFG : Health Facility Design Guidelines
HRS : Health Regulation Sector
HT : Hypertension
ICSI : Intracytoplasmic Sperm Injection
IPU : Inpatient Unit
IUCD : Intrauterine Contraceptive Device
IUI : Intra Uterine Insemination
IV : Intravenous
IVF : In vitro Fertilization
MI : Myocardial Infarction
MOHAP : Ministry of Health and Prevention
MSDS : Material Safety Data Sheets (MSDS)
PALS : Pediatrics Advanced Life Support
PCA : Post Conceptional Age
PPE : Personal Protective Equipment
RN : Registered Nurse
TIA : Transient Ischemic Attack
VTE : Venous Thromboembolism
ZIFT : Zygote Intra-fallopian Transfer
1. BACKGROUND
Developments in medical technology have resulted in a rise in the use of ambulatory surgery. The use
of fast- and short-acting anesthetics, analgesics, and muscle relaxants, and improved monitoring
techniques, have reduced anesthetic complications during recovery. Additionally, improvements in
surgical techniques have enabled physicians to provide more invasive and complex medical procedures
in an ambulatory care setting specifically Day Surgical Centres (DSC). A DSC is where admission,
preparation and simple to moderate operative or endoscopic procedures are performed; within the
same day and recovery/discharge is completed with patients who do not require hospitalization or
overnight stay beyond 12.00 a.m. DSC is a Unit with one or more Operating Rooms (or Procedure
Rooms) with the provision to deliver anaesthesia and accommodation for the immediate post-
operative recovery of patients. The international expansion of day surgery units over the past decade
has led to several publications highlighting the benefits of day surgery in respect to cost, safety,
organisation, and easy access to a range of surgical procedures. The benefits also extend to shortened
hospital stays and earlier mobolisation also reduce the risk of hospital-acquired infections and Venous
Thromboembolism (VTE). It is estimated that each surgical case performed in a Day Surgery setting
saves between 1 and 3 bed-days as Inpatient Unit (IPU) beds will not be occupied by the patient. These
savings preserve valuable IPU beds for major inpatient surgery. There are various models of care for
Day Surgical Centres which are dependant on service planning and patient flow.
For successful and safe ambulatory surgery and anesthesia, the surgeon and anaesthetistshould
consider various factors such as, appropriate patient selection, pre-operative assessment (including
the patients past history and family history), surgical and anesthetic methods and postoperative
management to reduce postoperative complications, postoperative pain. A multi-modal and
prophylactic approach to prevent postoperative complications should be considered in order to allow
early and safe discharge and return to activities of daily living. Finally, it is important to maintain
ongoing communication and cooperation between the patient and their carer, allied health
professionals, physician and anaesthetist.
2. PURPOSE
2.1. To assure provision of the highest levels of safety and quality within DHA Licensed Stand-Alone
Day Surgical Centres.
3. SCOPE
3.1. Stand-Alone Day Surgical Centres licensed by DHA.
4. APPLICABILITY
4.1. DHA licensed Healthcare Professionals and Health Facilities operating as Stand-Alone Day
Surgical Centre (DSC).
5. STANDARD ONE: REGISTRATION AND LICENSURE PROCEDURES
5.1. All health facilities providing Day Surgical Services (DSS) shall adhere to Federal and Local Laws
and Regulations.
5.2. A health facility seeking to provide Day Surgical Services shall comply with the DHA registration,
licensure and administrative procedures available on the DHA website: https://www.dha.gov.ae
5.3. A licensed DSC opting to provide DSS shall apply to the Health Regulation Sector (HRS) to
obtain permission to provide the required service(s).
5.4. All Day Surgical Centres (DSC) are mandated to be accredited in accordance to the required
timeframe set out by DHA Circular (18 months).
5.4.1. Accreditation shall include the following International Society for Quality in
Healthcare (ISQua) entities such as:
a. Accreditation Canada International (ACI).
b. American Association for Accreditation of Ambulatory Surgery Facilities
(AAAASF).
c. Australian Council of Healthcare Standards International (ACHSI).
d. Joint Commission International (JCI) Ambulatory Care.
5.5. The DSC shall have in place internal policies and procedures including but not limited to:
5.5.1. Service Description and Scope of Services.
5.5.2. Patient acceptance/referral criteria.
5.5.3. Lab and diagnostic services and turn-around timeframes for reporting non-critical and
critical results.
5.5.4. Patient assessment and admission criteria.
5.5.5. Patient education, communication and informed consent.
5.5.6. Staffing plan, staff management and clinical and privileging.
5.5.7. Patient health record, confidentiality and privacy.
5.5.8. Infection control measures and hazardous waste management.
5.5.9. Incident reporting.
5.5.10. Falls management.
5.5.11. Medication management and pharmacy services.
5.5.12. Reprocessing of reusable equipment, safe use of chemicals used for cleaning and
disinfecting and infection control.
5.5.13. Medical and hazard waste management as per Dubai Municipality (DM) requirements.
a. There should be an allocated medical waste storage and collection area that is well
ventilated and secured from public and patient access.
b. The medical waste storage and collection area shall be adequately labelled with a
hazard sign to prevent any unexpected entry from patients or the public.
5.5.14. Monitoring Medical, Electrical and Mechanical equipment, visual inspections for
apparent defects and maintenance by competent entity with valid testing certificates.
5.5.15. Laundry and housekeeping services.
5.5.16. Patient belongings.
5.5.17. Clinical Audit.
5.5.18. Pharmacy Services.
5.5.19. Quality, Performance Management and Learning System.
5.5.20. Violence against Staff/Zero Tolerance.
5.6. The health facility should ensure it has in place adequate lighting and utilities, including
temperature controls, water taps, medical gases, sinks and drains, lighting, electrical outlets and
communications.
5.7. The health facility shall maintain documented evidence of treatment protocols and care pathway
for surgical procedures to include, but not be limited to the following:
5.7.1. Referral criteria.
5.7.2. Consultation.
5.7.3. Clinical laboratory services and diagnostics.
5.7.4. Pre-op assessment and patient acuity classification.
5.7.5. Staffing requirements.
5.7.6. Informed Consent.
5.7.7. Surgical Safety Checklist for Surgical Procedures.
5.7.8. Patient Monitoring, Recovery and Discharge.
5.7.9. Emergency procedures and transfer of critical/complicated cases when required.
5.7.10. Patient discharge and follow up.
5.7.11. Patient complaints.
6. STANDARD TWO: HEALTH FACILITY REQUIREMENTS
6.1. Day Surgical Centres shall be granted a license based on the Health Facility Classification and
their permitted Anesthesia and Sedation Levels (Appendix 1-2).
6.2. Day Surgical Centre Shall Only provide Surgical and Diagnostic procedures for ASA PS
Classification I and II Patients (Appendix 1-3).
6.3. If the surgical procedure requires higher-level sedation, which does not align with the existing
day surgical category, then the provider is not allowed to perform the procedure.
6.3.1. Surgical procedures are limited to those where there is only a small risk of surgical and
anaesthetic complications and hospitalization.
6.3.2. The surgical setup shall be capable of providing the required level of
sedation/anaesthesia and emergency response.
6.3.3. The following exclusions must be considered during patient consultations and pre-op
assessments:
a. Emergency/unprepared patients.
b. Inpatients.
c. Uncooperative patients.
d. Patients with history of sleep apnoea.
e. Patients with history of drug or alcohol abuse.
f. Patients with airway difficulties.
g. Patients with severe allergies.
h. Patients with at risk of blood loss, excessive bleeding and may require blood
transfusion.
i. Patients that require cardiac catheterization or Interventional Cardiology
j. Patients with metabolic disorders (PSA 3 and above).
k. High-risk patients (ASA III-VI) in accordance to the American Society of
Anaesthesiologist (ASA) Classifications.
6.4. Day Surgical Services shall be Consultant or Specialist Led services.
6.5. The Health Facility shall comply with DHA Health Facility Design Guidelines (HFG) and staffing
requirements for DSC.
6.6. The Health Facility shall ensure access to non-treatment and treatment areas are safe for all
patient groups.
6.6.1. A comfortable treatment environment should be provided in the health facility and
assure patient privacy and confidentiality.
6.7. HRS must be informed and approve changes to existing or new services or staffing levels.
6.8. The health facility shall install and operate equipment required for provision of proposed services
in accordance to the manufacturer’s specifications.
6.9. The health facility shall always have in place appropriate equipment and trained healthcare
professionals to perform necessary diagnostics, patient assessments, surgery, resuscitation,
stabilisation and transfer of critical and emergency cases to a nearby Hospital.
6.9.1. Class CM and C Day Surgical Centres will have sufficient medical equipment
(ventilator, portable ventilator, EMS call system, pulse oximeter, anesthesia machine
with vital sign monitor (ECG), and hemodynamic monitoring equipment) with annual
certification of equipment by qualified maintenance company.
a. A back up anesthesia machine is only required for Class C Day Surgical Centres.
6.9.2. DSC shall ensure safe and appropriate practice system for sample collection, storage
and transportation of blood and other samples.
6.9.3. Assure medical equipment and devices are in place for emergency scenarios.
6.9.4. All DSC shall have access to diagnostics and laboratory services as per patient needs
to include urinalysis, complete blood count, bio-chemistry and necessary emergency
laboratory tests as determined by the medical team.
a. Class A and B DSC categories may outsource laboratory and diagnostics services.
Laboratory Services
i. Arterial Blood Gas (ABG)
ii. Point of Care Testing (glucose, Prothrombin time/International normalized
ratio (PT/INR), Dipstick urinalysis and hCG.
iii. Remaining lab services as per patient need may be contracted with an external
lab provider.
b. CM and C DSC categories must provide basic onsite radiology services and lab
services.
i. Radiology (or portable x-ray) to provide plain x-rays and chest x-rays.
 Physicians and Nurses shall have training to provide plain x-ray and chest x-
rays.
ii. Remaining radiology services as per patient need may be contracted with an
external radiology provider.
6.9.5. All laboratory equipment shall be calibrated and maintained as per DHA Policy for
Clinical Laboratory.
6.9.6. All DSC must have in place a written agreement for patient referral and emergency
transfer to a nearby Hospital setting. The transfer agreement shall detail the transfer
plan/protocol of patients and meet Dubai transfer timeframes for emergency
patients.
a. The Health Facility shall put in place an annual simulation scenarios with all
members of the surgical teams to manage patient recovery and transfer.
b. Simulation outcome and improvement plans shall be documented.
6.9.7. All DSC shall have in place a Business Continuity Plan to ensure the core functions of
the centre are met.
7. STANDARD THREE: STAFFING AND HUMAN RESOURCE REQUIREMENTS
Staffing requirements to provide day surgical and diagnostic services shall be based on what is required
to create a safe environment for the patient and to ensure the safe performance of services by
healthcare professionals. Both patient and procedural factors shall be considered in determining
staffing requirements.
7.1. To provide DSC procedures and diagnostic services, all healthcare professionals in the health
facility shall hold an active DHA professional license and work within their scope of practice and
granted privileges.
7.2. All physicians must have an up to date medical malpractice insurance.
7.3. The Privileging Committee and/or Medical Director of the DSC shall take responsibility to
privilege staff as per the DHA Policy for Clinical Privileging Policy.
7.4. For Endoscopic Standards refer to the DHA Standards for Endoscopy Services and Appendix 3.
7.5. Appropriate and sufficient number of healthcare professionals are always required to be on duty
to diagnose, plan, supervise and evaluate patient care. The number of licensed healthcare
professionals assigned to each health service in the DSC shall be determined by DSC
management and be consistent with DSC services, bed capacity and type of care provided. DSC
will adhere to the following:
7.5.1. At least one full time licensed specialist or consultant surgeon present in the Day
Surgical Centre.
a. The specialist or consultant surgeon is responsible to ensure the availability of
surgical team before and during the procedure.
b. The surgeon and anaesthesiologist must be present until patient discharge or
transfer to hospital setting.
7.5.2. There must be at least one full time Anaesthetist present in DSC Class CM and C Day
Surgical Centre to attend each surgical procedure.
7.5.3. There must be at least one full time licensed physician with role of the Medical
Director.
7.5.4. Minimum nursing requirements should consider the following:
a. The reception area(s).
b. The number of operating theatres and recovery rooms.
c. Nature of surgery and number of surgical or endoscopic procedures performed per
day and shifts.
d. Allowances for annual and sick leave, public holidays etc.
e. The DSC shall have sufficient number of staff as per the health facility licensure
requirements set out DHA Health Facility Licensing Policy. Additional staff must
be in place as per specialisation, service descriptions, scope and patient volume.
f. Adequate Registered Nurses (RNs), Assistant Nurses (ANs) and/or Operation
Theatre Technicians should be present to assist with the technical aspects of the
surgical or endoscopic procedures.
g. For DSC that provide full Laboratory Services, one full time or part time DHA
licensed pathologist shall be available to supervise and manage the clinical
laboratory services in the DSC and laboratory technicians.
i. At least one laboratory technician shall be available in each shift and shall only
be responsible for basic laboratory services.
h. For DSC that provide full Radiology Services, one full time or part time
specialist/consultant radiologist shall be available to supervise and manage the
radiology services in the DSC.
ii. At least one radiography technician shall be available in each shift and shall only
be responsible for basic radiography services.
i. The health facility shall employ a biomedical engineer or maintain a service
contract with a certified maintenance company to ensure safety, reliability, validity
and efficiency of medical devices and mechanical equipment.
j. DSC Class C should employ a pharmacist as per the scope of pharmacy services. In
the absence of a pharmacist, the anaesthetists shall be responsible for managing
anesthesia, narcotic and controlled medications, emergency medicine, any other
medication and record keeping in the DSC.
i. DHA licensing department must be informed where staffing levels fall below or
exceed the requirements for licensure or services provision.
ii. In charge, approvals for pharmacy must be obtained from DHA Drug Control
Section.
7.6. Staffing levels, required competencies, medical equipment, sedation and surgical environment
should never be compromised. If either of these factors come into play:
7.6.1. Patients should be offered an alternative surgical date or referred to another health
facility.
7.7. Human resources management shall ensure patient safety, healthcare quality, competent
workforce and satisfy the working environment for employees. Human resources management
includes:
7.7.1. Planning and Recruitment.
7.7.2. Continuing performance development.
7.7.3. Employee support systems.
7.7.4. Effective workplace relations.
7.8. Human resource practices should be supported by policies and procedures with supporting
systems to influence employee's behaviours, attitudes and performance for efficient, safe and
high-quality care.
7.9. The recruitment selection and appointment system shall ensure the skill mix and competence of
staff meet the DSC needs.
7.9.1. The DSC is responsible to put in place a written staffing plan to address high patient
volumes, staff sickness or staff resignations.
7.10. The DSC shall maintain accurate and complete personnel records for all employees, including
training records, such records shall be maintained and kept confidential.
7.11. A written policy on staff training along with the type and frequency of core competency
assessment should be documented and monitored on an annual basis.
7.12. A development system shall be in place to ensure the core skills and competencies of staff are
always met
7.12.1. Continuing Professional Development (CPD) activities and evidence of hands on
learning shall be documented.
7.13. A structured and uniform system shall be maintained to assure adequate staffing levels, staff
orientation, staff training needs, professional retention and staff performance evaluation.
8. STANDARD FOUR: PRE-OP ASSESSMENT, PATIENT CARE AND ANESTHESIA
8.1. All Day Surgical Centres must have in place a written Surgical Care Pathway (Appendix 4).
8.2. All patients who have been referred for surgery must have had a physician consultation with
appropriate lab and diagnostics testing and a follow up appointment with the physician to
discuss surgical and non-surgical options.
8.3. A comprehensive pre-op patient assessment process and testing shall be achieved with the
support of a multi-disciplinary team (as applicable) and be based on the clinical and priority
needs of each individual patient.
8.3.1. For DSC Class B, CM and C, pre-op assessment should include CBC, Blood Pressure,
Blood Glucose, Coagulation Profile, BMI and rule out the exclusions (see section
6.2.3.).
a. Pre-op assessments shall be conducted on the same site of DSC surgery.
b. The patient shall sign an initial consent at pre-assessment point to proceed for
elective surgery.
c. Patients or their next of kin/legal guardian shall be given written
information/instructions on the surgery and surgical preparation and copy of the
first signed informed consent form.
d. Patients shall be given sufficient time to make an informed decision prior to the
surgical procedure (cooling off period).
8.3.2. The timeframe from pre-op assessment to surgery shall be conducted within 4- weeks.
Patients exceeding the 4-week window should be re-assessed.
8.4. On the day of surgery, the patient must sign the second informed consent form that elaborates
risks, benefits and alternatives prior to commencement of the procedure. The physician shall be
available to answer any further questions in a non-technical way. The minimum requirements
for informed consent are set out in Appendix 5.
8.4.1. The second informed consent form shall be signed prior to surgery and a copy must
be issued to the patient or their next of kin/legal guardian.
8.5. Before commencing the procedure, the patient, staff physician performing the procedure should
verify the correct patient and procedure to be performed and identify any potential risks
following pre-op assessment.
8.5.1. A Physician, Anaesthetists and RN must be document, complete and verify the
Surgical Safety Checklist (Appendix 6).
8.5.2. All surgeries under Day Surgical Centre category B, CM and C must always be overseen
by a DHA licensed surgeon, anaesthetist and nurse.
8.5.3. The surgical team shall be competent to stabilize critically ill patients and transfer
them to a higher level of care if the health facility is unable to manage the patient
onsite.
8.6. Minimally invasive procedures shall follow Procedural Sedation and Analgesia (PSA), which is a
continuum of depressed level of state of consciousness ranging from minimal sedation to general
anesthesia.
8.7. The DHA Licensed anaesthetist shall be certified, trained and competent in:
8.7.1. Understanding the continuum of sedation and apply methods and levels of sedation,
conscious sedation and associated risks of moderate/deeper sedation training and
required competencies (Appendix 7-8).
8.7.2. Being able to conduct a physical assessment to assess the fitness and appropriateness
of the patient for PSA.
8.7.3. Reviewing the patient’s condition and vital signs prior, during and after a procedure
and during recovery to assess any change in the condition of the patient that may
affect the administration or management of PSA until discharge from recovery area.
a. Vital signs include level of consciousness, ventilatory and oxygenation status,
hemodynamic variables, temperature, pain and anxiety levels.
8.7.4. Recognising the important principle of minimum intervention, where the simplest and
safest technique, which is likely to be effective, is used to achieve the clinical goal.
8.7.5. Being able to maintain effective communication and clear explanation at every stage
of patient management to reassure the patient.
8.7.6. Understanding that loss of verbal responsiveness/deep sedation requires the same
level of skills and care as for general anaesthesia.
8.7.7. Understanding the fundamentals, actions and interactions of the sedative and
analgesic and multiple drugs being administered, their synergistic effects; how to use
reversal agents; and necessary adjustments to accommodate different patient needs.
8.7.8. Putting in place a pain signalling and stimulus system prior to the initiation of sedation
and understand the timeframe for the sedation effect to take place.
8.7.9. Titrating to patient needs in a small, incremental doses and be able to identify the sum
of the incremental doses has reached the maximum dose.
8.7.10. Providing simple and advanced sedation and be competent to manage failed sedation.
8.7.11. Determine stock levels and reversible agents required for managing sedation- related
side effects in a timely manner.
8.7.12. Ensuring patient safety is always paramount taking into account the number of
procedures conducted in a single sitting, duration of surgery, patient manipulation and
anticipated complications.
8.7.13. Safely delivering pharmacological sedation to appropriate patients and recognise the
limits of their competency and experience.
8.7.14. Discharging the patient, including but is not limited to the following checks:
a. The patient returned to their baseline level of consciousness.
b. Vital signs are stable and within acceptable limits.
c. Sufficient time has elapsed following administration of reversal agents (if
applicable) to ensure that patients does not become re-sedated.
d. All assessments for recovery, discharge and home release have been met and
completed (Appendix 9-10).
e. There is a responsible adult to accompany the patient home.
8.7.15. Being able to discuss where and when deeper levels of sedation or anaesthesia may be
indicated.
8.7.16. Detecting and rescuing patients from sedation-related adverse responses including
anaphylaxis and cardiorespiratory failure.
8.7.17. Declaring an emergency and directing the surgical team on emergency procedures and
protocol and where necessary lead on the emergency patient transfer.
9. STANDARD FIVE: PATIENT SAFETY
9.1. There is an array of Patient Safety considerations that are paramount and shall be considered
and documented in the patient record.
9.1.1. Patient identity (including history and family history).
9.1.2. Evidence of consultation, physical examinations and confirmatory lab or diagnostics
(patient selection).
9.1.3. Procedure to be undertaken and location with clear markings.
9.1.4. No emerging issues since the last pre-op assessment.
9.1.5. Informed Consent for the procedure.
9.1.6. Verification of Nothing by Mouth Status.
9.1.7. Mitigating circumstances/exclusions not to perform the surgery (6.2.3. and Appendix
3).
9.1.8. Adequate staff levels for the procedure.
9.1.9. Emergency training and preparedness of staff.
9.1.10. Up to date medical records.
9.1.11. Pre-anesthesia assessment and patient acuity (Class I or II).
9.1.12. Sedation/anesthesia and recovery plan.
9.1.13. Confirmation of functioning equipment and back-up plan.
9.1.14. Document adherence to the Surgical Safety Checklist (Appendix 6) for all surgeries.
9.1.15. A list of look-alike, sound-alike medication.
9.1.16. Medical devices are fully functional.
9.1.17. Control of concentrated electrolyte solutions.
9.1.18. Assuring medication accuracy and safe dosing.
9.1.19. Avoiding catheter and tubing misconnections.
9.1.20. Prophylaxis.
9.1.21. Infection control.
9.1.22. Single use of injection devices and insert of IV line.
9.1.23. Fully stocked crash cart and emergency medications and per DSC Classification
(Appendix 11-12)
a. A crash cart must always be available in the operating theatre, recovery, and
critical care area.
9.1.24. Stopping the procedure in the event the patient condition deteriorates.
9.1.25. Patient recovery plan.
9.1.26. Falls management.
9.1.27. International Patient Safety Goals.
9.1.28. Communication of staff and during patient hand-over.
9.1.29. Patient post-op instructions, discharge and follow up.
9.1.30. Patient transfer to referral or alternative health facility.
9.1.31. Restricted and semi- restricted areas.
9.1.32. Regular clinical audit and improvement plan.
9.2. The treating surgeon shall be available at the DSC facility until the patient is discharged safely.
9.3. Visiting surgeons must always ensure their patients are handed over to a competent physician(s)
to oversee patient follow up and patient care during their absence.
10. STANDARD SIX: PATIENT MONITORING AND DISCHARGE
10.1. All patient diagnostic or surgical procedures shall be constantly monitored in accordance to the
surgical procedure, patient safety and risk factors. Monitoring should be performed before the
procedure, after administration of sedatives, at regular intervals during the procedure, during
initial recovery and just before discharge.
10.2. Minor procedures performed under topical or local anesthesia, not involving drug-induced
alteration of consciousness other than minimal preoperative anti-anxiety medications (e.g. mole
removals or incision and drainage of superficial abscesses, etc.) can be performed by DHA
licensed physicians or dentist within their the scope of practice and privileges.
10.3. Procedures that require administration of light or moderate sedation/analgesia necessitate
intraoperative and post-operative monitoring commonly involving intravenous (IV)
administration of drugs with anxiolytic, hypnotic, analgesic, and amnesic properties either alone
or as a supplement to a local or regional anesthetic.
10.4. The surgical procedures in DSC are limited to those in which there is only a small risk of surgical
and anaesthetic complications, and hospitalization as result of these complications is unlikely
(Appendix 1-3).
10.5. When moderate sedation is targeted, the healthcare professional is assigned responsibility for
patient monitoring and may perform brief interruptible tasks. Monitoring includes electronic
assessment of blood pressure, respiratory rate, heart rate and pulse oximetry combined with
visual monitoring of the patient’s level of consciousness and discomfort.
10.6. Procedures that require, the use of deep sedation/analgesia, general anesthesia, or major
conduction blockade (e.g. liposuction) may be serious or life threatening (Appendix 1-3).
10.6.1. Major regional blocks include but are not limited to, spinal, epidural or caudal injection
of any drug, which has analgesic, anesthetic or sedative effects.
10.6.2. When deep sedation or general anesthesia is targeted, the healthcare professional
responsible for patient monitoring must be dedicated solely to that task and may not
perform any other function during the procedure.
10.7. The DSC shall put in place procedures to rescue patients who are sedated deeper than intended.
10.8. Documentation of the clinical assessments and monitoring data during sedation and recovery
and discharge is required to include:
10.8.1. Time, date, physician name, patient condition and action taken.
10.8.2. Food consumption appropriate for the patient and consistent with patient’s condition
and clinical care shall be provided.
10.8.3. Ability to pass urine following surgery.
10.8.4. Patient level on consciousness and ability to put on clothing without assistance.
10.9. The incidence of falls and fall injuries shall be minimized through a fall management program
and prevention strategies according to patient risk factors. A written policy shall be in place for
falls management. Patients shall be assessed for risk of falls:
10.9.1. Upon admission.
10.9.2. Once a change of health status has been identified.
10.9.3. After a fall.
10.9.4. Upon Discharge.
10.10. A discharge plan shall start from the point of patient admission and include various personnel,
information and resources. Considerations for discharge preparation shall include but not be
limited to:
10.10.1. Risk assessment and process for discharge.
10.10.2. Medication needed from pharmacy.
10.10.3. Physician written authorisation for discharge.
10.10.4. Documentation of the procedure for the patient and treating physician.
10.10.5. The pickup person and aftercare support within the first 24-hours.
10.10.6. No driving policy and travel distance to home.
10.10.7. Environmental conditions, such as stairs, access to toilet or bedroom.
10.10.8. The carer’s/authorized persons contact details and their awareness of possible issues
and requirements following discharge.
10.10.9. Contact numbers after discharge, such as the doctor or emergency contact.
a. Follow up phone call and follow up appointments.
10.10.10. Treating physician shall respect patients' choices if they decide to Discharge Against
Medical Advice (DAMA). DAMA patients must sign a form before leaving the facility
and be witnessed by the treating physician and a nurse.
11. STANDARD SEVEN: MEDICATION MANAGEMENT AND PHARMACY
11.1. Medications shall be managed to ensure safe and effective practice. The DSC shall maintain a
policy and procedures on medication management, medication storage and monitoring of
medication inventory and expiration dates consistent with applicable federal and local legislation
and regulations. Considerations for DSC include:
11.1.1. After admission to the DSC, only medication ordered or approved by the
surgeon/anaesthetist should be taken by the patient.
11.1.2. A written record for the dosages of drugs and the timing of their administration shall
be entered into a health record.
11.1.3. Special arrangements shall be in place for post-discharge medications with clear
written instructions, for example suitable analgesia should be provided for the
minimum required period after discharge.
11.2. DSC shall facilitate access to discharge medication where it is not provided by the facility.
11.3. DSC shall put in place a policy on proper storage and handling of anaesthesia agents and ensure
this abides by the Ministry of Health and Prevention (MOHAP) regulation on storage, handling
and records maintaining of narcotic and controlled medications.
11.3.1. A daily medication log shall be maintained.
11.3.2. All narcotic and controlled medication must be stored and kept in a safe and secure
place with a double locked or a lock with the provision of a code locking mechanism as
per Federal and local regulations.
11.3.3. Disposal of controlled drugs shall be locked in a cabinet, restricted to specified staff
and be compliant with federal laws and local regulations.
a. Up to date and accurate records must be kept on the receipt and disposition of all
controlled substances.
11.3.4. A log of narcotics and controlled medication and wasted vials used must be
documented and maintained.
11.4. A qualified and licensed healthcare professional (physician/pharmacist/RN) shall oversee
medication usage.
11.5. Medication shall be securely stored under environmental conditions consistent with the
manufacturer’s specifications.
11.5.1. DSC shall put in place a policy to promote safe and secure storage and use high
concentrated electrolytes and high alert medications.
a. Use pre-prepared bags for high concentrated electrolytes if available, or the
competent anaesthetist shall be responsible to prepare and dilute the required
medications.
11.5.2. The use of single-dose vials for all sedative and analgesic medications is strongly
recommended.
11.5.3. Healthcare professionals should have access to published guidelines for medication
Management.
11.6. Medication should only be given only under the order of the supervising physician.
11.7. A written policy shall be in place for the identification, documentation and review of adverse
drug reactions.
11.7.1. Reversal agents for opioids and benzodiazepines shall be readily available as per the
DSC facility classification.
11.8. Pharmacy services shall be provided in the DSC to meet the needs of patient directly or through
written agreement with an external pharmacy provider licensed by DHA. The experienced
Pharmacist shall:
11.8.1. Assure proper storage, control, handling, compounding and dispensing of drugs,
devices and biological materials shall be according to the applicable Ministry of Health
and Prevention (MOHAP) Laws and regulations.
11.8.2. Ensure provisions are made for storage and preparation of medications administered
to patients.
11.8.3. Ensure drugs, devices and biologicals must be stored in locked areas according to the
manufacturer’s instructions for temperature, light, humidity or other storage
instructions.
a. A specific refrigerator for pharmaceuticals storage and control shall be available.
11.8.4. Emergency drugs, devices and biologicals as determined by the healthcare
professional staff must be available for use at designated locations when an
emergency occurs.
11.8.5. The supply of drugs, devices and biologicals and controlled substances must be
protected and restricted for use for legally authorized purposes only.
11.8.6. The supply of drugs and devices must be checked on a regular basis to ensure expired,
mislabelled, unlabelled or unusable products are not available for patient use and are
disposed accordingly.
12. STANDARD EIGHT: CRITICAL CARE SERVICES AND EMERGENCY MANAGEMENT
Provision of critical care services and emergency management is paramount to ensuring early
detection and prevention of patient deterioration. DSC shall ensure:
12.1. Written policies and procedures must be established and implemented which define, describe
the scope of critical care services and ensure safe and competent delivery of the services to the
patients.
12.2. There is one competent Registered Nurse (RN) during surgery with suitable training and
experience in critical care on duty to provide the critical care services if required and evidence of
the competency and training shall include the following:
12.2.1. Recognizing arrhythmias.
12.2.2. Assisting physician in placing central lines or arterial lines.
12.2.3. Obtaining blood gases ABG’s.
12.2.4. Central Venous Pressure (CVP) line.
12.2.5. Infection control principles.
12.2.6. Glasgow Coma Scale (GSC).
12.2.7. Training in using defibrillator and care of patients on ventilators.
12.3. The DSC shall ensure periodic training and education for staff in the use of equipment for
emergency management. Training and assessment of competency shall be documented as per
the requirements of the training provider.
12.4. DSC Class B, CM and C must have a room for post-operative recovery of critical care patients
and emergency transfer. Critical care services equipment and supplies must be immediately
available in the DSC for immediate and safe provision of care and treatment required.
12.4.1. Critical care room will include medical gases outlets (02, Air, Suction), enough
numbers of electrical outlets, examination lights. Supply of medical gases shall be
available and centralized medical gas system shall be according to HTM 2022 or its
equivalent internationally accepted standard.
12.4.2. Pharmaceutical agents, oxygen, oral suction, laryngoscope, ambu-bag shall be readily
available in the health facility.
12.4.3. Equipment shall include Ventilators, Tracheostomy set, Defibrillator machine, Pulse
Oximetry and vital signs monitor, Infusion pumps, blood gas analyser with capability
for electrolytes measuring and emergency crash cart that includes all emergency
supplies and medications.
12.5. At minimum DSC shall have, a clear protocol and provision for basic emergency management for
illness and/or injuries occurred for patient, healthcare professionals, employees or visitors, which
needs immediate emergency care and assistance prior to transport to another health facility.
12.6. Emergency services must be provided by qualified and licensed physician(s) who are authorized
by their scope of practice to provide emergency services and received privileges from the facility
to perform specific emergency procedures.
12.7. All Physicians, Anaesthetists, Technicians and Nurses engaged in surgery shall maintain up to
date hands on/practical Advanced Life Support (ALS) or Advanced Cardiac Life Support (ACLS)
or Paediatrics Advanced Life Support (PALS) Certification as per the scope of services provided.
12.8. If the DSC manages paediatric cases, DSC must ensure anaesthetist are trained in managing
paediatric cases.
12.8.1. All RN who provide patient care are required to maintain a valid Basic Life Support
(BLS) certification.
12.9. RN providing emergency services in the DSC shall be trained and competent to provide the
emergency care, as needed:
12.9.1. Patient Triage.
12.9.2. Operating a Cardiac Monitor.
12.9.3. ECG Recording and Interpretation.
12.9.4. Pulse Oximetry.
12.9.5. Oxygen Administration.
12.9.6. Suctioning.
12.9.7. Intravenous cannulation.
12.9.8. Medication administration.
12.9.9. Emergency services will be available during the operational hours of the DSC.
12.10. Emergency drugs (Appendix 11-12), devices, equipment and supplies must be available for
immediate use for treating life-threatening conditions.
12.10.1. Defibrillator.
12.10.2. Emergency Cart with Emergency medicines.
12.10.3. Resuscitation Kit, Cardiac board and Oral airways.
12.10.4. Laryngoscope with blades.
12.10.5. Diagnostic set.
12.10.6. X-ray viewer.
12.10.7. Patient trolley with IV stand.
12.10.8. Nebulizer.
12.10.9. Refrigerator for medication.
12.10.10. Floor Lamp (Operating light mobile).
12.10.11. Sets of instruments, which shall include suturing set, dressing set, foreign body
removal set or minor set and cut down set.
12.10.12. Disposable supplies which shall include suction tubes (all sizes), tracheostomy tube
(all sizes), intravenous cannula (different sizes), IV sets, syringes (different sizes),
dressings (gauze, sofratulle, etc.), crepe bandages (all sizes), splints (Thomas splints,
cervical collars, finger splints).
12.10.13. All types of fluids (e.g. D5W, D10W, Lactated Ringers, Normosol R, Normosol M,
Haemaccel, etc.) and Glucometer.
12.10.14. Sufficient electrical outlets to satisfy monitoring equipment requirements, including
clearly labelled outlets connected to an emergency power supply.
12.10.15. Reliable source of Oxygen.
12.10.16. Portable vital signs monitor (ECG, Pulse-Oximetry, Temperature, NIBP, EtCO2).
12.10.17. Portable transport ventilator with different ventilation mode (IPPV, SIMV,
spontaneous, PS).
12.10.18. Suction apparatus.
12.11. Storage areas for general medical/surgical emergency supplies, medications and equipment shall
be under staff control and out of the path of normal traffic.
12.12. Policy for maintaining personal items and food in emergency area shall be established and
maintained by the health facility.
12.13. A record must be kept for each patient receiving emergency services and must be integrated
into the patient’s health records, the record shall include: patient name, date, time and method
of arrival, physical findings, care and treatment provided. Name of treating physician and
discharging/transferring time.
12.14. Well-equipped ambulance services shall be ready and nearby for with licensed, trained and
qualified Emergency Medical Technicians (EMT) for patient transportation if required, this
service can be outsourced with a written contract with an emergency services provider licensed
in Dubai.
12.14.1. Ambulance services shall meet Dubai emergency transfer timeframes.
13. STANDARD NINE: SUPPORT SERVICES
13.1. Allied Health Services
13.1.1. The DSC may provide necessary allied health services to meet patient needs and
based on the type services provided in the facility, such services may be available on
the premises or through a written agreement with an external provider.
13.1.2. Allied health services shall be provided by competent and licensed healthcare
professionals. The management shall support the Allied healthcare professional’s
education and training, such training shall ensure competency in specific area e.g.
lifting and manual handling, infection control, fire and Cardiopulmonary Resuscitation
training.
13.2. Nutrition Services
13.2.1. Nutrition services shall be provided as necessary by the DSC either on the premises
or through a written agreement with an external provider. If provided internally,
proper hygienic conditions shall be maintained in the DSC kitchen during preparing,
storing and serving food.
13.3. Laundry
13.3.1. DSC shall provide a laundry services either inside the facility or as an outsource
service. The laundry shall be fully equipped with machines used for cleaning and
washing clothes, sheets and covers.
13.4. Sanitary Services
13.4.1. Clean and hygienic water supply shall be provided in the DSC Water tanks shall be
maintained, clean and well closed.
13.4.2. Clean bathrooms for outpatients shall be provided (separate for male and female).
Each bathroom shall have at least one washbasin and commode with soap and hand
towel. All staff and patients’ toilets shall be kept clean.
13.4.3. All DSC drainage and sewage shall be connected to general sewerage and comply with
the drainage and sanitation requirements of Dubai Municipality regulations.
13.5. External Services
13.5.1. Many healthcare facilities use external contractor and/or services to provide specific
services that are essential to the ongoing operation of the DSC e.g. Nutrition, laundry,
cleaning, maintenance, transport, and security. Some clinical services provided by an
external contractor such as radiology, Lab and pathology and allied health. External
service providers shall be managed effectively to provide safe, high-quality care and
services.
13.5.2. While a contracted service agreement is important for both the health facility and
service provider to ensure quality maintenance of the services, the fundamental
responsibility for quality still rests with the contracting health facility. The health
facility shall precisely outline in its service agreement/contract, the type and standard
of the services expected and evidence compliance with relevant regulatory bodies such
as Dubai Municipality (DM).
13.6. Care for Deceased Patients
13.6.1. A policy for mortuary management shall be available in the health facility and assure
respect and dignity.
13.6.2. In the circumstance of patient death, the DSC shall be responsible for overseeing the
transportation of deceased patients from the DSC to the mortuary.
13.6.3. All deceased patients shall be considered infectious. Strict infection control measures
shall be adopted. The body shall be cleaned and wrapped according to the
requirements of the mortuary service.
13.6.4. Patient’s family rights shall be respected and considered; requests for
relatives/friends to view the deceased shall be arranged by the DSC staff or at the
mortuary.
13.6.5. Deceased registration and notification shall be reported to DHA and MOHAP and
maintained by the DSC.
14. STANDARD TEN: MEDICAL RECORD AND HEALTH INFORMATION MANAGEMENT
14.1. DSC shall ensure all patients have in place a medical file that is protected, secured, accurate and
up to date. As a minimum, the file shall entail the following:
14.1.1. Patients full contact details.
14.1.2. Emergency contact person (next of kin).
14.1.3. Patient health status.
14.1.4. Treating physician.
14.1.5. Any allergies or contract indications.
14.1.6. Prescriptions.
14.1.7. Lab and diagnostic information.
14.1.8. Data of last assessment.
14.1.9. Information on consent.
14.1.10. Date, time and observations for all consultations.
14.2. Up to date operating theatre records shall be maintained including but not be limited to:
14.2.1. Name, date of birth and identification number of the patient.
14.2.2. Date, inclusive of time of the surgical procedure.
14.2.3. Surgical procedure(s) performed, time in and time out.
14.2.4. Name(s) of Physicians, Nurses and Technicians.
14.2.5. Name of nursing personnel (scrub and circulating).
14.2.6. Type of anesthesia administered, dose, time, date and professional.
14.2.7. Name and title of person managing anesthesia.
14.2.8. Requirements for testing and disposal of surgical specimens.
14.2.9. Circumstances that require the presence of an assistant during surgery.
14.2.10. Procedures for handling infectious cases.
14.3. Maintain post-op quality data to inform a quality management and patient safety including but
not be limited to:
14.3.1. Recovery timeframe.
14.3.2. Wound healing time.
14.3.3. Complication rate.
14.3.4. Incidence of pain, nausea and vomiting.
14.3.5. Incidence of treatment related side effects.
14.3.6. Incidence of changes to patient mobility arising directly from the procedure.
14.3.7. Patient satisfaction rate.
15. STANDARD ELEVEN: ADMINISTRATIVE REPORTING
Unanticipated, undesirable or potentially dangerous occurrence of events such as never events, adverse
events and sentinel events in a healthcare organization might occur. DSC shall develop a written policy
for incident reporting to DHA when such events occur. This includes but is not limited to the following:
15.1. 0-48 hours
15.1.1. Any incident prior to or following surgery or administration of anesthesia that results
in patient death, loss of function or limb.
15.1.2. A patient fall that results in death or major permanent loss of function as a direct
result of the injuries sustained in the fall.
15.1.3. Serious criminal acts such as assault, homicide, or other crime resulting in patient
death or major permanent loss of function occurred inside the DSC premises.
15.1.4. Surgical and non-surgical invasive procedures on the wrong patient, wrong site, or
wrong procedure.
15.1.5. Unintended retention of a foreign object in a patient after surgery or other procedure.
15.1.6. Loss of patient data or patient files.
15.1.7. Full or partial evacuation of the DSC for any reason.
15.1.8. Major incident in the DSC premises (fire, flood, electrical outage, outbreak of disease
etc.)
15.2. Means for reporting adverse events, never events and sentinel events, and major incidences shall
include a written official letter to HRS Clinical Audit and Control Department at DHA either by
courier, in person and verified by email and follow up phone call unless specified by DHA
otherwise. DSC management team shall prepare a written evaluation of its response following
investigation, root cause analysis and action plan.
15.3. The response shall be submitted to HRS Clinical Audit and Control Department at DHA by
courier, in person and verified email and follow up phone call within 45 calendar days from the
date of the event.
15.4. Key Performance Indicators shall be captured by the DSC and reported to HRS within the 2nd
week of each quarter through the online QEYAS Portal. Submission reflect outcomes achieved
in the previous quarter. Data submission includes but is not limited to the following:
15.4.1. Patient waiting time for elective surgery
15.4.2. Number of diagnostic procedures Performed
15.4.3. Number of informed consent
15.4.4. Number of pre-assessments
15.4.5. Number of surgical procedures performed
15.4.6. Number of Surgical procedures performed by sedation classification
15.4.7. Number of Surgical procedures performed by Permitted Patient Acuity
15.4.8. Number of surgical cancellations
15.4.9. Number of surgical complications
15.4.10. Number of Surgical Site Infections
15.4.11. Number of 30-day re-operated
15.4.12. Number of Sentinel Events
15.4.13. Number of hospital emergency transfers
15.4.14. No. of Falls
15.4.15. Number of deaths within 30 days
15.4.16. Patient Satisfaction %
15.4.17. Staff Satisfaction %
16. STANDARD TWELVE: FACILITY MANAGEMENT
16.1. Medical Equipment and Supplies
Accurate and safe clinical equipment is an essential requirement in the provision of health
services. Medical equipment shall be installed and operated in accordance with manufacturer
specifications. The DSC shall maintain effective Preventive Maintenance (PM) as per the
manufacturer recommendations (at least 95% of medical equipment shall receive PM), the PM
shall include the following:
16.1.1. Electrical safety testing for patient related equipment.
16.1.2. Each piece of equipment has a checklist for its maintenance schedule, failure incidence
and repairs done.
16.1.3. Make use and maintain Statistical data of Preventative Maintenance (PM) for
upgrading/replacing equipment.
16.1.4. The DSC shall maintain copy of operator and safety manuals of all medical equipment
and inventory list with equipment location.
a. DSC healthcare professionals (physicians, nurses, and allied health) shall be
trained to operate the medical equipment assigned to them and the hazards
attached to it.
b. Training shall be documented and kept up to date.
16.1.5. Maintain written policy for tagging medical equipment which should include:
a. PM with testing date and due date.
b. Inventory number.
c. Safety checks.
d. Installation.
e. Removal.
f. Reporting incidents, hazards and corrective actions.
16.2. Safety and Quality Management Systems
16.2.1. DSC shall ensure that the healthcare environment is safe, functional, supportive and
effective for patients, family and staff members.
16.2.2. The DSC leadership shall plan and budget for all necessary support and resources for
safety.
16.2.3. The DSC shall designate a safety officer person(s) with skills and experience
responsible for the operation and implementation of the safety program.
16.2.4. The safety management system is supported by a policy and shall comply with the
related federal and local regulation in UAE, the safety officer shall undertake
appropriate training relevant to jurisdictional requirements.
16.2.5. The safety management system shall include fire safety, hazardous waste,
emergencies, security.
16.2.6. External service providers shall be supplied with relevant information and comply with
the DSC health and safety requirements.
16.2.7. Orientation on the safety measures shall be included in the induction program of new
staff.
a. Staff shall be educated and provided with information on waste management, fire
safety, hazardous substances and their responsibilities.
16.2.8. DSC shall abide with the prevention and safety measures required by Dubai Civil
Defence.
16.2.9. DSC management shall ensure the compliance with Federal Authority Nuclear
Regulation-FANR rules and regulations regarding the use of ionizing radiation and
radioactive materials in DSC.
16.3. Fire Safety
16.3.1. Fire is a potential risk for all healthcare organizations and is critical where immobile
patients are in locations that are difficult to evacuate. To respond to fire risk the DSC
shall:
a. Establish a fire safety plan for early detection, confining, extinguishment, Rescue
and alerting the Dubai Civil Defence.
b. Establish a No Smoking policy.
c. Assess the fire risks to the facility.
d. Understand and manage risks associated with the facility’s location and physical
structures.
e. Maintain and test fire protection and emergency communication systems
f. Train staff to respond to a fire event in the building.
g. Monitor whether adequate numbers of suitably trained staff are posted across all
shifts to respond appropriately to a fire event.
h. Rehearse emergency scenarios to assess preparedness.
16.4. Hazardous Substances and Dangerous materials.
16.4.1. The DSC shall have policies and procedures on the procurement, management and
disposal of dangerous materials and hazardous substances and shall comply with local
regulations.
16.4.2. There should be adequate space and ventilation for safe handling of dangerous
materials and hazardous substances.
16.4.3. Each DSC shall have a current list of hazardous substances and dangerous materials
used in their area, the list covers:
a. Purpose of use.
b. The responsible person.
c. Permitted Quantity.
16.4.4. All substances shall be clearly labelled; this includes corrosives, acids, toxic
material, hazardous gases and anesthetic gases.
16.4.5. Hazardous substances shall be properly labelled and maintained on a register of all
hazardous substances in the workplace. Labels should never be altered, and
substances shall be stored in their original containers.
16.4.6. Employees dealing with hazardous substances shall have protective clothes or
equipment as required.
16.4.7. Material Safety Data Sheets (MSDS) shall be available for employees at point of use
and for Civil Defence in case of emergency.
16.5. Waste and Environmental Management
16.5.1. Waste and environmental management shall support safe practice and a safe
environment. The DSC shall develop and implement a waste and environmental
management policy. The policy shall include segregation and disposal of DSC clinical
waste in a responsible manner in accordance with federal and local regulations in the
UAE.
16.5.2. The waste management policy shall cover handling, storing, transporting, and
disposing all kinds of waste:
a. Anatomical e.g. blood and organs (red).
b. Clinical/infectious waste (orange).
c. Clinical/highly infectious, pathological waste and sharps (yellow).
d. Medicine unused drugs (blue).
e. Cytotoxic, Cytostatic, Chemotherapeutic, hemotherapy medicines waste (Purple).
f. Dental (white).
g. Offensive but not hazardous (yellow and black).
h. Radioactive waste (lead box).
i. Chemical or pharmaceutical (brown).
j. Domestic waste (black).
16.5.3. Proper storage and containers for disposing waste material shall be maintained.
16.5.4. Contracting with a specialized company to transport and destroy medical waste
materials shall be according to the conditions issued by Dubai Municipality.
16.5.5. Disposing medical liquids, drugs, solutions and dangerous chemical materials into
usual sewage disposal is prohibited.
16.5.6. Cleanliness throughout the DSC shall be maintained by trained staff.
16.6. Emergency and Disaster Management
16.6.1. The DSC shall develop a plan and policies for dealing with and managing emergencies
and internal disasters, which shall include:
a. Duties and responsibilities of healthcare professionals and employees in the DSC.
b. Identifying the responsible person who announces the emergency state and calls
local authority.
c. The triage areas, their locations, and triage action cards.
d. Names of all staff called, including their contact.
16.6.2. The DSC shall conduct Emergency practice/drill exercises including fire and
evacuation with the aim to test the following:
a. The timely response of staff to the emergency call.
b. The efficiency of the communication system, e.g. bleeps, mobile phone and
overhead paging system.
c. If all staff can perform their expected roles.
d. The time taken to evacuate patients and beds.
16.6.3. There are evacuation maps posted in the DSC indicating locations of:
a. You are here.
b. Fire extinguishers.
c. Fire hose reel/cabinets.
d. Escape routes.
e. Assembly points.
f. Fire exits.
g. Call points break glass / pull station.
16.6.4. External service providers shall comply with the DSC requirements for the prevention
of emergencies.
16.6.5. Staff is educated and trained at orientation and annually in fire and evacuation.
16.7. Security Management
16.7.1. Security management shall support safe practice and a safe environment.
16.7.2. The facility management may assign specific personnel to take care of security in the
DSC or may ensure security by installing CCTV camera or other means of surveillance.
16.7.3. Security personnel (if available) shall be educated and provided with information in
relation to security risks and responsibilities and oriented on their scope of work, fire
safety and emergency codes.
16.7.4. There is a security policy, which includes identification of all the following by badge:
a. The DSC staff.
b. Temporary employees.
c. Trainees.
d. Contractor staff.
16.7.5. There are written policies on the following that includes but not limited to:
a. Lost and found items.
b. Safe keeping of patient belongings.
c. How to contact the local police, in case of need.
16.7.6. Major security risks shall be identified in the DSC.
16.7.7. Restricting access to sensitive areas by Security Personnel/Security System such as
operating area, no filming in operating theatre as per DHA Circular.
16.7.8. External service providers are supplied with relevant information and comply with
the DSC security controls.
17. STANDARD THIRTEEN: INFECTION PREVENTION AND CONTROL
17.1. There shall be in place an infection prevention control Policy and lead to oversee the DSC
infection prevention and control program and monitoring shall be implemented to prevent
transmission of pathogens across the DSC.
17.1.1. The lead shall report to the Medical Director or management committee.
17.2. Written policies and procedures regarding infection control management, prevention and
surveillance shall be in place and documented as part of the DSC policies and procedures.
17.3. The infection control program shall support safe practice and ensures a safe environment for
patients, healthcare workers and the DSC visitors. Infection control system shall address factors
related to the spread of infections among professional/patient and prevention which includes
but is not limited to:
17.3.1. The basic measures for infection control/hand hygiene/hand washing.
17.3.2. The procedures for minimizing risk/cleaning/disinfection/sterilization.
17.3.3. Use of standard precautions and additional precautions in certain cases.
17.3.4. Restriction of jewellery, nail polish, false nails and clothing in surgical theatre.
17.3.5. Healthcare professional vaccination and immunisations (Appendix 13).
17.3.6. Monitoring/investigation of demonstrated or suspected spread of infection within
the DSC.
17.3.7. Environmental cleaning, single-use items and reprocessing of sterile instruments.
17.3.8. Recommended cleaning, disinfectants and sterilisation in healthcare setting for
surgical and non-surgical areas as per Centre for Disease Prevention and Control
recommendations
(https://www.cdc.gov/infectioncontrol/guidelines/disinfection/index.html)
a. Sterilisation may be outsourced and is subject to DHA approval.
17.3.9. There should be a sterilizing area, which can be located near Operating Theatre area
with adequate high-speed autoclave machine. Operation instruments and trolleys may
be arranged at this area.
17.3.10. Post-exposure prophylaxis protocols.
17.3.11. External service providers and visitors shall be advised of the DSC infection Control
requirements. Surveillance to ensure maintenance of a clean and safe environment of
resources such as air conditioning units and water-cooling towers should be
conducted by DSC management.
17.4. An active infection prevention surveillance program and ongoing educational and competency
evaluation of staff regarding activities within the pre-procedure, intra-procedure and post-
procedure phases are necessary for overall safety of patients and healthcare professionals.
17.5. To prevent pathogens transmission resulting from improper use or reuse of syringes, multiple
dose drug vials and IV equipment the following shall be adhered to:
17.5.1. Preparing medications for multiple patients shall be done in an area away from direct
patient care or procedure rooms.
17.5.2. All medications shall be appropriately labelled by the nurse, including those used for
sedation, unless the medication is for immediate use (prepared and administered
immediately without leaving the provider’s hand).
17.5.3. Medications either marked on the container or noted in the package insert as “single
patient use” shall be used for a single patient only and any remaining drug should be
discarded.
17.5.4. New fluid administration sets (e.g., IV tubing) units shall be used for each patient.
17.5.5. Use of a single-dose vial is preferred over multiple dose vials, particularly when
medications are administered to multiple patients.
17.5.6. If a multiple-dose vial is used for more than one patient, they should remain in a
centralized medication area and not enter the patient procedure room. They should
be dated when opened and discarded according to protocols, in compliance with
nationally MOHAP accepted guidelines and those published by the Centers for Disease
Control and Prevention (CDC).
17.5.7. Re-use of a syringe to enter a medication vial or solution, even with a new needle shall
not be permitted.
17.5.8. The same syringe shall not be used to administer medications to multiple patients
regardless of whether the needle is changed, or an intervening length of IV tubing is
used.
17.5.9. Used syringes and needles shall be disposed of at the point of use in a sharps container
that is closable, puncture-resistant, and leak-proof.
17.5.10. If tubes of lubricant are used for more than one examination, appropriate infection
control habits should be observed and any tube that has potentially been
contaminated should be discarded.
17.5.11. Aseptic technique (i.e., cleansing the access diaphragms of medication vials with 70%
alcohol before inserting a device in the vial) should be used to prepare and administer
injections. Single-dose vials, ampules, bags, or bottles of IV solution should be used
for a single patient only.
17.6. A clearly defined policy for the management of sharps and sharps-related injuries, including the
reporting of blood and body fluid exposures shall be developed.
17.7. Hand hygiene shall be performed before patient contact (even if gloves are to be worn), after
patient contact and before exiting the patient care area, after contact with blood, body fluids or
contaminated surfaces, before performing invasive procedures and after glove removal.
17.8. Convenient access to hand-washing stations shall be available in all consultation, treatment,
patient care, sterilisation, dirty utility and housing keeping areas.
17.9. Use of soap and water is required when hands are visibly soiled.
17.10. Environmental cleaning of surfaces with a disinfectant is mandatory and shall follow
manufacturer recommendations, especially for surfaces that are most likely to become
contaminated with pathogens, such as those near the patient (e.g. side rails) and other
frequently touched surfaces.
17.10.1. The DSC shall maintain material safety data sheets (MSDS) for all chemicals used for
cleaning and disinfection. These sheets shall detail the safe and proper use and
emergency protocol for a chemical. Material safety data sheets should be used for
training staff on each chemical’s safe use.
17.11. There must be appropriate measures for cleaning and decontamination of spills of blood or other
potentially infectious material. The health facility should:
17.11.1. Follow the CDC directions for surface disinfection of patient care items.
a. Appropriate contact time of disinfectant to achieve germicidal kill shall be
followed.
b. Alcohol should not be used to clean environmental surfaces.
c. Properly clean and disinfect surfaces that are frequently touched like endoscopy
keyboards, video monitors, consoles or dirty equipment in the endoscopic
procedure area at the beginning of the day, between cases and during terminal
cleansing.
d. Endoscopy equipment shall be dried and stored in an endoscopy storage cabinet.
17.12. The use of Personal Protective Equipment is dictated by patient traffic patterns, location of care
and the potential of direct contact with patients and their bodily fluids during specific activities.
17.13. Healthcare professionals shall remove and appropriately, discard used PPE before leaving the
procedure room.
17.14. Contaminated clothing shall be placed in a bag and identified as potential biohazardous. The bag
with the contaminated clothing should be sent to a laundry capable of cleaning and disinfecting
them.
17.15. Healthcare professionals engaged in endoscopic procedures with potential
splash/contamination shall wear gloves, face/eye shields/impervious gowns.
17.16. Final rinse water of the endoscope washer disinfector and rinse sample cultures for endoscopic
channels and water bottle shall be tested on a monthly basis.
17.17. Single-use devices as determined by the manufacturer label or packaging insert should not be
reprocessed.
17.18. The reprocessing protocol of reusable medical equipment such as endoscopes and endoscopic
accessories must be strictly followed.
18. STANDARD FOURTEEN: PATIENT RIGHTS AND RESPONSIBILITIES
18.1. DSC must put in place a written policy that adheres to DHA requirements for patient rights and
responsibilities. Information on patients’ rights and responsibilities shall be communicated and
displayed in at least two languages (Arabic and English), at the entrance, reception and waiting
area(s) of the premise and website. Requirements for patient rights and responsibilities include
but are not limited to the following:
18.1.1. Patients have the right to full disclosure of healthcare service costs. Cost information
can be displayed in the form of price leaflet/brochure/online or any other feasible
manner.
18.1.2. Patients have the right to request information about a physician’s scope of practice,
credentials and license.
18.1.3. Patients have the right to be provided information concerning their diagnosis,
evaluation, treatment options, and prognosis.
18.1.4. Patients have a right to obtain comprehensive medical report based on their personal
medical records along with copies of all investigation reports.
18.1.5. Patients have the right to participate in decisions involving their care.
18.1.6. Patients have the right to refuse any diagnostic procedure or treatment and be
advised of the medical consequences of that refusal.
18.1.7. Patients have the right to seek a second opinion.
18.1.8. Patients have the right to make a complaint and to receive a written response.
a. Timescales for managing complaints shall be provided in writing to the patient.
b. Complaints made by a patient or by patient’s family shall be investigated,
documented including the resolution of the complaint.
18.1.9. The DSC shall ensure patients are made aware and understand their rights as well as
their responsibilities regarding the procedures/surgery, including but not limited to
provision of patient or next of kin/legal guardian identification, fasting times,
medications, financing, notification where change in their medical condition has taken
place and adherence to physician and staff instructions.
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APPENDICES
APPENDIX 1: DSC CLASSIFICATION (ANESTHESIA, SEDATION AND PATIENT SAFETY)
Health Facility CLASS A Health Facility CLASS B Health Facility CLASS CM Health Facility CLASS C
Minimal Sedation Moderate Sedation/Analgesia (Conscious Sedation) is a drug-induced depression Deep Sedation/Analgesia is a drug-induced General Anesthesia is a controlled state of
(Anxiolysis) of consciousness during which the patient tolerates unpleasant therapeutic or depression of consciousness or unconsciousness drug-induced unconsciousness state
is a drug-induced state to diagnostic procedure, responds purposefully to verbal commands, either alone or during which patients cannot be easily aroused accompanied by a loss of protective reflexes,
reduce patient anxiety during accompanied by light tactile stimulation while maintaining cardio-respiratory function. and respond purposefully following repeated or including loss of the ability to maintain a
in which the patient commonly involves intravenous administration of drugs with anxiolytic, hypnotic, painful stimulation or verbal command. The patent airway independently or to respond
responds normally to verbal analgesic, and amnesic properties either alone or as a supplement to a local or ability to independently maintain ventilatory purposefully to physical stimulation or
commands (technically regional anesthetic. Moderate sedation is a medically controlled state of drug induced function may be impaired thus, patients may verbal command. Cardiovascular function
awake). In this stage, the depressed consciousness that: require assistance in maintaining a patent airway may be impaired and Positive pressure
following should be present:  Allows protective reflexes to be maintained and spontaneous ventilation. Cardiovascular ventilation may be required because of
 Normal  Retains the patient's ability to maintain a patent airway independently and function is usually maintained. depressed spontaneous ventilation or drug-
respirations continuously; i. Topical anesthesia, oral sedative and induced depression of neuromuscular
 Normal eye  Permits appropriate response by the patient to physical stimulation or local Anesthesia function.
movements verbal command, for example, "open your eyes." ii. Regional Anesthesia i. Topical anesthesia, oral sedative
 Intact protective  The drugs, doses, and techniques used are not intended to produce a loss iii. Dissociative Drugs (including and local Anesthesia
reflexes of consciousness. Propofol) ii. Regional Anesthesia
 Amnesia may or i. Topical anesthesia, oral sedative and local Anesthesia iv. Spinal Anesthesia iii. Dissociative Drugs (including
may not be ii. Regional Anesthesia v. Epidural Anesthesia Propofol)
present iii. Dissociative Drugs (excluding Propofol) Note 1: The use of Endotracheal Intubation iv. Epidural Anesthesia
i. Topical anesthesia, oral Note 1: Regional Anesthesia involves the injection of local anesthetic in the vicinity of Anesthesia, Laryngeal Mask Airway Anesthesia, v. Spinal Anesthesia
sedative and local Anesthesia major nerve bundles supplying body areas, such as the thigh, ankle, forearm, hand or and/or Inhalation General Anesthesia (including vi. General Anesthesia (with or
shoulder, etc. so the patient cannot feel pain in that area. It is an umbrella term used to Nitrous Oxide) is prohibited in a Class CM without Endotracheal Intubation
describe nerve blocks, epidural blocks (pain relief and having a baby) and spinal blocks. Centre. or Laryngeal Mask Airway
Note 2: The use of Propofol, Spinal Anesthesia, Epidural Anesthesia, Endotracheal Note 2: Epidural Anesthesia is a fine plastic tube Anesthesia)
Intubation Anesthesia, Laryngeal Mask Airway Anesthesia, and/or Inhalation General (an epidural catheter) that is threaded through a Note 1: Major regional blocks including, but
Anesthesia (including Nitrous Oxide) is prohibited in a Class B Centre. needle and the tube is left in the epidural space in not limited to, spinal, epidural or caudal
the back. Local anesthetic is injected down the injection of any drug, which has analgesic,
tube to cause numbness, which varies in extent anesthetic or sedative effects are in the
according to the amount of local anesthetic same category as general anesthesia.
injected.
Criteria Health Facility CLASS A Health Facility CLASS B Health Facility CLASS CM Health Facility CLASS C
Minimal Sedation (Anxiolysis) Moderate Sedation/ Deep Sedation/Analgesia General Anesthesia
Analgesia (Conscious
Sedation)
Responsiveness Normal response to Purposeful response to verbal Purposeful response Unarousable even with
Verbal Stimulation and tactile simulation following repeated or painful stimulus
painful simulation
Airway Unaffected No intervention required Intervention may be required Intervention often required
Spontaneous Ventilation Unaffected Adequate May be adequate Frequency inadequate
Cardiovascular Function Unaffected Usually maintained Usually maintained May be impaired
ASA ASA I (A normal healthy patient ASA I (A normal healthy patient ASA I (A normal healthy ASA I (A normal healthy
PS Classification i.e. Healthy, non-smoking, no or i.e. Healthy, non-smoking, no or patient i.e. Healthy, non- patient i.e. Healthy, non-
minimal alcohol use) minimal alcohol use) smoking, no or minimal smoking, no or minimal
ASA II (Mild diseases only without ASA II (Mild diseases only alcohol use) alcohol use)
substantive functional limitations. without substantive functional ASA II (Mild diseases only ASA II (Mild diseases only
Examples include but not limited limitations. Examples include without substantive without substantive
to current smoker, social alcohol but not limited to current functional limitations. functional limitations.
drinker, pregnancy, obesity (30 < smoker, social alcohol drinker, Examples include but not Examples include but not
BMI < 40), well-controlled pregnancy, obesity (30 < BMI < limited to current smoker, limited to current smoker,
DM/HTN, mild lung disease) 40), well-controlled social alcohol drinker, social alcohol drinker,
DM/HTN, mild lung disease) pregnancy, obesity (30 < BMI pregnancy, obesity (30 <
< 40), well-controlled BMI < 40), well-controlled
DM/HTN, mild lung disease) DM/HTN, mild lung
disease)
Note 1: The American Society of Anaesthetists' Physical Class System was designed to describe the patient's current health status. As such, it is one of the most important factors used to assess
the overall perioperative risk.
Note 2: Level III-VI patients are not permitted in DSC setting
APPENDIX 2: DSC CLASSIFICATION AND PERMITTED MEDICATIONS
No. Health Facility Class/Type Method of Delivery Medications

(A, B, CM or C)
1. A Topical Anesthesia Benzocaine, lidocaine, lignocaine, prilocaine
A Oral sedative Alprazolam (Xanax)
Clonazepam (Rivotril)
Diazepam (Valium)
Midazolam (Dormicum)
Lorazepam (Ativan)
Chlordiazepoxide (Librium)* * (non-registered
medication)
Chloral Hydrate* (non-registered medication)
A Local Anesthesia Lidocaine
Prilocaine
benzocaine
Mepivacaine
Bupivacaine
Ropivacaine (Naropin)
Levobupivacaine
2. B Topical Anesthesia See Health Facility Class/Type A
B Oral sedative See Health Facility Class/Type A
B Local Anesthesia See Health Facility Class/Type A
B Regional Anesthesia Procaine* (non-registered medication)
Chloroprocaine* (non-registered medication)
Lidocaine
Mepivacaine
Tetracaine* (non-registered medication)
Levobupivacaine
Bupivacaine
Ropivacaine
Articaine
Novocaine
Oxymorphone* (non-registered medication)
Buprenorphine
Sufentanil* (non-registered medication)
Meperidine
Fentanyl
Morphine
B Dissociative Drugs (excluding Propofol) Ketamine
PCP (Phencyclidine)*
(non-registered medication)
DXM (Dextromethorphan)* -
(non-registered medication)
3. CM Topical Anesthesia See Health Facility Class/Type A
CM Oral sedative See Health Facility Class/Type A
CM Local Anesthesia See Health Facility Class/Type A
CM Regional Anesthesia See Health Facility Class/Type B
CM Dissociative Drugs (including Propofol) See Health Facility Class/Type B
CM Spinal Anesthesia Bupivacaine (Marcaine)
Ropivacaine (Naropin)
Lidocaine
CM Epidural Anesthesia Bupivacaine
Lidocaine
Fentanyl
4. C Topical Anesthesia See Health Facility Class/Type A
C Oral sedative See Health Facility Class/Type A
C Local Anesthesia See Health Facility Class/Type A
C Regional Anesthesia See Health Facility Class/Type B
C Dissociative Drugs (including Propofol) See Health Facility Class/Type B
C Spinal Anesthesia See Health Facility Class/Type C
C Epidural Anesthesia See Health Facility Class/Type C
C General Anesthesia (with or without Endotracheal Thiopental* (non-registered medication)
Intubation or Laryngeal Mask Airway Anesthesia) Inj Midazolam Dormicum
Inj Diazepam
Sevoflurane,
Isoflurane
Halothane
Nitrous Oxide* - (non-registered medication)
Propofol
Ketamine
Dexmedetomidine (Precedex)
Morphine Sulfate Injection
Pethidine Hydrochloride
Fentanyl
Alfentanil
Remifentanil (ultiva)
APPENDIX 3: LIST OF PERMITTED PROCEDURES BY DAY SURGICAL CENTRE CLASSIFICATION
No. Speciality/Procedure Names Minimum Health Facility

Classification/Type (A,B, CM or C)
Assisted Reproductive Techniques (ART)
1. Intra Uterine Insemination (IUI) C
2. In vitro Fertilization (IVF) C
3. Intracytoplasmic Sperm Injection (ICSI) C
4. Gamete Intra-fallopian Transfer (GIFT) C
5. Zygote Intra-fallopian Transfer (ZIFT) C
Note: The above procedures can only be performed in a fertility centre.

Endoscopic procedures
1. Colonoscopy B
2. Gastroscopy B
3. Laryngoscopy B
4. Bronchoscopy CM
5. Cystoscopy CM
6. Esophagoscopy CM
7. Sigmoidoscopy CM
8. Arthroscopy C
Note: Thoracoscopy and laparoscopy can only be performed in a hospital setting.

General Surgery
1. Ganglions A
2. In-grown toe-nail A
3. Excision of skin and subcutaneous benign mass A
4. Drainage of Abscesses A
5. Temporal artery biopsy B
6. Anal procedures - dilatation/fissure/bandin/low anal CM
fistula
7. Breast lump excision (benign) CM
8. Excision varicocele CM
9. Testicular fixation and Orchidopexy CM
10. Varicose vein surgery CM
11. Hernia repair – inguinal/epigastric/femoral/ C
incisional/umbilical
12. Hemorrhoids (2nd 3rd Degree) and Incision and Excision of C
superficial Thrombosed Hemorrhoid
Note: Appendectomy, abdominoplasty, Pilonidal Sinus, bariatriac and laparoscopic can only be performed in a
hospital setting.

Neurosurgery/anesthesia/pain management
1. Epidural Steroid Injections/Block B
2. Selective Nerve Root injections B

Obstetric/Gynecology
1. Bladder distension A
2. Endometrial biopsy A
3. Colposcopic procedures A
4. Urethral dilatation B
5. Cervical biospies B
6. Vaginoplasties, vulva repair and perineal repair CM
7. Cautery to cervix C
8. Dilatation and curettage C
9. Endometrial ablation C
10. Tension free vaginal tape C
11. Excision urethral caruncle C
12. Fenton's procedure C
13. Labial procedures/Bartholin's C
14. Polypectomy C
Note: Hysterectomy and laparoscopic surgery can only be performed in a hospital setting.

Oral Surgery
1. Apicoetomy A
2. Biopsy of oral lesions/swellings A
3. Gum surgery A
4. Excision of oral cysts A
5. Exposure and bonding of impacted incisors A
6. Exposure of impacted canines A
7. Removal of impacted canines A
Note: Maxillofacial procedures can only be performed in a hospital setting.

Orthopaedic Surgery
1. Excision of local skin lesion A
2. Casting, splinting, bracing, change of plaster A
3. Serial casting for limbs/spine deformities B
4. Implant Removal (Minor) B
5. DeQuervains release B
6. Trigger finger/thumb release B
7. Closed Reduction of Fracture/ Dislocation B
8. Tenolysis of trigger Finger (One, Two) B
9. Dupuytren's Contracture B
10. Claw Toe Reconstruction (One toe, Two Toes) B
11. Closed Reduction + Percutaneous Fixation CM
12. Amputation of digit CM
13. Carpal Tunnel decompression CM
14. Examination under anesthesia CM
15. Correction of Hallux Valgus (Soft Tissue) CM
16. Bunionectomy CM
17. Open Reduction of Fracture/Fixation (Small Bone) CM
18. Tendon repair (Minor) C
Note: Intramedullary nailing and plating of long bones can only be performed in a hospital setting

Otolaryngology (E.N.T.)
1. Biopsy mouth/tongue/ear A
2. Sinus washout B
3. Submucous diathermy B
4. Laryngoscopy B
5. Pharyngoscopy/oesophagoscopy B
6. Cautery/out fracture inferior turbinate CM
7. Division tongue-tie CM
8. Intranasal polypectomy CM
9. Excision lymph nodes C
10. Functional Endoscopic Sinus (FESS) Surgeries C
11. Uvuloplasty C
12. Myringotomy C
13. Grommet insertion, tympanoplasty and simple C
mastoidectomy
14. Antrostomy C
15. Tympanoplasty C
16. Uvulectomy C
17. Removal submandibular calculus C
Note: Rhinoplasty and tonsillectomy can only be performed in a hospital setting.

Ophthalmology
1. Cataract extraction A
2. BCC Excision and skin graft A
3. Sling Procedure A
4. Chalazion A
5. Conjunctiva Biopsy A
6. Conjunctival Suture Removal A
7. Cryotherapy A
8. Ectropian and Entropian A
9. Electrolysis A
10. Epilation of lashes A
11. Gold Weight Insertion A
12. Hughes Flap and Release A
13. Intraocular lens implantation A
14. LASIK and LASEK A
15. Peripheral Indectomy A
16. Pteryguim A
17. Ptosis A
18. Punctal Plug Insertion A
19. Second Stage Reconstructions A
20. Syringe and Probe A
21. Tarsorraphy A
22. Temporal Artery Biopsy A
23. Three Snip Procedure A
24. Trabeculectomy (glaucoma) A
25. Vitrectomy A
26. Keratoplasty, Keratomileusis, Keratoprosthesis A
Note: Keratoplasty, Keratomileusis, Keratoprosthesis is subject to DHA written approval.

Plastic Surgery
1. Excision of skin tag A
2. Minor Scalp Surgery (lipoma, cyst, cut wounds) A
3. Face, neck and eye brow lift CM
4. Blepharoplasty CM
5. Belly button surgery (or umbilicoplasty/navel surgery) C
6. Breast implants C
7. Calf, Cheek and Chin Surgery/implants C
8. Ear surgery (otoplasty/pinnaplasty) C
9. Liposuction (or lipoplasty/liposculpture) and fat transfer C
Note: Lip implants, breast surgery/reconstruction and abdominoplasty can only be performed in a hospital
setting.
Urology
1. Biopsies A
2. Suprapubic catheter A
3. Circumcision B
4. Urethral dilatation B
5. Locate/remove JJ stent CM
6. Epididymal cyst excision CM
7. Cysto-diathermy bladder C
8. Excision hydrocele C
9. Lithoclast C
10. Bladder neck incision C
11. Prostate - Plasma kinetic vaporisation/biopsy C
12. Orchidopexy, Testicular and penile prosthesis C
APPENDIX 4: DAY SURGICAL CENTRE CARE PATHWAY
Post Op
Follow up
**Discharge
Same day
*Pre-op surgical
Post Op
Surgery Recovery
Physician Assessment assessment
Recovery
Consultation and informed
and informed
Diagnostics consent
consent
Inpatient
Transfer
Cooling off
**Discharge
Emergency
Transfer
Note: Post Op
*Pre-op information provided Follow up
** Post Op information and analgesics and instructions
APPENDIX 5: MINIMUM REQUIREMENTS FOR INFORMED CONSENT FORM
Informed Consent Form for Patients
Name of Healthcare Professional: ______________________________________________________
Name of Health Facility: _____________________________________________________________
Name of Patient: _____________________________________ File No: _______________________
This Informed Consent Form has two parts:
• Information Sheet (to share information about the treatment with you)
• Certificate of Consent (for signatures if you agree to go ahead with the treatment)
You will be given a copy of the full Informed Consent Form
PART I: Information Sheet
Introduction:
I, Dr. _____________________________________________ with license No:______________ should be
performing the __________________treatment/ procedure on Miss/Mrs./Mr.__________________
aged _________years, on date _______________.
Description of the Procedure and Process

Describe to the patient or customer, the procedure and what will happen on a step-by-step basis. The patient
should be informed that procedure is newly introduced and the amount of supporting research and study
available.
Side Effects
Potential patients should be told if there are any known or anticipated side effects and what will happen in the
event of a side effect or an unexpected event.
Risks
Explain and describe any possible or anticipated risks. Describe the level of care that will be available in the event
that harm does occur, who will provide it, and who will pay for it.
Complications
Inform and explain any possible complications that could be caused as a result of the treatment.
Discomforts
Explain and describe the type and source of any anticipated discomforts that are in addition to the side effects
and risks discussed above.
Benefits
Mention only those activities that will be actual benefits of the treatment.
Confidentiality
Explain how the clinical team will maintain the confidentiality of data, especially with respect to the information
about the patient including photography and videography.
Right to Refuse treatment/procedure
This is a reconfirmation that the patient has the right to refuse the treatment.
Alternatives to clinical procedure or treatment
It is important to explain and describe the established standard treatment or procedure for the patient’s
condition.
Financial Implications
All procedures/treatments provided that are not covered by insurance or which may require the patient’s full
payment or co-payment.
PART II: Certificate of Consent
This section can be written in the first person. It should include a few brief statements about the treatment and
be followed by a statement similar to the one in bold below. The healthcare professional performing the
treatment and the person going over the informed consent should sign the consent.
Example:
Patient Consent statement
I have read the foregoing information, or it has been read to me. I have had the opportunity to ask questions
about it and any questions that I have asked have been answered to my satisfaction. I consent voluntarily to
undergo tis treatment and understand that I have the right to withdraw from the procedure or treatment at
any time without in any way affecting my medical care.
Name of Patient: ____________________________________________________

Signature of Patient:___________________________ Date: _______________
Witness statement
I have accurately read or witnessed the accurate reading of the consent form to the potential patient, and the
individual has had the opportunity to ask questions. I confirm that the individual has given consent freely.
Name of witness: ____________________________________________________
Signature of witness: _________________________ Date: ______________
Healthcare Professional Declaration:
I have adequately explained to the patient about the procedure along with risks, adverse effects and the standard
alternatives that are available for the procedure. I have permitted time and opportunity for the patient to ask
questions and all questions have been answered to my knowledge
Name of healthcare professional: _______________________________________

Signature of healthcare professional : __________________ Date: ____________
APPENDIX 6: SURGICAL SAFTEY CHECKLIST
APPENDIX 7: CONSCIOUS SEDATION COMPETENCY
AND DUTIES TRAINING OF PERSONNEL AND GENERAL CONSIDERATIONS
Physician:
1. Individuals responsible for patients receiving sedation/analgesia should understand the

pharmacology of the agents that are administered, as well as the role of pharmacological antagonists
for opioids and benzodiazepines.
2. Individuals monitoring patients receiving sedation/analgesia should be able to recognize the

associated complications.
3. At least one individual capable of establishing a patent airway and positive pressure ventilation, as
well as a means for summoning additional assistance, should be present whenever
sedation/analgesia is administered.
4. It is recommended that an individual with advanced life-support skills be immediately available.
5. Hence, physician intending to produce a given level of sedation should be able to rescue patients
whose level of sedation becomes deeper than initially intended.
5.1. Individuals administering Moderate Sedation/Analgesia ("Conscious Sedation") should be able

to rescue patients who enter a state of Deep Sedation/Analgesia.
5.2. While those administering Deep Sedation/Analgesia should be able to rescue patients who enter
a state of general anaesthesia.
Nursing Staff:
The following are the criteria for providing conscious sedation:

1. Qualified Nurses are responsible for monitoring and assisting treating physician for patients
receiving sedation/analgesia.
2. Qualified Nurses caring for the patient receiving sedation/analgesia should have no other
responsibilities that would leave the patient unattended or compromise continuous monitoring of
the patient from the administration of medication through the recovery process.
3. Responsibility cannot be delegated to a Non-Staff Nurse.
4. Nurses should have experience in areas such as, surgery, critical care, emergency, orthopaedic, and
Pediatric Nursing.
5. Should be trained in:
5.1. BLS.
5.2. Insertion of IV lines.
5.3. Assessment and monitoring patients under sedation.
5.4. Pain assessment and management.
5.5. Understand the pharmacology of the agents that are administered, as well as the role of
pharmacological antagonists for opioids and benzodiazepines.
General Considerations:
1. The provision of sedation/analgesia (conscious sedation) is an interdependent role, requiring a

physician's order prior to implementation.
2. Appropriate pre-procedure evaluation of patients' histories, physical findings and laboratory

evaluation reduces the risk of adverse outcomes and leads to improved patient satisfaction.
3. The individuals providing such care should have proven competency prior to administering conscious
sedation.
4. The individuals providing such care should be also knowledgeable about use of reversal agents.
5. The provider should also have current BLS knowledge.
6. Sedation/analgesia can be administered only in designated areas meeting all criteria in the protocol.
7. The appropriate choice of agents and techniques for sedation /analgesia is dependent on the
experience and preference of the individual physicians, requirements or constraints imposed by the
patient or procedure, and the likelihood of producing unintended loss of consciousness.
8. Excessive sedation/analgesia may result in cardiac or respiratory depression that must be rapidly
recognized and appropriately managed to avoid the risk of hypoxic brain damage, cardiac arrest, or
death.
9. Conversely, inadequate sedation/analgesia may result in undue patient discomfort or patient injury
because of lack of cooperation or adverse physiologic response to stress.
APPENDIX 8: MODERATE SEDATION/ANALGESIA
Locations Designated For Moderate Sedation/Analgesia
Moderate Sedation should be administered only in designated areas that meeting all criteria in the protocol.
This area must have specific structures, which include:
1. Pre-determined exclusion criteria for patients who are not candidates for Moderate sedation
2. A written protocol to ensure continuous monitoring of patients throughout the procedure, as well as
the recovery phase.
3. Instructions for medication administration to include drugs, drug routes, and amounts recommended
for administration.
4. Written guidelines for managing potential complications or emergencies.
5. Availability of Oxygen:
5.1. There should be a reliable source of oxygen adequate for the length of the procedure and a
backup supply.
5.1.1. Prior to administering any anesthetic, the physician should consider the capabilities,
limitations and accessibility of both the primary and backup oxygen sources.
5.1.2. Oxygen piped from a central source is strongly encouraged.
5.1.3. The backup system should include the equivalent of at least a full E cylinder.
6. Availability of emergency equipment
6.1. Appropriate emergency equipment for maintaining the patient's airway, Respiratory status and
cardiac status will be readily available when sedation medications are given to the patient.
6.2. Equipment should be suitable for the size and age of the patient.
6.3. The following equipment is essential, but not limited to:
6.3.1. Emergency cart with defibrillator (immediately accessible) Suction at bedside
6.3.2. Oxygen and oxygen delivery devices (cannula, mask)
6.3.3. Appropriate oral and nasal airways (pediatric and adult as appropriate)
6.3.4. Continuous noninvasive BP monitoring device
6.3.5. Cardiac monitor
6.3.6. Pulse oxymeter
6.3.7. Ambu bag
6.3.8. Intubation tray
7. Availability of emergency medication:
7.1. Adequate anesthesia drugs and supplies for the intended care.
7.2. Pharmacological antagonists (Naloxone and Flumazenil).
7.3. IV supplies
General Considerations for Moderate Sedation/Analgesia
1. The provision of moderate sedation/analgesia is an interdependent role, requiring a physician's order

prior to implementation.
2. Appropriate pre-procedure evaluation of patients' histories, physical findings and laboratory evaluation
reduces the risk of adverse outcomes and leads to improved patient satisfaction.
3. The individuals providing such care shall have proven competency prior to administering conscious
sedation.
4. The individuals providing such care should be also knowledgeable about use of reversal agents.
5. The provider must also have current BLS knowledge.
6. Sedation/analgesia can be administered only in designated areas meeting all criteria in the protocol.
7. The appropriate choice of agents and techniques for sedation /analgesia is dependent on the
experience and preference of the individual physicians, requirements or constraints imposed by the
patient or procedure, and the likelihood of producing unintended loss of consciousness.
8. Excessive sedation/analgesia may result in cardiac or respiratory depression and should be rapidly
recognized and appropriately managed to avoid the risk of hypoxic brain damage, cardiac arrest, or
death.
9. In order to avoid excessive levels of sedation, drugs should be titrated in increments rather than
administered in larger doses according to predetermined notions of efficacy.
10. Continuous infusions (propofol) are superior to intermittent bolus dosing because they produce less
fluctuation in drug concentration, thus reducing the number of episodes of inadequate or excessive
sedation and contributing to prompter recovery.
11. Conversely, inadequate sedation/analgesia may result in undue patient discomfort or patient injury
because of lack of cooperation or adverse physiologic response to stress.
12. The ideal sedation technique involves the administration of either individual drugs or combinations of
analgesic, amnesic and hypnotic drugs.
13. The drug(s) selected should allow rapid and complete recovery with a minimal incidence of nausea and
vomiting or residual cardio-respiratory depression.
14. Causes of Patient Agitation During Moderate Sedation/Analgesia:
14.1. Increased patient agitation may be a result of pain or anxiety.
14.1.1. Pain may be treated with systemic analgesics, regional techniques, or removal of the
painful stimulus.
14.1.2. Anxiety may be treated with reassurance and/or a Benzodiazepine.
14.2. Life threatening factors
14.2.1. Hypoxemia
14.2.2. Hypoventilation
14.2.3. Impending local Anaesthetics toxicity
14.2.4. Cerebral hypo-perfusion
14.3. Less ominous but often overlooked factors
14.3.1. Distended bladder
14.3.2. Hypothermia or hyperthermia
14.3.3. Pruritus, Nausea
14.3.4. Positional discomfort
14.3.5. Uncomfortable oxygen masks or nasal Cannula
14.3.6. Intravenous cannulation site infiltration
14.3.7. Member of surgical team leaning on patient
14.3.8. Prolonged pneumatic tourniquet inflation
15. Patient’s Outcome after Sedation/Analgesia:
Surgeries performed under Sedation/Analgesia may offer many advantages over procedures done under
general or regional Anesthesia such as:
15.1. Preservation of protective reflex
15.2. Decreased post-operative pain
15.3. Decreased post-operative nausea and vomiting
15.4. Reduced cardiovascular and respiratory side effect
15.5. Invoke less physiological disturbances, the factor which is more advantageous in older
and critically ill patient
15.6. Prevention of endotracheal intubation risks such as dental damage, sore throat or vocal cords
injury etc.
15.7. Allow faster recovery, shorter stay in PACU and faster discharge from hospital
16. Quality Assurance for Moderate Sedation/Analgesia:
16.1. The fundamental concept underlying modern Moderate Sedation is that the care delivered to
the patient should be of high quality
16.2. All concerned staff should become involved in clinical audit activities as this yields benefits for
all concerned. The audit activities include:
16.2.1. The satisfaction of the patient and the family.
16.2.2. Patient’s complaints: Peri-, intra- and post-operatively:
a. Pain.
b. Nausea and vomiting.
c. Amnesia.
d. Headache, dizziness,
e. Fainting attacks or tiredness.
f. Loss of appetite, etc.
17. Monitoring During the Moderate Sedation/Analgesia
17.1. Level of Consciousness:
17.1.1. It is important that a qualified staff continually evaluate the patient’s response to
verbal stimulation in order to titrate the level of sedation and to allow the early
detection of neurological or cardiopulmonary dysfunction.
17.1.2. The response of patients to commands during procedures performed with
sedation/analgesia serves as a guide to their level of consciousness.
17.1.3. Spoken responses also provide an indication that the patients are breathing.
17.1.4. Patients, whose only response is reflex withdrawal from painful stimuli are likely to be
deeply sedated, approaching a state of general anesthesia, and should be treated
accordingly.
17.1.5. Monitoring of patient response to verbal commands should be routine, except in
patients who are unable to respond appropriately (e.g., young children, mentally
impaired or uncooperative patients) or during procedures in which facial movement
could be detrimental.
17.1.6. During procedures in which a verbal response is not possible (e.g., oral surgery, upper
endoscopies), the ability to give a "thumbs up" or other indication of consciousness in
response to verbal or tactile (light tap) stimulation suggests that the patient will be
able to control his airway and take deep breaths if necessary.
17.2. Pulmonary Ventilation:
Monitoring of Respiratory function reduces the risk of adverse outcomes associated with
sedation/analgesia. Ventilatory function should be continually monitored by:
17.2.1. Visual, Tactile and Auditory Assessment
a. Rate, depth and pattern of breathing.
b. Pallor, Shivering, Cyanosis.
c. In circumstances where patients are physically separated from the caregiver,
automated apnea monitoring (by detection of exhaled carbon dioxide or other
modality) may decrease risks.
17.2.2. Auscultation: Heart and breath sounds (pre-cordial stethoscope)
17.3. Oxygenation:
The early detection of hypoxemia using Oximetry during sedation/analgesia decreases the
likelihood of adverse outcomes, such as cardiac arrest and death.
17.3.1. All patients undergoing sedation/analgesia should be monitored by pulse Oximetry

with appropriate alarms. If available, the variable pitch "beep," which gives a continuous
audible indication of the oxygen saturation reading, may be helpful.
17.3.2. The nurse will inform the physician of change in patient condition or drop in SaO2
below 92%, or the other parameter.
17.3.3. If hypoxemia is anticipated or develops during sedation/analgesia, supplemental oxygen
should be administered and titrate the oxygen.
17.3.4. Capnography (most effective in intubated patients but can be adapted (side-stream) in
non-intubated patients.
17.4. Hemodynamic:
Sedative/analgesic agents may blunt the appropriate autonomic compensation for hypovolemia
and procedure-related stresses. Early detection of changes in patients' heart rate and blood
pressure may enable physicians to detect problems and intervene in a timely fashion, reducing
the risk of cardiovascular collapse.
17.4.1. Continuous Electrocardiograph monitoring should be used in patients with
hypertension, significant cardiovascular disease as well as during procedures where
dysrhythmias are anticipated.
17.4.2. Blood pressure should be determined before sedation/analgesia is initiated.
17.4.3. Palpation of the arterial pulse,
17.4.4. Peripheral perfusion based on temperature of extremities and capillary refill
17.4.5. Once sedation/analgesia is established, blood pressure should be measured at regular
intervals during the procedure, as well as during the recovery period (at least every 5
minutes).
17.4.6. Routine blood pressure monitoring with the sedation of children often causes
unnecessary stimulation of the patient resulting in awakening. For this reason, blood
pressures are taken pre and post procedure and at intervals based on patient needs
and clinician judgment.
17.5. Temperature: especially in:
17.5.1. Elderly patients.
17.5.2. Prolonged procedures.
17.5.3. Cold operating rooms.
17.6. Availability of a Staff Person Dedicated Solely to Patient Monitoring and Safety
17.6.1. The presence of a vigilant anaesthetist is the single most important monitor in the
operating room.
17.6.2. Monitoring techniques and devices enhances the effectiveness of this vigilance.
17.6.3. A designated individual, other than the physician performing the procedure, should be
present to monitor the patient throughout procedures performed with
sedation/analgesia. This individual should not leave the procedure room while the
procedure is being performed.
APPENDIX 9: ALDRETH’S SCORING SYSTEM FOR RECOVERY & DISCHARGE FROM THE
RECOVERY ROOM
According to the evaluation and documentation the criteria for Activity, Breathing, Circulation,
Consciousness, SaO2
Discharge Criteria Discharge Score
Activity
Moving all four limbs spontaneously or on command 2
Moving two limbs spontaneously or on command 1
No movement of limbs neither spontaneously nor on command 0
Breathing
Able to breathe deeply, and coughing adequately 2
Dyspnea or shortness of breath 1
Apnea 0
Circulation
BP is + 20% of the pre-operative initial value 2
BP is + 20 to 50% of the pre-operative initial value 1
BP is > + 50% of the pre-operative initial value 0
Consciousness
Fully conscious 2
Responding to verbal commands 1
Not responding 0
SaO2
Able to maintain SaO2 > 92% on room air 2
Needs oxygen therapy to maintain SaO2 > 90 1
SaO2 < 90% despite oxygen therapy 0
Total Score
1. All patients should be assessed and scored on admission, in individual intervals and before discharge from the
recovery area.
2. Values should be documented in the anaesthesia chart.
3. The scoring includes five futures:
4. Activity, Breathing, Circulation, Consciousness and SaO2
5. Each feature will be scored with 0, 1 or 2 point, so that the maximum numbers of points will be 10 and the
least is 0 point.
6. The patient should be discharged from the recovery area only if the total score  nine or alternatively, at the
pre-sedation baseline.
APPENDIX 10: CRITERIA FOR HOME–READINESS
Evaluation and documentation the criteria for Vital Signs, Ambulation, Nausea and Vomiting,
Pain, Surgical Bleeding.
Post-Anaesthesia Recovery Score for Discharge Home (PARSDH)
Discharge Criteria Discharge Score

Vital Signs
Vital signs + 20% of pre-operative value 2
Vital signs + 20 – 40% of pre-operative value 1
Vital signs + 40% of pre-operative value 0
Ambulation
Steady gait and no dizziness 2
With assistance 1
None / dizziness 0
Nausea & Vomiting
No or minimal 2
Moderate 1
Severe 0
Pain
No or minimal 2
Moderate 1
Severe 0
Surgical Bleeding
No or minimal 2
Moderate 1
Severe 0
Total Score (Discharge Home)
1. All patients those going to be discharged home should be assessed and scored on the “criteria to go home”
after fulfilling the Aldrete’s recovery & discharge criteria.
2. Values should be documented in the sedation chart.
3. The scoring includes five futures Vital Signs, Ambulation, Nausea and Vomiting, Pain and Surgical Bleeding
4. Each feature will be scored with 0, 1 or 2 point, so that the maximum numbers of points will be 10 and the
least is 0 point.
5. The patient is ready for discharge home only if the totals score  9.
6. Make sure that the patient have responsible escort for transport and at home.
7. Driving and operating machinery should not be attempted for 24 hour.
APPENDIX 11: MINIMUM EMERGENCY MEDICATION (CLASS A, B and CM)
No. Drug Name Quantity Comments

Mandatory
1. Inj. Adrenaline 1:1000 5 Anaphylaxis or acute angio-oedema
2. Inj. Atropine 600mcg 10 Bradycardia, Organophosphate and
Carbamate overdose
3. Adenosine 3mg /ml 2ml inj. 3 -
4. Inj. Diazepam 10mg/2ml 2 Status epilepticus
5. Rectal Diazepam 2 For children with Status epilepticus
6. Inj. Amiodarone 50mg/Ml 2 Tachyarrhythmia, cardiac arrest
7. Inj. Dextrose 50%, 50ml 2 Hypoglycaemia
8. Inj. Furosemide 20mg/2ml 3 Relief of pulmonary oedema
9. Inj. Hydrocortisone 100mg/2ml 3 Acute asthma attack and post anaphylaxis
10. Inj. Dopamine 200mg/5ml 2 Hypovolaemic shock cardiogenic shock, CHF
11. Inj. Dobutamine 250mg 2 -
12. IV Fluids such as Ringer Lactate, 5 each For hypovolemia
Dextrose Water, Dextrose Saline,
Normal Saline.
13. Water for injection 1 Box To mix hydrocortisone inj, etc.
14. EpiPen Jr. (for child less than 30 2 -
kilograms)
15. Epinephrine (Auto-Injectors) 2 -
16. Normal Saline 10 ml 10 For flushing after Adenosine etc.
APPENDIX 12: MINIMUM EMERGENCY MEDICATION (CLASS C)
Include CLASS A, B and CM Drugs and the following:
No. Drug Name Strength Quantity

Mandatory
1. XYLOCARD (LIDOCAINE) 2%(100mg/5 ml) Stock as per scope of services and patient need and volume
(BOLUS)
2. ROCURONIUM BROMIDE 50mg/5ml Vial Stock as per scope of services and patient need and volume
3. 1/5 Dextrose/ Saline 250ML 1/5 Strength Stock as per scope of services and patient need and volume
Inj.
4. 1/5 Dextrose/ Saline 500ML 1/5 Strength Stock as per scope of services and patient need and volume
Inj.
5. Adenosine 2ML Inj. 3MG/ML Stock as per scope of services and patient need and volume
6. Adrenaline 1ML Inj. 1: 1000 Stock as per scope of services and patient need and volume
7. Amiodarone 3ML Inj. 50MG/ML Stock as per scope of services and patient need and volume
8. Atropine 1ML Inj. 0.6MG/ML Stock as per scope of services and patient need and volume
9. Calcium Chloride 10ML Inj. 10% Stock as per scope of services and patient need and volume
10. CISATRACURIUM 20mg/10ml Stock as per scope of services and patient need and volume
(2mg/1ml)
11. Compound Sodium Full Strength Stock as per scope of services and patient need and volume
Lactate FULL STRENGTH
12. Dextrose 50% 50ML Inj. 0.5GM/ML Stock as per scope of services and patient need and volume
13. Dextrose 500ML Inj. 5% Stock as per scope of services and patient need and volume
14. DIAZEPAM 5MG Stock as per scope of services and patient need and volume
(RECTAL SOLUTION)
15. Diazepam 2ML Inj. 5MG/ML Stock as per scope of services and patient need and volume
16. DOBUTAMINE 250 mg Stock as per scope of services and patient need and volume
HYDROCHLORIDE
17. Dopamine 5ML Inj. 40MG/ML Stock as per scope of services and patient need and volume
18. FLUMAZENIL (ANEXATE) 0.5mg/5ml Stock as per scope of services and patient need and volume
19. Frusemide 2ML Inj. 10MG/ML Stock as per scope of services and patient need and volume
20. Gelofusine 500ML Inj. 4% Stock as per scope of services and patient need and volume
21. K-Y Jelly - Stock as per scope of services and patient need and volume
22. Lignocaine 5ML Inj. 10MG/ML Stock as per scope of services and patient need and volume
23. Magnesium Sulfate 10ML Inj. 50% Stock as per scope of services and patient need and volume
24. MIDAZOLAM (DORMICUM) 15mg/3ml Stock as per scope of services and patient need and volume
25. Naloxone HCl 1ML Inj. 0.4MG/ML Stock as per scope of services and patient need and volume
26. NORADRENALINE 4mg/4ml Stock as per scope of services and patient need and volume
27. PROPOFOL 1% 200mg (10mg/ml) Stock as per scope of services and patient need and volume
28. Sodium Bicarbonate 50ML Inj. 8.40% Stock as per scope of services and patient need and volume
29. Sodium Chloride 10ML Inj 0.90% Stock as per scope of services and patient need and volume
30. Sodium Chloride 1L Inj. 0.90% Stock as per scope of services and patient need and volume
31. Sodium Chloride 500ML Inj. 0.90% Stock as per scope of services and patient need and volume
32. SUXAMETHONIUM 100mg (50mg/ml) Stock as per scope of services and patient need and volume
(SUCCINYLCHODLINE)
33. VASOPRESSIN 20iu/ml Stock as per scope of services and patient need and volume
34. XYLOCAINE JELLY 0.02 Stock as per scope of services and patient need and volume
APPENDIX 13: HEALTHCARE PROFESSIONAL VACCINATION AND
IMMUNISATION REQUIREMENTS
Mandatory Vaccination:
Hepatitis B:
If previously unvaccinated, give 3 doses series of Hepatitis B vaccine to all non- immune employees upon hiring.
Hepatitis B Antibody will be checked after the vaccination is completed.
If the level is < 10 international units, a second 3 doses series will be given. If the repeat Hepatitis B
Antibody is still <10 international units, then the employee will be labelled as non-responder.
Varicella Vaccine:
Check evidence of immunity to varicella.
Offer/provide Varicella vaccine to all non-immune employees.
Recommended vaccines:
Recommended Influenza vaccine annually to all clinical healthcare workers, before the influenza season.
Recommend Pneumonia vaccination at age 65 (one-time vaccine).
Recommend Tetanus booster (once every 10 years).

DHA Standards For Day Surgical Centres

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STANDARDS FOR DAY

Health Policies and Standards Department

Health Regulation Sector (2019)

Objective #1: Position Dubai as a global medical destination by introducing a value-based,

comprehensive, integrated and high-quality service delivery system.

Objective #3: Promote public and private collaboration in healthcare.

Objective #4: Foster innovation across the continuum of care.

Health Regulation Sector

Dubai Health Authority

EXECUTIVE SUMMARY ................................................................................................................. 5

5. STANDARD ONE: REGISTRATION AND LICENSURE PROCEDURES ................................... 15

6. STANDARD TWO: HEALTH FACILITY REQUIREMENTS ..................................................... 18

7. STANDARD THREE: STAFFING AND HUMAN RESOURCE REQUIREMENTS ...................... 22

8. STANDARD FOUR: PRE-OP ASSESSMENT, PATIENT CARE AND ANESTHESIA ................ 26

9. STANDARD FIVE: PATIENT SAFETY ................................................................................... 31

10. STANDARD SIX: PATIENT MONITORING AND DISCHARGE ............................................... 33

11. STANDARD SEVEN: MEDICATION MANAGEMENT AND PHARMACY .............................. 36

12. STANDARD EIGHT: CRITICAL CARE SERVICES AND EMERGENCY MANAGEMENT........... 39

13. STANDARD NINE: SUPPORT SERVICES .............................................................................. 44

15. STANDARD ELEVEN: ADMINISTRATIVE REPORTING ........................................................ 48

16. STANDARD TWELVE: FACILITY MANAGEMENT ................................................................ 50

18. STANDARD FOURTEEN: PATIENT RIGHTS AND RESPONSIBILITIES ................................. 63

APPENDIX 1: DSC CLASSIFICATION (ANESTHESIA, SEDATION AND PATIENT SAFETY) ......... 70

APPENDIX 2: DSC CLASSIFICATION AND PERMITTED MEDICATIONS ...................................... 73

APPENDIX 3: LIST OF PERMITTED PROCEDURES BY DAY SURGICAL CENTRE CLASSIFICATION77

APPENDIX 4: DAY SURGICAL CENTRE CARE PATHWAY............................................................ 84

APPENDIX 5: MINIMUM REQUIREMENTS FOR INFORMED CONSENT FORM............................ 85

APPENDIX 6: SURGICAL SAFTEY CHECKLIST ............................................................................. 88

APPENDIX 7: CONSCIOUS SEDATION COMPETENCY ................................................................ 89

AND DUTIES TRAINING OF PERSONNEL AND GENERAL CONSIDERATIONS ............................ 89

APPENDIX 8: MODERATE SEDATION/ANALGESIA .................................................................... 91

RECOVERY ROOM ........................................................................................................................ 97

APPENDIX 10: CRITERIA FOR HOME–READINESS ..................................................................... 98

APPENDIX 12: MINIMUM EMERGENCY MEDICATION (CLASS C) ............................................ 101

APPENDIX 13: HEALTHCARE PROFESSIONAL VACCINATION AND ........................................ 103

IMMUNISATION REQUIREMENTS ............................................................................................. 103

responsibilities are also included.

Adverse Event: is an unanticipated, unintended, undesirable or potentially dangerous

occurrence/injury in a Healthcare organization.

Consultant/Specialist Led Service: is a service where a consultant or specialist physician or dentist

specialisation, patient acuity and sedation levels.

detachment/dissociation from the environment and self.

requirements for the United Arab Emirates.

make an OR a hybrid operating room).

healthcare professional in a DHA licensed health facility.

kin/ legal guardian, as per UAE Federal Laws.

from Surgery or Sedation/Anesthesia.

example, the use of a drug, or a procedure, or risk in the care environment.

 Normal eye movements

 Intact protective reflexes

 Amnesia may or may not be present

Refer to CLASS A CENTRE (Appendix 1).

b. Moderate Sedation/Analgesia (Conscious Sedation) is a drug-induced depression of

while maintaining cardio-respiratory function. This commonly involves intravenous administration

depressed consciousness that:

example, "open your eyes."

Refer to CLASS B CENTRE (Appendix 1).

c. Deep Sedation/Analgesia is a drug-induced depression of consciousness or unconsciousness