Unit-1

Out Patient Department

Objectives
After going through this Unit, you will be able to:
 To know functions and types of the Out-Patient Services;
 To know physical structure and Layout of OPD;
 To understand the planning of equipment and human resources required in OPD;
 To know the policies and procedure governing functioning of OPD services;
 To understand the problems of OPD;
Structure
1.1 Introduction
1.2 Historical Aspect
1.3 Types of OPD
1.4 Functions of OPD
1.5 Planning
1.6 Designs Of Buildings
1.7 Equipment
1.8 Staffing
1.9 Work Flow Process-OPD
1.10 Administrative Issues
1.11 Monitoring and Evaluation

1.12 Management Structure

1.13 Summary
1.14 Key Words

1.1. INTRODUCTION
Out Patient department is the place in hospital, where a patient first reports to seek medical help.
Some institutions run only outpatient services. Examples can be given of consulting rooms of
specialists and dispensaries of general practitioners. Sometimes the doctor’s consultations services
are combined with diagnostic facilities like clinical laboratory and imaging facilities. Occasionally
there may be some observation beds or day care, generally aimed at providing medical help to
ambulatory patients. This is the place from where patients are admitted to inpatient facility as and
when necessary. OPD is an integral part of a ‘hospital’.
1.2. HISTORICAL ASPECT

The individual doctors have been providing medical care to ambulatory patients through their clinics
or dispensaries. So the history of outpatient department is as old as medical profession. A group of
doctors came together at one place to examine and advice patients in Paris during middle of
seventeenth century. This has been identified as the origin of present day OPD service.
It was in United States that the modern OPD were established on the framework of dispensaries. In
the early days the so called OPD catered to poor patients as charity. The increasing need for
specialist’s consultants and dependence on diagnostic services helped in bringing about the present
day status.

1.3 TYPES OF OPD

The OPD can be centralized where all the specialties in medical field are available under one roof.
They also have facilities for laboratory and radiological investigations. Some ambulatory treatments
can also be carried out in these departments. The OPD of corporate or government hospitals run on
these lines.
The decentralized types of OPD are those who cater only to particular specialty or service. The
specialist clinics, OPD of hospital dedicated to certain specialties like Heart institutes. Trauma care
hospitals, Infectious diseases Hospitals can be quoted as examples of the type.

1.4. FUNCTIONS OF OPD

The functions of outpatient department encompass any service that can be given on ambulatory
basis. The scope is ever increasing. Some of them can be summarized as under.
 Provide doctors consultation
 Provide facility for laboratory investigations
 Provide facility for X ray and imaging procedures employing electronic and electrical
tools
 Services for admission to hospital
 Provide facilities for follow up of patients already under treatment or those discharged
from hospital
 Carry out small day care surgical procedure (day care surgeries)
 Carry out treatments in the form of immunization administration of injections and
Wound dressings
 Administer chemotherapies on ambulatory basis
  Health education for patients, visitors etc.
 Education of medical students
 Collection and compilation of data for clinical, epidemiological & Social research
 Counselling services for family welfare programme, AIDs etc.
 Run special clinics like ANC, PNC well baby
 Rehabilitation activities for physically handicapped and mentally retarded

1.5. PLANNING

Physical Layout
OPD should be near a road and at the entrance of the hospital. There should be sufficient space for
parking the vehicles. This area should be dust free. The compound should be lined with tall trees
that can prevent dust from road to come in. Trees can also be planted along the building wall.
There should be an entrance gate, an exit gate and a gate for emergency that leads directly to the
emergency medical services department. Gates for entry and exit for staff should be separate and
they should lead to the staff parking directly. The gates should be guarded by security personnel
who should keep watch on the persons coming in. They should help the handicapped, disabled and
serious patients to reach the OPD / casualty by providing assistance through wheelchairs and
stretchers. They should keep eye on known and suspicious antisocial elements and prevent their
entry. Sometimes this cannot be done in such cases they should inform the central watch on the
movement and activities of such elements. The security personnel should see that the gate is always
clear of vehicles or pedestrians.

The arrangement for parking should be made in such a way that smooth passage of vehicles is
maintained at all times and there are no traffic jams.
In order to save space, multi-storeyed mechanized parking arrangement should always be
considered. Such parking is highly recommended in large cities and large hospitals, which have good
clientele. The cost of maintenance on parking can be met with by levying parking charges on hourly
basis
The entrance for ambulance should always be separate and it should lead to the casualty as most of
the patients brought in ambulance need immediate attention and expeditious management.
Occasionally such patients can arrive in private vehicles or by public transport. The guards at
entrance gate should detect and direct such patients to casualty.
The entrance for staff and utility vehicles should be separate. They should lead to staff parking or to
the store receiving area as the case may be. The vehicles of this type should have a sticker pass on
wind screen identifiable from a distance of 3 meters.
The OPD Building
The plinth level of building should be at least 1-2 above the road level. This shall avoid the building
becoming subterranean in due course of time due to rising road level. Secondly flooding of water
due to rains can be avoided. Thirdly it provides a better gradient for the toilets and bathrooms
effluents to pass down. The repairs and removal of blockages in the effluent lines can also be done
easily as the pipes are above ground level for certain height.
The OPD complex should preferably be located on ground floor for convenient access. However
certain departments with low clientele, non-emergency clientele can be accommodated on upper
floors.

While planning the department the scope for future expansion should always be kept in mind. The
diagnostic services like laboratory and radio diagnosis should be accommodated at one end of OPD
building or in a separate building annexing it. These facilities should be accessible for the indoor
facilities and intensive care unit also.

The average area required is about 18-20 sq. meters per hospital bed. The zones that need be
created are:

Circulation Zone
Circulation zone in the form of passages, foyer corridors. Lifts staircases ramps etc. This area
occupies about 30% of the total area for OPD. The corridors and passages should be wide enough for
passage of two stretcher trolleys and people on their feet, should be not less than 2.5 – 3 meters
wide. The floor should be non-absorbent and non-slippery. The walls also should have non-
absorbent washable surface up to 2 meters height. There should be adequate lighting and
ventilation. Air circulators should be provided for any corridor or closed passage of a length of 10
meters or more. Security posts should be provided at the entrance. CCTV cameras should be
installed at reasonable distance in the corridors and passages.

The Public Zone

It Comprises of:
 Entrance lobby
  Inquiry and reception counters
 Registration windows and records back office

The number of registration windows depends on the work load of hospital. However separate
windows for males, females, old and new patients and one for senior citizens should be provided. A
registration counter should serve 20 patients per hour. The records back office should be sufficient
to store record for 5 years. On an average 20 sq. meters area is recommended for this.

 Main waiting area – the recommendation is to provide minimum and above 4 sq. meters per
patient. This should be annexed to the registration windows.

 Snacks Bar should be provided in the waiting area.

 There should be some entertainment facility in the form of television, newspapers, periodicals,
booklets giving information about the hospital.

 Information about working of hospital, managing body, list of doctors and their working hours,
hospital fees structure, general instructions to patients, grievances redressal system, some
health education material should be displayed in the waiting area. The list of services available
and those not available in OPD should also be displayed.

 Wash rooms and toilets for the patients in ratio of 1 for 200 patients. They should be separate
for males and females.
The Clinical Zones
The clinical zones house the doctor’s offices cum examination rooms, small waiting areas for them.
Separate office should be provided for each specialty, sub specialty and super specialty. The offices
for specialties with large attendance should be nearer to the main waiting and registration area. The
clinics that need services of OPD operation theatre should be nearer to it.
Each clinical zone should have a sub waiting area adequate to accommodate average number of
patients. The recommendation is 0.8 sq. meter per patient. The doctor’s office and examination
rooms should be of 15 sq. meters, they should have wide door to admit the stretcher trolley
comfortably.
The name of clinical service, its pictorial symbol, room number and the name of doctor in
attendance should be displayed on a board at the door. The room should be well ventilated and
illuminated. There should be office furniture and examination table with steps to climb upon. Some
privacy for the table should be provided by using screen or curtain. The instruments and equipment
for examination should be provided depending on branch of clinical service. An x ray viewing box,
height and weight scales should be available. A computer also is installed now days and is connected
to all sections.
The room should be decorated modestly. Some health education material, posters, charts on
common problems related to the subject are not out of place, so also a few books on the subject.
The waste disposal bags and buckets of suitable colour code are essential.
The clinical zone also include, certain facilities like injections room, dressing room, pharmacy and
minor OT cum office procedures room, plaster room etc. Every OPD unit should be designed in such
a way that if can be built and operated at the lowest possible cost and at the same time. It can
achieve the functional goals of the unit which are as follows:

 To provide the highest possible quality of medical and nursing care for the patients.

 To provide necessary equipment, essential drugs and all other stores required for patient
care in an organized manner in the ward.

 To furnish most desirable environment substituting as temporary home for the patients
designed to accommodate all their basic needs (eating, toilet activities,
Diversional matters).

 To provide facilities to meet the needs of the visitors and attendants.

 To provide highest degree of job satisfaction for the nursing and medical staff and to render
opportunity for training and research.
The Injection Room
The area required for injection room varies between 10 to 40 sq. meters. The ratio is 0.8 sq. meters
per patient. It should be divided into four areas like waiting room, injection room proper,
observation room and small stores.
The injection room proper should be separate for males and females for the purpose of privacy.
Each room should have 2-3 tables. The observation room should have about 2 beds for patients who
develop anaphylactic or allergic reactions after administration of injections. The standard protocol
for management of such reactions should be displayed on the wall.
The equipment’s required are kept in ready for use condition. Injection room should be provided
with cold storage facility for storage of drugs. The immunization section can be housed in this part. A
separate room should then be added Dressing Room
This required 10-20 sq. meters area at a rate of 0.75 sq. meters per patient. It should be divided into
a waiting room, separate dressing room for males and females, with female attendant in female
dressing room, adequately ventilated and a small store. Arrangements for hand washing, dressing
tables, adequate illumination should be made. Supply of dressing material and waste disposal facility
should be created.

Minor OT cum Office Procedures Section

It is used by all surgical branches. This is the place where minor surgical procedures and office
procedures like endoscopies etc. can be performed without general or spinal anaesthesia. Though
minor procedures are carried out the set up can no way be less than a major OT. The area
requirement, monitoring equipment, aseptic precautions, air conditioning are to be made on the
lines same as a major OT. The supply for sterile instruments and material and their after use
management are to be ensured so also the waste disposal.
If the hospital also caters ‘day care services’, there should be two separate rooms, one for septic and
other for clean cases. An observation ward for operated cases, relatives waiting area etc. have to be
provided. A day care service is a separate establishment gaining popular acceptance in medical field
now days. It is a subject for separate discussion and hence not elaborated upon here.
Plaster Room
Here the plaster application and removal of old plaster is done. These two functions should be done
in separate rooms. Application of plasters without anaesthesia is undertaken here. Adequate water
supply and electrical points to attach plaster cutter should be provided. Arrangement for dressing
wounds and after removal of plaster should be made.
Pharmacy
This is the place where medicines are dispensed. It should be established as per the guidelines from
drug control department. Additionally there should be a waiting area a snacks bar drinking water
arrangement and toilets.
Diagnostic facilities like clinical laboratory, radiology and imaging blood bank physiotherapy, medico
social work Health education facility are established along with OPD in many hospitals. They are
discussed in detail in relevant modules.
Administrative zone
This houses administrative office, business sections and housekeeping section. The administrative
office accommodates administrator and assistants, business office deals with personal matters,
accounts and cash dealings, record and reporting etc. Housekeeping section looks after cleaning and
sanitation. A small section for linen should also be established.

Communication
There should be adequate number of telephone lines with a network of extensions to all sections of
OPD. There should be good fail proof connectivity with the indoor sections and all service centres in
the hospital. Though the atomization in PBX can give an access to every section provided the
extension number is known services of telephone operators should be made available.

The telephone connectivity should be on land line as well as mobile network. Internet connectivity
also should be installed. There should be an arrangement to give necessary information on
telephone. Appointments for the patients also should be given on telephone so as to avoid delays
and waiting.
In case an appointment is postponed, pre-ponded or cancelled, the information should be given to
the concerned well in advance from the OPD.
Signage
OPD has many departments and sections. It becomes difficult to find out the particular department.
For identification there should be some method. It can be simple numerical system. It may be
alphabetical or combination of them, however a pictorial signage is more effective. In recent past
graphic signs have been developed on the lines we see them on airports and railway stations. There
may be difficulty in developing graphic signage for every specialty. Artistic skill may overcome these
difficulties.

1.6 DESIGNS OF BUILDINGS

The building can be designed in different ways

A. One corridor with rooms on both sides
B. Two corridors with rooms on both sides.

C. Central hall with multiple wings.

The corridors or wings can be made with two rows of rooms on wither wise
D. Central circular hall with Radial wings
Single row of rooms on one side of corridor or two rows on either side

E. Storied structure based on any of above

The upper story can accommodate administrative offices, stores, conference, staff, cafeteria, blood
bank etc.

F. Peripheral Corridor

1.7 EQUIPMENT

There should be adequate number of stretcher trolleys and wheel chairs stationed near the
entrance. Similarly these should be provided with attendants.
The consultation room should have the necessary examination facilities like blood pressure machine,
ECC machine. Examination tray with instruments for general surgery, proctology ENT, ophthalmic
examinations, x ray viewing box, weighing machine (Paediatric in Paediatric OPD) should be
provided.
Resuscitation equipment and emergency drugs should be kept in every OPD section to meet
unforeseen emergencies. Wash basins should be available in every section.
1.8 STAFFING

 Security personnel at entrance, exit and cash section

 Stretcher bearer in adequate number depending on work load
 Attendant at every clinical department
 Nurses (Preferably females) in every clinical department
 Receptionists
 Public relation officer
 Medical Social Worker
 Registration clerks
 Operation Theatre attendants
 Dressers male and female
 Nurses in injection rooms
 Plumber, electrician, biomedical engineer (can be shared)
 Plaster room attendant
 Clerical staff
 Statistician (can be shared)
 Accountant
 Cashiers
 Administrator

The number of above staff should be decided on the basis of inspection of services provided,
duration of OPD services and work load.

1.9 WORK FLOW PROCESS-OPD

Two types of patients come to OPD. One type is that of patients who come by taking prior
appointments. The others are walk in.

There should be an appointment clerk who gives appointments and maintains record of this. The
appointments may be department wise or for particular specialists or investigation or a minor
surgical procedure. Appointments are also for review after investigations or follow up. All sorts of
appointments should be maintained properly and attended to.
The other category is of walk in patients and they are in larger number in most of the public
hospitals. Here the services are provided on first come – first served basis. Exceptions can be made
of disabled and elderly patients.
After coming to OPD patients should be received by the receptionists who inquire about nature of
their illness and directs them to the registration section to take out their case paper of specialty
relevant to their illness. Then they are directed to the concerned OPD section where they are
examined by the doctors. They may be asked to undergo certain investigations for which they are
sent to the laboratory or radiology department.
On completion of the investigations they go to the doctor again who review the reports and
prescribes treatment. They go to the pharmacy, collect medicines and leave OPD. Some patients
may be asked to get admitted to hospital. They go to admission office, get their indoor papers
prepared and are then escorted to the wards. Sometimes there in no vacant beds in the wards or the
type of accommodation patient wants, such patients may be given appointment for admission.
Before closing the OPD it should be ensured that every patient that has been registered is seen by
doctor and is advised properly.
The registration of patients should start half an hour before the doctors come in and should stop half
an hour before closing the consultation.

Flow Chart
Patient Reception Registration X-Ray
Investigation Laboratory

MSW Minor OT Doctor Investigation

Billing Injections, Dressing, Plaster
Counselling Pharmacy Out
Re appointment
Admission

IPD

1.10 ADMINISTRATIVE ISSUES

Policy
There should be a manual of the procedures to be followed by all health care personnel working in the
outpatient services. All the health care personnel should be trained and retrained in carrying out all or
any procedure related to their work area. All the procedures carried out in the outpatient department
should be carefully recorded and documented in a retrievable format so that the patient can be benefited
in future as well as outcome of treatment could be scientifically evaluated.

It is better to implement appointment system to spread out the reporting time of patients. This can be
either individual or block appointments. The block appointment system calls for a certain number of
patients to be present at a given time so as to provide a sufficient pool of patients; thus the physician
will at no time find himself idle and it limits the pool to the capacity of the waiting room.

Information graphics and signage system, name boards, pictorial representation of services provided,
direction signs, colour coding of different service areas facilitate easy understanding of hospital
procedures and routines by the patients.

Procedures
A written manual for the services should be prepared. All the staff be trained for discharging their
duties as per the manual.

Working Hours
In most of the hospitals, OPD are run in a single shift from 9 am to 2 pm. This may not be suitable for
some doctors as well as for clients coming from long distances particularly from rural areas. Some
hospital run OPD in morning and afternoon timings say 9 am to 1 pm. And 4 pm to 6 pm. some
places the working hours are 10 am to 4 pm. Depending on availability of doctors, particularly
consultants in super specialty branches, convenient OPD hours can be designed. Late evening OPD 6
pm to 10 pm are convenient in large cities.

Whatever the timing the punctuality and regularity should be maintained strictly.

Waiting Time
In large public hospitals, there are long queues and waiting time. This can be avoided to some extent
by: Introducing appointment system.
On arrival to the hospital, registration should be done and patient be given appointment for
consultation. Such appointment can be given on telephone or internet also.

The best way is to calculate workload per service provider and appoint adequate staff in that
proportion.

1.11 MONITORING AND EVALUATION

Monitoring the quantity and quality of services given through OPD is essential. This gives clues for
improvement, modification, up gradation and expansion of the services. Data needs be collected
compiled, analysed and suggestions to changes on that basis should be made.

Data on following functions should be collected.

 OPD attendance – department wise, old, new, fluctuations during days, weeks, months etc.
 Adequacy of services
 Cost of services
- Direct
- Indirect
 Revenue Generated

Overcrowding and Long Waiting Time: Many hospitals face the problem of overcrowding and long
waiting time. Due to various reasons, patient after initial waiting for registration waits for
consultations, diagnostics, and treatment or even for collection of medicines at pharmacy.
Adequate attention by all hospital administrations must be given to resolve this problem. A simple
random study of waiting patterns since the arrival of patients through his final disposal and reasons
thereof must be carried out and bottlenecks removed. The queuing theory which has been dealt in
Unit 1 of Block 4 of this course can be applied to resolve the problem.

1.12 MANAGEMENT STRUCTURE

This is different in different hospital. There should be a medical director or superintendent assisted
by supervisory staff for different services like medical, nursing, accounts support services etc. The
number and status depends on the size of OPD service, spectrum of service and size of clientele.
1.13 SUMMARY

Out Patient department is the place in hospital, where a patient first reports to seek medical help.
Some institutions run only out patient’s services examples can be given of consulting rooms of
specialists and dispensaries of general practitioners. Sometimes the doctor’s consultations services
are combined with diagnostic facilities like clinical laboratory and imaging facilities. Occasionally
there may be some observation beds or day care, generally aimed at providing medical help to
ambulatory patients. This is the place from where patients are admitted to inpatient facility as and
when necessary.

1.14 KEY WORDS

OPD - Out Patient department is the place in hospital, where a patient first reports to seek medical
help.
Types - The OPD can be centralized where all the specialties in medical field are available under one
roof. They also have facilities for laboratory and radiological investigations. Some ambulatory
treatments can also be carried out in these departments. The OPD of corporate or government
hospitals run on these lines.

The decentralized types of OPD are those who cater only to particular specialty or service. The
specialist clinics, OPD of hospital dedicated to certain specialties like Heart institutes. Trauma care
hospitals, Infectious diseases Hospitals can be quoted as examples of the type.
UNIT 2 ACCIDENT AND EMERGENCY SERVICES

Objectives

After going through this Unit, you will be able to:

1. To know the functions of accident and emergency services;

2. To understand the importance of accident and emergency services;
3. To know how to equip and provide human resources for accident and emergency services;

4. To Understand the various policies and procedures of this department.

Structure

2.1 Introduction
2.2 Definitions
2.3 Development and Scope
2.4 Functions
2.5 Type of Emergency Services
2.6 Planning Considerations
2.7 Equipment
2.8 Staff
2.9 Ambulance Services
2.10 Policies and Procedural Guidelines
2.11 Evaluation and Monitoring
2.12 The Workflow Process
2.13 Review (Audit) Committee
2.14 Summary
2.15 Key Words

2.1. INTRODUCTION

Accident and emergency services constitute vital and very sensitive part of a hospital. Smooth,
streamlined and efficient functions of this department project good image of the hospital. This departs
functions for 24 hours of a day and 365 days of a year without any breaks and holidays. To begin with
this type of units catered mostly to injured persons so were given the name ‘casualty’. As availability
of the services and health awareness in public improved other emergency patients also started
reporting to the casualty. Thus, it started catering services to all emergency cases from all branches of
medicine giving if the new name ‘Emergency Medical Service’ or ‘Accident and Emergency Services’.

The change is not only in the name, the space equipment physical amenities, staffing all changed to
meet the demands of the client’s conditions. The aim of the services is:
• Save life
• Minimize the disability
• Prepare patient for definitive treatment (surgical)

First one hour is the most important after an accident. This called ‘Golden hour’. The aim of the service
is to put in best efforts and provide all possible treatment.

Government of India since 1963 has been trying to set up centers throughout the country through
state governments. The activity is gaining momentum and the results are seen in the form of the
‘Training Centers’, Salvage Medical Teams, blood storage facilities in remote peripheral area and
various courses in the discipline.

2.2 DEFINITIONS

"Medical Emergency" is defined as a situation when the patient requires urgent and high-quality
medical care to prevent loss of life and limb and initiate action for the restoration of normal healthy
life.
“Emergency Services” means urgent resuscitative, therapeutic and diagnostic care to patients
with life threatening conditions.

2.3 DEVELOPMENT AND SCOPE

In the beginning of the twentieth century, every hospital had an "accident room" which for
treatment of patients injured in accidents. By the 1960's, these rooms evolved into "walk in"
medical clinics, and even patients with medical sorted utilizing them. In 1961, the Platt
Committee (U.K.) recommended "Accident and Emergency Department" after which this discipline
made rapid gain status of a full-fledged department in all developed countries.
In our country, the Central Council of Health in 1963 urged all state governments to set up emergency
medical services in all major cities and towns; which has subsequently been re-iterated by several
committees till date. However, despite some progress, he acts been given the necessary inputs to
develop it to the status of a department. The scope of accident and emergency services is gradually
broadening and in fact these are becoming "mini hospitals" within hospitals.

2.4 FUNCTIONS

The importance of this service lies in the fact, that out of all aspects of seeking health care, this is the
most crucial and vital, as it is perceived by the patient and the attendants as an "emergency" which
calls for urgent action. Therefore, not only is the patient’s life/limb at stake; but also, the image and
reputation of the hospital and the health care providers. From an administrative point of view, it is one of
the most stressful and sensitive areas, which can trigger off serious chain reactions hampering the
functioning of the hospital.
As you have read earlier in this unit, you must be aware about the important functions of and
emergency services which are:
1. To provide immediate and correct lifesaving medical care always and in all levels. Services
should be both effective and efficient as the patients are likely to deteriorate quickly.
2. To be sensitive to the emotional needs of the patients and attendants.
3. To liaise with the courts and police in medico legal cases whenever required.
In addition, some of the subsidiary functions are:
1. To provide ambulance services for pre-hospital care and transportation of patients to and
for the hospital.
2. To fulfill the role of information and communication center, especially during disaster
3. Education, training and research activities of medical staff.

However, you should understand that the accident and emergency services which can be provided
by any hospital, depends upon the number of beds and the policy the hospital.
In general, in our country, smaller hospital run accident and emergency services (called as
“Casually”) during non-outpatient dept, hours, and share facilities the OPD.

2.5 TYPES OF EMERGENCY SERVICES

There are four types of emergency services:

Major Emergency Services
The department is provided with all its specialized facilities. Diagnostic and therapeutic coupled with
specialty in different categories. Generally, such services are provided in large, teaching and tertiary
hospitals.
1. Basic Emergency Services
This is available in hospital where all basic emergency facility available the center is run by general duty
medical officer round the clock. Specialists in respective field are available on call duty.
2. Stand by Emergency Services
This type of emergency service is seen in PHC and Community Health Centre as first referral center.
These are run by trained nurses round the clock and Medical Officers are on call duty.
3. Referral Emergency Services
In these centers only first aid is given and the patient then refers to the health center/ hospital according
to the severity and need of the case. These types of services are provided by AIIMS and other tertiary level
hospitals.

2.6 PLANNING CONSIDERATIONS

A. Location
The department should necessarily be located on ground floor of the hospital building. It should be
easily identifiable from a distance and easily accessible from the road. For identification a neon or self-
illuminated sign visible from distance should be mounted. Direction boards can also be put on roads
and highways. There should be separate entrance leading to the department. There should be
adequate space for parking ambulances and for other vehicles.

B. Space & Architectural considerations

The space required is about 1000 sq. meters for average attendance of 100 patients. There should be
scope for expansion. There should be ramps and stairs with railings leading to the department to
facilitate movements of stretcher trolleys and ambulatory patients.
There should be a waiting area with basic facilities like seating arrangement, drinking water, toilets,
Public telephone etc. Reception enquiry and area for parking trolleys and wheelchairs. The treatments
area should ideally be divided into cubicles visible from a centrally located Nurses Station. The
treatment area can be sub divided into resuscitation, examination and observation cubicles.
In addition to this there should be rooms for doctors, nurses, registration, staff, store, police, MSW
and utility rooms with toilets facilities.
There should be an operation theatre complex. Clinical laboratory, X-Ray and imaging unit with dark
room. A separate room for brought in dead should be available. The design of the department should
be such that unidirectional traffic can be maintained as far as possible. The corridors should be about
3 meters wide for easy movements. The doors to rooms 1.25 meters wide.
The floor nonabsorbent, skid proof, washable surface and wall skirting up to 2 meters. The windows
should be at a height that is above eye level for persons standing on ground outside. There should be
easy access to the wards. Operation theatres, ICUs, Blood Banks and other important facilities of the
hospital by way of bed size lifts, ramps, staircases.
Telephone lines connecting all hospital sections and outside agencies like police stations, fire brigade,
and other important hospitals should be installed. Disaster call siren audible all over the hospital
should be installed.

2.7. EQUIPMENT

Many advanced and sophisticated equipment’s and machines are available for monitoring, diagnostic
and therapeutic purposes. These have enabled the doctors to have better understanding of patient’s
conditions and treat accordingly, ultimately changing the outcome in a case. Such equipment should
be installed in EMSD of every good hospital to impart optimal service to the needy.
Making the equipment available is not enough, the knowledge to use it properly is essential.
Maintenance, repairs of equipment is necessary for their smooth functioning which needs be taken
care of by a competent Biomedical Engineers who is armed with knowledge of spare parts and expert
assistance as and when required.
Following is a list of vital equipment / gadgets.
• Central Oxygen and vacuum for every bed
• Blood Pressure apparatus
• Thermometers – clinical and Rectal
• Cardiac monitors
• Defibrillator and space maker
• ECG machine
• Airway management Kit – airway laryngoscope, Endotracheal tubes, Ambubags, tracheotomy
sets.
• Ventilators
• Nebulizers
• ENT Examination sets
 • Slit lamps. Loop
• Equipment and instruments for operation theatre
• Bed side procedure trays like lumbar puncture suturing, ICD insertion, and abdominal
parenthesis.
• Equipment and instruments for operation theatre for performing major and minor surgeries
in adequate number depending on average workload.
For more details see the list of equipment for wards.

2.8. STAFF

Skilled and competent staff must be posted in EMSD. They should be calm and conversant to work
fast and best. The actual number depends on size of hospital spectrum of services provided, workload
and resources at the disposal.
The casualty works for 24 hours a day and 365 days a year. The staff is posted in shift duties in rotation.
The staffing pattern is maintained same during every shift.
The staff is given repeated training in relevant subjects and recent advances in them and in operating
the sophisticated equipment. They are also made conversant about disaster management plan
(internal and external) and disaster drills are connected periodically.
Following categories of staff are required.
A. Medical
• General duty – Casualty Medical officers – one or two in every shift depending on workload. They
are under control of an in charge of casualty. The CMOs should be minimum MBBS with
qualification in emergency medicine.
• Specialists - Postgraduate degree holders in General Surgery, Orthopedics, General Medicine,
pediatrics, OBGY and Anesthesiology are required to be posted round the clock in rotation. Other
specialists should be available on call basis.
B. Nursing
BPNA, GNM preferably B.Sc. Nursing nurses conversant and competent to handle serious cases,
initiate basic life support protocol and monitor the various gadgets. The ratio should be one nurse for
every Resuscitation bed and one for 3 observation beds. 3 in each shift for operation theatres.
C. Paramedics
Technicians for X-Ray. ECG, clinical Laboratory, Operation Theatre assistants, these people should be
qualified in their fields and should be posted in shifts.
Ward boys, Aayas, stretcher bearers etc. in adequate numbers in all shifts.

2.9 AMBULANCE SERVICES

Generally, ambulance services are a part and parcel of the Accident and Emergency Department. An
ambulance is defined as "a vehicle for emergency care which carries equipment and supplies for optimal
emergency care at the scene and during the period of transportation to afford maximum safety and
comfort and avoid aggravation of his condition.
It has been established through several studies that the speed of transfer of a patient from the site of
accident/emergency to the advanced treating center is of utmost importance in saving life and minimizing
mortality and morbidity.
The golden hour concepts, if a patient has best chance of survival and minimum disability if brought to a
center will be an honor. It should also be understood that the basic minimum lifesaving/support
equipment’s like oxygen cylinder, Ambubags, endotracheal tube and airways, foot operated suction
machine, portable ventilator, defibrillator with monitor, immobilizing splints, PSAG/MAST and emergency
drugs and fluids should be available in the ambulance.
The ambulance should also be provided with two ways communication system to facilitate its reaching at
the site will not delay and obtaining necessary guidance in rendering the prehospital case to the patient if
required.
Keeping in view the vastness and considerable geographical variation in the terrain, motor transport
ability of roads, transportation facilities can be considered under the two broad categories of urban areas
and rural areas. The essence of planning ambulance services should take these factors into consideration.

2.10 POLICIES AND PROCEDURAL GUIDELINES

In general, the policy is to provide service to every patient that reports to casualty. However, if the
hospital is dedicated to a specialty only, there is a problem in attending to patients from other
specialties. Under such circumstances, it should be remembered that basic life support and emergency
treatment must be given to needy to the best within the available resources and after stabilization
patient must be shifted to other suitable hospital under supervision. The arrangement for this must
be made by the hospital.
The procedures of management of individual emergencies vary from patient to patient. However
standard protocols should be prepared for management of different emergencies to quote a few
examples, the protocol for cardiopulmonary resuscitation, polytrauma cases, coma patients,
poisoning, snake bite, animal bite cases, patients in shock etc. can be prepare and standardized.
The casualty staff should be trained on basis of these protocols. The protocols are updated from time
to time to keep abreast with the advances and newer developments. Repeated training and mock
trials are necessary and should be conducted periodically.

A. Registration and Record Keeping

A simple and accurate registration system should be developed and practiced. In present conditions,
it should be computerized. It should always be remembered that the process of registration should
not be a hindrance in the way of patient management. It is always treatment first then the
documentation and other formalities. Any neglect or delay in treatment can lead to serious
consequences.
The record should contain demographic information about the patient in the form of full name, age,
sex, address, contact person etc. Date and time of arrival at hospital should be recorded and an index
or registration number be given.
Patient’s complaints, their duration, examination findings, basic investigations their results diagnostics
(may be provisional) and treatment given should be recorded by the CMO.
Whether patient is treated on OPD basis or admitted to hospital or referred to other hospital (with
reasons) should also be written.
The case papers should be preserved in hospital for minimum two years.
B. Admissions and Referrals
Depending on patient’s condition, the decision about admission to hospital is taken in consultation
with the concerned specialist. Patient may be admitted to ward or ICU. Record this effect is prepared.
Entries are taken on admissions register, indoor case papers prepared and sent to ward with the
patient.
The patient is escorted or taken on trolley stretcher to the ward. Serious patients are accompanied by
nurse or doctor.
At times it may not be possible to admit some patients to the hospital. This may be because of non-
availability of beds, accommodation (ICU, special room) particular specialist doctor, particular
treatment modality, it is responsibility of CMO to find out suitable hospital and shift the patient in
ambulance accompanied by a nurse and doctor.
The referral notes describing details about patient’s illness, treatment given, investigations done and
reasons for referral should invariably be sent. Contents of such case note should be explained to the
patient and / or relatives and transfer is done with their consent only. Copy of referral note should be
attached to case paper.
C. Medico Legal Work
A case, where investigation by law enforcing agency of the government (police) is deemed as essential,
the case is registered as medico legal. Police station under whose jurisdiction, the hospital is located
is informed in writing about the case. Some examples where medico legal registration is essential are
cases of assaults, injuries, accidents, poisoning etc. apart from these many more cases fall in this
category and the CMO has to use his knowledge and discretion to decide as to whether the case should
be registered as medico legal or not. However, it is always better and safer to register a case when in
doubt than that to report later.
A medico legal register is maintained in every institution for maintaining record of such cases.
Generally, there is a central register, where in every CMO takes entries of cases coming in his duty
period. At some places the decentralized registers one for every CMO are maintained but this should
be discouraged. The register should be maintained in a suitable format recommended in textbooks of
forensic medicine. A form commonly accepted is given at the end of this chapter.
In a medico legal cases of accidents or injuries. They are to be noted in detail in the medico legal
register as well as the patient’s case paper. A certificate of injuries should be sent to Police by 2-3
days. This certificate may be provisional. Final certificate may be sent on completion of treatment.
In case of poisoning cases, the stomach wash is to be given in casualty and a sample of the gastric
contents is preserved for chemical analysis. Such samples should be kept in screw cap bottle sealed
and labeled properly in the custody of CMO.
When a medico legal case is discharged or transferred elsewhere from the hospital, police should be
informed. Similarly, in case of death of such cases police should be informed.
Medico legal record is preserved in original permanently for producing to police or court as and when
necessary.
In case when patient is about to die medical officer has authority of recording dying declaration in
absence of magistrate. Treating doctors with two witnesses who are not related to patient can be
involved in this process. And then can be informed to police. Dying declaration should be in the
language of patient in his own words maybe it is grammatically wrong.
2.11 EVALUATION AND MONITORING

The emergency medical service department is very important as it can give good or bad image about
hospital. Therefore, the activities of this department should be scrutinized regularly and frequently
with reference to following:
• the number of patients, variation with days, months, season
• Peak and slack hour days, months, seasons
• Medical audit / Peer review of cases treated and their interfaces on point of
- Completeness of records and its adequacy and correctness
- Correlation between history, examination findings and diagnosis
- Errors in diagnosis and treatment
- Complications, the causes and death
• Promptness in attending by CMO, specialists
• Reasons for referral to other institutions
• Reasons for admission to hospital
• Competence of doctors

The audit should be done by an authority designated for the purpose. An audit committee is designed
for the purpose. An audit committee comprising of specialists from basic specialties should be
appointed. The review should be taken at fixed intervals. Recommendations of the committee should
be implemented. This committee should also investigate the complaints from public and ascertain
substance in them. They should recommend redressal measures for improvement and avoidance of
complaints.

2.12. THE WORKFLOW PROCESS

Whenever an emergency patient arrives in casualty the CMO on duty should examine and start
necessary treatment immediately. Based on his diagnosis, the patient is examined by concerned
specialist.
The specialist decides whether to admit the patient or to give him treatment and sent home, he is
advised to report to regular OPD for further follow up. If is to be admitted admission order is written
on the case paper, IPD case paper is prepared and patient is shifted to ward / ICU accompanied by a
nurse or doctor depending on patient’s condition.
Sometimes patient’s needs to be kept are casualty for emergency treatment and stabilization. In such
cases the specialists take over the case management.
Certain investigations may be required for arriving at a diagnosis, these are got done in casualty itself.
However patient needs be taken to CT scan or MRI sections. This should be done under supervision of
doctors.
“BROUGHT” in Dead persons should be treated as medico legal cases and police should be informed,
Cause of death should not be given in such cases.

2.13 REVIEW (AUDIT) COMMITTEE

It is essential that a review or audit committee is constituted by the appropriate and competent
authority to carry out this work, as it is of a highly sensitive nature. Senior Consultants belonging to
broad disciplines of medicine, surgery, orthopedics and pediatrics should be members of this
committee, along with the administration and medical record officer.
This committee should meet at regular intervals and take necessary corrective measures by training
the staff in order to overcome the hurdles in future. The reports of the committee should be kept
confidential.

2.14 SUMMARY

Accident and emergency services constitute vital and very sensitive part of a hospital. Smooth,
streamlined and efficient functions of this department project good image of the hospital. This departs
functions for 24 hours of a day and 365 days of a year without any breaks and holidays. To begin with
this type of units catered mostly to injured persons so were given the name ‘casualty’. As availability
of the services and health awareness in public improved other emergency patients also started
reporting to the casualty. Thus, it started catering services to all emergency cases from all branches of
medicine giving if the new name ‘Emergency Medical Service’ or ‘Accident and Emergency Services’.
The change is not only in the name, the space equipment physical amenities, staffing all changed to
meet the demands of the client’s conditions.

2.15 KEY WORDS

A. Major Emergency Services

The department is provided with all its specialized facilities. Diagnostic and therapeutic coupled with
specialty in different categories. Generally, such services are provided in large, teaching and tertiary
hospitals.
 B. Basic Emergency Services
This is available in hospital where all basic emergency facility available the center is run by general duty
medical officer round the clock. Specialists in respective field are available on call duty.
C. Stand by Emergency Services
This type of emergency service is seen in PHC and Community Health Centre as first referral center.
These are run by trained nurses round the clock and Medical Officers are on call duty.
D. Referral Emergency Services
In these centers only first aid is given and the patient then refer to the health center/ hospital according
to the severity and need of the case. This type of services is provided by AIIMS and other tertiary level
hospitals.
UNIT 3 OPERATION THEATRE
Objectives

After going through this unit, you will be able to understand:

1. Planning considerations of operation theatre;
2. Equipment planning for operation theatre;
3. Staffing and duties of various categories of staff;
4. Aseptic precautions in OT;
5. Policies and procedures for functioning;
6. Hazards in OT and disaster management;
7. Monitoring and evaluation.
Structure
3.1 Introduction
3.2 Planning Consideration
3.3 Engineering Services
3.4 Equipment
3.5 Staffing
3.6 Maintenance
3.7 Needle Stick Injury
3.8 Waste Disposal Procedure in OT
3.9 Hazards in OT & Safety Measures
3.10 Policies in OT
3.12 Summary
3.13 Key Words
3.1 INTRODUCTION

Operation theatre is a very important component of hospital. It is gaining more and more importance,
because of the progress being made in the field of surgery. Better understanding of the operable diseases,
safer anesthesia procedures, availability of various prosthesis and implants, blood and its components have
given birth to extensive and prolonged surgeries. The surgical and anesthesia teams have to stay in operating
rooms for longer durations. Ever increasing number and extent of trauma and emergencies have made the
operation theatre work round the clock. Advances in the field of surgery involving better equipment’s for
monitoring and therapeutic procedures. In nut shell, operation theatres have undergone revolutionary
improvement in order to provide services for delicate refined and prolonged surgeries. In order to put in the
best efforts, the comforts and convenience of the surgeons, anesthesiologists and support staff has to be
addressed to. Better knowledge about hospital acquired infections and their prevention have brought in
newer aseptic and bio safety requirement not only in procedures but also in designing and constructions.

3.2. PLANNING CONSIDERATIONS

The Aims of Planning

• Provide safety and comfort to patient and staff
 • achieve optimal utilization of the resource
• Create best possible working conditions for staff
• Keep scope for flexibility
• Ensure high standards of aseptic and bio safety.
Operation theatres can be a centralized facility for whole of the hospital or there may be decentralized
operation theatres for various departments. Out of these, centralized facilities are common because
duplication of same resources can be avoided, support services are easy to establish & access to control is
easier and unified, flexibility can be ensured, economy in construction can be achieved. The only
disadvantage is that if one of the operating room gets contaminated, the whole complex may have to be
shut down. In most of the sizable hospitals the emergency and septic theatres are constructed in casualty or
in outer zones of the central complex so as to avoid contamination of main complex. Similarly minor
procedures are done in operation rooms attached to OPD for use by surgery, orthopedics, OBGY and similar
departments.
Whether central or diversified the activities involved in operation theatre are same. They have to be allotted
separate and adequate areas for their functions. These are reception, preoperative area sterile stores,
trolley arrangement, operating room, post-operative observation area, staff changing and rest rooms and
separate for every category, scrub a governing area, records, store, sluicing and cleaning, administrative
office.
Location Area and Requirements
The location of operation theatre complex is decided on factors like easy accessibility, independence from
general traffic, maximum possible protection form direct sun, heat, dust, wind, rains and noise. It should be
easily accessible to blood bank, X-rays and imaging departments, clinical laboratory, ICU and operating
department wards. The installations about central supply of medical gases, vacuum, AC plant, electricity
supply.
Operation theatre should be located in a separate wing of an upper floor of a multistoried building. However
if it is located in a separate building future expansion becomes easier, the height required is 4 to 4.25 meters
which is possible and it is on top floor of a multi storied building or is a separate building. The carpet area
required for an operating room is about 40 sq. meters for specialized units like cardiac, orthopedics etc. the
requirement is 60 sq. meters. 35 sq. meters is generally enough for endoscopy OT.
A circular or complex on top of a circular intensive care unit is a modern trend which may be considered. In
such cases casualty on ground floor intensive care units above it and OT complex on top floor can be
designed.
The Areas required for other activities is as under
1. Scrubbing area - 5 Sq. meter for each OT
2. Sub sterilization - 5 Sq. meters for each OT
3. Plaster room - 12 Sq. meters
4. Reception - 12 Sq. meters
5. Preoperative room (10 beds) - 30 Sq. meters
6. Sterile store and trolley setting - 15 Sq. meters
7. Equipment Store - 20 Sq. meters
8. Anesthetic store - 10 Sq. meters
9. Instruments store - 10 Sq. meters
10. Doctors room - 10 Sq. meters
11. Nurses room - 10 Sq. meters
12. Support Staff room - 10 Sq. meters
13. General and linen store - 10 Sq. meters
14. Recovery room (10 beds) - 50 Sq. meters
15. X-Ray dark room and mobile unit - 8 Sq. meters
16. Trolleys bay (2) - 10 Sq. meters each
17. Dirty utility - 10 Sq. meters
18. Waiting room for relatives - 15 Sq. meters
19. OT in charge office - 10 Sq. meters
20. Students class room in teaching hospital - 30 Sq. meters
21. Corridors and passages - 2.5 Sq. meters wide.

The Number of Operating Rooms

The number of operating rooms depends on the workload, disciplines that are served and sophisticated
equipment’s available. For a 500 bedded multidisciplinary hospital can be calculated by using Macaulay’s
formula.

No. of Operations per day = No. of surgical beds XBOR x 365

ALS X No of OT days.
BOR = Bed Occupancy rate
ALS = Average length of stay

Projects recommends 3 major and 3 minor OTs for 300 beds 6 major and 3 minor for 500 beds and 11 major
and 3 minor for 1000 beds. Special disciplines like cardio vascular organ transportation etc. need special
theatre facilities. If such services are provided suitable operation theatres should be made available.
In USA the recommendations of number of OTs in one for 25 surgical beds while European standard is 10 for
50 beds. In Germany 6- 8 operation theatres are accommodated in one complex. In Sweden the number is 8
– 10 while in Scandinavian countries it is 12. It may be presumed that one OT complex should have 10
operation theatres. If the number is more than 10, another separate complex should be provided for ease in
management and control.
Zoning In Operation Theatre Complex
In order to ensure aseptic conditions in operation theatres, the complex is divided in to certain zones. These
zones are bacteriological and have varying degrees of cleanliness increasing and improving from outside to
inside. The bacterial counts in the zones diminish in the same fashion. The advantageous of zoning are that
the hazards and accidents can be reduced, equipment can be positioned suitably, ensure smooth workflow,
minimize traffic in OT and most important is that, the risk of hospital acquired infection can be minimized.
• The first and outer most zones is called ‘protective zone’. This lodges sections like waiting room
reception, staff room changing room, store room, trolley boy, and administrative office.
• the second zone is ‘clean zone’ The preoperative patients room, post operation recovery room,
plaster room, X Ray and dark room are housed in this zone.
• Third zone is termed ‘sterile zone’ the scrub zone operation theaters, instant sterilization room,
sterile store are accommodated here.
• Disposal zone is last of the lot – the dirty utility disposal corridor etc. is accommodated here.

3.3 ENGINEERING SERVICES

Electricity
Failure in electricity supply is hazardous and lead to complications and bad reputation. It is therefore
essential to ensure ‘zero interruption and no fluctuation electricity supply at all times.
Operation theatre should receive electricity from two different distribution boards. In addition there should
be a generator supply that takes over the function if the mains supply fails. There should be UPS to fill in the
gaps between these supplies.

The proper and adequate illumination in operation field is of vital importance. The inconvenience in
operation field should be 2000 to 3000 candles power. This becomes lesser in surroundings to reach about
300 candles power along the periphery of operating room with increasing complexities and delicacies in
surgery the luminance in operation field is required to be 10000 candles power.

Considering standard equipment and machinery and light requirements, an electricity load of 6 – 8 KVA is
essential for OT complex.
The lighting should be glare free. There should be adequate number of sockets to connect the machines and
gadgets.
The electric fillings used should be spark proof. If possible they should be behind a glass panel and remote
operated. The locations of these sockets should be convenient for the anesthesia team and for the surgeon
team. Wires lying over the floor should be avoided as they create problems in mobility of the persons. The
level of sockets above floor should be such that there is no drag over the fillings. This is recommended to be
2’ above floor.
Air Conditioning
Good quality air conditioning with positive pressure in the operating rooms. The temperature requirements
of pediatric surgery OT is required to be higher than other theatres. So the air conditioners should be set
temperatures desired. The air conditioners should be ceiling mounted above the operation table so that the
flow of air is maintained in vertical laminar pattern and the operation field & its surrounding get fresh and
microbe’s free air. In order to maintain positive pressure in operating rooms air conditioners of capacity 1.25
times the normal requirement should be provided. In order to maintain unidirectional flow of air only one
inlet should be provided. Of more than one inlets are provided, there is turbulence in air that keeps the dust
particles floating adding to the dagger of infection. The exhaust provided with air-conditioner should be
placed at a height of not more than 12” to 18” above the floor, so that the dust particles do not rise above
the level of operation table. Tow exhaust on opposite walls should be provided so that the particles do not
have to travel along distance to reach the. The surplus air escapes through the gaps in the door. The flow of
air from inside out prevents the passage of dust and microbes into the operating room. An air curtain may
be provided at the door of important operating rooms to doubly ensure that any particulate matter does not
enter from outside. The proportion of fresh air to re circulating air delivered through should be such that
adequate oxygen is maintained in atmosphere of the operating room. Accumulation of carbon dioxide here
leads to fatigue, irritability and decrease inefficiency of the persons working in OR. Therefore the proper
mixing of fresh and re circulating air is essential. The number of air exchanges per hour should be maintained
for the specialized OR’s 20 air exchanges per hour should be maintained and the 100% fresh air only is
supplied. The air conditioning plant should be provided with various types of filters including odor control
and HEPA filter so as to deliver 100% clean air. The temperature ordinarily maintained in between 20 to 24
degree Celsius with an average of 22 degree Celsius and humidity at 50 to 60.
Air conditioning thus plays a very important role in control of hospital acquired infection and maintaining
comfort and stamina of the personnel working in OT and therefore meticulous attention should be paid to
this.
Depending on the number of particulars contained in a cubic foot of air in the operating room, they are
given classes. A class 100 or air contains 100 particles per cubic foot. Thus class is generally adequate for
operation theatres. However advanced service operating rooms may require class 10 standards.
Plumbing and Sanitation
The sanitation arrangements need proper planning. They should be attached to changing rooms of staff and
the preoperative patient’s room and relating waiting area. The sanitary fittings should be of high quality the
pipes 100% non-porous. The sewage lines should not pass through the complex.
Scrub station should be provided near the entry of operating rooms. The working height should be 90 comes
and the water tap about 15 comes higher than this. The scrub sink should be 45 to 60 come deep to avoid
back splashes. The material of sink should be well polished, smooth and easy to clean. The water drains
should be adequate in number and size. The taps should be elbow or foot operated. Similar types of liquid
soap or scrub a solution dispenses should be provided. Soap cakes are not used anymore for scrub in
operation theatre or even elsewhere in hospital setup.
The water supply in OT should be filtered and chlorinated water. Now a day there is a trend towards using
RO water or UV radiated water to ensure it to be microorganisms free.
Walls and Floor
The walls and floor should be 100% imperious, electro conductive joint less, smooth, non-glazing and
resistant to chemicals and disinfectants used for cleaning. The walls should have this from top to bottom.
The door and window frames should flush with thinner wall and the joints air tight. The shutters of doors
should also be washable. It should be 1.25 meters wide X 2.1 meters in height with two shutters provided
with a kick plate.
The window should be flush with the inner walls, double air tight glass paneled and a protective grill on
outer side. The windows should be above the eye level of a person standing on outer floor. The passages and
corridors floor should also be covered with tough, chemical resistant and joint less material so also their
walls from floor to ceiling.

3.4. EQUIPMENT
The equipment in OT depends on the spectrum of services provided. However the common equipment is
listed here.
Operation Table
This is the main item in every OT. The type of table used depends upon the nature of surgeries done. The
table should be hydraulic, electrically operated and Radio compatible. It should provide facility to make it
possible to give desired position to the patient.
OT Light
Ceiling mounted lights are preferable. There may be a satellite light in addition to the main for special
procedures. It should provide a light of 40000 to 100000 lux. It should be shadow less. There should be
minimum heat radiation temperature, should not excess 50O C. it should be 2 meters above the floor level.
There should be arrangement to incorporate a camera and a sterile handle for adjustment.
Fiber Optic Light
This type of light does not transmit heat to the operation field. The light is conducted through fiber optic
cords. The fields of illumination are small used in surgeries on delicate tissues.
Service Pendent
Service prudent avoids wires crossing the floor. They are ceiling mounted. They may be of fixed length,
telescopic type for adjusting length or rotating type. The outlet for oxygen, nitrous oxide, compressed air,
vacuum and electrical sockets are provided on the pendent. The pendent should be located 45 cms away
from end of table. One pendent at either end of the table can be provided for use by anesthetists and
surgeons. The lower end of pendent should be about 2 meters above the floor.
• Microscopes for ophthalmic, ENT, vascular surgeries
• Anesthesia machines with vaporizers for anesthetic drugs
• Potable / mobile X - Ray unit and C-Arm image intensifier
• Diathermy
• Pulse Oxymeter
• Cardiac Monitor
• Defibrillator = pacemaker
• NIBP
• Portable / Operative ultra sound machine
• Central oxygen, nitrogen oxide, compressed air & vacuum
• Ventilator
• Fumigation machine
• Sets of surgical instruments
• Flash autoclave

3.5. STAFFING

The staffing required for operation theatre varies according to work load and the specialties available.
Though the number and specialties of surgeon is available, the categories and number of support staff has to
be standardized and provided.
The staff has to be available in all shifts. There is a separate emergency OT then the working of main OT is
for limited hours may be 12 to 16 hours. But the emergency OT has to be functioned for all 24 hours of the
day and 365 days of the year. Main OT complex may be closed on weekly holidays and public holidays. Like
OPD, main OT complex should not be kept closed on two subsequent days for reasons other than technical.
The fixed staff is of categories like administrative, nursing, technicians or assistants, radiographers, stretcher
bearers and sanitary workers. The in-charge of OT is the chief of anesthesiology services. He should be
assisted by a matron chief technician, chief of support staff and a store keeper. The number of nurses is
important. There should be 3 scrub nurses for 2 OTs, one circulating nurse for 2 OTs, one supervisory nurse
for 5 OTs. A nurse for flash autoclave, one nurse for 2 beds in post op recovery room and 1 nurse for 5 beds
in preoperative room. The numbers stated above are for one shift. Additionally 10% leave reserve staff
should be available to fill in gaps due to reserve staff absenteeism.
All the staff in operation theatre should be well trained. They should be given pre-placement training and
periodical retraining to keep their knowledge updated. An aptitude test before placement is also worth
considering.

3.6. MAINTENANCE

When separate emergency OT is available, the main OT complex should be closed for surgery for a day every
week. On this day the maintenance, cleaning and fumigation should be done, the civil and electrical repairs,
and maintenance are done. The filters and ducts of air conditioners cleaned and washing of all surfaces done
and then the fumigation is done. Swabs are taken for bacterial cultures and the OT is put to function as
usual.
Operation Theatre Management
Management of operation theatre has to be considered under various heads. Maintenance of OT premises is
very important. Clean and hygienic surroundings are of great help in maintaining asepsis in OT. Therefore OT
manager has to look after this aspect carefully and see that surroundings are maintained free from
contaminants like animal and human excrete, dumping of material that can decay and invite growth of
microbes.
It is also necessary to see that the windows are provided with airtight double panels fitted with non-
transparent unbreakable panels that will permit day light.
The points of entry of water supply pipes, electrical wires and those for sewage lines are well secured so as
to prevent trespass even by email insects like ants.
The points of entry of water supply and those for drainage lines should be separate so to avoid accidental
mix up.
Care has to be taken to make the entries for air conditioner ducts or the borders of the machines if it is of
window type to make air tight.
Management of Equipment, Machinery and Material
Operation theatre is provided with many equipment’s, machineries and instruments. There are important
for monitoring of patients, administering anesthesia and performing surgeries. All equipment’s going out of
order can hamper work of OT. A faulty machine can cost life to a patient and improper and inadequate
instruments can cause delays in surgery inviting risks of prolonged operating time and squeal thereof.
The first thing an OT in-charge should do is to take a note of all the material in dead stock register
maintained in OT, note the work done with help of every equipment. The history sheet and log book are
maintained. They can tell us about functioning and problems for of the equipment while log book gives us a
clue about its life.
The OT in charge should check all the equipment every day in morning and see that they are in working
condition. If not it should be removed and replaced if possible. The service engineer should be informed and
asked to repair the equipment. This should be brought to the notice of anesthetists and surgeon so that they
can read just the work.
A preventive maintenance of all equipment’s should be undertaken periodically at pre decided intervals by
the service engineer or the maintenance contractor. The machines not covered under maintenance contract
are to be taken care of by in house engineer.
In case a machine goes out of order during warranty period this has to be informed to the supplier
immediately and appropriate advantage of terms and conditions of warranty be taken.
The instruments have their own life and are subject to wear and tear depending on their handling and use.
Improper handing leads to shortcut the life of instrument.

Drugs
Every hospital has a policy about drugs that are used in operation theatre. The drugs commonly used are of
two types. One is the anesthetic drugs and other lifesaving emergency drugs. A third category that can be
included is that of desirable drug, which include antibiotics. The nurse has to maintain a good inventory of
the drugs. A close watch has to be kept on expiry date. Expenditure account should be maintained
accurately. The average weekly / monthly consumption should be calculated and taken in to consideration
while preparing indents.
Consumables Other Than Drugs
Lots of consumables are used in OT. Special care has to be taken in maintenance of stock of suture material
of different types. Every surgeon has his own choice of the suture material, its type, size, needle, etc.
similarly different types of surgeries require different suture material.
The nurse has to take into consideration these aspects and the average consumption so that adequate stock
can be maintained. The consumables also include catheters, tubes, and drains, dressing material and
adhesives tapes. The average consumption, buffer stock etc. are taken into consideration for these material,
also these material have expiry dates, which are to be kept watch upon.
The storage of these materials needs special consideration. Most of them are supplied in pre sterilized
condition. They have to be stored in such a way that their covers do not get torn due to contact with sharp
objects or under pressure of material stocked upon them.
Operation theatre has to be maintained in utmost clean and aseptic condition. Cleaning has to be done
every six hourly and between each two cases operated upon. Cleaning should be done with damp dusters so
that the dust particles are not set floating in the air.
The disinfections are done with suitable chemical of appropriate concentration and quality. Disinfections
should be done every 6 hourly of the whole theatre. It’s should be done for the floor and walks up 4’ height
after every case operated upon is shifted out and the waste generated during the surgery is removed from
the operating room.
Fumigation
Fumigation can be done by various methods. Fumigation is done at fixed periodical intervals depending upon
workload. Fumigation is done immediately after a potential or obviously infected or contaminated case is
operation up on. Apart from routine method of fumigation, rapid fumigation method is also used where a
potentially infected case is operated upon. Double dose fumigations methods is used in case a grossly
contaminated case or a HIV reactive or hepatitis B positive is closed down till the culture reports are
available in case of fumigation after a gross contamination. Fumigation and culture results confirmation is
essential if the operation theatre has undergone repairs and installation of new equipment’s.
Fumigation is done for all sterile zones once in a week or immediately after an infected or contaminated
case is operated upon.
Semi sterile zones are fumigated once a week on fixed days i.e. Saturday evening. Before fumigation, all the
horizontal and vertical surfaces, AC filters are cleaned with vacuum cleaner and thoroughly washed with
ample soap and adequate quantity of water it is permitted to get dried on its own and is never swabbed to
dry it earlier. The windows are sealed with adhesive tapes. After the OT is dry, fumigation is done;
Fumigation is done with aerosol method by using OT care machine.
The cubic capacity of every operating room and semi sterile zones are calculated and kept on permanent
record with OT in-charge.
The pre-decided quantity of formal delayed and water are poured in the machine & machine is kept in the
area to be fumigated with its switch outside the door. The door is closed and sealed with tapes. Machine is
started and run for the prescribed period and then shut off. Operation theatre is opened after 24 hours.
Swabs are collected for culture from all four walls, floor, surface of operation table, shadow less lamp and
trolleys.
Air conditioners are started and OT put to use without waiting for culture reports unless an infected or
contaminated case was done prior to fumigation.
Rapid fumigation is another method used in emergency where in the OT care is run for double the normal
time. OT is opened after 6 hrs. Liquor ammonia swabs are put in to absorb free formal- dehyde and OT put
to use, this method is used in case of emergency only.
Double dose fumigation is another method where in the quantity of formal dehyde is twice the normal dose.
The method is used for fumigation after infected or severely contaminated energy
Stabilized hydrogen peroxide or silver nitrates are used for fumigation of operation theatres. They are
nonirritant but costlier than formalin.

3.7. NEEDLE STICK INJURY

Wounds sustained during patient care due to any object and (sharp &/or pointed), patients care are defined
as needle stick injury. Being minor in nature these were mostly neglected during pre HIV era. After discovery
of HIV and HBV these injuries have gathered importance due to their potentiality of transmitting infections.
Needle stick Injuries are common in health setup particularly in operating rooms where activity and tensions
are at their peak.
The risk of contracting HIV infection by this method one 0.4% of HIV contaminated needle stick in hurries
(i.e. in 250)
Following Influencing Transmission
• Number of exposures
• Type of exposed area coetaneous 0.3% - Mucus membranes 0.1%
• Type of needle hollow (injection) needles more risky than solid suturing needles.
• Type of contaminating fluid
• Blood content of the contaminated sharp determines the concentration of virus. Higher the blood
contents more chances of transmission.
• Depth & site of injury
• Site of injury over more vascular parts carry higher risks
• If there was a barrier between sharp and injured part, is less
Prevention
Apart from the universal precautions following are has to be taken for prevention of needle stick injuries.
• Use double gloves (outer gloves ½ size bigger) this reduces chances of injury by 60%
• Periodical change of gloves during surgeries lasting for longer duration
• Minimal use of sharps
• Use staples & clips wherever possible
 • Develop and practice safe method of handling over and keeping sharps during surgeries
• Do not attempt recapping sharps, if unavoidable use single hand techniques
• Avoid rash and careless handling of sharps
• Thumb & index finger of non-dominant hand are at more risk so take care to protect them
• Discard used sharps without waiting for them to become blunt
• Do not test sharpness of sharp instruments on fingers & your body parts.
• Discard the sharp immediately after procedure into non retrievable puncture proof container
filled with disinfectant liquid
• Electric current point should be treated as sharp for all practiced purposes.
Care of Needle Stick Injury
• Don’t apply pressure over site of injury let it bleed freely
• Wash meticulously under running tap water with ample soap for 2-3 minutes after bleeding
stops
• Dip the injured part in savlon or butadiene for 15 – 30 seconds
• Report injury to head of institution
• Inform the patient about this and get his consented HIV and HBV tests done. HIV tests should be
done at 3, 12 & 24 weeks intervals.
Exposure Code
CDC evaluation of exposure
EC 1 – Exposure to small volumes (few drops) of blood or body fluids for short duration (few seconds) in an
individual with compromised skin or mucosal integrity.
EC 2 – Exposure of large volumes (many drops, splashes) of blood or body fluid irrespective of duration in
individuals with compromised skin or mucosal integrity.
EC 3 – Percutaneous exposure of severe nature with large bore hollow needle with visible blood on it. Post
exposure prophylaxis has to start 15 minutes of exposure ideally or within 1-2 Hrs.’ preferable.
Post exposure prophylaxis toxicity out drugs weighs the risk of transmission so no drugs are recommended.
EC- 2 Lamivudine 150 mg BD
+ 28 days
Zidevudus 300 mg BD
Or
Starudine 30-40 mg BD
EC- 3 Lamvudm 150 mg BD
+
Zidovudm 300mg BD
 OR
Starudm 30-40 mg BD
+
Indinavir

3.8. WASTE DISPOSAL PROCEDURE IN OT

Contaminated material generated in OT during operative procedure is of following types. Recyclable and
non-recyclable the recyclable materials are instruments linen the non-recyclable material are dressing
bandages remain materials and sharps.
The tissues removed during surgery from the third types. The empty vials, broken ampules etc. fall in fourth
group mucus, blood, body, fields sucked in container are in fifth group 1% 100 cc, sod hypo chloride solution
is put in this container in which the body fluids are sucked in. they get decontaminated and are disposed in
common drain.
The recyclable material are packed in two bags one for instruments and the other for linen. There are sent
separately to cleaning room. The body substances, parts, dressing, cotton; remains of suture material are
packed in another bag, and sent to sluice room from where it is sent for deep land filling or incineration.
Another group of material comprises of synthetic material like waterproof gowns, drapes, tubes, catheters
etc. They are shredded, decontaminated & packed in another bag and sent to store room from where it is
sent for disposal. The sharps like needles, blades etc. are put in the puncture proof non retrievable,
container filled with antiseptic solution and sent for disposal when full.
Thus every material is segregated disinfected packed properly and then only sent to sluice room. This avoids
contamination of passes through which the material has to travel. In old days separate horizontal or vertical
passages were constructed to transport this material for avoiding contaminated of the sterile & semi sterile
zones. This can conveniently be avoided by disinfections at point of generation, segregation, proper package
in color coded bags and then transporting them.

3.9 HAZARDS IN OT & SAFETY MEASURES

Hazards in OT are due to explosions, fire and discharge of static electricity

Safety Measures
• Spark proof wiring, snugly fitting connections and their preventive maintenance by competent
persons.
• Placement of which board outside operating room with remove control facility. OR their
placement 5 above floor level
 • Perfect insulation and earthing of electrically operated machines
• Electro conductive floor.
• Synthetic, Silk & woolen clothing should not be permitted
• Avoid accumulation of anesthesia gases by ensuring 15 air exchanges per hour.
• Placement of exhausts at floor level. Window air conditioners to be fitted at 3’ height
• Separate & isolated store for gases & inflammables
• Leaking anesthesia equipment’s should not be used.
• Fire extinguishers and fire hydrants should be provided in strategic positions
• Rodents proofing of OT complex
Disaster Management Plan
Disaster in OT can be due to
• Explosion of volatile inflammable gases & liquids
• These materials catching fire
• Discharge of static electricity
If a disaster occurs, following steps are taken to contain it.
• Inform Medical Superintendent & Dean immediately.

• Cordon off the affected area & restrict entry to it except for persons & material useful in control of
the situation.

• Area immediately neighboring the affected area is cleared of triage in hospital. The female ortho
ward is earmarked for triage & management of such victims.

• The victims if any are removed & taken to area earmarked for triage in hospital. The female ortho
ward is earmarked for triage & management of such victims.

• The triage & trauma management team is as under. The person’s in-charge of unit in ward at the
time of disaster from departments of general surgery, orthopedics, and ophthalmology along with
their lectures are designed for triage & management of victims. They arrive in the female ortho-ward
instantly on receiving the information. They triage and manage the victims.

• This ward is kept ready for such cases with 7 beds and all equipment’s, material, drugs required for
management of trauma cases.

• Clinical laboratory, X-Ray imaging on priority.

• The operation theatres in casualty are informed and cases are taken for surgery is necessary.

• A detailed enquiry into the incidence to be conducted by Medical Superintendent & report
submitted to higher authorities along with suggestions for avoiding recurrence.
3.10 POLICIES IN OT

Operation Theatre Committee

OT committee is headed by the head of institution, HOD anesthesiology is secretary. It is member by
representative from every department, OT sister technicians & attendant.
Blood Transfusion Policy
The blood transfusion policy of this hospital is based on following principles. It is governed by demand for
blood, its availability and storage & testing facilities available with us.
• Blood transfusions are avoided as far as possible
• Single unit blood transfusions are avoided
• Auto log transfusions are done whenever possible
• Suitable blood components are used wherever indicated
• Colloids & crystalloids are used to maximum permissible limit.
• Standard procedures as laid down by food & drugs administration for collection, testing, storage &
tissue of blood are practiced regularly
• It is always remembered that blood is a multipotent dearly available and most dangerous drug.
Operation Table Death
In case of death of patient on table following procedure is followed:
• Every table death is registered as a MLC
• The incidence should be informed to Medical Superintendent & Dean immediately
• Body and equipment, instruments, materials used for the procedures of the patient and that for
resuscitation should not be removed from operating room till “Panchnama” by police.
• Micro details of the incidence, resuscitation measures should be recorded on patient’s case
paper at least by a lecturer in proper chronology. Every entry must be signed by the persons who
make it.
• The relatives should be kept informed about patient’s condition from the moment the
complication was notices. This should be done frequently and preferably by senior team
member.
• After panchnama, wound should be stuttered up, dressed, body packed properly and sent to
mortuary.
• The operating room is cleaned, disinfected and fumigated before put to use again.
• The incidence should be discussed in micro details in the death audit meeting.
• Corrective measures are taken as suggested in death audit.
• Postmortem is must in such cases and should not be avoided.

3.12 SUMMARY

Operation theatre is a very important component of hospital. It is gaining more and more importance,
because of the progress being made in the field of surgery. Better understanding of the operable diseases,
safer anesthesia procedures, availability of various prosthesis and implants, blood and its components have
given birth to extensive and prolonged surgeries. The surgical and anesthesia teams must stay in operating
rooms for longer durations. Ever increasing number and extent of trauma and emergencies have made the
operation theatre work round the clock. Advances in the field of surgery involving better equipment’s for
monitoring and therapeutic procedures. In nutshell, operation theatres have undergone revolutionary
improvement in order to provide services for delicate refined and prolonged surgeries. In order to put in the
best efforts, the comforts and convenience of the surgeons, anesthesiologists and support staff must be
addressed to. Better knowledge about hospital acquired infections and their prevention have brought in
newer aseptic and bio safety requirement not only in procedures but also in designing and constructions.
The down time of equipment can be monitored. Modifications in repairs procedures can be made on this
basis.

3.13 KEY WORDS

No. of Operations per day = No. of surgical beds XBOR x 365
ALS X No of OT days.
BOR = Bed Occupancy rate
ALS = Average length of stay

Double dose fumigation is another method where in the quantity of formaldehyde is twice the normal dose.
The method is used for fumigation after infected or severely contaminated energy
Stabilized hydrogen peroxide or silver nitrates are used for fumigation of operation theatres. They are
nonirritant but costlier than formalin.
UNIT 4 INTENSIVE CARE UNIT

Objectives

After going through this unit, you will be able to:

1. Define and study types of Intensive Care Units;

2. Understand the planning considerations in ICU;
3. Study staffing and equipment required for ICU;
4. Policies and procedures for selection and management of cases;
5. Evaluation and quality analysis of ICU.
Structure
4.1 Introduction
4.2 Definition
4.3 Admission Criteria in ICU
4.4 Types and Levels
4.5 Planning Considerations
4.6 Equipment
4.7 Staffing
4.8 Policy and Procedures
4.9 Principles of Intensive Care
4.10 Monitoring and Quality Assessment
4.11 Aspects of Care
4.12 Step down ICU or High Dependency Units
4.13 Summary
4.14 Key Words

4.1. INTRODUCTION
Intensive Care Unit is an impatient accommodation in hospital where specialized nursing care, advanced
monitoring specific treatments and advanced life support can be provided. This is useful for critically ill
patients having life endangering illness or trauma.
The concept of ICU emerged in later half of 20th century. Units equipped with facilities for ECG monitoring,
defibrillator, pacemaker etc. monitoring other than these were done by doctors and nurses who were in
continuous attendance round the clock. Ventilator support was lacking or primitive. It was not possible to
have investigations like blood gas analysis electrolytes etc. These so called ICUs were multidisciplinary
gradually the ICUs dedicated to different specialties developed and how there are such units for almost
every basic and many super specialties.
There can be adequate on the necessity of ICUs in our country where adequate good indoor services are
with in accessible for many parts (particularly rural) with in medical science needs be used for services to
mankind at least those who can afford so these sophisticated units certainly have their place.

4.2 DEFINITION
An Intensive Care Unit (ICU) is a specific area of the hospital where sophisticated monitoring, titrated life
support, specific therapy and specialized nursing, can best provided for potentially salvageable, critically ill
patients with life threatening illness or injury.
It Is A Place and Not a Form of Treatment
The ICU's were developed to concentrate three critical components—the seriously sick patients, highly skilled
staff with the knowledge and experience to treat the patients and use equipment’s for better results at reduced
costs.

4.3 Admission Criteria in ICU

A.Selection of Appropriate Patient
One of the objectives of ICU is to decide which type of patient should be treated. The selection of patient
appropriate for Intensive Care not only depends upon medical and organizational factors but also on
financial, legal, ethical, moral and societal values. Life would have been much simpler if we believed that
we could characterize patients as too well, too sick and just right for intensive care. In this connection
following simple classification can be used.
 Patients expected to survive
 Patients potentially recoverable (a good chance of recovery)
 Patients having uncertain prognosis
 Not likely to survive whatever is done
 Patients in which death is apparently imminent
In view of public expectations of what medicine can achieve, intensive care should be provided for the first
two of these categories. However the classification system fails to recognize that these distinctions are not
always possible and not necessarily desirable.
In fact to choose appropriate patient one must broaden the admission guidelines and include not only the
too sick patients but also those who may be too well for intensive care requiring only monitoring to prevent
occurrence of serious complications.
B.Generic Goals
A qualitative basis for categorizing patients is required depending on generic goals of intensive care. The
categories, which generally apply to all specialty ICU patients besides distinguishing surgical ICU patients
from routine post-operative surgical patients have been identified. The three categories are:
 monitoring/observation
  extensive nursing requirements
 Constant patient care
Patients are considered appropriate candidates for ICU admission for just monitoring and observation even if
they are physiologically stable. This is for early detection and rapid response to serious complications.
C.Distributive Justice
Intensive Care Units encompass the total number of patients who could be considered eligible for care, given
the number of available beds. ICU beds are expensive and any hospital cannot afford to maintain excess of beds
with available staffing to accommodate emergency admissions. Emergency admissions are predictable although
not the timing. If all the existing care has been allocated, some decision will have to be made to distribute
resources so that no patient is deprived of necessary care. In terms of ethical principle of distributive justice the
principle usually followed is first come, first served in which the care is apportioned to appropriate candidate
seeking admission; and these continue to receive care until there outcome is determined. However, it is
inappropriate to devote limited ICU resources to a patient whose prognosis has resolved to one of vegetative state
in routine wards intensive monitoring and observation was never easy or effective as the nurse patient ratio is
usually 12:1 or 18:11 in night shift in regular wards in our hospitals.

4.4. TYPES AND LEVELS

The intensive Care Units on the basis of equipment and specialists services available are divided in to three
levels.
1. Level – I

Level – I Units, with basic specialty services, with arrangements for close personal observation and
noninvasive monitoring like ECG, and pulse. For example short term ventilator support, temporary pace
maker, basic imaging and laboratory facilities.
Level – II
Level I facilitate plus some upper specialties like cardiology neuro trauma etc. More advance imaging
techniques like CT scan, laboratory facilities for ABG electrolytes prolonged ventilator support.
Level - III
Level-III is all critical care monitoring and therapeutic facilities with super and subspecialty services. They are
arrangement for invasive procedures, services of intensivists, complex and advanced laboratory and imaging
facilities and definitive treatments wherever possible.
2. Types
As stated before the ICUs have developed in many specialties and super specialties.
 Cardiac care
 Post-operative cardiac care
  Neurology
 Neurotrauma
 Pulmonology
 Obstetrical
 Neonatal
 Pediatric
 Infectious diseases
 General Surgery
 Trauma Care
 Transplantation Surgeries
 General Medicine
 Burns Unit
 Acute nursing care unit
 Coronary care
They cater to the patients of the category the names suggest. Basically the equipment is more or less same.
But the services of specialist differ.
The beds compliment is in the range of 10% to 15% of hospital bed strength. Number of beds in individual
type depends on work load related to that subject.

4.5 PLANNING CONSIDERATIONS

A. Locations
The ICUs should be easily accessible from operation theatre, casualty. The imaging department and
laboratory should be within way reach. Still they should be away from main traffic of hospital.
Now-a-days there is a trend constructing a circular type of ICU on upper flowers of which operation theatres
are housed. Ground floor can be occupied by casualty. The space requirement is 50 sq. meters per bed.
B. The Patient’s Accommodation
There is an average overall spatial need of 50 meters square per bed. The entrance should be like an anteroom
with a place for gowning and a separate emergency entrance for patients.
C. Patient's Space
If it is a new construction each patient's space (whether separate rooms, cubicles or multiple bed space) should
have a minimum 15 sq. feet of clear floor area and minimum headwall width of 1.2 feet per bed exclusive of
anteroom, vestibule toilet room, lockers and/or alcoves. A staff assistance system should be provided on most
accessible side of bed which must annunciate at nurse station with back up from another staffed area from
where assistance can be called.
If private rooms or cubicles are provided view panel to corridor are required and should have drapes or
curtains which may be closed. Each patient bed area space should have space at each bedside for visitors, and
provision for visual privacy. There must be a minimum 8 feet between beds for both pediatric and adults units.
Patient’s bed should have visual access other than skylights, to outside environment. Therefore there should be
at least one outside window in each patient’s bed area. The distance from patient bed to outside window should
not exceed 50 feet.
Nursing Calling System: There should be two ways voice communication provided which must include provisions
for an emergency code resuscitation alarm to summon assistance from outside ICU.
Hand Washing Fixtures: These must be located convenient to nursing station and patient bed areas. It is
recommended that there should be at least one hand washing fixture for every three beds and should be
located near entrance to patient room. Moreover these should be sized to minimize splashing water on to
floor.
D. Patient's Services
The following are essential:
• Pipeline oxygen and suction outlets.
• Medical quality compressed air and Entonox.
• 12 electrical sockets.
• Outlets for transmission of biological data to central nursing station.
• Medical gases and suction devices.
• Mobile partitions/Bed divider system.
E. Nursing Station
This area must have space for counters, storage and may include centers for reception and communication.
The patients in ICU need to be visually observed at all times. The central station should geographically be so
located that:
• It allows for complete visual control of all patient bed
• It is designed to maximize efficiency in traffic pattern
• The patients should be so oriented so that they can see nurse but cannot see other
patients.
• The ICU should be well illuminated with non-reflecting paint works and other
surfaces.
F. Medication and Nourishing Areas
In ICU provision should be there for 24 hours storage and distribution of routine drugs and emergency
medication. The area should contain a work counter, cabinets (for storage of supplies) sink with hot and
cold water supply, refrigerator for Pharmaceuticals and should have a minimum 50 sq. feet area.
G. Isolation Rooms
These must have minimum 14 sq. meter area plus space for Ante room, minimum 20 sq. feet to
accommodate washing, gowning and storage. The electrical, medical gas, heating and air conditioning shall
support need for patient and ICU team member.
The following additional service space should also be available within ICU and may be shared by more than
one ICU, provided direct access is available.
H. Clean Lines Storage
I. Soiled Work Room/Holding Room
These must be separate from clean work room and should have separate access door, clinical sink, lavatory
(or hand washing fixture) for both cold and hot mixing formulas.
J. Nourishment Station
It should have sink, work counter, refrigerator, storage cabinets and equipment for hot and cold
nourishment between scheduled meals.
K. An X-Ray Viewing Facility
L. Equipment Storage Room
Appropriate room shall be provided for storage of large items of equipment necessary for patients.
M. 24 Hours Laboratory, Radiology and Pharmacy Services should be available.
The following should be provided and may be located outside ICU if conveniently accessible:
A. Visitors’ waiting room with convenient access to telephones and toilets. One waiting room may serve
several critical care units.
B. Adequate office space adjacent to ICU for medical personnel who should be large enough to permit
consulting with members of ICU team and visitors.
C. Staff lounges and toilets with telephones, intercom and emergency code alarm connection with
provision person for storage of coats. It should have space for comfortable seating and preparation
and consumption of snacks and beverages.
D. A special procedure room if required by functional programme.
E. Sleeping and personal care accommodations for staff on 24 hr. on call work schedule.
F. Multipurpose rooms for staff, patient and patient families for conferences, reports education training
session etc.
G. A house keeping room containing service sink for floor receptor and provisions
for storage of supplies and housekeeping equipment.
H. Storage space for stretchers and wheel chairs in a strategies location without
restricting normal traffic.
4.6 EQUIPMENT
Good accurate and advanced monitoring therapeutic equipment are very important component of ICU. The
equipment can be grouped as under.
1. Monitoring Equipment
A. Bedside monitors – ECG, multi parameters
B. Central monitors – connected to nurses station
 C. Pulse oxy meter
D. Intravascular pressure monitoring device
E. Expiratory CO2 analyzer
F. Glucometer
2. Respiratory Support Equipment
A. Ventilators
B. Humidifiers
C. Oxygen therapy devices
D. Endotracheal intubation instruments
E. Ambubags (various sizes, Airway vent mask)
F. Fiber optic bronchoscope, laryngoscope
G. Nebulizer
H. Tracheotomy sets open, continuous
I. Endo bronchial suction, catheters
J. Endo bronchial suction catheters
K. Central vacuumed points 3 per head
L. Central oxygen points 3 per bed
M. Compressed air points 2 per bed
3. Cardiac Resuscitation Equipment
A. Defibrillator
B. Pace maker (Temporary) external, transcutaneous
C. Intra-aortic balloon pump
D. CPR trolley
4. Medication Administration Equipment
A. Syringe Pump
B. Infusion Pump
C. Various drips sets
D. Transfusion sets
5. Laboratory Equipment (in the laboratory)
A. Blood gas analyzer
B. Electrolytes analyzer
C. Asmometer
D. Microscope
E. Auto analyzer
 F. Elisa Reader
6. Imaging Machines
A. Mobile X-Ray machine
B. Mobile sonography machine
C. Mobile 2D Echo cardiograph machine
D. CT scan, MRI, etc. in the concerned department
7. Dialysis Facility
A. Pressure distribution mattresses
B. Heating and cooling blankets
C. Instruments sets for bedside procedures like tracheotomy, venesection, CVP, IC
D. Drainage abdominal parenthesis. Lumber puncture, crieothyroidotomy, dressing
E. Suturing
F. Nursing care material
G. Sponge, mouth and back care sets
H. Enema Set
I. Catheterization
J. Naso gastric intubation
K. TPR sets and clinical and rectal thermometers
L. weighing machines

4.7. STAFFING
Qualified and trained staff is of vital importance. It is the men behind the machine that make difference.
Without proper staff ICU shall be just a show and show cases of equipment. The vital most category of staff,
are the doctors. There should be specialists from every possible branch. There should be intensivists for
round the clock supervision assisted by junior doctors. The decisions and actions should be very prompt.
The other important category is nurses. They should be qualified B. Sc. Nursing or at least GNMS with
training in critical care. They should be able to initiate life support and read and interpret various monitoring
devices.
In addition to these, services of biomedical engineer, ICU technicians, radiographer, laboratory technician,
dietician, attendants, Sweepers are essential. All the staff should undergo repeated framing to keep their
knowledge up to date.
The ratio of nurses is one nurse per bed per shift. There should be one intensivist and on assistant in every
shift. Adequate number of attendants and sweepers should be posted. Services of biomed engineer,
electrician, radiographer, lab technician can be shared with other facilities.

4.8. POLICY AND PROCEDURES

There should be policy about admitting types of patients. It should be governed by availability of facilities
and expertise. In case any of these is not available, the situation be explained and concerned persons,
Patient be given basic support, stabilized and shifted to other facility under proper supervision. It is best to
declare a list of services not provided and display them at prominent places in the hospital.
There is always a tension in and around ICU because of uncertainty of the outcome.
A standard protocol for patient management shall be developed. The staff trained to follow this protocol
strictly and completely without any comment or loose talk. A procedure of explaining situation to relatives
should be developed. The senior team member should be given this work and others should very strictly
refrain from any comment or delivering information to anybody other than the team member.
The procedure for admission should be easy. The patients commonly requiring critical care are
A. Serve poly trauma
B. Major surgeries
C. Airway and ventilator support
D. Support to maintain cardio vascular integrity
E. Control of toxemia
F. Patients of transplantation (donors and recipients)
G. Admissions to ICU is in consultation between the consultant under whom he is admitted and the
intesivist.
H. Admission is subject to availability of bed and necessary equipment
I. Admission is first in appropriate ward and then transfer to ICU. The bed in ward is kept reserved
for him. (All time this may be paper work).
J. The consultant under whom patient is admitted is responsible and answerable about day to day
management of the case.
K. He is responsible for initiation of treatment, changes in it, contuety of are, inter departmental
references etc.
L. He is responsible for liaison with the relatives and their counseling from time to time.
M. He is responsible for procedures done on patient
N. He should take decision about transfer / discharge of patient.

4.9. PRINCIPLES OF INTENSIVE CARE

Intensive care units can be managed better if the principles of critical care are properly decided and
understood. Few of them are discussed here.
Early Diagnosis
Patients are brought to ICU with illness complications that threaten life. Early identification of the problem is
first step towards management of cases.
Anticipating Complications
Intensivists should have complete knowledge about patient’s present condition and on this basis should be
able to foresee complications that can probable develop in near future. He should exert to prevent them and
treat them as soon as they are noticed to be forwarded is to be fore armed. Knowledge, wisdom and
experience of instensivist play crucial role in this.
Holistic Approach
The patient is viewed as a whole and not on basis of the disease, organ or part of his body affected. Team
efforts of different specialists are required. The opinions of different specialists have to be moderated and
interpreted, therapeutic procedures weighed in comparison to their hazards and benefit, in addition to
organ support, other interventions to maintain organ functions are essential. These are aimed at
psychological support, early mobilization, adequate and proper nutrition care to maintain skin integrity,
prevention of nosocomial infections, lung atatectests etc. The whole hearted efforts of nursing staff,
physiotherapists and social workers are essential to boost up the morals. Clinical psychologists can play a
crucial role in this. A critically ill patient required intensive monitoring. These may be noninvasive or invasive
and have their contributions to recovery of the patient. However the significance and over all benefits of
such monitoring should be considered before they are employed. It should always be remembered that
gadgetry are adjunct to the specialists and not his replacement.

4.10. MONITORING AND QUALITY ASSESSMENT

The importance of quality assessment and its effects on bedside practice in intensive care unit is not always
obvious. Every unit must develop plan for monitoring and evaluation quality of care, by whatever
definition.
The physician’s view of quality of trauma case is in terms of readiness of OT, availability of ICU intensive
care nurse and team protocol followed towards successful outcome. The patient’s perception of quality of
convenience, a caring staff, availability of services without undue wait and how he feels at the end of it.
Do no Harm
Do not harm is the ancient Hippocratic tenet. Patient should not be subjected to any investigation or
procedure when it cannot lead to any extra benefit to him. The risk-benefit ratio should always be at the
back of mind while prescribing the investigations and invasive procedures.
Evidence based Medicine
The treatment options should be based on data scientifically gathered. Other aspects like social, cultural
economic, philosophical, religious, genetic etc. should also be considered. Evidence available at one time
may change afterwards. It may not be perfect. It should be remembered that medicine is science and art in
almost equal proportions. Evidence based medicine ignores the art in it.
Recognition of Limits
The morbidity and mortality associated with critical illness does not change significantly in many cases with
the care and knowledge available at present. A good physician should know limitations of aggressive
management beyond ‘point of no return’. The limitations can be counter argued with doubts, difficulties and
dangers physician has to strike a balance between these on basis of his knowledge, experience and wisdom.
Thus even with availability of modern monitoring and therapeutic modalities, the clinical judgment about
how much of them should be prescribed to an individual patient remains a matter of clinical acumen of the
physician. The judgment should be based on cost benefit ration but it should also be seen that the relatives
are satisfied about the efforts taken to save their patient .Proper sympathetic counseling therefore plays
important role. Every action and even those not taken be explained in understandable words to avoid
misunderstandings.
The administrations may consider cost and length of patients stay as primary factors in assessing the
procedures quality.
The ten step plan for monitoring and evaluation is as follows:
1. Assign responsibility: Who is responsible – physician – in charge ICU/Staff?
2. Delineate scope of key function - What does one look at?
3. Identify important aspects of care - What activities have highlight priority?
4. How to know what you are doing are right - Set indicators
5. When one knows that there is need for improvement - get triggers for evaluation
6. What actually needs improvement - probably methodology (data collection and aggregation?)
7. Do not know why it needs improvement - Process of evaluation
8. Know why - Then action after evaluation and feed back
9. How much successful - Improvement is measured
10. Then what -Lastly documentation and communication

4.11 ASPECTS OF CARE

The monitoring and evaluation depends on aspects of care being provided in the ICU and the indicators and
triggers to evaluate procedure are developed. The different aspects of care provided in ICU include:
A. Mortality
B. Morbidity
C. Appropriateness of admission
D. Medication errors
E. Timeliness of discharge
F. Assessment of physician response time
G. Management of ventilator support patients
H. Performance of tracheotomy care
I. Performance of hazardous procedures (Arterial Blood gases sampling)
 J. Monitoring effects of medication ordered and administrated
K. Assessment of standard orders compared with actual practice
L. Evaluation of patient’s satisfaction
M. Evaluation of staff complaints and satisfaction
N. Evaluation of nutritional needs
O. Evaluation of patients care incidents
P. Assessment of appropriate use of intravenous lines
Q. Development of CPR protocol

Patient’s Perception about Quality

Convenience, care taken by staff, service with promptness information given to him from time to time, in
case of critical care, this is the perception of relatives.
Doctor’s Perception
Availability of ICU bed and equipment, adequate and proper assistance and support by ICU staff, prompt
availability of investigations report, timely information about changes in patients condition,
interdepartmental reference attendance.
Administrative Perception
Occupancy rates, length of stay, admissions declined on account of non availability of beds, equipment’s
down time of equipment, infection rates, revenue generation. The indicators on which the monitoring
should be done are:
A. Appropriate indication for admission
B. Physicians consultants response time
C. Timely performance of investigations and bedside procedures
D. Timely initiation of treatment, medication and procedures
E. Care of tracheotomy and vascular access site
F. Adhesive to SOPs compared to actual practices, CDR protocol
G. Timely discharge / transfer
H. Iatrogenic complications
I. Nutritional needs of patient
J. Patient care incidences
K. Equipment failure
L. Staff neglect
M. Patients satisfaction / complaints
N. Staff satisfaction / grievances
O. Errors in diagnosis and assessment
 P. Infection rates
Q. Death audit
R. Clinical audit
S. Accidents

4.12 STEP DOWN ICU OR HIGH DEPENDENCY UNITS

Sometimes patients are in such a condition that general ward but not intensive monitoring. The care
required is mare of intensified nursing. Such patients may one that is transferred from ICU or from wards.
Some patients who are not likely to recover or improve despite of intensive care may with proper consent
from their legal heirs be shifted here to save on the resources of ICU and these resources may better be
utilized for some needy cases.
The setup of HDU may be on similar lines except that the equipment and human resources are lesser. The
care taken is proportionate to the needs of patient’s condition. Specialist’s services and services of intesivists
are not to the tune of ICU. The space component may also be lesser. But nursing care is of same standard.
Such units save burden on intensive care units and resources of the hospital. There are no norms set for
accommodation equipment and staffing. Hospital may decide those on the basis of their experience and
local demand.

4.13 SUMMARY
Intensive Care Unit is an impatient accommodation in hospital where specialized nursing care, advanced
monitoring specific treatments and advanced life support can be provided. This is useful for critically ill
patients having life endangering illness or trauma. The concept of ICU emerged in later half of 20th century.
Units equipped with facilities for ECG monitoring, defibrillator, pacemaker etc. monitoring other than these
were done by doctors and nurses who were in continuous attendance round the clock. Ventilator support
was lacking or primitive. It was not possible to have investigations like blood gas analysis electrolytes etc.
These so called ICUs were multidisciplinary gradually the ICUs dedicated to different specialties developed
and how there are such units for almost every basic and many super specialties.

4.14 KEY WORDS

A. Principles of Intensive Care: Intensive care units can be managed better if the principles of critical
care are properly decided and understood. Few of them are discussed here.
B. Early Diagnosis: Patients are brought to ICU with illness complications that threaten life. Early
identification of the problem is first step towards management of cases.
C. Anticipating Complications: Intensivists should have complete knowledge about patient’s present
condition and on this basis should be able to foresee complications that can probable develop in
near future. He should exert to prevent them and treat them as soon as they are noticed to be
 forwarded is to be fore armed. Knowledge, wisdom and experience of instensivist play crucial role in
this.
D. Holistic Approach: The patient is viewed as a whole and not on basis of the disease, organ or part of
his body affected. Team efforts of different specialists are required. The opinions of different
specialists have to be moderated and interpreted, therapeutic procedures weighed in comparison to
their hazards and benefit, in addition to organ support, other interventions to maintain organ
functions are essential. These are aimed at psychological support, early mobilization, adequate and
proper nutrition care to maintain skin integrity, prevention of nosocomial infections, lung collapse
etc. The whole hearted efforts of nursing staff, physiotherapists and social workers are essential to
boost up the morals. Clinical psychologists can play a crucial role in this. A critically ill patient
required intensive monitoring. These may be noninvasive or invasive and have their contributions to
recovery of the patient. However the significance and over all benefits of such monitoring should be
considered before they are employed. It should always be remembered that gadgetry are adjunct to
the specialists and not his replacement.
 UNIT 5 NURSING SERVICES – ORGANIZATION AND ADMINISTRATION

Objectives

After going through this unit you will be able to:

1. Understand the role of ‘Nursing’ in healthcare;

2. Know the organization, staffing pattern and duties of various categories of nursing staff;
3. Make effective utilization of nursing services;
4. Evaluate and monitor nursing functions.

Structure

5.1 Introduction
5.2 Evolution of Nursing Education in India
5.3 Role of Nursing Services
5.4 Organization of Nursing Services
5.5 Duties and Responsibilities
5.6 Staffing Pattern
5.7 Norms Recommended For Nursing Staff
5.8 Summary
5.9 Key Words

5.1 INTRODUCTION

The nursing profession is an important component in health care. A patient taking indoor treatment
in a hospital ordinarily has interaction with nurses for maximum time more than that with his
treating doctor.
The roots of nursing profession are in the services rendered by the sisters in Christian religion and
then the defense services.
In India the history of nursing dates back to 500 BC, when Lord Gautama Buddha established
hospitals attached to monasteries. These hospitals had male nurses. The literature by Sushrut and
Charkas has mention about attendants to the patients who are comparable to present day nurses.
References are also found during the period of Emperor Ashoka. Nurses who knew cooking and
patient care were appointed during this period.
The basic concepts about a modern hospital and the nursing profession were formulated by Florence
nightingale. She was the first person to write her ‘Notes on Nursing’ in the year 1859 and also to
start ‘School of Nursing’ in 1860.
5.2 EVOLUTION OF NURSING EDUCATION IN INDIA

We can summarize the history of nursing education in India as follows.

1871 – School of Nursing started in general hospital Madras.
1886 – School of Nursing in full-fledged form was started in J.J. Hospital, Bombay.
1892 – Many hospitals in Bombay started nursing associations which were intended to
provide additional facilities for the training of local nurses.
1908 – TNAI established.
1909 – Bombay presidency nursing association was formed.
1910 – United board of examination for nurses was organized.
1913 – South India Board was organized.
1926 – First Nurses registration act passed in Madras.
1935 – Madras and Bombay nursing councils were established.
1942 – ANM programme started.
1943 – School of Nursing at RAK College, New Delhi.
1943 – Diploma programme in nursing administration started in New Delhi.
1946 – Four year B. Sc. nursing programme started in RAK College and CMC, Vellore.
1947 – INC act was passed.
1949 – INC was established.
1959 – M. Sc. Nursing started in RAK College.
1963 – Post basic B. Sc. programme started in various institutions
1968 – M. Sc. nursing at CMC, Vellore
1972 – Basic degree programme started in Kerala.
1985 – M. Sc. nursing stated in CMC Ludhiana.
1985 – IGNOU established.
1986 – Curriculum change for GNM programme from three and a half years to three
Years.
1986 – M. Phil programme started in RAK, Delhi.
1987 – M. Sc. Nursing started in Kerala
1987 – Separate directorate of nursing was created in Karnataka State.
1988 – M. Sc Nursing at Nimhans
5.3 ROLE OF NURSING SERVICE
One of the classic definitions of nursing, as formulated by Virginia Henderson (1966) delineates the
unique function of the nurse as follows:
To assist the individual, sick or well, in the performance of those activities contributing to health or
its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength,
will or knowledge. To do this, in such a way is to help him gain independence as rapidly as possible.
Professional nursing is changing and adapting to meet changing health needs and expectations. One
such adaptation can be noted in the expanded role of the nurse. The nurse who functions in an
expanded role provides direct care to patients through independent practice, team or
interdependent practice, or practice within a health care agency or with a physician. Specialization
had evolved within the expanded roles of nursing. Fundamental areas of functioning include
practice, teaching, leadership and research.
However although each role carries specific responsibilities various aspects of each role interrelate
with one another and are found in all nursing positions. Accomplishment of each of these roles is
designed to meet the immediate and future health care and nursing needs of the patients who are
the recipients of nursing care.
A. General Role
 Round the clock nursing services
 Monitoring and coordinating nursing care
 Assisting other professionals in implementing their plans of care
B. Specific Role
 Assess the patient care needs
 Plan and provide nursing care interventions
 Prevent complications and promote improvement in the patients comfort and well being

 Alert other care professionals to the patient’s condition

 Documentation
C. Role of Nurse Executive
 Participating with the organization leaders in designing and providing patient care and
services by allocating sufficient number of qualified nursing staff to care for the patient.
 Ensuring continuous and timely availability of nursing services to patient.
 Developing, presenting and managing the nursing services portion of budget.
 Implementing the findings of current research into policies and procedures governing the
provision of nursing care.
 Measuring, assessing, and improving patient outcomes achieved through developing and
implementing nursing standards of patient care and nursing standards of practice.
 Organize continuing education programmes.
 Assigning responsibility to individual or groups of nursing staff to take action to improve the
nursing services performance.

The nurse executive has the authority and responsibility of establishing standards of nursing
practice, and nursing policies and procedures and to coordinate and control the nursing/care
activities, through continuing education programmes and research.

5.4 ORGANIZATION OF NURSING SERVICES

Organization of formal structure that helps in coordination of resources to establish policies and
procedures, determine positions, qualifications, job descriptions in order to achieve goals and
objective has to be established.
The Government organization for nursing services can be described as under.

Director or Superintendent
of
Nursing services

Deputy Nursing Superintendent

Matron

Deputy Matron Tutor

Specialist Nurses Head Nurse (Sister)

Staff Nurse

ANMS
5.5 DUTIES AND RESPONSIBILITIES

A. Superintendent of Nursing Services

The responsibility is administration and planning of nursing services. SNS is responsible to the
Director of nursing services (or head of the institution).
The functions can be grouped as administrative and supervisory.
Administrative Functions
Planning of human resource and material requirements preparation of budget for the
department.
 Coordination and control of nursing staff.
 Determination of nursing policies for achieving predetermined standards of nursing
services.
 Prepare a manual for job description of various categories of nurses, procedural manual
for their day to day activities and code of conduct of nurses.
 Recruitment of nursing staff.
 Maintain reports and records and correspondence.
 Plan and organize program for on job training in areas of need for institutions.
 Interdepartmental relations and coordination.
 Organize teaching and research programmes.
 Evaluation of functions and activities of nursing staff.
 Distribution of nursing personnel to various departments.
 Manage establishment matters like leaves, promotions, disciplinary actions, complaints
etc.
 Works on various hospital committees.
Supervisory Functions
 Ensure efficient nursing services.
 Supervise general upkeep, cleanliness of institution.
 Coordinate good interpersonal and educational and training programmes.
 Surprise and regular rounds to supervise work of nurses.
 Supervise records maintained by nursing staff about patients care and management.
Deputy Nursing Superintendent
 Responsible and answerable to SNS.
 Look after the jobs of SNS during leave.
 Contribute to formation of policies and procedures of nursing services.
 Helps in recruitment of nursing personnel.
 Helps in distribution of nursing staff amongst departments.
  Keep duty roster of nurses.
 Keeps reports and records of nursing services.
 Maintain confidential files and reports of nursing personnel
 Takes regular and surprise rounds of hospital for supervising work of nursing personnel.
 Works on various committees if appointed to.
 Works as a liaison between nursing staff and superiors.
 Checks various hospital reports (night reports etc.).
 Maintains leave, attendance register of nurses.
 Conducts physical verification of stocks in various departments.
 Assist in organizing teaching and training programmes for nurses.
 Provides technical guidance to nurses.
 Maintains discipline amongst nurses.
 Helps in organizing social functions for nurses.
 Duties and responsibilities assigned by superiors...

B. Duties and Responsibilities of Matron

Nursing works under superintendent and deputy NSG superintendent.

 Help in recruiting of nursing staff.
 Arrange duties of nurses as per need of the sections.
 See that specially trained nurses are posted in the sections of their specialization.
 Take round of all section of hospital and supervise work of nurses, find out their
difficulties, guide them and correct them whenever necessary.
 Organize and conduct training, refresher classes for nursing staff.
 Review day and night reports and submit them to superiors every day. Discuss with
them problems if any.
 Handle grievances of the nursing staff and solve their problem.
 Investigate complaints about nursing staff and report them to superiors with remarks
and suggestions.
 Hold meetings of nursing staff for administrative and technical purpose.
 See and monitor ward procedures.
 Keep attendance of nursing staff and recommend leave to them and maintain leave
record.
 Report absentees and recommend actions.
 Organize yearly checkup of all nurses, 3 monthly checkup of nurses working in
tuberculosis wards. 6 monthly check up of nurses working in casualty, ICU and OT.
 Implement policies and instruction of administration and management.
  Participate in professional training, workshops and similar activities to keep knowledge
up to date.

 Maintain and carry out correspondence related to professional, establishment and

administrative matters.
 Matron shall be answerable to medical Superintendent and Dean.
 Carry out physical verifications (routine and surprise) of dead stock and consumables in
all sections of hospitals.
C. Duties and Responsibilities of Asst. NSG Superintendent

 Supervise and monitor nursing services in all sections of hospital.

 See that staff as per norms is available in all sections at all times.
 Help and guide ward sisters to arrange duties, get indents, establish inter department
relations amongst other departments of hospital.
 Help NSG superintendent in organizing in service education programme.
 Take rounds of all sections of hospital supervise and monitor nursing services.
 Check whether treatments are carried out as per prescription and take corrective measures
as and when necessary.
 Check day and night reports books and discuss them with NSG Superintendent.
 Check duty assignment books in each section and see that duties are carried out accordingly.
Take corrective actions if necessary.
 Check dead stock and consumables accounts and stock once in three months, reports
observations to superiors.
 Jobs assigned by superiors.
D. Duties and Responsibilities of Sister In charge

 Sister In charge is over all responsible for smooth running of her ward.
 Distribute duties amongst the staff nurses and see that they are attended.
 Arrange duties of support staff and see that they are attended.
 Maintain discipline in the ward.
 Receiving, monitoring and giving reports.
 Keep custody of dead stock and consumables and maintain their account up to date.
 Maintain good interdepartmental relations.
 Report to higher authorities, emergencies accidents, deaths and incidents of importance.

 Maintain proper record of patients.

 Supervise and get done cleaning of ward, sanitary blocks.
 She must know patient’s condition and nursing care needed.
 Supervise and ensure that the treatments are carried out as prescribed and their records are
maintained properly.
 Observe and report patient’s conditions to doctors from time to time
 She must accompany heads of units on their rounds.
 Supervise transportation of patients.
 Teach and guide student nurses.
 See that proper aseptic and bio-safety precautions are taken by the nurses and support staff.

 Supervise waster segregation and disposal.

 Prepare diet indents and supervise diet distribution.
 Supervise and ensure that patients for operations and procedures are prepared properly.

 Keep custody of patient’s belongings.

 Submit records of MRD.
 Take care about medico legal, abscond, AMA procedures.
 Keep account of hospital fees and see that the charges are recovered regularly.
 Arrange repairs of equipment’s if out of order.
 Maintain ward statistics and display it along with the name of personnel on duty every day.

E. Duties and Responsibilities of Staff Nurses

 Look after duties of sister in her absence.

 Maintain cleanliness of ward and sanitary block.
 Administer medicines, injections as prescribed and maintain record.
 Give nursing care with sponging, mouth and back care etc. and maintain record.
 Maintain instrument and bedside trays ready for use at all times.
 Take detailed over from nurse on previous duty. This includes all patients, serious, operated
patients, delivered ladies and new born etc. instruments, equipment, linen and supplies.
 Prepare beds of patients and change their clothes.
 Prepare patients for operation and procedures.
 Transport patients to OT or procedures room under own supervision with all necessary
record.
 Obtain written consent for operation, procedure etc.
 Take rounds with doctors and note down the instructions, changes in treatment etc.
 Collect specimen for investigation, label them properly and send them to laboratory.
 Monitor patient’s condition, record it and inform doctors as and when necessary.
 Check every new admission and see that the papers are prepared properly. Inform every
admission to the doctor.
 Check every new transfer in patients and see that the papers are complete.
 Read case papers carefully, carry out the orders accurately, and keep the record.
  Maintain case papers investigation reports, X-rays, charts etc. properly and keep them in
such a way that they are not available to relatives or common public.
 Keep medico legal record with utmost care and do not permit anybody else than treating
doctor to see it.
 Talk to patients posted for surgery to reduce their tensions and fear and give them
confidence.
 Listen carefully to patient’s problems and help them.
 Explain follow up instructions to patients discharged.
 In case of death, AMA absconds, complete the case papers and procedure before going off
from duty and hand it over to next nurse.
 Inform any important incidents in the ward to superiors.
 Supervise work of support staff and guide them properly.
 Observe strict bio-safety and waste segregation and disposal protocol.
 Report needle stick or any injury sustained during course of duty.
There are many variables to be considered when planning for staffing. The more accurate the
assessment, the higher the probability of containing costs while providing high quality care.

5.6 STAFFING PATTERN

The nursing care of patients in hospital depends on the numbers and quality of nursing personnel on
duty at all times of the day and night. The number of nurses required to man the nursing services in
a hospital, depends on many factors, some of them are.
 Number of beds in a hospital
 The type of hospital and the prevailing medical practice, including kinds of treatment and
medications given, and tests and services required for the patients.
 The design and layout of the hospital compact or spread out, and the type of physical facilities
provided (single layout beds or multiple beds).
 Pattern of assignment of nurses- based on functional method, case method or team method.
 The type and the number of emergency cases coming into the hospital.
 Available labor saving devices; automation, mechanization – centralization.
The staffing depends on the time spent by nurse on the patient. The work load to be undertaken in
caring for patients may be considered from three points of view:
 The quality of nursing
 The characteristics of the patients
 The schedule of nursing care
Extensive research has been done to ascertain the average number of hours a patient needs nursing
care in a hospital. It has been worked out that average number of bedside nursing hours required
per patient in 24 hours is as under:
 Ward Hours of Care
a) Medical/Surgical and Mixed Ward - 3.2
b) Maternity Ward - 2.3
c) Neonatal Ward - 5.5
d) Children’s Ward - 4.3
e) Communicable Diseases Ward - 4.7

f) Private patients: 1) Mixed - 5.4

2) Maternity - 6.5

Every hospital has to work out its own need based on the above factors. According to the
recommendations of the Nursing Committee set up by Ministry of Health, Government of India
(Shetty Committee), the ratio of nurses to patients in a hospital should be 1:3 These figures do not
include teaching and administrative staff and staff for special departments which are to be
provided in addition.
1. The Master Staffing Pattern
Making the Staffing Pattern for the nursing service of the whole hospital is relatively a simple task
once the staffing patterns for each needed for each category are decisions made by the Director of
nursing service, with the help of her assistants, Supervisors and head nurses.
The development of Master Staffing Pattern based upon a study of the needs of patients and
availability of personnel should result in a sound, realistic, reasonable and understandable plan.
Studies in some general hospital, however, indicate that the effective ratio for their particular need
is one professional nurse to two auxiliary nurses.
2. Shortage and Turnover
Shortage of nurse is an old problem existing the word over. This is partly due to the rapid expansion
of medical care programmes and the general lack of understanding on the part of the public about
the duties and responsibilities of the nurses.
Connected with shortage is the problem of turnover of nurses. By turnover is meant the
replacement of trained nurse due to her resigning or getting out of service.
In a survey conducted in Chaster Hospital (USA) over a period of 4 years it was found that 55.8% of
resignations were due to personal reasons like change of town, domestic reasons and so on; and
44.2% due to factors related to the job.
It is here in the later group that the hospital can reduce the turn over by using better man
management techniques. Some of the major reasons related to job are given below:
 Lack of job Satisfaction
 Inadequate Supervision
 Maladjustment with Fellow Employees
  Poor Personnel Policies

5.7 NORMS RECOMMENDED FOR NURSING STAFF

Ratio of Staff nurses and Nursing sister

Department Nursing sister Staff nurse

General Medicine 1 for 25 beds 1 for 3 beds

And surgical ward
ICU, ICCU and other 1 for each shift 1 for each bed /shift
Special ward
Labor room 1 for each shift 4 for each bed
O.T. 1 for each shift 3/ table /shift
Obs. & gynae. 1 overall 1 for each room of Dept.
1 for gynae. OPD
OPD 1 for each OPD Actual needs
Pediatrics 1 each shift 1 for two beds
Casualty and emergency 1 for each shift 2-3 / shift depending on
No. /No.of admission
Leave resource 30% in all
Categories

5.8 SUMMARY

The nursing profession is an important component in health care. A patient taking indoor treatment
in a hospital ordinarily has interaction with nurses for maximum time more than that with his
treating doctor. The roots of nursing profession are in the services rendered by the sisters in
Christian religion and then the defense services.
In India the history of nursing dates back to 500 BC, when Lord Gautama Buddha established
hospitals attached to monasteries. These hospitals had male nurses. The literature by Sushrut and
Charak have mention about attendants to the patients who are comparable to present day nurses.
References are also found during the period of Emperor Ashoka. Nurses who knew cooking and
patient care were appointed during this period.
5.9 KEY WORDS

1. General Role:
 Round the clock nursing services
 Monitoring and coordinating nursing care
 Assisting other professionals in implementing their plans of care.
2. Specific Role:
 Assess the patient care needs
 Plan and provide nursing care interventions
 Prevent complications and promote improvement in the patients comfort and wellbeing.
 Alert other care professionals to the patient’s condition
 Documentation.
UNIT 6 WARDS MANAGEMENT AND NURSING CARE

Objectives

After going through this unit you will be able to:

1. Understand the concepts of ward management;

2. Understand the nursing tasks related to patients;
3. Know material required for patients care;
4. Know the records maintained in wards;
5. Learn procedures for various activities related to patients care.
Structure
6.1 Introduction
6.2 Role of Nurse
6.3 Nursing Care Methods
6.4 Functions of Nurse
6.5 Equipment in Ward
6.6 Monitoring And Evaluation
6.7 Summary
6.8 Key Words
6.1 INTRODUCTION

A patient is admitted to hospital for various purposes.

 For observations of symptoms, signs and complications of the disease process and their treatment.
 For administration of drugs at specific times.
 For performing surgical procedures particularly major ones.
 Complete rest for restoration of health.
 Supervision of nutrition.
 Isolation in cases of infectious diseases.
 Academic and research purposes.
Thus the objective of ward management and nursing care is to organize the service in such a way to
meet the demands of the purposes for which patient is admitted. This can be achieved by providing:

 Comfort and satisfaction

 Comprehensive patients care based on needs.
 Timely and accurate assessment of illness.
 Keeping adequate resources in terms of manpower and materials.
 Health education

A nurse is regarded important for patient management since ancient times. Ayurveda states that the
tripod of treatment stands are the physician, the nurse and the drugs. Charaka described four
qualities of a good nurse. They are knowledge, skills, affection and cleanliness.
Some more qualities a nurse is expected to poses are healthy physique, good manners, even temper,
sympathy and habit of keen observation, punctuality, obedience and accuracy of statements.
Nursing is defined as a profession of actions, reactions and interactions. To assist individuals to meet
their basic needs to cope up with their basic health needs.

6.2 ROLE OF NURSE

The main functions nurse is expected to perform are:

 Planning total patients care

 Selection of persons for assignments of activities
 Organizational duties
 Interdepartmental correlations
 Public relations
 General supervision
 Training subordinates
 Formulating standard practices

6.3. NURSING CARE METHODS

Three methods of providing care to the patients are commonly followed in most of the hospitals.
The hospital has to make a policy decision about the method to be followed, whichever the method,
it should be followed uniformly throughout the hospital.
Functional Method
The different tasks of nursing care like bed making, sponging, back and mouth care, giving injections,
giving tablets, monitoring etc are distributed amongst the nurses available in the ward. The nurse
that has been assigned the tasks shall do them for all patients in the ward. This method improves
efficiency of staff, saves time, maintains uniformity, helps develop proficiency in particular skills. But
this becomes mechanical and monotonous.
Case Method
Here a nurse is given the work of total management of a group of patients. In this method a nurse
can develop all nursing skills. Care is more individualistic and gives better satisfaction to service
providers and patients both.
Team Method
A group of nurses is assigned with a group of patients under a team leader. The team leader
distributes tasks and patients to the group members and gets them done under supervision and
guidance. This method is said to provide better care, better planning, opportunities for nurses to
learn from their leader. The success depends on the team leader. The number of nurses required is
more than the norms ordinarily accepted.
The working methodology of ward pertaining to different functions and procedures shall be
discussed now.
6.4 FUNCTIONS OF NURSE
Receiving Patients
When a patient admitted to a ward reports, the nurse on duty received him / her. She checks the
indoor case paper to ensure that all the details are filled in and the patient has reported to the ward
he is admitted to. The time patient’s entry to the ward is written on case paper and admission
discharge book. Then a bed is allotted to the patient depending on the needs of monitoring and
closeness of attention dictated by his condition and nature of illness. Patients who need more
attention are kept on beds nearer to Nurse Station. The nurse goes through the doctors instructions
regarding investigations to be carried out and the treatment prescribed. The treatment prescribed is
administered immediately except in cases certain investigations are to be done before it. Vital
parameters of the patient are recorded and entered in the chart. The entries about the patient are
taken in the admission discharge register and general order book of nurses.
In case the instructions regarding investigations and treatments have not been written in the case
paper, the nurse informs the doctor immediately to come and do needful. In small hospitals this is
done by sending a written call in a call book with a messenger. The doctor is called in if the nurse
feels that the vital parameters recorded by her are not with in normal limits.
On receiving the call, doctor goes to the ward, examines the patient and writes relevant notes and
instructions which are then carried out by the nurse and entries to that effect are taken in the record
and chart of the patient. Instructions regarding diet are given to the patient and diet indent is made.
Rounds by Doctors
The ward doctor first examines the patient and enters his notes and orders in the case paper. The
senior doctor / consultant then examines the patient, goes through the writing of ward doctor and
writes his own examinations and findings and orders. Some more investigations may be asked for
this time.
The nurse attends the rounds. She carries with her the examination tray and round book. She helps
the doctors in examining the patient by arranging screens around, giving suitable position and
making required instruments available to the doctors.
After the rounds she goes through the new instructions, enters them in the G.O.B and administers
treatment newly ordered. She also collects samples for investigations. In case some bed side
investigation is to be carried out she informs concerned persons. In case patient is to be sent to
some other section for investigations she escorts the patient.
Investigations
Getting investigations done is an important activity. They have diagnostic and prognostic
importance. The responsibility of getting the investigations done is with the nurse. When
investigations are prescribed, she should make a note of them in the G.O.B. and a chart maintained
in the ward. She should collect the samples properly. If certain prerequisites are necessary say like
fasting for certain hours, collection after certain hours after meals, bowel preparation not voiding
urine for some hours, suitable instructions are given to the patients and samples are collected after
that. The nurses should remember that majority of errors in investigations are because of improper
pretest procedures. While collecting samples, the bulbs with suitable preservatives are taken, they
are labeled with necessary details about patient’s demographic information, diagnosis and tests
desired. Then the samples are collected, added to these bulbs, mixed well, capped and sealed
properly and preserved under required conditions. Then all such samples collected from different
patients are sent to laboratory. The names, registration no., name of sample tests required are filled
up in a laboratory investigation form and register. The forms are filled up and signed by the doctor.
The samples and register are sent to laboratory under proper bio-safety precautions described
under the relevant chapter. The laboratory technician received samples and signs the register as a
token of receipt. After the reports are received they are checked as per the register marked so and
attached to the case record of the patient. In case of reports that are required urgently, the nurse
informs them to the concerned doctor on telephone or by sending a written call.
In case of emergency investigations, the samples are sent immediately with note to that effect.

In case of Radiological imaging and other investigations for which the patient has to be sent to other
departments, the patient’s case paper and requisition form are sent with an attendant. In case
patient’s condition demands, the nurse accompanies the patient.
Interdepartmental References and Transfers

Patient’s illness and / or complications may need opinion and advice from specialists other than
patient is admitted with. Such references may be of two types.
If the reference is urgent, the concerned specialist is informed is informed accordingly. Who then
comes to the ward and sees the patient, as such and patient is non ambulatory. If it is not urgent, an
appointment is taken and patient with the case paper is sent to specialist’s office with an escort and
is brought back to the ward after examinations and notes to that effect on case paper by specialist.
The advice of the specialist is communicated by the nurses to ward doctor on telephone if it is
urgent. Any investigations suggested by the specialist are got done. The treatment recommended is
administered and entries to that effect are made in GOB and treatment chart. Sometimes the
patient has to be transferred to other ward under care of the specialist to whom the case was
referred to, who writes instructions on patients case paper. The ward nurse informs this to the
doctor in charge of the patient and after his consent, initiates the transfer procedure. She informs
her counterpart in the ward to which the patient is proposed to be transferred about this. That
nurse goes through the occupancy list and identifies a bed for this patient, if bed is available, she
accepts the transfer. The nurse then explains this to the patient, prepares him, takes a note in the
transfer register, the patient with his case paper and transfer register are then escorted to the
concerned ward. The receiving nurse signs the Transfer register as a token of receipt and sends it
back. Sometimes immediate, transfer is not possible due to non-availability of vacant bed. In such
case the patient waits in the ward till the receiving nurse intimates about availability of bed.
However the treatment advised by specialist is administered without waiting for transfer.
Bed Side Procedures
Many procedures like abdominal paracentesis, pleural tapping, lumbar puncture, venesection, and
tracheostomy are done in the wards. Though called bed side procedures, they should be performed
in a room designed for the purpose in every ward.
It should be a room of 120 to 150 sq. ft. with a sink for washing hands. A minor operation table with
head low and lithotomy arrangement, a showdowless lamp, suction machine oxygen cylinder,
laryngoscope, endotracheal tubes and ambubag, emergency drugs and adequate number of
instruments sets for performing the procedures should be available. The procedure room should be
maintained as clean as an operation theatre and discipline as in operation theatre should be
observed.
The procedures should be performed in presence and supervision of a qualified doctor. Patients and
relatives are explained about need, nature, advantage, dangers of the procedures and also the
effects if they are denied. This should be done in a language, they understand. Sometime should be
given to them to think over and then if willing, a consent in written format duly read and explained
to them should be taken. A witness should also sign the consent form. The nurse who has recorded
the consent should also sign it with date and time of recording. The patient should then be shifted to
the procedures room, procedure performed and patient shifted back to the bed.
The material (Tissues, fluid, pus) removed during procedure should invariably be sent to laboratory
for analysis. The linen and instruments used are immersed in antiseptic solution. The disposables
used are discarded in suitable containers.
A note of the procedure done should be taken in a register maintained for the purpose. The
procedure room cleaned, disinfected and locked. The patient shifted to bed should be monitored for
vital parameters, bleeding / leak from the site. Patient and relatives are explained about the results
of the procedure and after care to be taken.
Patients for Surgery
Patients for surgery are admitted in general surgery, Orthopedics, ENT, Ophthalmology, obstetrics
and Gynecology wards. The nurses must know how to counsel and convince these patients, obtain
consent, prepare them for surgery and how to look after them after surgery.
The surgeries are advised by the surgeon in charge of the case. Ordinarily the surgeon explains the
need for surgery, advantage and disadvantages etc. about the surgery to patient and relatives. They
are admitted only when they are willing for surgery. Since patients are in contact with nurses for
longer time, they can explain and reassure the patients.
The written consent is then obtained. Most of the hospitals have printed proforma of consent in
which the name, age, registration number, diagnosis, name of surgeon, date etc. are filled in and the
whole form is explained to patient’s relatives and the consent obtained. The consent of a person
above the age of 18 years, who is mentally stable, and not in an unconscious, semiconscious
delirious, drowsy condition and not under influence of any sedatives or tranquilizers. Consent of the
parents or guardian has to be obtained in case of the condition mentioned above. Consent of
mentally retarded persons also is not valid. In case patient is not in a condition to give consent
relatives are not available to give consent and patient is in dire need of surgery, notes to that effect
should be written in case paper and consent from medical superintendent can be obtained and is
valid.
Preparation of patient and part are then started patient has to be kept fasting for variable length of
time depending on nature of surgery. This is divided and ordered by the doctor. This is explained to
patient.
Preparation of part is done by shaving a broad area beyond the site of surgery. Hairs on extremities
are also removed. In elderly patients and those who may need urinary catheterization, the perineum
is also shaved.
This should be done in the morning before surgery. Beards, mustaches are also shaved. Patient is
then given a bath with ample soap and water. The part prepared is then cleaned with antiseptics.
Patient is given clean clothes to wear. Ornaments and undergarments are removed.
An operation list is prepared by the doctor and is sent to operation theatre one day prior to the date
of proposed surgery.
The anesthetist comes for preanesthetic checkup. Nurse should assist them during examination of
the patient look into the instructions given and implement them.
On the day of surgery the patient, case paper, investigation reports x-ray, films, material brought for
surgery, blood etc. are sent to OT at the time asked by anesthetist. Patient should be sent on a
trolley stretcher and never be walked to operation theatre. The nurse should accompany the
patient, hand over the case paper and material to the preoperative nurse. A check list for this
purpose is prepared and sent with the patient duly signed by ward nurse and pre op nurse. A sticker
label is pasted on left wrist of patient, patient’s name, age, sex, reg. no., ward no diagnosis and
surgery proposed with side are written on. This is for matter of identification.

After completion of surgery and patient is ordered to be shifted to ward, the nurse in post-operative
room informs the nurse of patients ward. The ward nurse goes to OT with a stretcher trolley, takes
charge of patient, all his record. She checks the tubes, drains, catheters and shifts patient to the
ward under her supervision.
In the meantime a bed is prepared for patient in the ward. Patient is shifted to the ward. Suitable
position given, tubes and catheters arranged properly and patient’s vital parameters and other
observation recorded. Orders in past operative notes are recorded and entered in the record. The
treatment ordered is then administered. The patient’s vital parameters are recorded periodically.
Any change in them or development of any symptoms and signs are taken note of and the doctor
informed immediately. The doctor comes to the ward, checks the patient and gives further
instructions which are carried out immediately. The relatives are informed about parent’s condition
from time to time.
All the treatment orders and instructions are entered in the GOB register and treatment charts.

Above management is in relation to planned surgeries. For emergency surgeries, same steps are
followed immediately after patient’s admission to ward and are completed by the time emergency
surgery is proposed at.
Discharge
Discharge is a common eventuality of a patient’s admission to hospital. The other eventualities are
absconding, leaving against medical advice, transfer to other institutions and death. The discharge is
given by the doctors when they are convinced about patients being relieved of symptoms or cured.
When the discharge is decided about, orders to that effect are written on patient’s case paper. It is
explained to the patient. A discharge summary on a discharge card in duplicate is prepared. The
columns on the cover are completed and signed by the doctor. A copy of the discharge card is
handed over to the patient with instructions regarding further treatment and follow up. The entry
about discharge is taken in GOB and admission discharge register and patient sent home. When told
about discharge, patients are anxious to go home therefore the procedure is completed
expeditiously.
Patients remarks about hospital and services should be obtained in a patient’s remark book
maintained in the ward. Even their complaints and suggestions should be recorded. These help in
improvement. These remarks should be seen by administrations periodically. Complaints should be
brought to notice immediately.
Patients wish to donate something in cash or kind. This may be encouraged. A donation box is fixed
in every ward. Patients are directed to deposit cash donations in the box with their own hands.
These boxes are under lock and key and seal. They are opened by a team of staff designated to do so
by the administration. The box is opened in presence of the sister of the ward. All money taken out,
box cleaned from inside, ensured that it is not damaged, locked and sealed again. The money taken
out is counted, entered in the register for this purpose, total made and signed by all team members
and the sister in charge. Her signature is obtained separately for having received the box in good
condition, locked and sealed. The money is deposited to the donations account. Hospital should
have a policy about utilizations of such donations collected.
The donations in kind should be sent to administrative officer with a letter to that effect. The
donations are received, entry taken in the register for this purpose and also in the dead stock
register and then the donations transferred to the ward for which it is received. A letter of thanks is
issued to the donor.
Some patients wish to felicitate the doctors and nurses. They may be given this opportunity.

After the patient is discharged the case paper is taken care of. All the pages are numbered and
patients name and register number written on each page if not already done. The investigation
reports are arranged in chronological order. The rays and films and other imaging procedures are
also arranged in chronological order. The whole bunch is stapled firmly and kept in the file. The case
papers of all discharged patients are sent to medical records department under receipt
The body and bed linen used by the patient is changed. The mattress is also changed. The mattress
of discharged patient is exposed to sunlight for 2-3 days and then brought for use again. The
mattresses in strategic departments like ICUs are sterilized in a bulk autoclave. The body and bed
linen sent to laundry for washing. The bed and bedside locker are cleaned with water and
disinfectant and solution then the bed is prepared for new patient.
The other mode of discharge is discharge on request. Patient is asked to write his request for
discharge on the case paper under his signature. The probable consequences of the discharge are
explained to him and if he still wants to leave, is permitted to do so. Rest of the procedure is same as
discussed above.
Sometimes patient wants to leave hospital, while the doctors want patient’s to stay in hospital for
completion of treatment. Here again the consequences of leaving the hospital are explained and
recorded on the case paper. Patient asked to write a note stating that he is leaving the hospital
against medical advice on his own responsibility. Then he is permitted to go.
Occasionally patients leave hospital without a discharge of any of above types, unnoticed by
anybody. He may do so with the linen or / case paper which are hospital properties. Taking away
such hospital property amounts to theft. The hospital should have a policy about the actions taken in
such cases. Hospital may bear the loss of stolen material. But the case paper may be misused. If a
medico legal patient absconds even without hospital property, police has to be informed in writing.
Patients with psychiatric illness, mental retardation, minors below age of 18 years, operated patients
with incomplete treatment and prior to removal of sutures, female of any age disabled and
physically, visually compromised patients absconding are treated similarly. They may meet with
accidents or land up in some problems. If absconding has not been recorded accurately, hospital
may have to face problems. In order to make hospitals responsibility clear, such cases should be
notified to police immediately. The patient absconded may return after some time. In such case the
time of absconding and coming back should be recorded accurately. It is possible that patient may
be involved in law and order problem and if there is no record about the duration of his absence it is
proved and some culprit or criminal may escape legal action. Therefore accuracy in recording the
times of absconding and returning must be written on case paper. When the patient returns to ward
whether to accept him or not is a policy matter. Some hospitals accept and continue the same case
paper after recording timing as above. Patient is asked to write on case paper that he was not in the
hospital for a duration from time and to time and the responsibility of any incident, accident
happening is his own and not on hospital. So hospitals accept him as a new case taking care to note
the exact time of admission and reporting to the ward.
Death
Patients come to hospital with hopes to get cured. Some of them meet the ultimate eventuality. It is
a sad event for the bereaved family and friends irrespective of the seriousness of illness.
Occasionally death, when totally unexpected may lead to serious out bursts causing damage to
hospital property and staff. The situation of death therefore has to be tackled very seriously and
tactfully.
When a patient becomes serious or develops life threatening complications, a senior doctor should
invariably examine the patient, supervise the management and explain the situation to relatives in
soft and sympathetic words. He should also ensure them that all due and possible case is being
taken to overcome the problem. The care being taken should be distinctly visible. Since every action
and move is watched by relatives, the behavior and actions of all staff, doctors and nurses should
give clear signals of their concern and involvement in case management. No amount of efforts can
be said to be adequate when human life is at stake.
The information about patient’s condition should be explained to relatives frequently. The death
should be declared by a senior doctor. A tracing of ECG showing some activity and then no activity
(straight tracing) should be preserved. Where EEG is available straight line tracing for 3 minutes
should be preserved as proof of brain death.
The medical certificate of cause of death should be prepared carefully. Mistakes in names, age,
spellings etc. should be corrected before filling up certificate. Body is handed over to relatives under
a receipt on the case paper.
The case paper is dealt with as described under preceding discussion on ‘discharge’. The linen is also
handled in same way. In medico legal cases post mortem may be asked for. In such cases the
medical certificate of cause of death should not be issued. In case the death is within 24 hours after
admission, and the diagnosis is not clear autopsy to know the cause of death should be insisted
upon. Cause of death certificate should not be given in case of death of a woman falling in the
category of ‘Daori Death’.
When a patient is on the verge of death or brain death has taken place, relatives should be explained
the situation and some hints towards organ donation should be given considering the situation and
psychological condition of the relatives. If they agree or show such desire, necessary arrangement
should be made for the same.
6.5 EQUIPMENT IN WARD
Cots, bedside cupboards, back rests, infusion stands, stools, tables, chairs, stretcher trolleys, wheel
chairs, black board, drinking water, arrangement, waste disposal buckets, storage cupboards,
shelves, refrigerator are required. The cots may be regular ones, semi fowler and some fowler beds
should be provided. The equipment can be grouped in categories as under.
Resuscitation Equipment
 Suction – central electrical, mechanical
 Suction catheters different sizes, sterile
 Airways
 Laryngoscope
 Endotracheal tubes all sizes
 Ambu bag suitable sizes
 Defibrillator
 Ventilator
 ECG machine
  Tracheostomy set
 Venesection set
Oxygen Delivery Equipment
 Central Supply
 Oxygen cylinders, flow meters and humidifiers (and spanner)
 Oxygen mask, nasal catheters, head boxes (tent)
 Nebulizer
Drugs Delivery material and Equipment
 IV cannula, 3 way connections, umbilical vein catheters
 Drip sets
 Measured volume sets
 Blood transfusion sets
 Syringes and needles
 CVP catheters
 Syringe Pump
 Infusion Pump
 Venesection sets
 Feeding tubes
Measurement Materials
 Weighing Machines adult, infant, electronic
 Infantometer
 Shakir tapes
 Measuring tapes
 Skin fold calipers
 Height measuring stand
Monitoring Equipment
 Thermometers clinical, rectal
 BP apparatus, adult and children
 Cardiac monitor. Multipara monitors
 ECG machine.
Bedside procedure Sets
 Pleural taping and ICD sets
 Abdominal Paracentesis sets
 Lumber Puncture set
 Bone Marrow set
 Biopsy needles true cut, silverman, pleural
 Suturing and suture removal set
 Dressing tray
 Catheterization tray
 Ryle’s tube set
 Stomach wash tray
Nursing care Sets
 Sponge tray
  Back and mouth care trays
 Enema Sets
 Bladder wash set
 Flatus Tube
 Splints
 Steam in haler
 Cervical collar, lumbar belts
Examination Tray
 General, CNS, ENT,
 Torch
House Keeping Material
 Buckets
 Mops
 Dusters
Records and Registers
 Staff Record
 Duty Register all staff
 Assignment Register all staff
 Leave account all staff
 Material Record
 Dead Stock Register
 History Sheets of equipment
 Repairs Book
 Sterilization Book
 Consumables
 Linen Register
 Laundry Book
 Drugs and Medicines
 Other Material
 Petty Supply and housekeeping material
 Patients Record
 Admission discharge Register
 General Order Book
 Bedside Procedure Book
 Investigation Register side lab and control lab
 Call Book
 MRD Book
 Dead Body Register
 Patients Remark and complaint Book
 Patients Property Register
6.6 MONITORING AND EVALUATION
Bed occupancy, bed turnover rates are the basic indices that should be monitored. Complications
rate, infection rates are important. Rates of patients absconding and going AMA reflect on over all
patients’ management and ward management. Patient’s remarks and complaints are direct
reflections of the services given. Similarly exit interviewers also throw light on client satisfaction.
Absenteeism and leave tendencies of staff may be a matter of individual difficulties, habits, and
attitudes but can give some clue about the management of ward. Maintenance of uninterrupted
supplies of drugs, material should be monitored.
Cleanliness of ward, toilets should be monitored. Staff found sleeping during night duty should taken
account of.
Donations received by a ward, is an index of high client satisfaction. A check list for monitoring of
ward functions is given here.
Ward Checklist

Department Ward Dates Person

A. House Keeping
i. Cleanliness
Wards -
Corridors -
Toilets -
Furniture -
Linen -

ii. Functioning of Electricity Fixtures Y/N

Tubes
Fans
Plugs

iii. Water Taps

Tubes Y/N
Drains Y/N

iv. Drinking Water Y/N

B. Arrangement
Beds locker Stools
Trolleys - Medicines Injections - Dressing
Waster Disposal Bin - Bags
Telephone
Duty List Ward Statistics
Job charts Standing Instructions
C. Emergency Materials
Beds Backrest IV stands Blocks
Suction Machine Oxygen Cylinder
Laryngoscope ET Tubes
Ambu Bag and Mask
Nebuliser
Bed Side Monitor Pulse Oxymeter
ECG Machine Others Specify

D. Emergency Drugs
(Check 5 Drugs) for adequacy with Expiry date
1.
2.
3.
4.
5.

E. Bed Side Procedure Trays

Check 2 Procedure Trays for availability and sterility
Check 2 Nursing care Trays for availability and contents
1.
2.
3.
4.
F. Inventory
Book Balance Actual Stock Difference
If any

1. Dead Stock Items -

2. Linen -
3. Petty Supply Articles -
4. Medicines -
5. Equipment Other than C -
G. Record
1. Admission Discharge Register for completeness
2. Check entries of treatment from 3 case papers
No Drugs Prescription GOB Stock Remarks
Register

3. MLC Record

H. Clinical Work
i. Doctors Rounds Mention Time
Residents
Lecturer
Units I/C
HOD
Administration
Support Services - Biomed Engineer
- Electrician
- Plumber
ii. Investigation
Lab X-Ray Others
No of investigations sent on prior day
No of Reports Received
Reports Not Received with reasons

iii. Interdepartmental References

No of References sent
No of references attended
No. of references Not Attended
(with patients name and Doctors name)
iv. No. of Patients AMA and absconding
v. No. of Patients with stay more than 1 month with reasons
I. General Impressions and Suggestions
6.7 SUMMARY
A patient is admitted to hospital for various purposes. Observations of symptoms, signs and
complications of the disease process and treat them promptly for administration of drugs at specific
times, performing surgical procedures particularly major ones, complete rest for restoration of
health, Supervise nutrition, For isolation in cases of infectious diseases, academic and research
purposes.
A nurse is regarded important for patient management since ancient times. Ayurveda states that the
tripod of treatment stands are the physician, the nurse and the drugs. Charaka described four
qualities of a good nurse. They are knowledge, skills, affection and cleanliness.
Some more qualities a nurse is expected to poses are healthy physique, good manners, even temper,
sympathy and habit of keen observation, punctuality, obedience and accuracy of statements.
6.8 KEY WORDS

Methods of Nursing
Functional Method, The different tasks of nursing care like bed making, sponging, back and mouth
care, giving injections, giving tablets, monitoring etc. are distributed amongst the nurses available in
the ward. The nurse that has been assigned the tasks, shall do them for all patients in the ward. This
method improves efficiency of staff, saves time, maintains uniformity, helps develop proficiency in
particular skills. But this becomes mechanical and monotonous.
Case Method
Here a nurse is given the work of total management of a group of patients. In this method a nurse
can develop all nursing skills. Care is more individualistic and gives better satisfaction to service
providers and patients both.
Team Method
A group of nurses is assigned with a group of patients under a team leader. The team leader
distributes tasks and patients to the group members and gets them done under supervision and
guidance. This method is said to provide better care, better planning, opportunities for nurses to
learn from their leader. The success depends on the team leader. The number of nurses required is
more than the norms ordinarily accepted.
UNIT 7 RADIO DIAGNOSIS AND IMAGING SERVICES

Objectives
After going through this unit, you will be in a position to know:
1. The different imaging modalities;
2. Learn the planning at premises for the department;
3. Plan organizational structure for best output;
4. Evaluation and quality control.
Structure
7.1 Introduction
7.2 Modalities of Radiology
7.3 Planning
7.4 Equipment Management
7.5 Staffing
7.6 Policies and Procedures
7.7 Radiation Safety Policy
7.8 Monitoring And Evaluation
7.9 Summary
7.10 Key words
7.1 INTRODUCTION
Radio diagnosis and imaging services is important tool in the hands of clinicians. Advances in
biophysics and applications of computer science have helped medical science to invent new and
improve existing modalities, bringing in speed and precision in the area. On account of the costs of
these technologies, the department has become a major consumer of hospital finances. The
financial burden is not only on purchase of these equipment’s but also on the special arrangements
that have to be made for housing them, maintain them and provide consumables for them along
with expert human resources to run the machines and interpret the results.
7.2 MODALITIES OF RADIOLOGY / X –RAY BASED FACILITIES

1. Conventional X-Rays

This is the oldest tool available based on principles of transmission. Images are taken on films.
2. Ultra Sound and Color Doppler

There are no significant biological hazards. The machines are less bulky than others. Portable
machines are also available. Dichromatic and polychromatic versions and three dimensional viewing
are available.
3. Computer assisted Tomography

Based on X-Ray technology, improved clarity gives more clear pictures. Best used in imaging of
central nervous system Contrast studies are possible.
4. MRI
Magnetic are used to produce magnetic fields over parts of body resulting in radio frequency signals
emitted by hydrogen nucleus in tissues. The radiofrequencies have characteristics called as
relaxation time. Longitudinal magnetization time is called T1. While the transverse magnetization
time is called as “T2”. Different tissues have different T1 and T2 properties that give particular
characteristics to the images produced by different tissues. The anatomical and physiological aspects
of tissues can be studied. Contrast imaging is possible.
5. Positran Emission Tomography

Isotopes with short half-life are used. Fundamental metabolic processes can be studied. It is possible
to study blood flow, blood volume, oxygen metabolism etc.
6. Mammography

Modality based on principles of X-Rays, used specifically for detection of breast pathologies, widely
used in detection of breast cancers.
7. Nuclear Imaging

Radio nuclides are injected and target organs imaged. Study possible ‘in vivo’, Scans of organs like
kidneys, liver, thyroid, bones and myocardium can be scanned. Absorption, excretion and
hematological uptake of the isotopes are studied. Nuclear medicine is an independent unit by itself.
Since imaging is possible, a reference is made here.
8. Single Photon Emission Computed to Tomography (SPECT)

Based on study of gamma – emitting radionuclide studies, these can cross blood brain barrier used in
epilepsy, Alzheimer’s, Parkinsonism etc. The modality is not as sensitive as PET.
9. Cardiac MRI

Used in evaluation of coronary vessels non-invasively.

10. Nuclear Magnetic Resonance Spectroscopy (NMRS)

Brain functions at molecular and metabolic levels can be studies.

11. Spiral Dual Source CT scan

This is a newer technology in which chemical composition of the material under study can be
visualized. Two sources of energy at two different KV levels working synchronously are used. Two
spiral data sets are acquired in a single scan. This enables differentiation in composition of urinary
calculi like uric acid, calcium oxalate etc. the angiography can reveal the calcification of vessel and
extent of true stenosis.
7.3 PLANNING
1. Premises
The department should be located at such a place that it can conveniently be accessed from OPD
and wards. It should be at one end of the accommodation so as to avoid radiation hazards. Ground
floor is perfect as a matter of convenience in putting the heavy machines with in the department.
The modalities more used should be near the entrance. While minimally used ones should be at the
rear. Actual square area and number of rooms depend on number of modalities and machines.
These requirements depend on the bed strength of the hospital and number and types of specialties
available.
Following machinery is necessary
X-Ray machine
500 MA - One
200 MA -2
100 MA -2
60 MA Mobile -5
CT Scan - One
Mammography - One
C Arm – image intensifier - One
Ultra sonography machines -4
Color Doppler -1
MRI - One
Optional
SPECT, PET, Gamma camera
Accommodation has to be planned on basis of workload. The international statistics shows a work
load of 7000 to 15000 cases per year per radiologist. In India it is around 500 cases per day. Thus the
population of the department on a given day is likely to be 100 to 1500 excluding staff of the
department.
The waiting area for the department should be near the entrance and entry beyond this should be
restricted. The reception counter and toilets for the people should be arranged in this area. The area
should be large enough to accommodate about 200 persons at a time. Waiting sub areas adjoining
individual sections like sonography MRI, CT scan should be separate and should accommodate 5 -10
patients at a time. Patients on trolleys and wheel chairs should be considered while planning waiting
areas as these patients are about 15-20%.
Circulation area which includes corridors and passages should be planned in a way such that
crowding and crossing of traffic is avoided. It should not be narrower than 2.8 meters and permit
free passage of stretcher, wheel chairs and walking patients.
The technical areas have to be planned meticulously. The area requirement of each service is
different.
2. X-Ray Rooms
X- Ray room should be of size of 6.5 meters X 5.5 meters and should have a height of 3.5 meters. The
walls should have or thickness of 20 cms but the wall behind chest stand should be 20 cms thick.
Alternatively, a thinner wall should have a lead sheet cover of 2 mm thickness and of the size of 1
meter X 2 meters. The control panel should be as far as possible from the X- Ray tube and should be
protected by a lead screen of 1.5 meters X 2 meters and a thickness of a 2 mm. it should have a peep
in window at eye level filled with a glass of 10 mm thickness.
 Mammography also uses the X-Ray Technology for study of breast diseases. Constructional
principles used are same as for any X-Ray room. A changing room for patients should be provided.

 Cardiac Cath laboratory is another modality that uses X-Ray. Since this is an intervention
activity, best possible aseptic precautions are essential. The equipment requires about 40.45 sq.
meters area. The room is built on principles of radiation protection and operation theatre.
 Arm image intensifier is a specially built X-Ray modality used in operation theatre in
Orthopedics and urology surgeries.
3. Ultra Sonography and Doppler Unit
The ultra sonography is a safe technique that uses sound frequencies of 3.5 to 10 MHZ. the echoes
returning from organs and tissues are picked up on monitor. Color Doppler gives red and blue colors
to flow of blood visualizing arteries and veins. This technique is maximally used in cardiology and
obstetrics. The sound energy has hardly any harmful effect on human body. Intervention techniques,
now days are employed with USG visualization. No specific precautions are necessary. The room
should have changing facility. There should be a separate waiting sub area. A changing room for
patients, toilets, sonologist office, record room and the sonography rooms are necessary. The
sonography room should be of 25 sq. meters each machine should have a separate room. Larger
areas are required for intervention sonology.
4. C.T. Scan
CT scanner is another machine based on X- Ray Technology. The X –rays passing through patient are
picked up on a detector, passed on to computers and stored there. The pictures can be viewed on
computer monitor or can be taken on film. The machine is larger in size than X- Ray machine. Other
equipment like ventilator, monitors, intervention equipment and instruments may be required to be
accommodated depending on patient’s condition. Thus, larger area is required on an average 30 sq.
meters space for machine and 6 E sq. meters separate accommodation for the control panel are
necessary. The walls specifications should be same as for X –Ray room. There should be a glass
observation window between the machine room and control room. The glass should be 10 mm
thick.
5. MRI
The modality is combination of magnetic resonance and computer. The magnets used are super
conductive magnets. The magnetic field requires protection from influence from surroundings that
can interfere with the field. The ferromagnetic substances can interface, distort and degrade the
images. On the other hand, the magnetic field can interface in the function of electrical and
mechanical devices like cathode rays scopes, pace maker etc. the ferromagnetic material like beams
and other iron material used in construction. They are compensated by using shims. Moving Fero
magnetic objects like patients trolleys etc. are difficult to be compensated hence sufficient distance
between the machine and the corridors used for the ferromagnetic objects has to be maintained.
The area also has to be shielded from radioactivity in adjoining areas installed with X- Ray machines.
The shielding is done with copper or aluminum with perfect sealing of joints between the sheets.
The temperature in MR room has to be maintained around 210C. Adequate air exchanges have to be
maintained considering heat generated from the machine.
The MR machine gives out an irritating sound / noise which should be taken care of by acoustic
treatment of the room.
The structural reinforcement, AC ducts sewage pipes, electrical conduits around the MR machine
should preferably be of non-ferromagnetic material.
The room should be specious enough to accommodate ventilator, monitoring machines and
intervention material. Central oxygen and vacuum connections should be available. The MR room
should be about 30 sq. meters and total 120 – 130 sq. meters be given for the ancillary arrangement
like sub waiting , offices, stores, record and toilets.
6. Mammography
Area requirement is 12 – 15 sq. meters for the machine room, a changing room office sub waiting
and record room and toilet.
7. Nuclear Medicine Department
 Artificially prepared radio isotopes are used for diagnostic and therapeutic purposes. The procedures
are in-vivo in-vivo types. The in-vivo procedures are imaging or non-imaging types. Scintilography is
the imaging procedure where in radioactive substance is administered in the body and images of the
organ or tissues understudy are obtained. In non-imaging types gross activity in organs under study
is measured. Serial measurements over time produce a time-activity curve.

Some important applications under nuclear medicines are:

 Imaging of organs like thyroid, brain liver, kidneys, bones etc. absorption study in GI tract, blood
volume iron kinetic studies, renal functions study etc. Radioimmunoassay’s of various hormones are
the types of in-vitro studies.
 Therapeutic applications of nuclear medicine are in treatment of thyrotoxicosis, thyroid cancers,
poly cythaemia Vera (P-32), malignant ascites and effusions etc.
 The equipment should be located, designed and planned in such a way that the staff and general
public receive minimum exposure.

 Imaging in nuclear medicine from organs / tissue is detected by a large lead shielded crystal. There
are photomultiplier tubes behind the crystal. These tubes detect and localize the scintillations. The
resultant electrical signals are analyzed by computers which reconstruct the image.
 Construction and radiation protection precautions as for X-Rays should be taken for nuclear
medicine department also.
1. PET
Space provision for the scanner and cyclotron, Radioactive and non-radioactive labs are required for
both these. Special ventilation system with monitors, sensors and alarms is required to vent out the
gases and chemicals liberated during the process. The cyclotron is water cooled. The heat
exchangers with chilled water connection from water chiller are necessary. The returning water has
to be stored in a tank and tested for accidental leakage of radioactive material from the cyclotron.
Separate space with radiation protection has to be provided for the Radio Pharmacy where
radionuclides are stored and doses are calibrated and prepared.
The organization of nuclear medicine department has to be made in hot areas, diagnostic areas and
patient support area. The hot area is meant for receiving, storage, and stirring, dilution, measuring
and dispensing the radio isotopes. The work with solid isotopes is performed in a glove box or under
a hood. The floor and work platform for the liquid isotopes should have nonporous surfaces.
Counting or measuring of the radio activity of a dose of isotope area. All the hot area has to be
protected so that radiation does not spread beyond this.
The diagnostic area lodges the scanner, counting units, scintillation camera. This area should have
direct assessed to the hot area to facilitate functioning. Support area has waiting, reception, staff
accommodation and toilets. The toilets for patients to whom radioactive isotopes have been
administered should be separate from others. The wall should be painted with washable paint.
There should be minimum furniture, the surfaces of floor and tables should be laminated with
nonporous material. Remote handling devices should be used. Ventilated fume hoods should be
used while handling the radioactive materials. The drainage pipes from sinks, basins and toilets
should be connected directly to main sewage system. Ordinary walls thickness is adequate except
for the area where dose is administered to patient and they are hospitalized. Lead boxes and bricks
should be provided in storage and handling sections. Staff should use monitoring badges.
 2. Radio Therapy
Brachytherapy and megavoltage. Brachytherapy is used in treatment of cancers of specific sites.
Isotopes of Radium, cobalt, cecum or iridium are used. Because of hazards of ionizing radiation, the
facility has to comply with regulatory requirement specified by Radiation Protection Act. The
equipment purchased has to be approved by Atomic Energy Board.
The Isotopes have to be stored, administered and in vivo or in – vitro counting is done in radiation
protected rooms. Rooms for patients treated and those not treated have to be separate.
Mega voltage therapy (Teletherapy) uses high voltage radiation of more than a million volts. Cobalt
60 and variety of accelerations are used to deliver radiation at 4 - 12 million volts.
Linear acceletors emit electrons from a gun and produce high quantum energy which penetrates
better depth and higher intensity of X-Ray.
3. Betatron uses magnetic field for induction and guiding the electrons. Betatron uses high energy
electrons. The dose drops sharply after they enter certain depth. Scattering sideways is low.
However the beam cannot be focused well, scattering radiation to surrounding tissues. The patient
output of linear accelerator is about 8 – 10 times more that cobalt unit. The life of the machines is
about 12 years.
It should have the following facilities:
a. The examination section includes reception, registration, consultation rooms and rooms for
doctors, staff and waiting area for patients etc.
b. The treatment section has a treatment planning area for dissymmetric planning. It should have
access to Tomography, simulator treatment planner and dosimeter help in accurate localization of
tumor and accuracy.
c. The simulator unit needs simulator room, control room, x-Ray processing room and preparation
room.
d. The mold room is used for preparing applicators for tumor sites. Patient’s impressions are taken
and appliances are prepared here. Vacuum forming and injections molding area is necessary. The
use of inflammable material makes it essential to provide good ventilation.
e. For insertion of radioactive material in the patient an operation theatre is required. This has to
be provided with extra area for radiation protection.
f. The treatment room has to be provided with adequate shielding with maze arrangement. The
thickness of head depends upon amount of radiation; maze design depends on weekly workload.
Baryt concrete should be used for the wall which is hit directly by radiation while for others ordinary
concrete may be used. The thickness should be 20 – 25 cms. High concentrations of ozone and oxide
of nitrogen are liberated during radiotherapy about 12 air exchanges per hour should be provided to
minimize the concentrations of these gases
g. Support Area
Conference room, library, store, records, staff room, toilets for staff should be provided.
 The radiation zone and not radiation zones should be separate. Patients and even staff should not be
required to pass through radiation zone for going to non-radiation zone.
 The walls of the rooms where X Ray. Mammography and CT scan machines installed should be 25
cms thick. It constructed with bricks and cement. If it is RCC casting, they may be 12.15 cms thick.
Alternatively a lead sheet of 2 mm thickness can serve the purpose of non-penetration. The lead
sheet fixed behind a chest stand should be 2 meters X 2 meters in size. The control panel should be
protected with a lead sheet of same size and 1 mm thickness. The windows in the walls should be
 1.5 to 2 meters above floor level. People should not be permitted to stand in a distance of one meter
from the window.
 The floor should be strong enough to bear the load of machine or alternatively concrete
strengthening of the area should be provided. Floors and walls up to a height of 2 meters should be
washable and minimally reflective. The doors should be 1.25 meters wide and have 1 mm thick lead
protection. A small peep in glass window may be provided in the door shutter. The wall adjacent to
the dark room should have a film pass box. This box has a double door, one opening in X-Ray room
and the other in dark room. The shutters of the box should be of convenient size. The doors are
opened one at a time.
 A changing room should be attached to every X-Ray room to facilitate. Changing clothes while taking
X-Rays. A toilet should be attached to the X-Ray room where in special procedures are carried out.
 The X-Ray room used maximally (say for chest X-Ray) should be nearer to entrance to avoid
crowding in the passage.
 Electrification – As all the machines in this department need electricity supply at a constant voltage
and it has to be uninterrupted. In addition to the main supply, there should be a generator and UPS
for individual machine particularly, the CT MRI and the machine on which special procedures are
done. The intervention machines should also have UPS.
In addition to the equipment now a days are highly sophisticated and based on computer
technology. These machines generate lot of heat that has to be taken care of so as to maintain
optimum temperature for proper functioning of the machines. While providing air conditioning,
this heat has to be made additional provision for. While construction is being planned scope for
future expansion should be kept in mind.

7.4. EQUIPMENT MANAGEMENT

The various equipment used in the department, has already been enumerated and their functions
described. It is a matter of the policy of the management, availability of finance, number of
specialties, clientage etc. to decide what equipment to buy. While doing this the specifications
should be worked out. A reputed vendor should be selected. The warranty, after sales service,
availability of spares should also be considered.
Service during warranty period with clear terms and conditions, It should be seen that the
maintenance is actually done during this period and it does not remain only on paper.
After the warranty period machines should be put on annual maintain contract on predetermined
terms. They should include periodicity of visits, supply of spares breakdown service and penalty
clause for downtime due to delay in service or supply of spares.
In house concurrent maintenance by the biomedical engineer of the hospital can be arranged for
equipment that is not on maintenance contract. The objective of maintenance service should be
minimum downtime, safety of equipment and staff, cost effective service and increase in life of the
machine.

7.5 STAFFING

The staff required is:

 Radiologist
 Technicians
  Nurses
 Attendances
 Clerks
 Maintenance Engineer
 Receptionist
 Electrician
The qualification should be determined and number be decided. Staff employed should be given
induction training and on job training periodically. They should be conversant with policies and
procedures of the institution and the working methodology. They should be able to detect errors
and faults in the machines in time. The radiation measuring badges should be prepared for every
employee of the department. Female nurses should be protected from radiation particularly during
child bearing age.
7.6 POLICIES AND PROCEDURES

The department should prepare standard operational procedures for every procedure performed
therein. All the staff should be conversant with these SOPs and they should be followed stringently.
The SOPs should be documented and revised periodically if necessary. The policies should be based
on the following.
a. Organizational Structure
The organization is under control and supervision of HOD. He has chiefs for sections like MR, CT,
Sonology, X-Ray etc. They are assisted by junior doctors and technicians. Support staff should be
attached to each section. The staff should be rotated periodically from section to section. Job
specifications of every person should be specified and the person be explained about it in detail.
b. Work Schedules
The department works 24 hours of a day and 365 days of a year. The duties of staff including
radiologists should be arranged in such a fashion that the work in emergency hours is also attended
to immediately.
c. Working Capacity
The capacity of staff and functional of every machine should be calculated. The maximum out put
that can be given by each machine be calculated and number of procedures that can be performed
in a day (number of shifts) should be calculated. The appointments given on a day should co inside
with this. This is for planned cases only. Emergencies have to be taken as and when they report.
d. Equipment Management
There should be plan for concurrent maintenance, periodic maintenance and breakdown repairs.
This should be considered while calculating the output of every machine so as to carry out
maintenance without hampering the work.
Criterion for proposing purchase of new machines should be prepared and the procurement planned
well in advance so that the work schedules can be adhered to. Similarly there should be
condemnation policy to guide condemnation of the machines.
The policy for procurement of consumables should also be laid down and brought into practice. The
objective should be to maintain adequate stocks in reserve to meet emergencies, market crises,
prolonged lead time etc.
7.7 RADIATION SAFETY POLICY
 The Atomic Energy Act 1962 and radiation protection rules 1971, Radiation Surveillance Procedures
1989 specify the conditions for radiation protection.
a. Effects of Radiation

Radioactive substances used for diagnostic and therapeutic purposes emit energy in the form of
waves. They have ionizing effects on human body. The injurious radiation comes from sources like
Gamma, Beta and Alpha rays and neutrons. The effect on body depends on source of radiation, its
dose and the type of body cells exposed to it.
The effect may occur as Acute Radiation syndrome or delayed effects.
b. Acute Radiation syndrome

This occurs over a period of hours or weeks after the radiation. It has three phases.
 Prodromal signs that occur within hour after radiation and last for a day or weeks
 Latent phase which lasts for days to weeks.
 Manifest Phase recovery or death occurs within 6 weeks after exposure.
c. Delayed effect

These occur months or years after the exposure to radiation. It can affect various tissues and organs.
The effects are
 Shortening of life span
 Development of cataract
 Chronic radiation dermatitis
 Leukemia
 Cancer
 Fertility Problems
 Epilation
 Genetic invitation
The procedure and precautions for radiation safety should be prepared. They should be documented
and explained to all staff. It should be mandatory to follow them. Instructions for patients and
visitors should also be available and exhibited at prominent places in waiting area.
It should be a must for every staff member to wear the lead apron, gloves, goggles and the radiation
dosimeter. The dosimeter films are sent to BARC and the reports received from there be filed and
preserved carefully. Actions as suggested in these reports are taken as and when necessary.
Specifications for X-Ray Machines
a. Tube Housing

 The place of focus should be marked on tube. The leak of radiation in any direction should not be
more than IMGY in a distance of 1 sq. Meter from the target when the tube is operating at its
maximum KVP.
 Tube should be provided with light beam collimators complying with specifications for tube
housing
 Beam filtration should not exceed 1.5 mm at for tube of 70 KVP, 2.0 for tubes of 100 KVP and 2.5
for tubes of more than 100 KVP. The total filtration should be indicated on the tube.
 Positioning of tube should be such that the target to film distances selection, beam centering and
angulation, positioning of patient can be adjusted in desired manner.
 Locking facility for the tube housing in a desired position and angle should be available.
 Bucky alignment to and locking in desired position for positioning grid, bucky tray and cassette
should be available.
 The cable lengths should be such that the control switch can be operated from a distance of
minimum 3 meters from the tube for mobile and portable units.
 One control panel can operate more than one tubes in such cases the control panel should have
indicator showing the tube in operation.
 When mechanical time is provided, there should be arrangement to terminate exposure after the
set time and it should not give re exposure unless the timer is set again. The timer should have an
exposure range of 0.05 to 5.00 seconds.
 Radiation leak from transformer at 5 cm distance should not exceed 5 uGy in one hour.
 Dental X-Ray unit should have focus to skin distance of 10 cm for machine of 50-60 KVP, 20 cm for
60-75 KVP and 30 cm for machine of more than 75 KVP.
 For tomography units focus to skin distance should not be less than 15 cms. Protective shielding to
attenuate the transmitted radiation should be available.
 Dental cases should provide the beam diameter of less than 7.5 cms at specified distance.
 For mammography unit, the tube housing should prevent radiation leak beyond an area of 100 sq.
cms. The dose should not exceed 0.07 mGy in one hour. The beam limiting device should reduce
the beam radiation limit as above. The beam should not exceed the size of beam receptor by more
than 2% in any direction. Beam filtration shall not be less than 0.03 to 0.05 mm depending on type
of target (screen films)
b. For CT scan

 The beam limiting criterion is same as for any x ray machine. The filtration should be of bow tie
type so that beam flattening and hardening are possible.
 Scan places visualize indicating the topographic plane on patient with in + 2 mm should be
provided.
 Couch position accuracy should be + 2 mm independent of direction of motion of couch.
 Beam on indicator on gantry and control panel should be provided
 Actual scan increment shall not exceed + 0.5 mm with a weight of 100 kg.
 Gantry operative at any angle should permit scanning of 50 cm thick patient.
 The local protection of 2 mm thickness should be provided for 100 KVP and 0.01 mm per KVP for
additional KVP
c. For Fluoroscopy Equipment

 The useful beam should have a filtration of not less than 20 mm aluminum. The protective lead
over the fluoroscopy screen should be equivalent of 2 mm lead up to 100 KVP machines and
additional 0.01 mm per KVP for larger KVP machines.
 Protective lead flaps of 0.5 mm thickness of lead suspended from bottom of the screen up to the
table top.
 Screen alignment should be such that axis of beam passes through center of the tube.
 The diaphragms control knobs on the frame of the screen should be protected with 2 mm thick
lead screen.
 Maximum cumulative exposure time should not be more than 5 minutes.
 A foot switch visualizer should be provided.
d. For Image Intensifier System Equipment
The criterion for tube housing is same as for any X-Ray unit. A beam limiting device in the form of
adjustable collimator is used to provide beam of restricted size to the area of interest. The
collimators are adjusted for spot film imaging by automatic change of shutter before every exposure.
Tube- receptor alignment
Tube and collimator should be adjusted in such a way that the beam is centered on the image
receptor assembly.
If the tube is permanently located under the table, the bucky slot closed by 0.5 mm lead sheet to
prevent scattering of radiation under the table.
The Kerma rate measured at a position at which the radiation beam enters the patient’s body should
be less than 5 cGy / minute.
The Kerma at image intensifier for maximum tube potential should not be more than 3.0 uGy per
exposure for photofluorography and not more than 0.3 uGy for line fluorography. The length and
width of x ray field in the plane of image receptor shall not exceed by more than 3% of the source to
image distance.
Digital subtraction angiography image intensifier should have an intrinsic resolution of at least 4 line
pairs / mm at modulation transfer function value of 0.1.
The video camera should have a signal to noise ratio equal to or greater than 500: 1
e. Radiation Protection Devices

 Protective Barrier – Operator of X-Ray machine has to be protected from leakage and
scattered radiation. This is done by using a shield / barrier of thickness of 1.5 mm of lead or its
equivalent. The viewing window should also have a glass of same equivalent.
 Luoroscopy Chair –lead thickness should be same.
 Protective apron – the thickness should be 0.25 mm equivalent of leaf. The size should be
such that the torso and donads are protected.
 Gloves – should permit easy movement of fingers and wrist should protect fingers, hands,
wrist and 2/3 forearm. Thickness should be 0.25 of lead equivalent.
 Gonad shield - Thickness of equivalent of 0.55 mm lead should be provided
 Cassettes Pass Box – The box should have a lead lining of 2 mm thickness. The arrangement
should be such that door on one side only can be opened at a time.
 Temporary film storage - Lead lining of not less than 2 mm on all sides.
 Mobile Van X-Ray Unit Should be provided with adequate protection. The machine
compartment should have walls of thickness equivalent to 2 mm lead equivalent of glass.
Appropriate overlapping of lead sheets should be ensured to prevent leak of radiation from
joints. To prevent exposure to persons holding a patient during procedure, immobilization
devices should be used, or the person should be given lead apron and gloves to wear.
f. Work Place Practice

 X-Ray room occupancy should be minimized to persons specifically concerned with the
procedure. The room should be kept closed during the procedure and red light displayed at
the door.
 Assistance to patient should be provided by an adult relative or escort and not by a staff
member. The person should be given the protective devices to wear during the procedure.
  Fetal Protection – A notice in bold letters should be displayed at prominent places in the
department informing. If the female patient is likely to be pregnant, such females are not
being permitted to stand or sit in front of the doors of X-Ray room when work is in progress.
 The radiation hazards sign as under should be displayed on the above notice board and on the
door of every x-ray room.
 Use of personal monitoring devices.
 X-Ray films should be protected properly. Films in cassettes should be kept in lead lined
storage boxes only.
 X-Ray Tube should not be pointed towards the door, window or dark room.
 Automatic serial films changer should be used if the work load is high.
 The field size of exposure, dose and exposure time should be optimum. Gonads should be
protected with shields.

g. Radiotherapy

Apart from the wall thickness and lead partitions, the brachytherapy applicators should be stored in
a lead protected storage safe. Lead shielded transport containers for the source should be available.
Lead bench should be provided for sending the decayed and damaged sources to BARC. The
radioactive waste from brachytherapy and teletherapy units those are useful for therapeutic
purpose units, which are no longer useful, have to be sealed in lead boxes and sent to BARC for
disposal with great precautions. Waste from nuclear medicines has shorter half-life, are also to be
stored in lead boxes. They can be taken as non-reactive after 24 half-life periods. Adequate radiation
protected storage for these has to be arranged for.
Construction material used for the branchy and tale therapy units should be of proper specifications.
Ordinarily concrete of density of 2.35 gms per cc is used. Higher densities like hematite which as
density of 3.5 gm/cc and baryt concrete of density are also used. The thickness of the walls is
inversely proportionate to density of concrete. Alternatively steel sheets can be used. 10 mm thick
steel can replace 33 mm of concrete of 2.35 densities. The thickness of the roof also needs
consideration. As far as possible there should be no occupancy on upper floor. If this is not possible
the thickness and concrete density same as that for the walls has to be provided.
One wall should be constructed after the crates are moved in and those only the constructions
should be completed. To facilitate the movement of crates a ramp should be provided.
Viewing system has to be provided for observing the gantry movement and the patient under
treatment. Close circuit TV or lead glass window is necessary for this. The viewing should be of 120
cm X 120 cms at a height of 135 cms from floor and 100 cms to the side of central line of the unit.
The viewing window should be provided with a glass thickness of 4 mm lead equivalent. There
should be an observation panel on the door of the treatment room. It should be 140 cm above the
floor. It should also be filled with same glass thickness like viewing window. The observation panel is
meant for observing movement of patient in the mirrors fitted at appropriate locations in the
treatment room.
CCTV system can also be used and is mandatory when accelerators are used. Alternative
arrangements for use if CCTV fails have to be made.
The door unit can be ordinary wooden made with a breadth of 150 cms for tele therapy and 12 cms
wide for brachy therapy units. There should be an electrical interlock between the door and the
machine to ensure that door cannot be opened when the machine is in use. A red warning light over
the door should be provided and should be interlinked with control panel. So that it glows only when
the machine is operational. A conduit for the cables and wires from control panel to the machine
should be provided. The lower end of the conduct should be at 15-20 cms above the floor.
Air conditioning ducts should pass from above the door along the ceiling over maze in the treatment
room. When central AC is provided, the conduit for ducts of split units should be of minimum
diameter and be placed at a height of 1.5 meters from floor. It should be at an angle in a specified
wall. For accelerator special air conditioning arrangement are to be made.
h. Legal Regulatory Control

 The manufacture should obtain design certification and type approval certificate from
competent authority.
 No objection certificate should be obtained for imported equipment.
 The owner should obtain an approval for entire installation.
 The equipment should be registered with competent authority, purchase, transfer; gift,
leasing or loaning should be informed to the authority.
 Equipment should not be commissioned unless it is registered.
 The equipment should be available for inspection to the licensing authority.
 The service engineer should possess a valid registration certificate from competent
authority for the purpose of maintenance and repair.
 Persons like owner, operator, and service engineer are duty bound to follow the
Radiation Protection Rules 1971 and its amendments. Contraventions are punishable
under section 24, 25 and 26 of the Atomic Energy Act 1962. The punishment may
include imprisonment, fine or both depending on nature and severity of the offence.
i. Radiation Dose Limits

For Staff
 Cumulative dose over a block of 5 years not more than 100 msv.
 Effective dose in a calendar year in a block of 5 years not more than 30 msv.
 Equivalent dose to lenses of eyes in a calendar year not more than 150 msv.
 Equivalent dose to skin, hand an feet in a calendar year not more than 500 msv.
  For a female worker, protection of lower abdomen should be provided, when pregnancy
is confirmed, not more than 2 msv for remaining pregnancy.
For Public
 Effective in one calendar year not more than 1 msv

j. Collection and Disposal of Radioactive Waste

The half-life of most of isotopes ranges from few hours to few days. The disposal of such material is
done by the method of ‘decay and dispose’. Specific instructions given with the product should be
followed.
k. Licensing

The design of unit has to be cleared by RPAD or BARC. Proposal with detailed layout and dimensions
of walls has to be submitted. The proposed material, purpose of use, information about staff has to
be given to RAPD.
The nuclear medicine specialists have to be cleared by the nuclear medicine committee for human
administration of radio pharmaceuticals.
After being satisfied, RPAD recommends supplies to Board of Radiation and Isotopes Technology
BRIT which is under control of Department of Atomic Energy.
l. Registration Timings

For planned work, patients come in for routine procedures and special procedures. For routine
procedures, it may not be possible to ask the patient to come again so such procedures X-Rays and
sonographies are done on first come first served basis unless some preparation is necessary. The
procedures and preparation cases can be given a mutually convenient appointment and asked to
report accordingly. When the number of cases that walk in for routine work is more than what can
be done in schedule working hours. That may be asked to come next morning when they are done as
first cases. Client’s priorities and convenience should always get consideration.
m. Malpractice and Pilferages

Pilferages of films, chemicals parts of machines are common. A strict account of all the inventories is
a must. Miserably some minor but important part of machine may be removed or damaged by some
staff. There should be a policy, guidance about the disciplinary actions on such erring staff members.
7.8 MONITORING AND EVALUATION

The activities that should be monitored are

 Number of X-Rays done wise
 Number of Radiological procedure
 Number of pornographies
 Number of sonographies intervention’s
 Number of CT Scans
 Number of MRI
 Number of Mammography
 Number of Doppler
This should be monitored on basis of parts, referring departments and consultants
  Number of films spoiled
 Number of negative X-Rays / procedures
 Chemicals used
 Output against time ratio
 Down time of equipment’s – Electrical
 Down time of equipment’s – Mechanical
 Down time of equipment’s – Human Resource
 Expenditure total and per procedure
 Revenue generated
 Errors in diagnosis – No clinical correlation
7.9 SUMMARY
Radio diagnosis and imaging services is important tool in the hands of clinicians. Advances in
biophysics and applications of computer science have helped medical science to invent new and
improve existing modalities, bringing in speed and precision in the area. On account of the costs of
these technologies, the department has become a major consumer of hospital finances. The
financial burden is not only on purchase of these equipment’s but also on the special arrangements
that have to be made for housing them, maintain them and provide consumables for them along
with expert human resources to run the machines and interpret the results.
Radioactive substances used for diagnostic and therapeutic purposes emit energy in the form of
waves. They have ionizing effects on human body. The injurious radiation comes from sources like
Gamma, Beta and Alpha rays and neutrons. The effect on body depends on source of radiation, its
dose and the type of body cells exposed to it. The effect may occur as Acute Radiation syndrome or
delayed effects
7.10 KEY WORDS

 Conventional X-Rays: The oldest tool available based on principles of transmission. Images
are taken on films.
 Ultra Sound and Color Doppler: Comparatively newer modality with ever improving
accuracy. There are no significant biological hazards. The machines are less bulky than
others. Portable machines are also available. Dichromatic and polychromatic versions and
three dimensional viewing are available.
 Computer assisted Tomography: Based on X-Ray technology, improved clarity gives more
clear pictures. Best used in imaging of central nervous system Contrast studies are possible.
UNIT 8 LABORATORY SERVICES

Learning Objectives
After going through the unit you will understood:
1. Functions and components of laboratory;
2. Concepts of planning and construction of laboratory;
3. What equipment’s will be required;
4. The importance of policies and procedures related to laboratory;
5. The management and administrative aspect of laboratory;
6. The hazards in laboratory and their control.

Structure
8.1 Introduction
8.2 Functions
8.3 Components
8.4 Physical Facilities and Layout
8.5 Staff Requirement
8.6 Equipment
8.7 Work Flow
8.8 Policies and Procedures
8.9 Quality Control
8.10 Monitoring
8.11 Hazards in Laboratory
8.12 Animal House
8.13 Summary
8.14 Key Words

8.1.1 INTRODUCTION

Medicine today is becoming increasingly dependent on laboratory examinations. Technological

advances in diagnostics and principally in pathology have brought about a sea of change in the
practice of medicine. New tests and investigations are being devised regularly so as to assist the
physician to come to a precise diagnosis and treatment with minimum loss of time. Therefore speed
and accuracy are the key wards that decide reliability and popularity of a laboratory. A third
dimension that can be added is economy, fourth on is round the clock services.
8.2 FUNCTIONS

The primary functions of pathology services are to provide:

 Facilities for the application of scientific techniques for diagnosis and treatment of diseases.

 Indices for prognostic evaluation.

 Scientific data, including post mortem studies to evaluate clinical and therapeutic
procedures.

 Laboratory facilities for medical education and research.

 Specialized and advanced training facilities for specialization and super specialization.
 Blood transfusion services.

8.3 COMPONENTS

As stated in introduction, the function of laboratory is to carry out investigations rapidly, accuracy
and in cost effective manner.
The components that constitute a laboratory are:
- Hematology
- Microbiology
- Biochemistry
- Histopathology
- Research work
 Hematology deals with detection of abnormalities in blood and its components
 Microbiology studies the microorganisms like bacteria parasites, viruses, fungi, and the
identification of the microbes, their cultures, sensitivities and serology. To know the effect of
these microbes are done here.

 Biochemistry many normal components produced in the body as an effect of disease process
to identity and estimate them is the job of biochemistry.

 Histopathology processes tissues for examination and diagnosis under microscope for
studying changes in them characteristic of diseases.
 Research laboratories conduct research work for diagnostic purpose, development if
equipment, never techniques, modifications in existing techniques, equipment’s etc.
 Laboratory may be central where all the work is done in one place.
 Decentralized laboratories separate for OPD, indoor, casualty are occasionally seen. They
require the staff and equipment in large quantities. Teaching hospitals may have
laboratories attached to the departments of pathology, microbiology, biochemistry in order
 to avoid duplication of equipment. They are mainly used for academic and research work.
Investigations done on equipment available avoiding duplication of equipment

8.4 PHYSICAL FACILITIES AND LAYOUT

The planning and construction depend on size of the hospital, spectrum of services, working hours,
bulk of equipment and machinery, number of staff and workload. Some scope for future expansions
should be kept in mind.

Location
It should be located in an easily accessible area. The size and location of different components vary
according to the amount of work expected to be carried out in the laboratory. It should be in close
proximity to Polyclinic, OPD complex, ICU and OT complex.

Accommodation and Layout

The following areas are essential:
 Waiting Area
 Reception
 Sample collection room
 Biochemistry section
 Hematology Section
 Histopathology section
 Virology
 Immunology
 Serology/media room
 Bacteriology complex
 Animal house
 Storage complex
 Sanitary complex
 Library/conference room

All the areas should be well ventilated and illuminated. The floor should be washable and chemical
resistant. Walls should have similar skirting up to 2 meters height. There should be working plat
forms with similar surface. Washable basins and sinks should be provided for every section. Electrical
points should be adequate with some extras and distributed as per the sites of installation of
equipment’s.

Workspace/workstation Fitments
The following facilities must be catered for:
 Workbenches
 Fluorescent lighting
 Water supply
 Gas supply
 Biosafety Cabinet
 Cold storage/refrigeration
 Terrazzo flooring

Microbiology Hematology Histopathology Biochemistry Store

Staff Reception and

Collection Collection Pathologist Office
Toilet Reports

Toilet

Waiting
Toilet
8.5 STAFF REQUIREMENT

Time required to perform the test is calculated. Then the number tests that can be performed in
given time by a technician are calculated. Based on this and the workload number of technician is
calculated and appointed. An additional 10% is taken as leave reserves. Similarly the number of lab
assistants, attendants can be standardized. Because of automation in the equipment’s and the speed
at which they work, the number of technician as calculated above becomes irrelevant. Now a day a
technician can deliver 60 – 70 tests during a shift of 7 hours.

8.6 EQUIPMENT

Less equipment with automation and speed are introduced constantly. The latest versions should be
purchased old equipment upgraded and replaced with newer ones some equipment is enumerated
below.
1. Centrifuge
2. Water bath
3. Hot air oven
4. Incubator
5. Ph. meter
6. Automatic biochemistry analysis
7. Semi-automatic biochemistry analysis
8. Automatic cell counter
9. Automatic urine analyzer
10. Elisa reader
11. Elisa washer
12. Micro time
13. Wax melting bath
14. Tissue processor (automatic)
15. Microscopes binocular, monocular
16. Reagent for various tests
8.7 WORK FLOW

OPD Wards Emergency OT Out Reach Research

Patients or samples

Collection Rooms Collection Counters

Samples
Analysis Processing

Microbiology Hematology Biochemistry Histopathology Research

Reports Samples for Preservation

Quality control

Delivery of Report

8.8 POLICIES AND PROCEDURES

Division of Work: For smooth and efficient working, the entire technical work programed of
the lab complex is divided into various sections.

Reception and Dispatch of Results: Every laboratory should have a well-organized

reception
- to receive samples
- check samples with the request forms
- dispatch the samples to the appropriate sections of the lab
- Collect the reports from the different sections
 - Distribute the results to the right place (wards/OPD/ICU etc.)
- An Lab automation system must be in place to for ease of data storage, retrieval and
distribution
Policy on Biomedical Waste Disposal

8.9. QUALITY CONTROL

Quality management improves reputation of laboratory with increase in efficiency and effectively.
The factors that need be developed are:

 Enthusiastic and effective leadership

 Properly functioning organizational frame
 Developing institutional work culture and healthy practices
 Making the service client focused
 Continued staff training an education activities
 Bench marking
 Analysis of quality
 Recognitions, rewards and disincentives
 Standardizations of employment criterion

The functions of leadership are to lay down policies and procedures, planning, decision making,
organizing, deputizing, controlling etc. Inputs in the form of men money and material have direct
effect on the results. The leader has to be conversant with these tools.

The leadership has to be supported with proper personnel for carrying out various functions. The
personal, mainly the laboratories technicians should be qualified, well trained, conversant with the
equipment and the processing / analyzing techniques. There should be good personal relations need
based duty distribution and specified job responsibilities. The third aspect is equipment and
reagents. These are governed by work load, product specifications, automation, after sales services,
maintenance of equipment, condemnation procedures up gradation facilities etc. the reagents
should be of excellent quality and easily available. There should be standardization of the operating
procedures for equipment’s and for every test that is performed. The quality control can be external
where a sample is analyzed by different laboratories and results are compared by an external
agency. It is also done periodic monitoring of work in a particular laboratory.
Internal Quality Control
Internal quality control can be exercised by monitoring results of analysis performed by the
technicians. There should be regular standardization of the machines. The sample be processed by
different technicians, on different machines with reagents of different batches. Attention should also
be paid to improving speed avoiding mixing up to specimen, avoid calculation errors. Action on
repeatedly erring technicians is necessary.

Accreditation/External Quality Control

Accreditation laboratory is done by various agencies like ISO./NABL/JCI accredited assured reliability
accuracy and definite policies and procedures .External quality control can be carried out with
respect to standards of CMC Vellore.

8.10 MONITORING

 Workload of various tests and also the total output should be monitored Bench marking
 The consumption of reagents, wastage rates be noted
 Down time of equipment number of tests performed on each equipment be noted
 Error percentage be looked into
 Tests asked for but not done in the laboratory be listed with frequency of their demands
 Punctuality of regularity of staff
 Delays in reporting, misplacement of reports be seen
 Errors in clinical correlations be considered
 Gaps in supply of reagents be noted
 Investigations requisitioned by each department and consultant
 Number of individual tests performed
 Cost per test
 Number of tests performed in a kit (or set of reagents)
 Revenue generated
8.11 HAZARDS IN LABORATORY

The hazards in laboratory can be physical in the form of burns, scalds, electric burns, injuries due to
glass objects chemical hazards due to contact with concentrated acids used in analysis, inhalations of
fumes. There are biological hazards in the form of inhalation of ingestion of inoculums prepared for
cultures, material infected by bacteria, viruses etc. needle stick, and injuries during collection of
specimen or during processing.

Precautions should be taken to avoid the hazards. Some of them are as under.
 Do not store eatables and drinking water in laboratory refrigerator
 Do not eat or drink while at work
 Use face mask and hand gloves during collection and analysis
 Scrupulous hand washing with ample soap and water
 Decontamination of work area, twice a day and whenever spills occur. Avoiding spills,
their treatment when they occur
 Minimize aerosols and fumes’ holes such objects away from face
 Training of the staff
 No mouth pipetting
 List of biosafety gadgets in all functions in laboratory
 Decontamination of waste of point of generation and the disposal as per protocol
 Recording, reporting and taking lessons from the hazards
 Periodic medical checkup of all laboratory workers
 Management of needle stick injuries as per protocol
 Treatment of injured / affected workers

8.12 ANIMAL HOUSE

Animals like guinea pigs, rabbits, mice, rats etc. are used for certain experiments. Chick embryos are
used in virology and sheep for serological work. Separate accommodation is required for these
animals. Rooms should have wire mesh and should be well ventilated. Regular sweeping, cleaning
and washing are essential to ensure hygienic environment.
8.13 SUMMARY
Hospital laboratory is a place where various investigations are carried out. These investigations have
diagnostic and prognostic importance in management of patients. Speed and accuracy are the key
wards that decide reliability and popularity of a laboratory. A third dimension that can be added is
economy, fourth on is round the clock services.

8.14 KEY WORDS

Internal Quality Control: Internal quality control can be exercised by monitoring results of analysis
performed by the technicians. There should be regular standardization of the machines. The sample
be processed by different technicians, on different machines with reagents of different batches.
Attention should also be paid to improving speed avoiding mixing up to specimen, avoid calculation
errors. Action on repeatedly erring technicians is necessary
Accommodation and Layout: The following areas are essential:
 Waiting Area
 Reception
 Sample collection room
 Biochemistry section
 Hematology Section
 Histopathology section
 Virology
 Immunology
 Serology/media room
 Bacteriology complex
 Animal house
 Storage complex
 Sanitary complex
 Library/conference room
All the areas should be well ventilated and illuminated. The floor should be washable and chemical
resistant. Walls should have similar skirting up to 2 meters height. There should be working plat
forms with similar surface. Washable basins and sinks should be provided for every section. Electrical
points should be adequate with some extras and distributed as per the sites of installation of
equipment’s.
UNIT 9 MORTUARY SERVICES

Learning Objectives
After going through the unit, you will understand the:
1. Importance and functions of mortuary;
2. Concepts of planning and construction of mortuary ;
3. Process of embalming;
4. Equipment’s required in mortuary.

9.1 Introduction
9.2 Functions
9.3 Planning Considerations
9.4 Policies and Procedures
9.5 Embalming
9.6 Equipment’s
9.7 Safety Measures
9.8 Summary
9.9 Key Words

9.1 INTRODUCTION

Inevitable part of doctor’s duty is not only caring for the living but also in helping to arrange for the
disposal of his dead patients. The procedure associated with this process is not only a psychosocial
problem but also has delicate sentiments and psychological aspect attached to it. The effect of death
and the look of dead body is a great demoralizing and sad event. Therefore, dignity of the dead person
and lending a helping and sympathetic hand to the relatives is essential morally, ethically and also
from the public relation point of view.

9.2 FUNCTIONS

The mortuary has to cater for the following functions:

 Acts as a store house for the dead body.
 Provide facilities for pathological autopsy.
  Provide facilities for medico legal autopsy.
 To cater for the religious functions connected with the last rites of the body.
 To act as a place for training and education.

9.3 PLANNING CONSIDERATIONS

Location
It should be located in a separate wing of the hospital with independent entry and exit on the
ground floor or at the basement. It should be well connected to ICU, Casualty and pathology
department.

Physical Facilities

Body Storage Room

Bodies are kept in refrigerated body storage the number of refrigerated storage cabinets required
will depend on

 Type of hospital
 Number of beds
 Number of ICU beds
 Location of the hospital
 Disaster prominences of the area

On an average 4 cabinets per 100 beds are required. The s depth of the cabinet should be 3.4 m. These
cabinets should be fitted with thermographs and thermostat control and alarm.
The storage temperature before loading should be 5.5 C and contents should be reduced to 3.5 C.
A bay of 6.5 m should be kept in front of the refrigerated cabinets for loading and unloading of the
bodies.
UPS back up of the chambers is essential

Refrigerating Plant
This plant should be located in the immediate vicinity of the body storage cabinets. The main electrical
intake and switch board may be sited here. Access for maintenance and servicing should be arranged
externally so that any fault can be rectified without entering the mortuary premises. The plant should
have 24 hours generator back up.

Autopsy Room
It should have the following facilities:
  Two or more stainless steel top autopsy tables.
 Hospitals up to 400 beds require 2 tables.
 The tables to be made up of porcelain, stainless steel, fireclay.
 Working area for dissection of removed organs.
 Built in wall cupboards.
 Sink with elbow operated faucet taps.
 Water hose as well as saline wash because only washing with water will hemolysis
the RBCs and cause deterioration of the specimen.
 Individual water hose should be supplied with water from a thermostatically
controlled mixing valve.
 Water suction pumps are to be avoided.
 Floor service ducts are also to be avoided.
 A two tabled room should have an area of 40 SQM.
 Two large sinks with hot and cold water to be provided near to the table.
 The room should have a writing top
 X ray viewing box and a small sterilizer to be provided.
 The floor should be of terrazzo with adequate draining system.
 Lighting inside the room should be adequate 1500-2000lux with adequate color
rendering index.

Foul Room
One separate cabinet is kept for decomposed bodies. Similarly, for highly infectious body a separate
cabinet is kept.

Embalming Area
This consists of a preparation area where the embalming machine is kept and an embalming area
where the process is carried out.

 Medico legal Record Room

 Mortuary attendant’s Room

 Pathologist’s room

 Change room

 Clean store and instrument area

 Dirty store

 Sluice room/Janitor’s closet

  Relative’s waiting area

Viewing area with an elevated platform and facilities for washing of the body. This room should have
clean, solemn interiors where people can pay their respects to the dead body.

The mortuary complex at both the entrance and exit points should have covered porch and ramp.

9.4 POLICIES AND PROCEDURES

The mortuary must have the following policies:

 Identification of the dead body

 Consent for autopsy in case of pathological autopsy.
 Handling of medicolegal cases
 Handing and Taking over of bodies
 Handling of infectious bodies
 Embalming of bodies
 Protocol on how to conduct postmortem
 Protocol on preservation of viscera
 SOP on sending of viscera/specimen to Forensic lab
 Protocol on guarding of bodies
 Policies on infection control

Model Autopsy Protocol

 Photograph of the body as it is found after it has been removed.

 Record the body position.
 Record the body warmth and coolness, lividity/ rigidity.
 Protect the hands of the deceased.
 Record the ambient temperature.
 Where the time of death is an issue, rectal temperature should be recorded and if any
insects are found, they should be collected for forensic entomological study.
 Examine the blood stain found on the body, collect these.
 Interview any emergency medical personnel who had treated the body.
 Obtain past medical history of the dead.
 Obtain and record identification mark of the deceased.
 If the deceased was hospitalized, get all the medical and investigation records.
 Record the date, starting, finishing time and the place of autopsy.
  Record the Doctor’s and assistant’s name and other particulars.
 Take colored photographs where required.
 Each photo should contain a ruled reference scale, and identifying case name/number.
 Photographs should be comprehensive in scope and must include all demonstrable signs of
injury or disease
 Photographs of the full frontal aspect of the face, right and left profiles need to be taken.

Examination of the Body

 Record the weight, length, hair style

 Record apparent age, sex, nutritional status
 In children record head circumference, crown heel length and crown rump length
 Note any decomposition changes
 Record all injuries :
- Color
- Course
- Location
- Direction
- Depth
- Structure involves
- Singing present or absent
- Presence of gunpowder

 Photograph all injuries

 Examine the skin for the following:
- Scar
- Keloid
- Tattoos
- Increased/decreased pigmentation
- Birthmarks
- Moles
- Bite marks
- Abrasions
- Burn marks

 Collect blood sample from subclavian/femoral veins-50 ml

 Examine the head/scalp.
  Cut 20 representative hairs/preserve
 Examine the teeth and note their condition
 Check gums
 Photograph dentures
 Check the inside of mouth for trauma, injection sites, bites
 Take a swab from the mouth
 Examine the eyes and conjunctiva for petechial, icterus. Collect 1 ml of vitreous humor.
 Examine nose/ears for trauma/building
 Examine the neck for bite/injuries
 Examine the limbs carefully for:
- Missing nails
- Save finger naol clippings
- Injuries
- Defense wounds
- Nail beds for injuries/bleedings/tissue
- Take fingerprints.
- If fingerprints cannot be taken, remove the glove of the skin.
- Examine the palms/soles

 Examine the external genitalia for injuries/bleeding/foreign objects

 Look for injuries around the perianal area
 Take swabs.

Systemic Examination
 Examine the chest for the following:
- Injuries
- Rib fractures
- Record thickness of subcutaneous fat
- Examine the pleural cavities/pericardial sac
- Save the fluids present in the sac.
- Note for air embolism.

 Examine the abdomen for the following:

- Injuries
- Trace the injuries
- Note any blood/fluid
- Remove 50 gms of adipose tissues.
 - Record details of liver(weight/color/scar/cirrhotic features, Injuries)
- Record details of kidneys((weight/color/scar/)
- Remove the GI Tract
- Examine the contents of stomach
- Collect the fluids for toxicological investigations
- Examine aorta/inferior vena cava
- Examine all pelvic organs
- Note for signs of pregnancy/injuries/tumor

 Examine the Central Nervous System for the following:

- Examine the scalp for fractures/injuries
- Remove the caldarium carefully and note epidural/subdural hematoma
- Quantify, date and save any hematomas
- Remove the brain Dissect
- Evaluate cerebral vessels
- Examine the vertebral column for injuries/fractures

Tissue
 Preserve 100 gems of liver/kidney
 50 ml of all body fluids to be saved.
 Samples of all major organs to be saved.
 All foreign objects to be saved

Viscera Preservation

 Whole of stomach
 Stomach contents 100-200ml
 I meter of small intestine
 100 ml of intestinal contents
 1/3 rd. of liver and gall bladder
 Half of spleen
 Half of each kidney.
 100ml of blood
 100 ml of urine
 In case of poison injection/snake bite- the skin and the muscle around the site.
 In case of criminal abortion, uterus and cervix
  In alcohol poisoning- blood, CSF, Lungs
 In heavy metal poisoning-Nail/hair/bone
 In cardiac poison-Heart
 In Strychnine poisoning-Brain/spinal cord

Preservatives Used
 Saturated salt solutions except in acid poisoning
 Rectified spirit in all cases of acid poisoning
 Saturated salt solutions in carbolic acid poisoning

The viscera sent to the Forensic lab should be properly packed with right preservative and must be
accompanied with proper documentation.

9.5 EMBALMING

Need
1. Body preservation for relatives
2. Body transportation for last rites
3. Preservation of body pending cremation

Suitable time: Within 12 hours of death. In case of winters it can be delayed up to 24 hours.

Pre Requisites for Embalming

 Body identification
 Death certificate
 Case summary of the deceased
 Consent
 Police clearance certificate from police in case of medico legal cases.

9.6 EQUIPMENTS

 Mechanical injector with Y Cannula

 Drip sets with bone plastic cannula
 Disposable gowns
 Steel top table with central hole
 Instrument trolley
 Autoclave machine
  Instruments

Chemical Used: Vascular perfusion is done with 30% formalin with ethylated spirit 65% and water.

9.7 SAFETY MEASURES

Primary Barriers
 Autopsy room should be sufficient size.
 Through cleaning and disinfection of the autopsy table to be done.
 Proper mechanical ventilation with exhausts to be in place.
 Separate autopsy room/table for highly infectious/decom [posed bodies.
 Avoid aerosol
 Careful disposal of biomedical waste as per regulations.
 Prevention of needle stick injuries

Secondary Barriers
 Mandatory use of universal precautions
 Prohibition of eating and drinking in the area.
Active immunization against Hip B
Tertiary Barriers
 Prevent unauthorized entry
 Use of protective clothing by all.

9.8 SUMMARY
Mortuary is an importance place in the hospital which is usually neglected. It is often equated with
Dead House. Sanctity of the dead is a universal concept which is deeply ingrained in the culture of the
community. Moreover emotions run high in such a place. Therefore the Mortuary should be so
designed so as to have all modern facilities, a clean and tastefully designed interiors which will not
only provide dignity to the dead but also where the aggrieved will find solace.

9.9 KEY WORDS

Body Storage Room: Bodies are kept in refrigerated body storage the number of refrigerated
storage cabinets required will depend on
o Type of hospital
o Number of beds
 o Number of ICU beds
o Location of the hospital
o Disaster prominences of the area

On an average 4 cabinets per 100 beds are required. The s depth of the cabinet should be 3.4 m. These
cabinets should be fitted with thermographs and thermostat control and alarm.
The storage temperature before loading should be 5.5 C and contents should be reduced to 3.5 C.
A bay of 6.5 m should be kept in front of the refrigerated cabinets for loading and unloading of the
bodies.

Autopsy Room: it should have the following facilities:

 Two or more stainless steel top autopsy tables.
 Hospitals up to 400 beds require 2 tables.
 The tables to be made up of porcelain, stainless steel, fireclay.
 Working area for dissection of removed organs.
 Built in wall cupboards.
 Sink with elbow operated faucet taps.
 Water hose as well as saline wash because only washing with water will hemolysis
the RBCs and cause deterioration of the specimen.
 Individual water hose should be supplied with water from a thermostatically
controlled mixing valve.
 Water suction pumps are to be avoided.
 Floor service ducts are also to be avoided.
 A two tabled room should have an area of 40 SQM.
 Two large sinks with hot and cold water to be provided near to the table.

Safety Measures in Mortuary

Primary Barriers
 Autopsy room should be sufficient size.
 Through cleaning and disinfection of the autopsy table to be done.
 Proper mechanical ventilation with exhausts to be in place.
 Separate autopsy room/table for highly infectious/decom [posed bodies.
 Avoid aerosol
 Careful disposal of biomedical waste as per regulations.
 Prevention of needle stick injuries
Secondary Barriers
 Mandatory use of universal precautions
 Prohibition of eating and drinking in the area.
Active immunization against Hepatitis B
Tertiary Barriers
 Prevent unauthorized entry
 Use of protective clothing by all.
UNIT 10 BLOODS TRANSFUSION SERVICES
Learning Objectives
After going through the unit you will understand:
1. The planning of a blood transfusion service – lay out, construction;
2. Human resource, equipment and consumables requirements;
3. The history and development in field of blood transfusion services;
4. The role and functions of the services;
5. The policies and procedures of the services;
Structure
10.1 Introduction
10.2 History
10.3 Categories and Functions
10.4 Planning
10.5 Equipment
10.6 Staffing
10.7 Policies /procedures
10.8 Infections Associated With Blood / Product Transfusions
10.9 Blood Components
10.10 Autologous Transfusion
10.11 Monitoring And Evaluation of Blood Bank
10.12 Summary
10.13 Key Words

10.1 INTRODUCTION

Blood transfusion services do the work of collection, tasting and issuing compatible, harmless and
good quality of blood and blood components from various medical subjects like hematology,
immunology, genetics, cellular, marketing, economics, bio engineering, logistics management,
statistics and law. There are many ruling from the apex judiciary which have guided the services.
Advances in the field of surgery bringing in major, extensive and prolonged procedures,
understandings of hemophilia and similar disorders have increased demand of blood diseases like
hepatitis B,C, HIV, syphilis, malaria and many more have made pre transfusion testing mandatory and
hence the facilities for the testing.
Public awareness about blood donations has increased and the voluntary donor’s expectations are
increasing. Thus a service that has a history of about 60 – 70 years has undergone tremendous
advancement. The progress is accompanies by liability and responsibility. The responsibility is to such
an extent that mismatched transfusion is taken as culpable homicide and is liable for a punishment
even of hanging till death.

10.2 HISTORY

The use of blood as ‘therapy ‘ dates back to the year 1400 when Pope innocent VIII was given probably
by mouth without success. In 1667 blood from a lamb was administered to a man, the procedure failed
and they were banned in Paris. First human to human transfusion was given in the year 1818 by James
Blundell with success and survival of patient. The three initial blood groups 1, 2 and 3 were discovered
by Landsteiner in the year 1900. These were later on named A, B, and C. the AB group was identified
in the year 19802 by Decastello and Sturli. Sodium Eitrate as anticoagulant was introduced in the year
1914. First blood bank was started at Cook Hospital in United States in 1937 in the year 1939, Levin
and Stetson discovered Rh typing. Other blood groups were identified in succeeding 10 years. Austrian
antigen was discovered in the year 1964.
In India, the blood banks are controlled, monitored and licensed by Food and Drug control
administration who laid down norms for structure, construction, equipment, staffing, testing,
collection storage and issue and disposal of blood.

10.3 CATEGORIES AND FUNCTIONS

• Identification of voluntary blood donors and maintaining their directory, particularly that of
rare groups for emergency use

• Selection of donors, their protection

• Collection, storage, pre transfusion testing, cross matching and issuing of blood for transfusion

• Separation of blood components, preservation and issuing

• Propagate and develop blood donation culture in society
• Teaching, training and research activities
• Therapeutic functions
Depending on the consumption of blood, the blood banks are grouped in three categories.
I – Consumption of 3 -7 units per bed per year
II – Consumption of 8 – 15 units per bed per year
III – Consumption of more than 16 units per bed per year.
Thus the bed strength of hospital, spectrum services provided and their nature contribute to this
grouping.
10.4 PLANNING

Accommodation
Blood bank should be located preferably on ground floor, easily accessible from outside and from
casualty, operation theatre, ICU, Trauma care Unit from where there is maximum demands. It should
be away from dirty areas like lavatories, sewage lines and similar unhygienic conditions and insects
breeding places.
The areas required, preparation area bleeding area, laboratory complex, preparation area and
teaching area. The spaces required for these and the components are as under.
Area in sq meters for blood banks

Category - I Category - II Category - III

I General Area
Blood Bank Office 15 20 25
Doctors Office 15 15 20
Social worker and clerks 25 30 50
Office 15 20 25
Store 20 25 35
Technicians Room 15 20 25
Toilets 3 3 5

II Bleeding complex 10 10 10
Donor Recruitment area 10 15 20
Medical Examination 40 55 100
Bleeding Room 15 25 30
Refreshment and Rest Room 5 5 10
Pantry - 0 40
A Pheresis Room - 30 50
Therapeutic Area - 25 30

III Laboratory Complex 15 25 50

Routine Donor Work - - 50
Laboratory Routine work 15 20 20
Laboratory Special Test 8 10 15
Laboratory Emergency 25 30 50
Issue Counter 10 20 30
Components Work - - -
 Storage - - -

IV Teaching Area - 50 50
class Room, Students Room
Library Toilets

Total Approximate 250 450 1000

The whole complex should be easy to clean. Air conditioning is necessary for all areas, for offices it is
a matter of choice.
Water supply should be Pyrogen free and non-contaminated electricity supply for lighting, air
conditioning and operating equipment is essential. There should be generator and UPS back up.
Steam may be required for cleaning the equipment and sterilization purposes.
Communication system in the form of telephone, cell phone internet should be available. A director
of hospitals, consultants, blood donors, their organizations, other blood banks should be maintained.
Services of laundry canteen should be available in the nearby locations.

10.5 EQUIPMENT

Blood storage refrigerator - Three refrigerators one for non-tested and another for tested blood bags
are essential. They should have stainless steel inner surface and pull out shelves. There should be two
doors on regular outer and a full glass on inner side, so that the stocks can be removed without
disturbing temperature. Third one for cross match blood. In addition to these there should be separate
refrigerators for group sera, reagents and blood samples of recipients.
Centrifuge machine – accurate timer 1 – 30 minutes, 3500 X 9 RPM, accurate tachometer, rapid
declaration, should accommodate 16 – 20 tubes of 12 X 100 mm size and micro plates. The number
should be equal to the number of technicians in a shift.
• Water bath
• Incubator
• Hot air oven
• Binocular microscope
• Weighing balance for collection
• Tube stripper and cutter
• BP operators
• Ph meter
• VDRL shaker
 • Blood bank stands
• Test tube rocks
• Table lamps
• Magnetic stirrer
• Vortex mixer
• Analytical Balance
• Laminar air flow
• Micro plate operator
• Elisa reader, washer, incubator
• Reagents
Equipment’s for Blood Component Laboratory
• Freezer 700 c with inbuilt temperature display and recording facility, alarm system and
uninterrupted power supply
• Freezer 200 – 400 c other accessories as above
• Refrigerated centrifuge with 5000 X 9 swing head with wing shield
• Temperature range of 0 to 250 c. Timer 1 – 60 minutes
• Accurate Tachometer
• Dielectric tube sealing device
• Plasma separation stand
• Tube striper and cutter
• Platelets agitator incubator
• Cryoprecitritate thawing bath
• Laminar r air flow
• Weighing scale 2 kg accurate 200 mg
• Balance for weighing plasma bags 1 kg to 5 mg accuracy
• Office equipment’s like computer printer scanner etc.

10.6 STAFF

The blood has to be under control of qualified pathologists with master or equivalent degree o the
rank of a professor. He is assisted by junior doctors with same qualifications with a rank of associate
professor and lecture, nurses, social worker, public relations persons etc. The laboratory should have
a technical supervisor laboratory technicians and lab assistants. The office staff includes storekeeper,
clerks, typists, record keeper and peons. The number depends on category of the blood bank.
10.7 POLICY AND PROCEDURES

Blood bank should have a written policy. The aim should be to meet the requirement of blood and
components in the field of activity of the standard laid down by food and drugs administration.
The procedures for every activity of blood bank should be drafted carefully and documented. Every
staff member should be conversant with them and it should be a binding on them to follow the
procedures stringently. Blood is a multipotent dearly available and extremely dangerous drug. But
when used in its best form it is lifesaving. There is no substitute for blood available till now. Considering
responsibility of the blood bank to provide safe product of best possible quality at all times at
affordable costs. The procedures in blood bank should aim at this certain guide line are given by FDA
which have to be followed stringently.
Selection of Blood Donor
A blood donor should be screened by recording history and clinical examinations prior to every
donation. The aim is safety of donor and recipient both. The criterions are as under:
• Age 18 to 60 years
• Body weight 55 kgs or more
• Body temperature less than 37.50 C
• Pulse rate 50 – 100 per minute
• BP 90/50 to 180 / 100 mm of mercury
• Hemoglobin in males 13.5 gms% in females 12.5%
• Hematocrit 41% in males 38% in females.
Rejection criterion
Permanent Factors
• Jaundice of any cause
• Malignancies after infancy
• Blending disorders
• Serious cardiopulmonary disease
• High risk sexual behavior, HIV reactive
• Drug user
• Diabetes
Deferment conditions
Person suffering from following conditions should not donate blood at least for a period mentioned
below
 Sr.
Condition Duration of Deferment
No.
1 Abortion / Delivery 6 Months
2 Blood Recipient 6 Months
3 Alcohol Consumption 12 Hours
4 Aspirin Consumption 72 Hours
5 Minor Surgery 3 Months
6 Major surgery 6 Months
7 Typhoid Fever 6 Months
8 Malarial Fever 3 Months - Endemic area 3 years
9 Tattoo 6 Months
10 Acute Nephritis 6 Months
11 Recipient of vaccines (Typhoid, Cholera, Tetanus etc.) 24 Hrs. after symptoms subside
12 Rabies Vaccination 1 Year after bite by Rapid animal
13 Recipient of immunoglobulin 1 Year after bite by Rapid animal
14 Syphilis Tuberculosis 6 Months after cure

The record about donor should be prepared and preserved in the format given here. It should be
prepared every time before proposed blood donation.
Donor Card
Name of Blood Bank, address, Telephone Number
Name of Donor (Surname) Father’s / Husbands Name Age -
Address Telephone No
Identification marks on visible part of body
Weight - Kgs Temperature - Pulse - / min BP – mm hg
Hemoglobin - gm% Hematocrit - %

History
- Suffered from Hepatic Disease / Jaundice Yes / No
- H/o taking self-injected drugs Yes / No
- Received blood in past 6 months Yes / No
- Suffered from malaria / treatment for if in 3 years Yes / No
- H / o any serious illness / hospitalization Yes / No
- Taken any medicine during last 1 month Yes / No
- H / o heart disease / chest pain Yes / No
- H / o prolonged bleeding / drugs for this Yes / No
- H / o convulsions or paining attacks Yes / No
- H / o cancer of any type Yes / No
- H / o immunization / vaccination in last one year Yes / No
- H / o minor surgery / dental treatment in last 3 months Yes / No
- Pregnancy / abortion / delivery in last 6 months Yes / No
- Tested positive sex HIV, HBSAG, HIV
- Had unprotected sex with person other than spouse Yes / No
In last one year
- H / o night sweats, weight loss, fever, discovered yes / No
Punches over skin or in mouth swelling in neck,
Axillae or groin, persistent, diarrhea or cough
- H / o pus discharge per urethra, clears over genitals Yes / No

- H / o blood donation Date –

Declaration and consent of the donor

• The information given by me in this form is correct.
• I want to donate my blood for use as needed.
• I understand the information given to me today about spread of HIV HBV, HCV through
blood donated by me, if I am at risk to do so, I agree not to donate blood for transfusion
to any other person.

Signature

Donor No –
Date of last blood donation
Decision
Accepted - Donated Blood on dated ………… time ………
Deferred – Permanently – Temporary till date

Blood Type Whole Blood No.

Message to Blood Donor

This message should be printed in broad letter and exhibited in blood bank. It may be translated in
vernacular language.
- Please read this information carefully before you decide to donate blood. You have to sign a
statement saying that you have read this, and you understand that your donation of blood may not
be accepted as this may harm the recipient.
1. You are at risk of spreading AIDS you had
- Sex with any person other than spouse even once after 1977.
- Injection of illegal drugs (shot up)
- Have AIDS or symptoms like
- Unexplained weight loss (5 kgs. or more in 2 months)
- Night sweats that wet the sheets
- Blue or purple spots on skin or oral mucosa
- White spots in mouth
- Swollen lymph nodes in neck, axillae, groins
- Fever more than 37.5 c for several days 2 weeks
- Persistent diarrhea for more than a month
- You are hemophilic
- Tested HIV reactive
2. Hepatitis
- Suffered from jaundice any time
- Tested positive for hepatitis HBV, HCV
3. Syphilis
- Suffered from ulcers over genitals
- Tested positive for syphilis
4. Malaria
- If a native of area endemic for malaria
- If visited a country where malaria exists
- If you have suffered from malaria or have received anti-malarial drugs

5. Please note that your blood will be tested for above diseases. If they test positive or the tests are
unclear, your blood will not be used for transfusion. You will not be informed about this. Your name
will be reported to competent authorities of state.

Procedure for Phlebotomy

 • Bleeding donor should be painless and smooth procedure
• Strict aseptic and bio safety precautions are must
• Venipuncture site should be free of skin lesions
• Donor record, blood bag, sample tube, should be labeled and identified before drawing
blood.
(Single, double, triple, quadruple for whole red cell concentrate cryoprecipitate and platelets)

The bag should be examined for defects and anticoagulant in it.

• The phlebotomy site is cleaned and disinfected thoroughly with spirit or betadine
• Tourniquet is applied above the site
• Venipuncture is done and tourniquets is released
• Ensure there is no leak from puncture site and there is free flow of blood in the bag.
• See that the blood mixed well with coagulant in the bag
• After completing collection, with draw the needle and seal compress puncture site till
bleeding stops.
• The tubing should be stripped several times before sealing it. So that the blood in tube
mixes with consultant.
• Donor should be made to rest for 15-20 minutes or more if necessary and then be taken
to refreshment room. He is given some snacks tea, coffee or fruit juice.
• Ensure that the donor is in fit condition and does not have fainting, giddiness etc. and the
then only let him go.
• In case there is giddiness or fainting, put patient in bed record pulse rate and blood
pressure, gives head low if BP is low, start I.V. fluid, if BP is below 80 mm. systolic observe
him till pulse rate and BP return to predation level and are maintained for at least 2 hours
before he is sent home.
• Give post donation advice and thanks
• Send the blood bag to storage immediately
Labeling and Storage
• Donor’s blood should be stored between 10 – 40 c in blood storage cabinet
• Untested bags should be kept separate from tested bags
• First grouping and Rh typing are done and labels with imitational color code are pasted
over the bags. The labels are to be marked with donor no, date of collection, date of
expiry, blood group and Rh type.

Tests on Donors Blood

• ABO and Rh typing
• HIV I & II
• Hepatitis B & C
 • Malaria Parasite
• VDRL
• Confidentiality is maintained about positive results
• Documentary proof about every test should be maintained
• Standard operating procedures should be kept on record & it should be observed that
they are followed.
Movement of Donor Blood
• After collection, donor blood bag is sent for storage in refrigerator for untested blood and
kept there till taken for testing or sent to component preparation room
• Pilot tubes are sent to laboratory for testing
• After completion of tests on pilot tube blood, the blood bag is moved to labeling area for
appropriate labeling
• Then the blood bag is transferred to stock refrigerator
• As and when necessary the blood bag is cross matched and the cross matched blood bag
shifted to issue / reserved refrigerator from here they are issued on demand.
Pre transfusion testing of recipient blood
• Full name, age, sex, registration no. ward dept. should be recorded on requisition form.

• Specimen should be labeled at patient’s bedside and all particulars should be same as on
requisition form.

• When blood sample is drawn from, intravenous cannula, it should be flushed with normal
saline. First 5 ml blood drawn should be discarded and then sample collected.

• When additional transfusions are required, fresh samples of recipient’s blood should be
taken, 48 hrs. after every transfusion and identity incompatibility from antibodies
developed by anamnestic response be tested.

• Hemolysed samples are not accepted as they mask the hemolysis of donor or cells in cross
match.

• RBCS should be washed routinely before testing

• ABO and Rh typing should be done on every recipient before issuing blood
• If more than one unit is to be transfused to one patient, cross matching between the units
to be transfused should also be done with cross match with recipient with recipient blood.

• Blood is reserved or issued on receiving the standard requisition / reservation from duly
filled in and signed by competent authority.

• Blood is issued in a vaccine carrier or cold box is kept in it till the time it is taken for
transfusion.
 • The reaction form duly filled in and signed by competent authority should be sent back to
blood bank.
• In case of any reaction, blood transfusion should be stopped instantly. The reaction form
with blood bag (remaining) and the transfusion set should be sent to blood bank.
Universal Precautions
• In order to avoid infections and contaminations, certain precautions should be taken by
the persons working in blood bank.
• Entry to the laboratories and work areas id permitted only to the staff that has been
trained to handle infectious material and in bio safety precautions.
• Laboratory door should be closed and should bear the ‘Biohazard’ sign and words ‘NO
ENTRY’.
• Laboratory should be kept clean and free from extraneous material and equipment.
• Staff should wear water proof ‘wrap around’ gown, cap, mask and gloves while working
in laboratory, handling infections material blood and blood products.
• Work plat form should be cleaned and disinfected after completion of work and before
beginning.
• Use of sharp like needles, stellates should either be avoided or to be handled carefully.
• Needles should not be bent, broken or recapped with bands
• Mouth pipe ting should never be done
• Hands should be washed before putting on gloves after removing them and whenever
gloves are punctured.
• Storage of eatables and drinking water should not be permitted in laboratory or blood
refrigerators.
• Eating, drinking, smoking, Tabaco chewing should be prohibited strictly in work areas.
• Waste disposal should be done as per bio medical waste rules as applicable.
• Report needle stick injuries to head of institution and take post exposure prophylaxis as
indicated.

10.8 INFECTIONS ASSOCIATED WITH BLOOD / PRODUCT TRANSFUSIONS

• Viral
- Hepatitis
- Toxoplasmosis, Cytomegalovirus, Epstein, Barr
- HIV I TLV II
- Parvpo Virus
- Colorado Tick Fever virus

• Parasitic
- Loiasis, Filaria
• Protozoal
- Malaria, Babesiosis, Trypanosomiasis, Leishmaniasis
• Sprirochetal
- Syphilis, relapsing fever
 • Bacterial
- Brucellosis, Salmonellosis, Yersoniosis
• Rickettsioses

10.9 BLOOD COMPONENTS

The advance in transfusion therapy tool place with introduction of PVC blood bags with integral
tubing’s as the separation of components could be done in a closed system avoiding the chances of
contamination by microbes.
The advantages are:
• The single unit of blood can be used for different patients
• The shelf life of component is no longer than whole blood
• Specific components that are not required
• Cost effective
The components that are separated and therapeutically used now days are as under.
Cellular Components
Red Cells: Whole blood in PCD, semi packed Red Cells, Heparinized red cells, heparinized whole blood,
buffy coat poor red cells, washed filtered red cells thawed washed red cells, frozen washed red cells,
phenotype red cells, CMV negative red cells irradiated cellular products.
Platelet Components: Platelet rich plasma, platelet concentrate
Granulocyte Components: Granulocyte concentrate
Plasma Components: Fresh frozen plasma, liquid stored plasma, plasma from outdated blood, cryo
depleted, cryoprecipitate

Component Preparation Scheme:

Whole Blood

Low Spin High Spin

 Plate rich plasma Platelet Poor Plasma
High spin freezing at 300 c
Fresh frozen plasma Thaw siphoning at 4 0 c
And Cryoprecipitate
Protolet concentrate F VIII Poor plasma
Fractioning

Heavy Spin Light Spin

Packed Red Cells Platelet rich plasma

Platelet Concentrate Platelet rich plasma
Plasma Pharesis cell free plasma
Leucocytes poor red cells
Cryoprecipitate

HEMA PHERESIS
Collection of anti-coagulated from patient or donor separation at desired components from it and
then returning remaining portion to the same donor or patient. It is done for harvesting specific
components like platelets, while cells or plasma from healthy donor and transfusing them to needy
patients. It is also done for removing unwanted pathogenic component or to replace an essential
plasma substance in treatment of specific diseases.

Apheresis is done by using blood cell separator of intermittent flow cell separator or continuous flow
cell separator. Cell separator is rapidly rotating container force the different cellular contents from
different layers and plasma. The desired component is withdrawn and remaining blood returned.

10.10 AUTOLOGUS TRANSFUSION

It is the process of drawing blood from an individual and infusing it to the same individual
The method came in to practice during 1970. It gained importance due to the problem of AIDS
There are three categories in practice.
 • Redeposit where blood is withdrawn and stored before intended transfusion.
• Hem dilution and short storage when blood is drawn just before surgery and stored for being
transfused during or after surgery. The volume drawn is replenished with blood substitutes.
• Intraoperative blood salvage.
Advantages
• eliminates risk of transfusion transmitted diseases
• eliminates allo-immunisation of red cells, leucocytes platelets and plasma proteins
• no risk of transmission reactions
• can be practiced to remote areas where blood is not available
• acceptable to religious beliefs that do not accept transfusions
• good supplement to blood supply
Indications
• patients belonging to rare blood groups
• prevention of allo – immunization
• religious belief
• any elective surgery in otherwise individual
Criteria
• No age is contra indication.
• On an average individual weighing 45 kg can give 350 ml blood those weighing 55 kg can
give 450 ml.

• Hemoglobin should not be less than 11 gms% but never less than 10 gms %
• Bleeding done once a week before surgery for prolonged storage. Last bleeding should be
72 hrs. before surgery.

• Iron supplementation with oral ferrous sulphate 300 mg. TDS should be given if donations
and be continued till hemoglobin is restored to normal level.

• Autologous transfusion process is undertaken after explaining it to patient and under

written consent.

• It is not necessary to conduct tests like HIV HBV HCV etc.

• Blood grouping and Rh typing should be done
• Donor’s signature should be obtained on the able immediately. In case the blood so
obtained is not used for the same person it can be used for others after carrying out the
mandatory tests.

Intra operative Blood salvage

There can be considerable blood loss in operations like those on hip replacement, aneurism in liver or
in cases it rupture of spleen or ectopic pregnancy. The blood is collected processed and re infused to
the same patient. The devices for collection, filtration, and mechanical, washing and concentrating
such blood are available. Blood so obtained should not be transfused to other patients.

Blood salvage procedures are contraindicated where the blood is like to be contaminated as in case
of perforations open injuries, cancer surgeries etc.

10.11 MONITORING AND EVALUATION OF BLOOD BANK

• Blood Transfusion Committee

• The committee is established as under
• The committee meetings are held once a month, minutes maintained and suggestions
implemented.
The functions
• Ensure appropriate use of blood
• Ensure safe transfusion practice
• System audit and clinical practice audit are done for this purpose
System Audit
• No of blood units transfused during proceeding month
• No. of patients given transfusion and number of units transfused per patient
• Proportion of whole blood transfused to components
• Proportion of cross matches to transfusion reactions
• Out of date rate
• Transfusion Reaction
• Turnaround time from recipient of requisition to time of issue
• No of emergency requisitions
• Cancellation of surgeries for want of blood

Clinical Practice Audit Judge Criteria and justification for transfusion of whole blood and appropriate
component.

Quality Control and Evaluation

Strict quality control is essential to ensure that the patients get good quality of blood and avoid risk
to donors.
Following quality control measures are followed

• Voluntary blood donations only are accepted

• Recording proper donor history, examination of donor and collection of good quality
blood.

• Use of disposable for collection of blood

• Strict aseptic precautions at the time of collection, processing, testing and storage of
blood.

• Storage of blood at desired temperature continuously.

• Use of standardized sera and reagents.
• Cross by comb’s method only
• Timely regular preventive maintenance and prompt break down services with alternative
arrangement for care of blood during down time.

• Accurate record of all activities

• Strict control of blood, sera, reagents etc.

10.12 SUMMARY

Blood transfusion services do the work of collection, tasting and issuing compatible, harmless and
good quality of blood and blood components from various medical subjects like hematology,
immunology, genetics, cellular, marketing, economics, bio engineering, logistics management,
statistics and law. There are many ruling from the apex judiciary which have guided the services.
Advances in the field of surgery bringing in major, extensive and prolonged procedures,
understandings of hemophilia and similar disorders have increased demand of blood diseases like
hepatitis B,C, HIV, syphilis, malaria and many more have made pre transfusion testing mandatory and
hence the facilities for the testing.

A revolution in the field of production of therapeutic plasma components, new therapeutic

approaches in the field of certain cancers and a plastic anemia are coming up due to better
understandings of immune physiology. Various immunoglobulin preparations are being made
available. Thus genetic engineering monoclonal antibody preparations and immune therapy products
appear to be on progress in the future.
Synthetic red cell substitutes and action of desired component will increase reducing the whole blood
donations.
Bone marrow transplantation will a field of new activity for blood banks. Bone marrow transplantation
is being considered as treatment in increasing number of diseases like miliogent hematologic,
disorders like acute leukemia non Hodgkin lymphoma. Bone marrow registers will develop where
transplantations from fully matched unrelated donors will be undertaken. The scope of bone morrow
transplantations in cases of melanomas, breast cancers, testicular malignancies etc. will become a
mode of therapy.
Patients receiving total body irradiation, will require RBCs and platelets that will have to be obtained
by apheresis. Patients may become refractory to platelets therapy because of developing HLR
antibodies. Blood banks will have to be ready with HLA type platelet donor program. White cell
mediated. Febrile response is seen in some cases this can be avoided by giving leno-reduced
components. This may also reduce the incidence of all immunization to white cell antigens.
Hemopoietic reconstitutions are reported to have been achieved by transfusing these stem cells that
have undergone cryopreservation. This has scope in treatment of neoplastic disorders like acute
leukemia, Hodgkms disease, multiple myeloma Breast cancers, neuro blastoma etc.
Bone and tissue banking offers an opportunity for expansion of services of blood banks. Bones, cornea,
skin, semen are some of the tissues that come to mind as pumicing. The trends of autologous
transfusion in planned surgeries will be on increase and blood banks will have a role in collection and
preservation of the blood for this.
Health care delivery system is changing from hospital care to home care and outpatient care
transfusion of blood and its components will have to be undertaken in these settings and blood banks
will have a role in organizing them.

10.13 KEY WORDS

Selection of Blood Donor

A blood donor should be screened by recording history and clinical examinations prior to every
donation. The aim is safety of donor and recipient both. The criterions are as under
• Age 18 to 60 years
• Body weight 55 kgs or more
• Body temperature less than 37.50 C
• Pulse rate 50 – 100 per minute
• BP 90/50 to 180 / 100 mm of mercury
• Hemoglobin in males 13.5 gms% in females 12.5%
• Hematocrit 41% in males 38% in females.
Rejection criterion
Permanent Factors
• Jaundice of any cause
• Malignancies after infancy
• Blending disorders
• Serious cardiopulmonary disease
• High risk sexual behavior, HIV reactive
• Drug user
• Diabetes
UNIT 11 PHYSICAL MEDICINE AND REHABILITATION (PMR)

Learning Objectives
After going through the unit you will understand:
1. The design and area requirements of the PMR department;
2. To know the functions of the department;
3. Understand the concept of disability and importance of rehabilitation;
4. The requirement of equipment’s and staff of this department.

Structure
11.1 Introduction
11.2 Brief history of PMR services
11.3 Disability
11.4 Various Approaches to Prevent Disability
11.5 Rehabilitation
11.6 Physical Facilities and Designing
11.7 Staffing and Human Resource
11.8 Functions of the Department
11.9 Equipment Planning
11.10 Summary
11.11 Key Words

11.1 INTRODUCTION

PMR is a branch of medicine that aims at total rehabilitation of patients .The therapy is based on
abilities than disabilities. They aim at minimizing the disabilities and compensate them with
alternatives.
The science focuses on:
• Restoring, enhancing and reinforcing performance /function
• Facilitating learning of skills and functions that are essential for adaptation and productivity
• Diminishing or corroding pathology
• Promoting and maintaining health
• Maintaining physical and mental capacities throughout life
Efforts are taken to encourage patients to become as independent as possible for their day today
activities, productivity, play and leisure.
The Various therapies treat disabilities in the fields of cardio respiratory, muscular skeletal,
neurological, neuromuscular, congenital, age related, sports related and psychological.
The approach should be patient centered, it should be flexible, culturally safe and accessible and
assessable.

11.2 BRIEF HISTORY OF PMR SERVICES

The history of Physical Medicine and Rehabilitation is as old as the mankind. There is mention in our
ancient literature of treatment of disease and disability by use of hot and cold water, of mud, use of
various types of leaves from plants and trees, in the form of poultice etc.
Thereafter, revival of rehabilitation services was due to the selfless and devoted efforts of
philanthropist and non-profit organizations, and the credit for this goes to personalities like Mrs.
Fatima Ismail, Mrs. Kamla Nimbkar, and a number of other devoted personalities, who made efforts
to sustain the rehabilitation services in India. It needs to be a mentioned that whatever efforts were
made to provide the rehabilitation services were not well organized and were patchy. With the
development of modern medicine, Physical Medicine and Rehabilitation did not get its due
importance, as more importance was laid to curative medicine. Now, with the passage of time, its
importance is being realized, and, Physical Medicine and Rehabilitation finding its place in modern
medicine. It is now a growing specialty based on sound scientific principles. There is ever increasing
awareness in the medical fraternity and people at large about its role, and its demand is increasing
day by day.
In the last one a half decades, awareness has increased greatly and several significant landmarks
attained in the disability sector both at the international and national levels.
United Nations General Assembly declared the year 1981 as the international Year of the Disabled
Persons (IYDP), and called upon the member nations to start rehabilitation programmer for the
persons with disabilities in their countries.
Following this, the period 1983-92 was proclaimed by the General Assembly as the UN Decade for
Disabled Persons. The major outcome of the Decade was the emergence of a global movement
recognizing the importance of integration of people with disabilities in the society through a world
program me of Action. The Economic and Social Commission for Asia and the Pacific (ESCAP,) at it 48th
session in April 1992 declared the period 1993 to 2002 as the Asian and Pacific Decade of Disable
Persons. The Proclamation on the “Full Participation and Equality” of People with Disabilities was
adopted. The primary focus of ESCAP decade action is expansion of opportunities for the full
participation of the people with disabilities. (PWD) in the society and their equality in the process of
development.
At the country level, the nodal ministry to provide rehabilitation services to the disabled persons is
the Ministry of Social Justice and Empowerment. It has developed National Institutes in each area of
disability, which are engaged in providing services, training of manpower, development of educational
material and research activities. Their names are mentioned in the following pages. Some institutes
have regional centers in different parts of the country.
The Ministry of Health and Family Welfare is taking care of the medical rehabilitation component. The
ministry of Health and Family welfare, in its 5th Conference of Central Council of Health and Family
Welfare in 1997 passed the following resolution:
The council noted that there are a number of ongoing National Health Programs run by the Health
sector, which has a direct bearing on prevention of disability. They are:
• National Leprosy Eradication Program me
• Blindness Control Program me
• Iodine Deficiency Disorders Control Program me
• National Mental Health Program me
• National AIDS Control Program me
• Universal Immunization Program me including the Clinic Survival and Safe Motherhood (CSSM)
Program me.
These programmers may be further strengthened and attention be given towards preventive and
rehabilitative aspects.
The council recommended that state/UT governments may consider establishment of center for
rehabilitation in the district hospitals and further added that the existing health infrastructure be
utilized and further strengthened to incorporate the various aspects of prevention and rehabilitation
of various disabilities.
The council felt that there is need for development of trained manpower base to tackle the problem
at the periphery within the community and for transfer of technology to grass root level. To achieve
this States and UT’s should fully utilize the opportunity for training of PHC doctors and paramedical
personnel to reorient them to the various aspects of Rehabilitation with the help of training
institutions under the Ministry of Welfare as well as Ministry of Health and family Welfare as a
collaborative effort. The council recommended strengthening of research on causation and
prevalence of disability within the community.
The council resolved the Medical Council of India recommendations of starting Physical Medicine and
Rehabilitation Department in every Medical College should be strictly implemented which would
enable doctors and paramedical to be trained in PMR, who in turn can act as trainers for middle level
and grass root level workers.
Presently, there are National Institutes of Rehabilitation under the Ministry of Health and Family
Welfare and Ministry of Social Justice and Empowerment. These are:
Apex Institutes under Ministry of Health and Family Welfare are:
• All India Institute of Physical Medicine and Rehabilitation, Mumbai (AIIPMR)
• All India Institute of Medical Sciences; New Delhi (AIIMS) which is also collaborating center for
Community Based Rehabilitation (CBR)
• All India Institute of Speech and Health, Mysore (AIISH)
• National Institute of Mental Health & Neuro Sciences (NIMHANS), Bangalore
• Department of Rehabilitation, Safdarjung Hospital, New Delhi
Apex Institutes under Ministry of Social Justice and Empowerment are:
• National Institute for Visually Handicapped (NIVH), Dehradun
• Ali Yavar jang National Institute for Hearing Handicap, (AYJNIHH) Mumbai.
• National Institute for Mentally Handicapped (NIMH), Secunderabad.
• Institute of Physically Handicapped (IPH), New Delhi
• National Institute for Rehabilitation Training & Research (NIRTAR), Cuttack.
• National Institute for Orthopedically Handicapped (NIOH), Calcutta.

Besides these, there is an Artificial Limb Manufacturing Corporation of India (ALIMCO), at Kanpur, UP
which is engaged in mass manufacture of assistive devices for people with disabilities to assist their
ambulation and improve their functional level. In addition to this a large number of non-governmental
organizations (NGOs) are providing need based service especially in the area of education, training
and therapeutic interventions.
Under the Ministry of Labor, there are 17 Vocational Rehabilitation Centers in the country where
facilities of training for gainful employment are available, 40 special employment exchanges for
people with disabilities exist, and who register them for various categories of jobs.
In spite of all this progress, the rehabilitation services reach approximately to 2% of disabled
population and that too concentrated to the urban areas mainly. With the result majority of rural
disabled are still deprived of rehabilitation services.

11.3 DISABILITY
The conventional medical view of disease is as follows:
Causes – Pathology – Manifestation
In chronic progressive of irreversible disorders, the sequence is
Disease – Impairment – Disability – Handicap
In order to understand the above terms, let us take the example of a person who has met with a traffic
accident and has lost his one leg below the knee (Impairment). The loss of one leg by this person will
result in decreased mobility like walking, running, going to place of work etc. (Functional limitation).
In addition to the physical loss of the limb, the person also suffers from psychological setback, social
segregation, and it can also lead to loss of his earning capacity (Disability). In addition to the
consequences of the disability upon the disabled person himself, the family, the society, and the
Nation as a whole also has to face the burden of supporting the disabled person physically, socially
and mentally. The society has to come up with increased demands and the country as a whole has to
spend on the care and maintenance of the disabled person, and decreased productivity because of
the disability resulting in low G.N.P. (Gross National Product).
Definitions of the terms concerned with the disability process are as follows:
Impairment
An impairment is a permanent or transitory anatomical, physiological or psychological loss or
abnormality, e.g., a missing limn, paralysis after polio, mental retardation etc.
Functional Limitation
Impairment may cause functional limitation which are partial or total inabilities to perform those
activities necessary for motor, sensory or mental functions within the range and manner of which a
human being is normally capable, e.g., walking, seeing, speaking, hearing etc.
Disability
It is defined as an existing difficulty in performing one or more activities, which in accordance with the
subject’s age, sex and normative social role are generally accepted as essential basic components of
daily living.
There are many components that interact with each other in disability process:
• The patient
• The environment
The patient has two components – disease, disease and psychological response.
The environment also has two components – social and vocational. Disease factors are reciprocally
influenced by psychological factors. On the other hand social factors are mutually influenced by
vocational factors. That means that the patient and the environment mutually influence each other
resulting in a disability.
Recently, WHO has proposed revision of this definition (ICIDH-2 beta draft-unpublished)?
These are as follows:
Impairment
Impairment is a loss or abnormality of body structure or of a physiological or psychological function.
Activity Limitation
Activity is the nature and extent of functioning at the level of the person. Activities may be limited in
nature, duration and quality.
Participation Restriction
Participation is the nature and extent of a person’s involvement in life situation in relationship to
impairments, activities, health conditions and contextual factors. Participation may be restricted in
nature, duration and quality.
Disability types, magnitude and causes
Broadly, the disabilities can be grouped into the following groups:
• Locomotor disability i.e. Disability of moving
• Visual disability i.e. Disability of seeing
• Hearing and speech disability i.e. Disability of hearing and speaking
• Mental retardation i.e. Low I.Q.
The people with Disabilities Act has also included the following as disabilities:
• Low vision
• Leprosy cured
• Mental illness
However, there are certain anomalies in this grouping Pulmonary conditions like chronic obstruction
pulmonary diseases (COPD), cardiac conditions like Myocardial Infarction, Thalassemia, Loss of kidney,
though cause permanent impairment are not included as disabling conditions.
As regards the magnitude of the problem, estimates of the number of disabled vary a great deal
depending upon certain factors such as the definition used, the source of information, the
methodology of the survey, the extent of use of scientific observation methods in identifying and
measuring the degree of disability and so on.
According to one estimate, the population with disability in India is approximately over 90 million
(based on 10% prevalence of disability) of which 12 million are blind, 28.5 million are with low vision,
12 million are with speech and hearing defects, 6 million are orthopedically handicapped, 24 million
mentally retarded, 7.5 million persons with leprosy related handicaps.
A comprehensive country wide sample survey of person with disabilities was undertaken by the
National Sample Survey Organization (NSSO) in 1981. This survey indicated that 1.8% of the total
population of the country has physical or sensory disabilities.
No survey of mentally retarded persons was done at that time. Another survey was conducted by the
NSSO in 1991. The survey indicated that 1.9% of the population of the country have physical or sensory
disabilities which include locomotors, visual, speech and hearing disabilities.
Almost all the disability prevalence studies undertaken in India have been based on questionnaires.
The appropriate survey of the prevalence of disability must be based not on questionnaire only, but
on examination and observation of each household member. Thereof, it appears that the findings of
survey conducted in India are an under estimate of the magnitude of the problem in the country.
Furthermore, whatever the magnitude of the disability may be, there are trends to indicate that there
is anticipated rise in the number of people with disability, and also, the spectrum of the causation of
disability is changing. As we are able to control the communicable diseases like polio, leprosy, etc., the
prevalence of disability due to these causes is on the decrease. On the other hand with the ever
increasing population, worsening of food situation and consequently increase in number of cases of
malnutrition, the prevalence of disability is on the rise. Similarly, with the change in the age
composition, wherein there is more elderly population, work related and age related disability is on
the rise. The overall scenario reveals that we are going to have more people with disability than
henceforth. Therefore, there is a need for laying more emphasis on their rehabilitation.
Medical Causes of Disabilities:
Congenital Disorders
Genetic: Genetic defect
Non-genetic: Include consequences of disease or
Functional disturbances affection the fetus during pregnancy
or delivery.
Genetic
• Mental retardation
• Hearing impairment
• Speech disturbance
• Visual impairment
• Genitor urinary
• CHD
• Malformations of digestive systems
Non-genetic Disorders
Perinatal disability, low birth weighs
• Malnutrition, severe anemia during pregnancy.
• Disease during pregnancy
- Communicable disease : Rubella
- Syphilis
- Tetanus
- Drug Use
• Complications during delivery owing to low quality midwifery
- Birth trauma
- Brain damage
- Respiratory or circulatory disturbance

Communicable Disease
Common
- Poliomyelitis
- TB
- Leprosy
- Trachoma
Others
- Meningitis
- Encephalitis
- Herpes
- Osteomyelitis
- Venereal disease
- Septic arthritis
- Chronic eye infections
- Otitis media
- AIDS

Non-communicable Somatic Diseases

- Back disorders
- Paralysis
- Arthrosis
- Rh. Arthritis
- Heart Conditions
- CVA
- Pulmonary Dysfunctions
- Epilepsy
- Vision impairments
- Hearing impairments
- Diabetes
- Cancer

Functional Psychiatric Disorders

- Psychotic: Schizophrenia
- Non-psychotic: Phobic states

Alcoholism and Drug Abuse

Trauma and Injuries

- Traffic accidents: rail, road, air, sea

- Work accidents: industrial, agricultural
- Home accidents
- Other sources
- Recreation and sports
- War and civil unrest
- Natural catastrophes
- Earthquake
- Floods
- Cyclones

Malnutrition
- Protein calorie
- Vitamin Exophthalmia
- Nutritional anemia

Other Causes
- Exposure to toxic substances un air, water, food.
 - Unsuccessful suicidal attempts
- Crime : infliction bodily injury, psychological disturbance
- Iatrogenic disturbance
Common Causes of Disability
Visual: Cataract
Trachoma
Trauma
Congenital
Vit. A Deficiency
Hearing: Congenital nerve deafness
Chronic Otitis media
Noise pollution
Speech: Congenital
Brain damage
Locomotors: Poliomyelitis
Amputation
Cerebral Palsy
Accidents
Mental: Congenital
Cerebral Palsy
Cretinism

11.4 VARIOUS APPROACHES TO PREVENT DISABILITY

The old dictum “prevention is better than cure” still holds well in the modern day world. Prevention
is usually defined at three levels – primary, secondary and tertiary prevention.
Primary Prevention
Primary prevention can be defined as “action taken prior to onset of the disease”, which removes the
possibility that a disease will occur. Primary prevention may be accomplished by measures designed
to promote general health and wellbeing and quality of life of the people or by specific protective
measures. It includes the concept of “positive health”, a concept that encourages achievement and
maintenance of an “acceptable level of health” that will enable every individual to lead a socially and
economically productive life. It concerns an individual’s attitude towards life and health and the
initiative he takes about the positive and responsible measures for himself, his family and the
community.
Common examples of primary preventive measures are:
• Proper antenatal, natal and postnatal care, to prevent child born with disability.
• Avoid consanguineous marriages.
• Prevention of accidents.
• Proper immunization to prevent diseases like polio.
Secondary Prevention
It can be defined as “action which halts the progress of the disease at its incipient stage”, and prevent
complications. The specific interventions are “early diagnosis and adequate treatment”. It is largely
the domain of the clinical medicine.
Tertiary Prevention
When the disease process has advanced beyond its early stage, it is still possible to accomplish
prevention by tertiary prevention. It signifies intervention in the late pathogenesis phase. Tertiary
prevention can be defined as all measures available to reduce or limit impairments and disabilities and
minimize suffering caused by existing disability. The tertiary phase of prevention is also called
rehabilitation, which includes physical, psychosocial and vocation measures taken to restore the
patient back to normal or near to normal condition.

1.5 REHABILITATION

Rehabilitation has been defined as the “combined and coordinated use of medical, social, educational
and vocational measures for training and retraining to the highest possible level of functional ability”.
It includes all measures aimed at reducing the impact of disabling conditions and at enabling the
disabled to achieve social integration. Social integration has been defined as the active participation
of the disabled person in the mainstream of community life. Rehabilitation medicine has emerged in
recent years as a medical specialty. It involves discipline such as physical therapy, occupational
therapy, audiology and speech therapy, psychosocial work, prosthetics and orthotics, education,
vocational guidance and placement.
Types of rehabilitation:
Medical rehabilitation: It means restoration of function.
Vocational rehabilitation: It means restoration of the capacity to earn livelihood.
Social rehabilitation: It means restoration of family and social relationships.
Psychological rehabilitation: It means restoration of personal dignity and confidence of the disabled
person.
Rehabilitation measures include:
• Training to increase independence in self-care.
• Educational and vocational measures aimed at achieving economic independence.
• Social measures to ensure full integration and acceptance in community.
Independence in Self Care:
It is training and teaching of patients or family members and neighbors etc.
Independence in self-care is for independence in:
• Activities related to daily life such as dressing, eating, drinking, washing, personal hygiene etc.
by giving.
- Training activities
- Provision of simple technical aids (at times).

• Mobility, sitting, standing, walking etc. They require the provision of shops, crutches, etc.

• Physical environmental changes suited to the kind of functional limitation.

Economic Independence
It includes:
• Educational training
• Vocational training
• Employment opportunities
Social Integration
It means bringing out attitudinal changes in the community at large by ratifying their misbelieve and
misconceptions about disability and ensuring social integration. It requires education of people at
large through mass media and community leaders.

11.6 PHYSICAL FACILITIES AND DESIGNING

• The design depends on nature of services provided

• They may be related to particular specialty like musculoskeletal, pediatric, sports etc.
• The services may be offered in a clinic or patients accommodation like ward ICU etc.
• Work load, equipment a human resources planned
• Finances available
Location
The department should be located on ground floor. It should easily accessible from outside and
also from the wards (Op) there should be ramp for morning trolleys and wheelchairs.
Railing should be provided for support.
• Flooring should be archaized type preferably wooden.
• Doors automatic
Functional areas
• Consultation cum examination rooms of 150 sq. ft.
• Therapeutics area should be minimum 2000 sq. ft.
Divided into different section
Manual therapy section – two cubicles of 100 sq. each Electrotherapy section – two or three
cubicles of 100 sq. ft. each traction section clerical lumber and cold pack unit
Total 3 cubicles of 100sq ft. each
Reception area – should be large enough to admit the number of patients and accompanying
persons.
Toilets, drinking water, cafeteria facilities should be available.
• Diagnostic area – 200 sq. ft.
• Hydrotherapy area – 300sq. ft.
• Staff office
• Store.
• Record room
• Toilets for staff
• Facilities like Electrification plumbing to such the equipment’s and facilities.

11.7 STAFFING AND HUMAN RESOURCE

• Minimum staff necessary should be:

• A chief therapist
• 4 physiotherapists
• Receptionist clerks
• Helpers etc.
If indoor services are also provided additional physiotherapists are required depending on bed
strength, occupancy rates and specialties served by hospital on an average a physiotherapists is
appointed for 10 – 12 patients per day.
 11.8 FUNCTIONS OF THE DEPARTMENT

• To detect anatomic patho-physiological important resulting in dysfunctions.

• To make appropriate diagnosis.
• To plan and implement specific Physical medicine and rehabilitation measures.
• To select proper strategies for ‘care and cure’
• To offer most suitable restoration and rehabilitate measure
• To ensure desired compliance of client
• To promote health in general
• To follow the code of ethics for physiotherapists.

11.9 EQUIPMENT PLANNING

The equipment required for a good Physical medicine and rehabilitation unit are:
Musculoskeletal section
• Dynamometer
• Hand evaluation kit
• Biofeed back unit = EMG attachment
• Video camera a player with Jogshntile facility for movement analysis
• Isokinetic unit
• Motion analysis
NeuroPhysical medicine and rehabilitation section
• Channel EMG C nerve conduction
• Biofeedback machine with quantitative analysis therapy
• Sensory integration kits
• Balance boards
• Video camera players jog shutter facility for movement analysis
• Motion analyzer
• Balance master
Cardiopulmonary section
• Ergometer –Treadmill ,Bicycle = leg an arm unit
• Spirometer
• Peak floor meter
• Tools for CPR demonstration
 • Body composition analyzer
• Energy consumption analyzer
Pediatrics Section
• Play room = Toys
• Sensory integration kit
• Swiss Balls
• Positioning devices
Sports section
• fitness measurements instruments
Gymnasium
• Parallel bars
• Multigym equipment
• Balance Training equipment
• Weighted balls
• Tilled balls
• Tilt belt

11.10 SUMMARY

Physical medicine and rehabilitation is a branch of medicine that aims at total rehabilitation of
patients .The therapy is based on abilities than disabilities .The science focuses on Restoring,
enhancing and reinforcing performance /function , Facilitating learning of skills and functions that are
essential for adaptation and productivity ,Diminishing or corroding pathology ,Promoting and
maintaining health , Maintaining physical and mental capacities throughout life.

The Various therapies treat disabilities in the fields of cardio respiratory, muscular skeletal,
neurological, neuromuscular, congenital, age related, sports related and psychological. The approach
should be patient centered, it should be flexible, culturally safe and accessible and assessable.

11. 11 KEY WORDS

• Impairment: An impairment is a permanent or transitory anatomical, physiological or

psychological loss or abnormality, e.g., a missing limn, paralysis after polio, mental retardation
etc.
• Functional Limitation: Impairment may cause functional limitation which are partial or total
inabilities to perform those activities necessary for motor, sensory or mental functions within
the range and manner of which a human being is normally capable, e.g., walking, seeing,
speaking, hearing etc.
• Disability: It is defined as an existing difficulty in performing one or more activities, which in
accordance with the subject’s age, sex and normative social role are generally accepted as
essential basic components of daily living. Impairment is a loss or abnormality of body
structure or of a physiological or psychological function.
• Activity Limitation: Activity is the nature and extent of functioning at the level of the person.
Activities may be limited in nature, duration and quality.
• Participation Restriction: Participation is the nature and extent of a person’s involvement in
life situation in relationship to impairments, activities, health conditions and contextual
factors. Participation may be restricted in nature, duration and quality. Rehabilitation has
been defined as the “combined and coordinated use of medical, social, educational and
vocational measures for training and retraining to the highest possible level of functional
ability”. It includes all measures aimed at reducing the impact of disabling conditions and at
enabling the disabled to achieve social integration
• Medical rehabilitation: It means restoration of function.
• Vocational rehabilitation: It means restoration of the capacity to earn livelihood.
• Social rehabilitation: It means restoration of family and social relationships.
• Psychological rehabilitation: It means restoration of personal dignity and confidence of the
disabled person
UNIT 12 PHARMACY SERVICES

Objectives
After going through this chapter you will be able to:

1. Understand the functions of pharmacy services;

2. Know the importance of pharmacy services and that of a pharmacist;
3. Understand the various policies and procedures;
4. Know the importance of hospital formulary and drugs and therapeutic committee;
5. Know how to handle medication errors;
6. Understand the quality assurance programme in pharmacy services.
Structure
12.1 Introduction
12.2 Important definitions
12.3 Functions
12.4 Physical Facilities
12.5 Pharmacy and Therapeutic Committee
12.6 Hospital Formulary
12.7 Drug Distribution Service
12.8 Drug Information Service
12.9 Pharmacy Policy/procedure manual
12.10 Labeling
12.11 Human Resource Management
12.12 Logistics management in Pharmacy
12.13 Medication Incident and Discrepancy Reporting
12.14 Security
12.15 Narcotics and Controlled drugs
12.16 Steps to prevent pilferage and thefts
12.17 Quality Management
12.18 Summary
12.19 Key Words

12.1 INTRODUCTION

Pharmacy can be defined as the licensed premises run and operated by licensed persons for compounding
drugs and their supply to the patients as per prescriptions from doctors.
Pharmacy council of India was founded in 1949 on recommendations of Copra committee (1921) and Bhore
committee (1946). Licensing the premises was made compulsory. The qualification for pharmacists was
decided to be a Diploma in Pharmacy. The Indian pharmacy Act was passed in 1948 amended in 1959 and
1976. The act is related to regulation of practice of pharmacy and the qualification of pharmacists. The Drugs
and Cosmetics Rules (1940), National Formulary 1960 also contain directives for functioning and control of
pharmacy. The control at state level is with food and drugs control administration.

12.2 IMPORTANT DEFINITIONS

Adverse Drug Reaction

An undesirable, unintended response to a drug that occurs at doses normally used for the diagnosis, treatment
or prevention of a disease or the modification of an organic function. The reaction provides neither
therapeutic, prophylactic nor diagnostic benefit to the patient.

After Hours Cabinet/Cart (Night Cabinet)

It is a locked storage area (cabinet, cart or automated dispensing machine) secured to a wall or located in a
locked room, stocked with a minimum supply of drugs most commonly required for immediate use within the
institution when the pharmacy is closed. The drugs are stored in properly labeled containers supplying a
sufficient quantity of medication until such time as a pharmacist is on duty.
Automatic Stop Order
The practice of automatically stopping a drug order after a specific time period provided the physician has not
specified the number of doses or time limit. The purpose is to avoid prolonged administration of medications,
which may inadvertently result in harmful consequences to the patient and unnecessary expense.
Biological Safety Cabinet
A ventilated cabinet having an open front with inward airflow for personnel protection, a HEPA-filtered
downward airflow for product protection and a HEPA-filtered exhaust air for environmental protection.(Class
2, Type B2, externally vented, suitable for antineoplastic preparation, Class 2 Type A/B3, internally vented,
suitable for preparation of allergy potentiating medications such as Penicillin)
Class 100 Environment
Describes a level of cleanliness for environments that have concentrations of less than 100particles (0.5 micron
size and larger) per cubic foot of air
Compounding
It is the preparation of a drug or device for individual patients, within a specific patient population, pursuant
to a prescription written within an established prescriber-patient-pharmacist relationship. The preparation of
products or specialty dosage forms includes sterile or non-sterile topical, oral or parenteral preparations
including IV admixtures and TPN, which are not commercially available in the market place.
Continuous Quality Improvement (CQI)
It is a proactive process with the underlying assumption that every process can be improved. The core
theoretical constructs: focus on patients; focus on the process and continuous improvement. CQI builds on
quality assurance by extending activities beyond problem resolution to ongoing improvement of all key
processes involved in patient care. (See definition of Quality Assurance)
Controlled Dose System
A form of drug distribution, also known as a monitored dose system, in which medication orders are filled
individually and packaged in blister packs or dosage, in accordance with scheduled administration times.
Each package contains no less than a one-day and no more than 35 days’ supply of medication.
Dispense
To provide patient specific medication in response to a medication order but does not include the
administration of the medication.
Drug Allergy
It is an allergic manifestation mediated by the immune system that results from previous exposure and
sensitization to a particular chemical or to one that is structurally similar. An allergic drug reaction is
commonly IgE or immune-complex-dependent.
Drug Distribution Service
A pharmacy coordinated hospital system used to provide medications to the patient.
Drug Recall
A request for, and subsequent removal, of a medication from stock.
Drug Use Evaluation
The prospective or concurrent analysis of the pattern of use of drugs against a predetermined set of criteria,
followed by assessment, implementation of corrective action, and reassessment.
Drug Utilization Review
The retrospective analysis of the pattern of use of drugs against a predetermined set of criteria, followed by
assessment, implementation or corrective action, and reassessment.
Established Pharmacist-Patient-Prescriber Relationship
A relationship that can be demonstrated to exist between:
• a pharmacist and a patient
• a pharmacist and a prescriber
• a patient and prescriber and/or
• a pharmacist, patient and prescriber

Expiration Date
It is the time during which a pharmaceutical may be expected to meet the requirements of the pharmacopeia
monograph provided it is kept under the prescribed manufacturer’s conditions. This date limits the time during
which an article may be dispensed or used and is based on scientifically sound stability studies care out by the
manufacturer.
Extemporaneous Compounding
It is an all-encompassing term used to define all forms of compounding, such as non-sterile compounds
(creams, ointments, oral liquid preparations, capsules etc.), sterile product preparations (prefilled syringes, IV
admixtures, TPN etc.) and sterile compounds (sterile eye drops).
Formulary
A dynamic compilation of medications, information, and related policies, approved for use within the hospital
that reflects the current clinical judgment of the medical and pharmacy staff.
Good Manufacturing Practices (GMP)
These are good manufacturing practices
Hazardous Waste
These are chemicals or pharmaceuticals in which the concentrations, toxicity, environmental persistence,
degradation characteristics, flammability, corrosiveness, or reactivity, are dangerous and may represent a risk
to the health of humans and/or other living organisms.
High Efficiency Particulate Air Filter (HEPA filter)
It is a filter which removes 99.9% of particles 0.3 microns and greater in diameter (these particles include
bacteria, pollen and dust)
Hospital Pharmacy Satellite
Any physically separate area used for the provision of pharmacy services that is dependent upon support
services from a hospital pharmacy department.
Individual Patient Prescription System
It is a form of drug distribution, also known as a traditional drug distribution system, in which medications are
dispensed by the pharmacy in patient-specific labeled prescription containers.
Laminar Airflow Hood (LAH)
It is a ventilated cabinet (with stainless steel surfaces) that provides a linear pattern of airflow through a HEPA
filter to create a suitable environment for preparation of sterile parenteral admixtures. The directional airflow
pattern of a laminar airflow hood can be horizontal or vertical providing product protection not personnel
protection. In a LAH air is drawn through a pre-filter to remove gross contaminants, and then it is pressurized
and forced through a HEPA filter. This is considered a Class 100 environment (no more than 100 particles of
0.5 micron size or larger per cubic foot of air).
Medication Discrepancy (patient health not compromised)
An error that does not involve the actual incorrect administration or omission of a drug to a specific patient,
but was detected and corrected before reaching the patient. This definition includes the unexplained loss or
theft of a medication.

Medication Incident (patient health compromised)

A patient-related error that involves the incorrect administration or omission of a medication to a specific
patient.
Medication Order Review
An analysis by the pharmacist to ensure the prescriber’s order is authentic, accurate, appropriate for the
condition and compatible with the patient’s current medication profile.
Medication Profile
An ongoing record of patient specific information used to monitor drug therapy. This record includes all
medications currently prescribed and dispensed for the patient.
Non-Formulary Drug
A drug not listed in the hospital formulary.
Patient Counseling
The counseling of patients about their medications. Written information may be provided to supplement
verbal counseling.
Pharmacist
Pharmacist is a person licensed with the Manitoba Pharmaceutical Association to practice pharmacy.
Pharmacy and Therapeutics Committee
A committee composed of representatives from pharmacy, medicine, nursing, administration, and other
disciplines, which serves as a policy recommending body on all matters relating to the use of medications in
the hospital(s). In absence of a Pharmacy and Therapeutics Committee in smaller hospitals, the Medical
Advisory Committee may address these issues.
Repackaging
The re-distribution of commercially available package sizes in ready-to-administer or ready to dispense units.
Repackaged products are not for resale unless repackaging and labeling complies with the guidelines and
standards that ensure quality and safety of the pharmaceuticals. Pharmacies may repackage drugs in ready-
to-administer or ready to dispense units, for several purposes that include but are not limited to:
• providing unit dose drug distribution services
• providing supplies of drugs to personal care homes
• to enhance the efficiency of the dispensing
Satellite Pharmacy
Satellite Pharmacy is a hospital pharmacy associated and supported in terms of management and/or inventory
control services by a main hospital pharmacy. The satellite pharmacy is generally located within the same
physical complex as the main pharmacy and encourages innovative pharmacy services while providing special
needs to specific units or wards within the hospital. (I.e. Neonatal Intensive Care).
Self-Administration Program
An organized program in which patients are allowed and taught to administer their own medications in the
hospital, in accordance with the hospital and pharmacy policies and procedures.

Unit Dose System

A form of drug distribution in which orders are filled individually and packaged in non-patient specific unit-of-
use packages. Each package contains generally not more than a 48-hour supply of medication is available in
the patient care area at any time.
Verbal Order
A medication order given verbally, either by telephone or person to person, by a prescriber.
Ward stock
Medications stocked in a patient care area not individually labeled for a specific purpose.

12.3 FUNCTIONS OF A HOSPITAL PHARMACY

The pharmacist is responsible for:

• Reading and interpreting the written prescription

• Determining if more information is needed before the prescription can be filled
• Contacting the patient and/or prescriber, if needed and documenting any discussion(s)
• Identifying the use of the product for the patient
• Locating the source of formulas through knowledge of standard reference sources
• Using resources to determine whether there are any physical or chemical incompatibilities

• Calculating the required quantities of all ingredients

• Knowing the medicinal and pharmaceutical function of each ingredient
• Verifying the dosage calculations for each order and patient condition
• Developing policies and procedures to compound prescriptions
• Using the appropriate equipment and techniques to compound the prescription (prescription
balances, dilution techniques, trituration and levitation)

• Ensuring proper maintenance, cleanliness and use of all equipment used in prescription
Compounding process
• labeling the prescription in accordance to the regulations to the Manitoba Pharmaceutical Act,
attaching auxiliary label(s) when appropriate (i.e. swallow whole, refrigerate, shake well, external
use only)

• Determining stability and expiry date of compounded preparations

• Choosing the appropriate container and closures for compounded products
• Determining the storage conditions appropriate for the product
• Inspecting, approving or rejecting all drug components and processing materials
• Preparing and reviewing all records to ensure no errors have occurred in the compounding process
• Ensuring quality control procedures are in place
• Training to pharmacists
• Education of patients
• Drug usage review
Pharmacists should be knowledgeable in the preparation of the following:
• solutions
• suspensions
• emulsions
• ointments
• creams
• pastes
• colloids/keratolytics
• hematological
 • Suppositories

12.4 PHYSICAL FACILITIES

The drugs store should be located on ground floor of hospital building to facilitate the receipt of goods from
vendors. The retail out let for OPD should be just outside or near the exit door. This outlet may work only
during OPD hours. But if it is outside the OPD complex, it can be made 24 X 7 service and can serve the OPD
and casualty patients also. In this case it may not be necessary to have a separate outlet for indoor section.
The retail outlet should be easily accessible and identifiable.
The floor area recommended is 10 sq. feet per bed for 100 beds but reduces to 5 sq. feet per bed for hospital
bigger than 500 beds.
The store should have restricted entry. Hospital staff should be permitted up to the delivery counter and chief
pharmacist office only.
The rooms required are:
• Material receipt area
• Material verification area
• Storage area
• Delivery counter
• Pharmacists office
• Chief pharmacists office
• Room for employees
• Record room
• Toilets, sinks, wash basins, drinking water

The purpose of each room is suggested by the name itself, storage area should have a regular store, cold
storage, storage for inflammables, medical gases and one for dangerous drugs.
The floor should be of sturdy hard material, resistant to chemicals. Walls should have washable skirting up to
2 meters height. The windows should be above the level of 2 meters from floor and should be provided with
strong mesh grills and glass in order to prevent pilferage through them and to prevent entry of rodents.

12.5 PHARMACY AND THERAPEUTICS COMMITTEE

Hospital pharmacies shall be represented by pharmacist(s) on either an in-house or regional Pharmacy

&Therapeutics Committee.
Pharmacy and Therapeutics Committee membership should include representation from:

• Medical Superintendent
• Pharmacy
• Medical staff, (Heads of clinical departments)
• Head of Nursing
 • other disciplines as required
The Pharmacy & Therapeutics Committee shall:

• Ensure Pharmacist Participation In The Development of All Drug-Related Policies And Procedures.
• Review Compliance to All Relevant Policies Relating To Medication Use, Administration and Direct
Patient Care.
• Make Recommendations To Administration And Medical Staff On The Ongoing Review And
Improvement Of Policies And Procedures Relative To The Safe, Effective And Economical Use Of
Medications.
• Compile And Effectively Maintain A Formulary Suited To The Hospital’s Need
• Critically Evaluate All Requests For Formulary Additions And Deletions.
Pharmacy and Therapeutics Committee shall meet at least quarterly and minutes of the meeting, indicating
activities, findings, recommendations and actions resulting from these recommendations, shall be distributed
to all members for future reference.

12.6 HOSPITAL FORMULARY

The pharmacy service, in cooperation with the Pharmacy and Therapeutics Committee, shall develop and
maintain a formulary system, based on both the therapeutic and economic considerations of drug use,
governing the selection and usage of medication in the hospital, or hospitals within a regional health authority.
Features
• The formulary shall be approved by the appropriate hospital or regional hospital committee. (E.g.
Regional Health Authority).
• The formulary shall be available to all professionals prescribing, administering, or dispensing
medications within the hospital.
• The formulary shall be reviewed regularly, revised as necessary, and dated indicating date of last
review or revision.

The Minimum Requirements For A Hospital Formulary Are:

• A written list of selected drug products approved for use within the hospital, classified according to
pharmacologic-therapeutic use
• Information about available dosage forms and strengths
• Information on the use of the formulary and its administration by the relevant hospital committees
• Policies and procedures governing the use of medications within the hospital
A formal published hospital formulary should contain, in addition to the above information the following:
• A cross-index of selected medication products according to generic and trade names
• Aids for medication use, such as tables, dosing charts, and equivalency/comparison charts
• A list of abbreviations and symbols approved for use within the hospital.
Policies and Procedures that shall be included in the formulary:
Formulary drug use
• non-formulary drug acquisition
• additions to the formulary
 • deletions to the formulary
• use and store of patient’s own medication
• medications for self-administration
• therapeutic substitution of drugs
• automatic stop orders
• sample use within the hospital
• emergency release drug acquisition
• investigational drug use
• restricted drug use

In addition to medicines, surgical material and other patient care material is also dealt with by the store.

12.7 MEDICATION /DRUG DISTRIBUTION SERVICE

The pharmacy department shall develop and provide medication distribution services to meet the needs of
the patients and to optimize safety, efficacy and economy. In designing the medication distribution system for
an institution, the following methods to reduce the potential for medication error should be considered.
• Reduce or eliminate transcription errors (i.e. physician direct order entry)

• Provide medication in identified dosage units ready for administration

• Eliminate medication cups and medication ticket as a means to store identify and schedule

• medications

• Minimizing the need to maintain ward stock

The system shall also:

• utilize the original or direct copies of physician’s orders (i.e. self-copying order forms or faxed copies

• protect medication from contamination,

• minimize nursing time required to prepare the medication prior to administration,

• Provide a safe and effective method of recording medications at the time of administration.
Ward stock Distribution System /Floor Stock System
Total Ward stock Distribution Systems are associated with the greatest potential for error, are poor from a
drug control perspective and the least desirable form of drug distribution. Large area and manpower to
manage the stock resulting in uncontrolled inventories Therefore, ward stock medications should be limited
to those medications:

• commonly prescribed on a “as needed” basis

• of low potential for toxicity

 • required on an urgent basis

• that is bulky in size

The pharmacy shall establish a list with minimum and maximum levels of ward stock medications for each
patient care area and that list shall be reviewed on an annual basis by the pharmacy.
Narcotic, controlled and targeted drugs provided as ward stock shall be maintained on a running inventory
system.
Medications required on an urgent or emergency basis shall be readily available and stored appropriately.
Procedures shall be established specifying individuals responsible for checking the emergency drug storage
unit and replacing stock:
• after each use
• Inspecting the unit quarterly for outdated product
Traditional System (Individual Patient Prescription)
Medications shall, be dispensed in individually labeled prescription containers. The amount of drug dispensed
shall be determined by hospital policy. Medications shall be prepared for administration in a manner to
minimize the potential for error. This would involve minimizing the number of transcription steps by
eliminating patient identification cards/tickets and by using medication carts.
Controlled/Monitored Dose System
Medications shall, when possible, be dispensed in individually labeled controlled dose cards/containers. The
system shall be designed in order for each dose to be administered at a specific time directly from the
medication card/container. Medication shall not be removed from the controlled dose package until it is to be
administered. The amount of medication supplied shall be determined by hospital policy.
Unit Dose Medication System
The pharmacy receives a copy of prescription directly. A pack of medications for individual patient for 24 hours
is prepared and sent to the ward for administration to patient
There is no piling of drugs in the wards so a better inventory controls lesser requirement of space. The pack is
prepared for individual patient so no medication errors. The correct doses are packed so less chances of
pilferage. There is better inventory control and drug administration monitoring.
Medications shall, when possible, be dispensed in single unit-of-use labeled packages, removed from the
package and administered directly to the patient. The number of doses supplied at any one time shall be
determined by hospital policy.
Automated Medication Distribution System
Medications shall, when possible, be dispensed in single unit-of-use labeled packages, removed from the
package and administered directly to the patient.
Automated Dispensing Units shall be used for medication storage on the ward.
Policy and procedures must be in place whereby medication prepared by the pharmacy department is
delivered to the ward and verified by a nurse prior to administration to the patient.
Combination Method
Certain stocks of all medicines and materials are kept in every ward. The quantities decided on basis of average
consumption study, bed occupancy and turnover rates of individual wards.
Indents on daily basis are prepared, medicines brought from store and administered to patients. Emergency
needs are met with from the stocks at hand in the wards and then replaced after daily indents are received.
Instead of daily indents, indents for 3 days are made. Whichever system is followed, there is holding of some
stocks in the wards, therefore the storage and accounting has to be done properly. This consumes lots of time
of the nursing staff.
Proper accounting and inventory control of essential drugs and administration monitoring is also possible.
Patient’s Own Medication
The pharmacy shall develop policies and procedures with respect to the use of patient’s own medications,
and the return of patient’s medications to the patient upon discharge. Medications brought to the hospital
by the patient shall not be administered unless written orders to administer the medication are given by the
prescriber. The medication must be examined by a pharmacist with respect to identity and integrity at the
earliest opportunity and a mark or initial placed on the container indicating the product has been checked.
Where the identification of herbal remedies, homeopathic medicines or other alternative therapies is
impossible, concerns in regards to product safety, efficacy, quality and possible drug interactions exist.
Pharmacists are encouraged to use the pharmaceutical care approach and consider the patient’s overall care
and anticipated outcome, instead of considering the medicinal product alone.
A pharmacist upon determining a patient’s own medication cannot be identified and dispensed, the
pharmacist shall communicate this decision to the prescriber and provide factual unbiased information about
the medicinal product as required. Patient’s own medication not used during their stay, shall be stored in a
secure manner, separate from hospital medication storage areas.
Hospital policies and procedures shall be developed specifying which medications (i.e. creams, drops etc.) may
be given to patients upon discharge and which medications are not to be given to patients upon discharge.
Medications not sent with the patient shall be returned to the pharmacy for destruction in accordance with
hospital policy.

12.8 MEDICATION ORDER REVIEW

Provisions shall be made for sending a direct copy or faxed copy of all medication orders to the pharmacy
department and subsequently retaining the original medication order on the patient’s chart. All medication
orders shall be reviewed by the pharmacist to ensure they are authentic, accurate and appropriate. It is the
responsibility of the Pharmacy and Therapeutics Committee to prioritize the type of orders that must be
reviewed by the pharmacist prior to medication administration. Orders received after pharmacy hours or ward
stock medication orders must be reviewed by the pharmacist and acted upon at the earliest opportunity.
Medication orders shall include:

• Patient name, age, location and hospital number

• Medication and dosage
• Route and frequency of administration
 • Duration of treatment, if limited
• Identification of authorizing professional
• Date order was written
• Time order was written, if appropriate
• For verbal orders, the name and signature of the person who received the order followed by
the Medication Profiles
The pharmacist shall ensure a medication profile is available for each patient for whom medication is
prescribed, except for patients admitted for less than 24 hours to specified diagnostic or treatment areas such
as: day surgery, ambulatory care, and emergency.

Patient medication profile information shall include:

• patient name, location and hospital number
• attending physician and/or prescriber’s name
• date of birth
• gender
• weight and height, if applicable to therapy
• allergies, sensitivities or adverse drug reactions
• medication(s) name, dose, quantity, route, dosage form and directions for use
• dates medications were dispensed, refilled and discontinued
• alcohol
• drug samples
• initials of the pharmacist or technician entering the information into the computer
The pharmacist shall review medication orders, utilizing the patient’s medication profile prior to releasing the
medication and intervene when appropriate. It is the responsibility of the Pharmacy and Therapeutics
Committee to prioritize the type of orders that must be reviewed prior to medication administration. For
orders received after pharmacy hours or ward stock orders, where the patient profile and medication order
review is not possible at time of dispensing, orders shall be reviewed and acted upon at the earliest
opportunity.

12.9 DRUG INFORMATION SERVICE

The pharmacist shall provide drug information, including patient-specific drug information, to health care
professionals and patients. The pharmacist shall select from the current drug literature those reference
sources which will meet the drug information needs of their specific area of practice and the pharmacy shall
have the latest editions of these reference materials.
The pharmacist shall provide information on medications and medication therapy when:
• providing information related to a specific patient’s pharmacotherapy
• attending patient rounds and patient-care conferences
• responding to drug-related questions posed by staff or patients,
 • recommending drug-related references for use by the hospital
• participation on the Pharmacy and Therapeutics Committee
The pharmacist should provide drug information services through the preparation of newsletters, patient
information handouts, seminars and in-service presentations.

12.10 HOSPITAL PHARMACY POLICY AND PROCEDURE MANUAL

General Policies
• Organizational Chart
• Departmental Goals
• Departmental Objectives
• Philosophy
• Facilities
• Locations
• Responsibility and Scope of Practice
• Hours of Service
• After Hours Pharmacy Service
• Night Medication Cupboard/Cabinet
• Access to Pharmacy
• 24 Hour Medication Clock
• Metric System Conversion
• Standard Abbreviations
• Transfer of Function to Nursing
• List of Medical Staff and Sample Signatures
• Manufacturer Representatives
• Pharmaceutical Display
• Department Tours
Administration
• Responsibilities of the Director of Pharmaceutical Services
• P&T Committee membership
• Maintenance of Formulary
• Hospital Formulary System
• Restricted Antimicrobial Agents
• Dispensing of High Cost Medications
• Adding New Drugs to the Formulary
• Maintenance of IV Manual
• Departmental Telephone Use/Taking and Giving Information via the Telephone
• Release of Patient Information to Police or Other Individuals
 • Shredding Confidential Information
• Workload Measurement
Committee Activities
• Departmental Committees Terms of Reference
• Pharmacy & Therapeutics committee
• Infection Control Committee
• Drug Utilization Committee
• Nutritional Support Committee
• Intensive Care Committee
• Emergency Care Committee
• Palliative Care Committee
• Patient Education Committee
• Medical Audit and Utilization Committee
• Workplace Safety and Health Committee
• Product Evaluation Committee

Reporting Systems
• Adverse Drug Reaction Reporting
• Medication Incident/Discrepancy Reporting
• General Incident Reports
• Drug Information Request Reporting
• Poison Control Reporting
• Blood Products Record Keeping
• Employee Accident Reports
• Monthly Financial Report
• Year End Report
• Quality Assurance Report
• Continuing Education Report
Personnel Policies
• Pharmacist’s Role in Patient Care Planning
• Position/Job Descriptions
• Staff Orientation
• Performance Appraisals
• Personnel Files
• Scheduling of Staff and Report of Hours
 • Notification of Absence from Work
• In-services and Continuing Competency
• Pharmacy Service for Employees
• Dress Code
• Prohibition of Smoking
• Volunteer Services to Pharmacy
• Time Card
• Overtime Authorization
Drug Procurement/Inventory Control/Materials Management
• Budgeting Process
• Capital Requisition
• Drug and Supply Purchasing/Ordering
• Contingency Purchases
• Non-Formulary Drug Purchases
• Receiving Procedure
• Authorization for Payment/Signing Authority
• Handling of Pharmacy Invoice Discrepancies
• Drug Importation
• Drug Recall Procedures/Urgent Drug Recall Procedures
• Inventory Control
• Order/Reorder Alert
• Drug Price Books
• Return and/or Disposal of Drugs
• Returns due to Product Failure
• Medication Returns from Inpatient Wards
• Disposal of Hazardous Waste
• Handling and Disposal of Sharps
• Restocking the Dispensary
• Drug Samples for Use by Hospital Patients
• Resale of Pharmaceuticals
• Drug Storage
• Perishable Drug Control
• Ward Stock
• Labelling of Drug Containers
• Prepackaging Records
Fire and Safety
• Fire Alarm Response Plan/Procedure
 • Fire Alarm Response Plan/Procedures After Hours
• Bomb Threat Plan/Procedures
• Safety Contingency Plan
• Search for Missing Person
• Evacuation Orders
• Preventive Maintenance of Laminar Flow Hood
• Robbery – Cash or Drugs
• Adverse Weather Contingency Plan
• External Disaster Plan
• Telephone Fan Out
• Security Restrictions
Inpatient Drug Distribution Services
• Hours of Services
• Prescriptive Authority
• Prescription Form and Required Information
• Medication Containers
• Drug Quantities
• Screening Prescriptions
• Inpatient Computer System procedures
• Signing On and Off
• Patient Demographics
• Profiling and Monitoring
• How to view a Patient History
• Medication Review
• New Order Processing
• Repeat Order Processing/Repeat Orders
• Multiple Ingredient Order Processing
• Drug Order Clarification Notice
• Filling Prescriptions
• Preparation of Prescription Labels
Contingency Plan for Computer Failures
• Filling Prescriptions – Non-Computerized
• Repeat Orders – Non-Computerized
• Preparation of Prescription Labels – Non-Computerized
• Recovery
• Telephone Orders
• Verbal Orders
 • Final Checking of Prescriptions
• Signed Physician Orders
• Canceling or Discontinuing Orders
• Resumption of Pre-Op Medications
• Dispensing Records
• Distribution Times
• Drug Administration Schedules
• Drug Administration Checks
• Automatic Stop Orders
• Therapeutic Equivalent Dispensing
• Automatic Substitution
• Generic Equivalent Dispensing
• Restricted Antimicrobial Agents
• Dispensing of High Cost Medications
• Clozapine Dispensing
• Alcoholic Beverages
Investigational Drugs and Emergency (Special Access Medications)
• Additions/Deletions to Ward Stock Medications
• Filling Ward Stock Drug Orders
• Final Check of Ward Stock Drug Orders
• Packaging Drugs for Transport
• Issue and/or Delivery of Drugs by Messengers
• Intramuscular Drug Administration
• Intravenous Drug Administration
• Addition of Drugs to Blood
• Bedside Medication
• Patient Self-Medication
• Patient’s Own Medication
• Safekeeping of Personal Medications
• Handling of Medication on Discharge
• Topical Preparations to Patients upon Discharge
• Leave of Absence/Pass Medications
• Reuse of Aero chambers and Aero chambers with Masks
• Ward/Drug Storage Site Inspections
Clinical Pharmacy Services
• Areas of Service
• Clinical Privileges
 • Documentation in the Patient Medical Record
• Medication History Service
• Patient Monitoring
• Toxic Drug Conc. Monitoring Service
• Medication Counseling/ Patient Education
• Participation in Medical Service Rounds
• Pharmacokinetic Services
• Therapeutic Consults
• Drugs requiring Serum Creatinine Monitoring
• Drugs requiring PT/PTT Monitoring
• Drug Utilization Review/Drug Use Evaluation
• Pharmacist Involvement in CPR Team
• Student Teaching Program
Drug Information Services
• Hours of Service
• Maintenance of Drug information resources
• Responding to Drug Information Requests
• Maintenance of Drug Information Statistics
• Library Loans
• Drug Information Postings/Newsletters
• Poison Control Service
• Antidote Information and Supplies
• Maintenance of Pharmacological Nursing Reference Manual
• Maintenance of Formulary
• Suspected Drug Reactions Reporting Program
Education Services
• Hospital Pharmacy Residency Program
• Undergraduate Teaching Program
• Staff/Resident Drug Information Training
• Orientation to Pharmacy Department
• Staff Training and In-service Education
• Staff Continuing Education
Outpatient Drug Distribution Services
• Hours of Service
• Patient Eligibility
• Prescriptive Authority
• Prescription Forms and Required Information
• Reimbursement for Prescription Services
• Drug Quantities
• Medication Containers/Child Resistant Containers
• Receiving Prescriptions
• Screening Prescriptions
• Outpatient Computer System Procedures
• Signing On/Off
• Patient Demographics
• Patient Medication Profiles
• Discontinuing Previous Orders
• How to View Patient History
• New Order Processing
• Repeat Order Processing
• Multiple Ingredient Order Processing
• Filling Prescriptions
• Dispensing Records
• Preparation of Prescription Label
• Contingency Plan for Computer Failure
• Filling Prescriptions – Non-Computerized
• Repeat Orders – Non-Computerized
• Pricing Prescriptions – Non-Computerized
• Preparation of Prescription Labels – Non-Computerized
• Uncollectible Accounts Receivable (Bad Debt) – Non-Computerized
• System Recovery
• Final Checking of Prescriptions
• Dispensing Oral Liquids and Provision of Measuring Devices
• Printing Patient Information
• Medication Counseling
• Prescription Filing
• Verbal Orders
• Telephone Orders
• Discharge Orders
• Providing Prescription Copies
• Pricing Prescriptions
• Verbal Authorization for Third Party Billings
• Updating Billing Plans
• Uncollectible Accounts Receivable (Bad Debt)
 • Cash Register Procedures
• Delivery Service
• Mailing Prescriptions
• Returning Unclaimed Prescriptions to Stock
• OTC Sales
• US Currency Exchange
Narcotic, Controlled or Targeted Drug Distribution
• Narcotic, Controlled or Targeted Drugs Prescription Regulations
• Maintenance of Narcotic Inventory Records (Acquisition/Distribution)
• Receiving Narcotic, Controlled and Targeted Drugs (Acquisition)
• Withdrawal Records of Narcotic, Controlled and Targeted Drugs from Main Pharmacy
• Disbursements of Narcotic, Controlled and Targeted Drugs to Wards
• Prescription forms and required information
• Medication Containers
• Filling Narcotic, Controlled or Targeted Drugs Requests
• Individual prescriptions
• Ordering Ward Stock Narcotics
• Outpatient prescriptions
• Narcotic, Controlled or Targeted Drugs for Patient on Pass
• Prepackaging Narcotic Ward Stock
• Preparation of Narcotic Delivery Cart
• Delivery of Narcotics to Wards (Individual Patient Prescriptions and Ward Stock)
• Transporting Narcotic, Controlled or Targeted Drugs outside of scheduled delivery times
• Drug Security/Storage in Pharmacy and on Ward
• Returning Narcotic Medication from the Ward
• Returning/Processing Completed Narcotic Recording Sheets (Drug Usage Records)
• Reconciliation of Narcotic Issues
• Obtaining Credit for Narcotic, Controlled and Targeted Substances
• Disposal/Destruction of Unusable Medications
• Diversion/Drug Abuse by Staff
• Methadone Programs

12.10 MEDICATION LABELING

Inpatient Medication
There shall be standardized format, terminology, metric units, and generic labeling on all inpatient medication
labels. A list of abbreviations and symbols approved by the Pharmacy and Therapeutics committee for use
within the facility shall be readily available in the hospital formulary to all professionals prescribing, dispensing
or administering medications.
Medication labels shall be typed or machine printed, shall be free from erasures and strikeovers and firmly
affixed to the container. Only pharmacy personnel shall alter medication labels.
Other labeling considerations should include, when appropriate:
• acceptable route of administration for Parenteral medications
• directions for medications requiring dilution or reconstitution
• dosage, frequency and/or flow rate
• drug classification
• expiration
• lot numbers or codes for repackaged medications
• proper storage conditions
• accessory or cautionary statements
Ward stock medications not provided in the original manufacturer’s packaging shall be labeled
With, but not limited to:

• pharmacy name and address

• drug and strength
• lot number and expiry date
Individual Patient Prescriptions shall be labeled with
• pharmacy name and address
• patient name and location
• drug and strength
• date dispensed
Controlled/Monitored Dose blister cards/containers shall be labeled with, but not limited to:

• pharmacy name and address

• patients name and location
• drug and strength
• date dispensed
Unit-of-Use packages shall be labeled with, but not limited to:
• drug and strength
• lot number and expiry date

12.11 HUMAN RESOURCE PLANNING

The manpower required is based on number of hospital beds, occupancy rate and turnover rate. The 1968
study group has recommended 3 Pharmacists for 50 beds, 5 for 100 beds, 8 for 200 beds. 10 for 300 beds, 15
for 500 beds and 18 for 750 beds. The posts created are chief Pharmacists should be B. Pharm. The pharmacists
should be D. Pharm.
12.12 LOGISTICS MANAGEMENT IN PHARMACY
Procurements
Generally procurement of drugs is made by fixing a rate contract for variable period of one to five years. All
the drugs are purchased routinely from the rate contract holder. When the requirements are large or as a
matter convenience, preferential purchases are made from the R.C. holders. They could be in order of
preference as first, second, third or percentage of purchases from each RC holder can be fixed like say party
No. 1 – 50%, Party No 2- 30%, Party No. 3- 20%. The percentages are just exemplary. The stock maintained as
per requirement and some reserves. The points considered are consumption over a stipulated period, and
reserve for an equal duration and buffer stock for another similar duration. The Pharmacy should calculate
the levels of these three stock levels. Similarly minimum order level, lead time, economic order quantities
should be calculated and kept on record. When the stock of a drug touches minimum order level, the
Pharmacist prepares a proposal for approval of head of institution, after approval, the purchase officer places
order with the RC holder firm. The availability of budget is taken in to consideration while preparing the
proposal.
In case of budgetary constraints preference is always given to vital drugs and then to essential drugs. For this
purpose the Pharmacist should prepare a list of vital, essential and desirable drugs in consultation with the
Therapeutic committee.

Sometimes a drug goes out of stock due to unforeseen reason or a drug that is not on the standard list of
hospital has to be purchased. Such purchase is called emergency purchase. Head of institution should have a
financial power up to certain limit for this type of purchases.
A standard list of drugs should always be prepared and only the listed drugs should be made available. The
drugs listed should be by generic names and not trade names. 2-3 alternatives of every drug should be
available. All the strengths should be available. Drugs for pediatric use should receive special attention
towards their strengths. The drug list should cover wide range of options and latest drugs should be included.
Receipt and Inspection
The material should be received at a designated place by a designated person. The quantity, strength, packing,
expiry date should be verified and material received. Entries of the material received should be taken in a
register and signed by receiving and inspecting authority. Then the material be handed over to pharmacists.
The Pharmacist classifies the material according to VED lists storage condition and schedules of drugs and
hands them over to Pharmacist of the relevant sections. These Pharmacists take entry of the stocks received
on the Bin cards and arrange the drugs on the shelf.
The newly received stock is kept behind the old stock, so that the principle of First in First out (FIFO) is followed.
Occasionally the drugs newly received may have expiry date earlier than old stocks in such cases the drugs are
stored in front of the old stocks so as to obey the principle of Last in Last out (LIFO).
Arrangement of drugs on shelves can be in alphabetical manner or in pharmacological order. The alphabetical
arrangement makes it easy to locate the drug. While the Pharmacological order is one where providing
substitute becomes easy. Some demarcation should be made between the regular stock and buffer stock and
reserve stocks so that when the regular stock is exhausted or is about to exhaust, it is noticed by the
pharmacist and he can initiate the procurement procedure.
The expiry dates of a batch of drugs should also be notified in bold letters so that the stock clearance action
can be initiated well in advance to prevent the crossing of expiry date.
The BIN card carries all this information and also the account of drugs on day to day basis. BIN card is not a
substitute to the stock registers. These cards are displayed on the shelf where drugs are stored.
Stock Clearance For Nearer Expiry Drugs
The expiry date of drugs in printed on the strip, vial, ampule or bottle. If a drug is not being used as per
expectations, stock gets piled up and nears the expiry date. The cognizance of expiry date should be taken 3 -
4 months prior to the date of expiry and a circular notifying this to the clinicians should be sent requesting
them to prescribe the drug and help to utilize, the stock before expiry, however despite of all efforts, some
quantity of drugs may cross the expiry date. Such stocks should be removed from circulation and kept
separately. They should be written off by competent authority.
Drugs declared substandard by Food and Drugs Administration should be withdrawn from circulation and also
from all wards and other sections. They should be sealed in a container and kept aside. They should be written
off by competent authority.
Indenting Procedure
We have already discussed the distribution system. Intending of medicines is done by the wards and other
sections of hospital. It is done in prescribed formats designed by hospital. The nurse in charge prepares the
indent. The medical officer in charge of the ward checks and signs it. Then it is sent to the chief Pharmacist
who checks it and makes changes depending on the stock position. He can also decide about substitutes. The
indent then goes to the stock section where pharmacist of every section delivers the material from his section
and takes a note of this on the BIN card and the register. The material from every section is collected in crates
which are labeled with name of the ward and indent number. The crate is kept at the delivery counter which
delivers the contents to the authorized person of the indenting ward and obtains signature as a token of
receipt.
For the medical stores of large hospitals, it may not be possible to serve the indents on one single day to every
section. However if the unit dose system of distribution is followed it has to be done. To save time, every ward
is given specific time for submitting the indent and collecting the drugs.

12.13 MEDICATION INCIDENT AND DISCREPANCY REPORTING PROGRAM

The quality management program must include a Medication Incident and Discrepancy Reporting Program to
ensure medications are ordered, prepared and dispensed according to established procedures and provided
to the patient in an accurate, safe and timely manner.
All medication incident and discrepancies throughout the facility shall be recorded, reported and examined,
and written policies and procedures to report, document, analyze, and follow-up on medication incidents
and/or discrepancies shall be developed. Monitoring medication incidents and discrepancies is a management
responsibility and shall be jointly managed by hospital administration, pharmacy, nursing, medicine, and other
 disciplines as appropriate. The Pharmacy and Therapeutics Committee or a multidisciplinary committee
accountable to the hospital and/or Pharmacy and Therapeutics Committee shall be established to develop,
implement and provide ongoing review of the medication incidents/discrepancy reporting program.
The purpose of the committee shall be to provide an ongoing assessment of medication incidents and
discrepancies in prescribing, dispensing or administration of medication. The resulting information shall be
communicated to all pharmacy staff and used as an educational tool with the ultimate objective of enhanced
accuracy and patient safety. Upon discovery of a medication incident or discrepancy, the following shall be
notified, as soon as possible to head/charge nurse, attending physician, pharmacy manager and other
disciplines, as appropriate. The appropriate party shall take immediate corrective action.

MEDICATION ERRORS
PROCEDURE FOR HANDLING MEDICATION INCIDENTS

Medication
PATIENT Error
Patient
AWARE
Unaware

Pharmacist Pharmacist
Takes charge Takes
charge

Patient ingested Patient not

Evaluate ingested
The Patient

Non-Emergency Rectify
Emergency Reassure
Rectify and
Reassure the The patient

Notify prescriber

Direct To Hospital
 Document
System evaluation
Quality Assurance
Root Cause Analysis

MEDICATION INCIDENT/DISCREPANCY REPORT SAMPLE

ABC HOSPITAL
PATIENT INFORMATION ERROR INFORMATION

Patient Name: Discrepancy: Error discovered

prior to administration
Unit/Ward/Room/Bed: Incident: Error discovered
following administration
Physician: Date(s) of Occurrence: Time(s):
Patient’s Age :
Patient’s Age: Date of Discovered:
Time
Sex: Date Report Completed:
Physician’s Order:

SECTION I - TO BE COMPLETED BY PERSON DISCOVERING INCIDENT/DISCREPANCY:

Nature of incident/discrepancy *Check One or More Error Types

Incorrect Medication Incorrect Quantity Supplied

Incorrect Dose/Strength Incorrect Brand Supplied
Incorrect Dosage Form Expired/Outdated Medication
Incorrect Patient Name on Label Incorrect Route/Site
Incorrect Dosage/Directions on Label Incorrect I.V. Solution
Incorrect Dosage Preparation Incorrect Rate of Administration
Dose Omission/Unavailable Incorrect Administration Technique
Extra Dose Given Incorrect Narcotic Count
Unordered Medication Drug/Drug Interaction

Incorrect Time/Day Given Incorrect Time/Day Given

Incorrect Patient Received Medication Other (specify):

SECTION II - TO BE COMPLETED BY PHARMACIST INVOLVED IN THE INCIDENT/DISCREPANCY:

Possible Contributing Factors to Incident/Discrepancy *Check one or more

Medication Order Information Order Processing Related

Illegible Handwriting Failure to Note Order

Ambiguous/Incomplete Order Wrong or No Addressograph

Error in Recording Verbal Order Error in Transcription
Error in Writing Medication in Chart Failure or Delay in Sending to Pharmacy
Medication Written in Wrong Chart
Medication Preparation Related Medication Administration Related
Order/Label Misread Improper Patient Identification
 Calculation Error Delay or Failure to Record
Administration
Failure to Clarify Substitution Medication Left at Bedside
Failure to Check Expiry Date Medication Ticket System
Medication Not Received on Medication Misplaced on Unit/Ward
Unit/Ward
Incorrectly Removed from After Hours Malfunctioning Equipment
Cabinet
Pharmacy Unnecessarily Accessed Inadequate Monitoring of IV Rate /
Chart Not Checked if Previously
Given
Environment Related Miscellaneous
Shift Change Sound Alike/Look Alike Drug Names
Assignment Conflict Look Alike Drug Products
Interruptions Trade/Generic Name
Distraction Name
Short Staffed Patient Off Unit

SECTION III - SECTION TO BE COMPLETED BY PERSON INVESTIGATING ERROR:

Medication Incident Risk Index

Classification of Type of Route of Classification of

event Incident/Discrepancy Administration Drug
Incident 5 Omission 2 I.V. 4 Specify points
Discrepancy 0 Incorrect dose 2 IM/SC 3
Wrong patient 5 PO 2
Extra dose 2 Inhaler 2
Incorrect Drug 5 Eye drop 2
Incorrect time 1 Other 1
Incorrect route 2
Allergy 3
Others 1

Classification of Drugs/I.V. Solutions

Antacid 1 Antiemetic 2 Anti-infective 3 Anticoagulant 4 Antineoplastic 6
Ant diarrheal 1 Antidepressant 2 Anticonvulsant 3 Thrombolytic 4 TPN 6
Laxative 1 Anxiolytic 2 Diuretic 3 Bronchodilator 4 Insulin 6
Unmediated IV 1 Antihistamine 2 Narcotic Analgesic 3 Cardiovascular 4
Expectorant 1 NSAID 2 Oral Hypoglycemic 3
Antitussive 1 Hormone 2 Steroid 3

Acetaminophen 1 Eye/Ear Nose 3 Muscle Relaxant 2

Vitamin 1 Sedative 2 Ant parkinsonism 2
Electrolyte 2
Misc. 1

SECTION IV - TO BE COMPLETED BY PHYSICIAN

Physician’s Report *For Incidents Only
Physician’s Report *For Incidents Only
Severity Assessment
0 No effect
1 Minor Transient
2 Minor Permanent
3 Major Potential
4 Major Transient
5 Major Permanent

SECTION V - NOTIFICATION SIGNATURES *WHERE APPLICABLE

Incident Discovered By:
Incident Reported By:
Pharmacist Involved:
Technician Involved:
Pharmacy Director:
Nurse Involved:
Head/Charge Nurse:
Director of Nursing:
Physician:
QA Coordinator:

12.14 SECURITY

The hospital pharmacy shall ensure:

• Secure drug storage satisfactory to the Therapeutic Products Programed.

• Access to the pharmacy is restricted to authorized personnel only.
• All premises are secured with locks and alarms to detect unauthorized entry after pharmacy hours.

• Procedures are developed and known in the event the pharmacy alarm is triggered.
• Strict control is placed on the number of keys available to access drug storage sites.
• Strict control is placed on the number of individuals having knowledge of the safe combination(s)

• Pharmacy maintenance and cleaning is completed during regular pharmacy hours when pharmacy staff
is on duty.

• Pharmacy stock shipments arriving at the hospital after pharmacy hours are stored in a secure area until
such time as a pharmacist is on duty.

The pharmacy, satellites and other drug storage areas should be locked at all times to prevent unauthorized
access for the safety and security of medication and pharmacy staff. Doors to the pharmacy and satellites
should be closed when occupied during regular pharmacy hours and must be locked when unoccupied. The
use of a wicket, window or half door to provide limited access to hospital staff may be a consideration. When
the pharmacist is on duty within the institution, but not necessarily in the pharmacy, or just prior to the arrival
of the pharmacist in the morning, technical staff may be left unsupervised for short periods of time. The
pharmacist however, must be readily accessible. The pharmacy manager is responsible for implementing
policies and procedures for the non-professional functions which may be performed by pharmacy technicians
in the pharmacist’s absence.
DRUG STORAGE SITE AUDIT
ABC PHARMACY
LOCATION DATE:
PHARMACIST/TECHNICIAN: TIME:

1. SECURITY Yes/no
a) Is medication storage site locked?
B) If not, is the medication cupboard/cart kept locked?
c) Are keys carried by registered/license nurse?

2. MEDICATION STORAGE
a) Medication storage site neat and clean.
b) Contents of cupboards/drawers organized.
c) Contents of the cupboards/drawers properly separated.
(i.e. internals from externals, patient’s own medications)
d) Medication containers and cards properly labeled, neat & clean, not worn or
illegible
e) Labels firmly affixed to containers.
f) There is no evidence of handwriting on labels.
g) Ward Stock medications accurately labeled with log number (control no.) and
Expiry date Where applicable.
I) Ward Stock rotated to ensure oldest stock is used first.
I) The ward Stock drug list with minimum/maximum quantities posted.
j) The quota of ward stock reasonable.
k) Medications within expiry date.
l) Reconstituted drugs properly labeled, dated, and stored.
m) Multi-dose vials dated upon first opening and not used past 3 months.
(Including Salbutamol, Normal Saline, Insulin, eye/ear preparation, etc.)
n) Bottles of liquid clean and free from spills.
o) Deteriorated and discontinued medications removed and returned to the
Pharmacy
p) Emergency and After-Hours Cabinet medications checked and in date.

3. REFRIGERATOR

a) Drugs requiring refrigeration properly stored.

b) Medications are within expiry date.
c) Refrigerator clean and well organized.
d) Food and other non-pharmaceuticals stored separately from medication.
e) Refrigerator clean, free from excess frost, and between 2 and 8 ℃.

4. NARCOTIC AND CONTROLLED SUBSTANCES

a) Narcotic key carried by a registered/licensed nurse.

b) Narcotic cabinet/drawer locked.
c) Narcotic and Controlled Substances accurately accounted for.
d) Quota of narcotic and controlled drugs reasonable.

5. LIBRARY

The following are readily available on the unit:

a) Hospital Formulary
 b) IV manual
c) CPS
Feb/013 Major Potential
4 Major Transient
5 Major Permanent

12.15 NARCOTIC AND CONTROLLED DRUGS

Narcotic and controlled drugs shall be stored in a secure manner throughout the hospital. Access to all
narcotic storage areas shall be kept to a minimum and restricted to authorized personnel only.

Keys and safe combinations shall be strictly controlled.

Narcotic and controlled drugs stored in medication carts shall be in a locked drawer. The count book shall be
stored out of sight when not in use, so as not to advertise narcotics are stored within. The entire medication
cart should be locked whenever a nurse is not in direct attendance and when not in use, should be locked to
the wall or inside a locked medication room. Narcotics and controlled drugs stored in the medication room
shall be in a locked cabinet, safe or drawer. The keys to medication room and narcotic storage site must be
kept secure at all times, generally transferred directly from one charge nurse to another at shift end. Keys to
the narcotic cabinet shall never be left unattended.
Narcotic and Controlled Drug Perpetual Inventory Records shall be maintained for all narcotic and controlled
drug orders. Targeted substances, subject to abuse, should also be monitored on the running inventory.
Completed inventory records shall be returned to the pharmacy forthwith. Breakage, wastage, discontinued
or outdated Narcotic, Controlled and Targeted Substances,
Other than unserviceable injectable, shall be returned to the pharmacy for destruction where a pharmacist or
supervised hospital employee will destroy the drugs in the presence of a second health care professional.
Inventory records shall be maintained of all drugs returned for disposal, signed and where possible, co-signed
by a second health care professional. For these purposes a health care professional is defined as the person in
charge of the hospital, a pharmacist, practitioner, nurse, pharmacy intern, certified pharmacy technician or an
inspector with the Manitoba Pharmaceutical Association.
Breakage, wastage of unserviceable injectable Narcotic, Controlled and Targeted Substances, such as partial
ampoules shall be destroyed by a health care professional. Inventory records shall be maintained of all drugs
destroyed, signed and where possible, co-signed by a second healthcare professional. Physical counts of
Narcotic and Controlled substances on the wards shall be performed and documented on the perpetual
inventory record not less than once a week. The count shall be signed by the person conducting the count and,
where possible, co-signed by another health care professional. Physical counts of Narcotic and Controlled
substances in the pharmacy shall be performed and documented on the perpetual inventory record quarterly.
The count shall be signed by the person conducting the count and, where possible, countersigned by another
health care professional.
Should discrepancies be identified during inventory counts, steps shall be initiated to identify the cause of the
shortage, the responsible staff person and corrective actions documented. An incident report shall be
completed and kept on record at the pharmacy. Significant shortages or diversion incidents must be reported
to the pharmacy manager, Pharmacy shall ensure procedures are in place for Narcotic and Controlled
substances to be delivered to the ward with the least amount of delay, safely, promptly, intact and placed in
the proper storage area upon arrival to the patient care area and receipt thereof signed for by a registered
nurse.

Alcoholic Substance Control

Policies and procedures shall be established regarding the use, control, distribution and storage of alcoholic
substances for compounding and dispensing within the institution. Policies with respect to the beverage
alcohol need not preclude patients from bringing in their own supply, but must state:
• written orders must be received from the physician prior to administration to the patient
• the information is placed on the patient’s medication profile, pharmacy must obtain a special
Manitoba Liquor Control Commission permit for alcohol
• Purchased by the hospital for patients, patient’s own alcohol is to be returned to the patient upon
discharge or sent to the pharmacy for disposal.
Drug Disposal
Hospital pharmacy departments shall take responsibility, through policies and procedures, for
Environmental practices by efficiently managing the disposal of wastes in the pharmacy area.
Handling and disposal procedures relating to pharmaceuticals shall be the responsibility of the
Director of pharmacy or a designate.
Every attempt shall be made to minimize the amount of pharmaceutical waste generated. Pharmacists should
investigate municipal and provincial legislation regarding disposal in sewers and landfills. All non-useable and
expired medications shall be disposed of in accordance with professional standards and legal requirements.
Disposal of small amounts of unused pharmaceuticals or excreted pharmaceuticals and their metabolites into
the sewer system should not present a hazard. However, the sewer system shall not be excessively or
indiscriminately used, as it may result in contamination of the water supply and disruption of the sewer
processes.
Secure chemical landfills may be used to dispose of pharmaceuticals although this is the least
Desirable method of disposal. Pharmaceuticals shall be disposed of in such a manner to render them unusable.
Disposal of Narcotics, Controlled and Targeted Substances shall be in accordance with legislation. Destruction
shall be conducted by two health care professionals under the supervision of a pharmacist. For these purposes
a health care professional is defined as the person in charge of the hospital

12.16 PRECAUTIONS TO PREVENT PILFERAGE AND THEFTS

• Secured premises
• Access restrictions
• proper receiving mechanism
• proper storage system
 • proper issue procedure
• checking of receipts and issues at least by three different persons
• Proper receipts
• Printing / stamping name of hospital on labels of ampules, vials, bottles etc.
• No trade names, only generic names of drugs
• Dealing with authorized persons only
• Frequent regular and surprise checking of the stocks through in house staff, administrative authorities
drugs committee members

• Strict deterrent actions against erring persons

• Frequent verification of stocks in every sections of hospital
• Verification from patients case paper – Prescription dosage duration
• Cross checking from the patient about being given particular tables, number of injections etc.

• Checking empty vials, ampules, tablet strips, syringes, needles, infusion sets etc.

12.17 QUALITY MANAGEMENT / IMPROVEMENT PROCESS

The pharmacy service shall have or be part of, an ongoing quality management/improvement programs
including, continuous quality improvement, risk management and utilization reviews appropriate for the level
of pharmacy services provided. The programs shall monitor pharmacy personnel, performance, equipment,
facilities, services and patient care.

The quality management program should include but not be limited to the following:

• Documentation of Periodic Audits of The Medication Distribution Process

• Appropriateness and Consequence of Patient-Oriented Recommendations
• Review Process of Indication, Content, Format and Appropriateness of Individual Pharmacy
Documentation.
• Notes in The Patient’s Health Record
• Evaluation Process of Medication Use Relative to Predetermined Criteria, To Correct Inappropriate
Medication Use and Assess Follow-Up.
The pharmacy service should implement or be part of a continuous quality improvement (CQI) process to
evaluate the quality of pharmacy services provided to the patient.
Documentation supporting this process should include, but not be limited to:
• identification of pharmacy department’s customer
• evaluation by those customers of pharmacy services
• staff training, specific to CQI
• staff involvement in the processes, and
• Feedback to staff and appropriate customers.
Documentation supporting the CQI process also should include, but not be limited to:
• Identification Of Problem Or Area For Improvement
• Identification Of Customers Relevant To The Problem
• Implementation Of Quality Improvement Teams With Staff And Cross-Functional Representation
 • Application Of Relevant Tools And Techniques (E.G. Flow Charts)
• Data Collection And Analysis
• Identification Of Key Measurements
• Identification Of Target Levels
• Analysis Of Gaps In Performance
• Actions Necessary To Improve Performance Or The Process, And
• Implementation and Evaluation Plan.

12.18 SUMMARY

Pharmacy can be defined as the licensed premises run and operated by licensed persons for compounding
drugs and their supply to the patients as per prescriptions from doctors.
Pharmacy council of India was founded in 1949 on recommendations of Copra committee (1921) and Bhore
committee (1946). Licensing the premises was made compulsory. The qualification for pharmacists was
decided to be a Diploma in Pharmacy. The Indian pharmacy Act was passed in 1948 amended in 1959 and
1976. The act is related to regulation of practice of pharmacy and the qualification of pharmacists. The Drugs
and Cosmetics Rules (1940), National Formulary 1960 also contain directives for functioning and control of
pharmacy. The control at state level is with food and drugs control administration.

12.19 KEY WORDS

Adverse Drug Reaction - An undesirable, unintended response to a drug that occurs at doses normally used
for the diagnosis, treatment or prevention of a disease or the modification of an organic function. The reaction
provides neither therapeutic, prophylactic nor diagnostic benefit to the patient.
Controlled Dose System - A form of drug distribution, also known as a monitored dose system, in which
medication orders are filled individually and packaged in blister packs or dosage, in accordance with scheduled
administration times. Each package contains no less than a one-day and no more than 35 days supply of
medication.
Formulary -A dynamic compilation of medications, information, and related policies, approved for use within
the hospital that reflects the current clinical judgment of the medical and pharmacy staff.
Pharmacy and Therapeutics Committee - A committee composed of representatives from pharmacy,
medicine, nursing, administration, and other disciplines, which serves as a policy recommending body on all
matters relating to the use of medications in the hospital(s). In absence of a Pharmacy and Therapeutics
Committee in smaller hospitals, the Medical Advisory Committee may address these issues.
UNIT 13 AMBULATORY CARE SERVICES (ACS)

Objectives
After going through this unit, you will be able to:

1. Understand the concepts of ambulatory care services;

2. Know the importance of ambulatory care services;
3. Understand the various requirements of ambulatory care services.

Structure
13.1 Introduction
13.2 Ambulatory CARE Sensitive Conditions (ACSC)
13.3 Ambulatory Care Design Principles
13.4 HPMG’s Care Model of Ambulatory Care
13.5 Ambulatory Care Surgery
13.6 Requirements for Ambulatory Care Surgery
13.7 Physical Facility
13.8 Developing the Future Ambulatory Care Model
13.9 Summary
13.10 Key Words
13.1 INTRODUCTION
Rising cost of hospitalization, shortage of hospital beds and overutilization of operating theatre lead
to the concept of Ambulatory care. This is an innovative method of health care delivery by which
various modalities and specific types of investigations, treatment and surgeries are provided to
patients in a separate and well organizes unit without admitting the patient and discharging the
patient on the same day (within 24 hours).The Ambulatory Care Center has staffed this facility with
highly skilled personnel who have a complete understanding of the outpatient surgical setting
therefore offering our patients quality services through knowledge and efficiency. The staff at the
Ambulatory Care Center takes pride in accommodating specialists in a number of medical and surgical
specialties.
The Increasing Focus on Ambulatory Care Services (ACS)
Ambulatory Surgery Centers—known as ASCs—are modern health care facilities focused on providing
same-day surgical care, including diagnostic and preventive procedures. ASCs treat only patients who
have already seen a health care provider and selected surgery as the appropriate treatment for their
condition.

ASCs have transformed the outpatient experience for millions by providing them with a more
convenient alternative to hospital-based outpatient procedures—and done so with a strong track
record of quality care and positive patient outcomes.
What ASCs Are Not
ASCs are not rural health clinics, urgent care centers or ambulatory care centers that provide
diagnostic or primary health care services. ASCs are not physicians' offices either. All ASCs must have
at least one dedicated operating room and the equipment needed to perform surgery safely and
ensure quality patient care.
Managing ambulatory care has become critically important from numerous perspectives, including
the financing and delivery of comprehensive, coordinated patient care. In more advanced managed
care markets, successful ambulatory operations are essential to effective patient care and population
health management. Outpatient care continues to expand as increasing numbers of procedures and
treatments transition to the ambulatory setting. For these and other reasons, improving ambulatory
performance has become a top strategic priority for health systems nationwide.

13.2 AMBULATORY ACRE SENSITIVE CONDITIONS (ACSC)

ACSCs are defined as “conditions for which good outpatient care can potentially prevent the need for
hospitalization, or for which early intervention can prevent complications or more severe disease.”
The Agency for Healthcare Research and Quality (AHRQ) has defined a list of 16 ACSCs which apply to
the span of age ranges. AHRQ recommends that these 16 measures be used on the population level
by public health groups to compare quality and access to care across communities and states:
 Short and long-term diabetes complications
 Uncontrolled diabetes
 Lower extremity amputation among diabetic patients
 Perforated appendix
 Pediatric asthma
 Adult asthma
 Chronic obstructive pulmonary disease
 Pediatric gastroenteritis
 Hypertension
 Angina without procedure
 Congestive heart failure
 Low birth weight
 Dehydration
 Bacterial pneumonia
 Urinary tract infection

Common Conditions Dealt In Ambulatory Care Centers

 Arthroscopic Surgery
 Cardiology
 Gastroenterology and Endoscopy
 General Surgery
 Gynecology
 Laparoscopic Surgery
 Ophthalmology
 Oral and Maxillofacial Surgery
 Orthopedics
 Pain Management
 Pediatric Dentistry
  Podiatry
 Pulmonology
 Urology
 Vascular Surgery

13.3 AMBULATORY CARE DESIGN PRINCIPLES

A successful ambulatory care operating model must be founded on the following design principles
to ensure success:
Culture & Alignment: Leadership must set a direction for ambulatory operations by aligning around
the expectation that the organization achieve excellence across all three aims: health, experience, and
total cost. Leadership must explicitly signal their intention to transform care delivery, and their belief
that achieving all three aims is desirable and possible.
Reliability: Key processes must systematically and consistently deliver the best care. This often
requires some level of standardization to an identified best practice, minimizing variability resulting
from individual provider preference.
Customization: Once a process has been standardized to support reliability, care is then tailored to
individual patient needs and values. Customization is not at the whim of the practice or individual
provider, but rather dictated by what the patient requires.
Access: Access to care and information is the foundation of care delivery. Design must ensure
streamlined access to care, as well as to the information and knowledge needed by patients and
referring providers to understand and participate in decision-making to achieve healthier lifestyles.
Coordination: As ambulatory care becomes more complex and organizations seek to move
patients to the most cost-efficient care setting possible, effective and efficient mechanisms to
coordinate care across sites, specialties, conditions and time are required.
Practice Team Development: Design and execution of the new care delivery processes depends
on a high functioning practice team. To succeed in the future, practices will need to reassess
staffing complements in light of new care requirements and then ensure all members work to the top
of their licensure. Defining the right mix of care providers – physicians, associate providers, RNs, LPNs
and medical assistants – to provide the right care, is an essential ingredient to ensuring that care is
accessible and affordable. As ambulatory networks become large and complex, a strong, well defined
practice team can innovate to continually improve processes and roles, leading to improved
performance.
Harnessing Information and Data: Although many organizations have mastered measurement of
some core operational processes, such as revenue management and productivity, most have not
evolved systems of measurement to include a closer scrutiny of experience and health outcomes,
access to care and cost across the continuum or episode of care. Building capabilities and harnessing
systems to inform care delivery (for example, to understand what the next care intervention should
be),and understanding performance across all three components of health, experience cost, will
become increasingly important as health care systems evolve to manage patients across the
continuum of care and respond to payers’ increasing interest in outcomes and care settings.
Provider Capacity and Utilization Management: More than ever before, it is important to optimize
the use of provider and facility resources. After defining the optimal staffing complement, practices
will need to translate the clinical commitments of their providers into effective schedules that are
coordinated across the practice and sites, and which optimize facility use. Organizations will need to
create more sophisticated and proactive methods for managing provider capacity and utilization to
ensure optimal performance.
Incentives: As organizations evolve their operating models to meet future ambulatory care
requirements and strive towards optimal results, they inevitably will need to revisit how they are
incenting their staff, particularly physicians. As described before, many aspects of the operating model
will need to change, requiring individual behavior to change as well. For employed physicians, the
compensation model must be realigned with the new organizational objectives, must be affordable,
and must instill greater individual discipline and accountability. For non-employed physicians,
organizations will need to push aggressively towards clinical integration, to support alignment and
achievement of common interests. As organizations embark on their own ambulatory care design
initiatives, these comprehensive operating model components can serve as building blocks for each
organization to establish sustainable ambulatory performance improvement. As the ambulatory care
landscape continues to transform, providers will need to successfully position themselves by putting
into place new operating models designed to support increasingly higher levels of performance.
Achieving simultaneous results in health, patient experience and cost in the ambulatory setting is not
only doable, it is imperative, as overall health system success will be increasingly linked to
ambulatory care success.

13.4 HPMG’S CARE MODEL OF AMBULATORY CARE

HealthPartners Medical Group (HPMG) in Minneapolis introduced an innovative program that

successfully integrates care delivery while simultaneously improving health, experience and cost. Over
time, HPMG has applied this innovative approach to its entire patient population of people, spanning
multiple payers and conditions and has achieved significant system-wide improvements in service,
outcomes and costs.
With a motto of “Health is what we do. Partnership is how we do it,” HPMG’s model fosters
collaboration with its patients, referring providers, and its internal teams. Starting with Ed Wagner’s
 Chronic Care Model, HPMG’s Care Model Process which evolved from an initial concept HPMG called
‘The Planned Care Model.’ This models centered on creating continuous healing relationships through
the partnership of the prepared practice team, the informed, activated patient, and the availability of
health information (see Figure *). Early initiatives focused on patient access, operations improvement
and practice team role definition. In addition, a system-wide EHR was implemented enabling health
information availability across providers and sites of care. Ultimately, the overarching framework of
the newly developed Care Model Process which brought together all previous initiatives and
components to optimize ambulatory care design.
The HPMG model transforms the traditional office visit into a broader relationship with the patient
that extends beyond the visit (see Figure "). From the outset of the design process, it set goals for the
overall design including:
 Be transferable across all conditions;

 Increase provider efficiency;

 Have the right person doing the right work;

 Reduce variation in all work, flows;

 Support the patient-provider relationship;

 Align accountabilities;

 Most significantly , utilize no incremental resource

INFORMED CONTINUOUS PREPARED

ACTIVATED HEALING PRACTICE
PATIENT RELATIONSHIP TEAM

HEALTH
INFORMATION
AVAILABILITY
Once the steps in the overall visit cycle were identified, modules were developed for each segment of
the process. The modules were designed by physician-led, cross-functional teams which included
nurses, operations and clerical staff, patients and other providers as needed (e.g. dieticians,
pharmacists, and patient educators). The tasks within each segment were identified, optimized for
efficiency, and assigned to a specific staff or provider role. HPMG began the design process with the
“during the visit” stage, as it was easiest to engage patients when they were physically in the clinics,
had the fastest time-to-implementation of the design changes, and allowed design team members to
witness immediate results, helping to inform the design processes.
Before Visit Activities
In this module, patient care is a continuous focus, even during administrative tasks, such as
appointment scheduling. Utilizing a centralized appointment center, clinic schedulers use standard
processes and protocols. Regardless of the primary care discipline or physician with whom the patient
is seeking an appointment, the scheduler reviews health maintenance care needs with the patient and
offers scheduling of any additional services, in addition to scheduling the originally requested
appointment. Once the visit is scheduled, the patient is contacted in advance of the visit to verify the
required patient information and arrange for any pre-visit requirements, such as forms to complete
or lab tests to be performed, to ensure an efficient clinic encounter.

VISIT SCHEDULING
Appointment scheduling
› Identification of additional care
needs
› Accurate data capture
› Informed patient
re: visit preparation

BEFORE
VISIT
ACTIVITIES
PREVISIT PLANNINGS
Health maintenance needs
› Lab screening
› Medication refill system
› Data system maintenance
› Patient education
identified & planned
 During The Visit Activities
Upon arrival at any of HPMG’s "' primary care and numerous specialty clinics, patients are greeted in
a welcoming, yet scripted manner. All patients consistently proceed through a standardized check-in
process that includes verification of insurance and demographic information and collection of co-
payments. The physician’s (or other provider’s) on-time status is communicated to the patient, and

CHECK IN
Any outstanding vital patient Minimized rooming tasks
information gathered
› Review of health
› Updates on providers on- maintenance needs
time status › Medication refill
DURING
› Communications with › Visit summary offered to
THE VISIT
patients patient ACTIVITIES
› Minimized rooming › Follow-up appointment
scheduling

the patient is offered several options if the provider is running behind. Regardless of the reason for
the patient’s visit, general health maintenance needs are reviewed with the patient to provide ongoing
management of periodic health needs (e.g. medication refills), chronic care conditions, and/or
required immunizations and the like. At the conclusion of the visit, patients are provided with after-
visit summaries, and future appointments are scheduled before the patient leaves the clinic.

After visit
Perhaps the most significant contributor to this ambulatory care model success is consistent and
standardized management of the intervals following visits and between visits. Patients receive timely
notification of every test result by their preferred method of contact – mail, phone call, or electronic
message. This aspect of the model keeps patients informed and engaged in their own care and
increases patient compliance and satisfaction. Patients feel “really cares about me,” due to the follow
up calls and information provided. It should have between visit protocols for diabetes, CHF,
depression, mammography, colorectal screening and other preventative services, tobacco cessation,
pediatric immunizations, child and teen well visits, and pediatric asthma.
13.5 AMBULATORY CARE SURGERY

The earliest reference for day care surgery is mentioned as early as beginning of the 19th Century by
James Nicole a Glasgow surgeon who performed almost 9000 outpatient operations on children in
19031 and later in 1912 when Ralphwaters from Iowa, USA described “The Down Town Anesthesia
Clinic”, where he gave anesthesia for minor outpatient surgery.2 However, over the next two decades,
it lost its momentum. In 1960, the first hospital based ambulatory unit was developed. The formal
development of ambulatory anesthesia occurred with the establishment of the ‘Society for
Ambulatory Anesthesia’ (SAMBA) in 19843 and with the evolution of postgraduate subspecialty
training programme. The potential for day care surgery has increased over the last few years. Success
of day care surgery can be attributed to advances in surgical technologies and in the field of
anesthesiology. Advances in surgical technologies that made outpatient surgery and minimally
invasive surgery possible include various endoscopic procedures i.e. Laparoscopy, arthroscopy, laser
and shock wave lithotripsy, laparoscopic cholecystectomy, vaginal hysterectomy, thyroidectomy,
shoulder, knee and ankle repair. Apart from cost containment, other benefits of out patient’s surgery
are: decompression of busy hospital beds, less nosocomial infections and early recovery in home
environment with the family. Thus, there is less disruption of personal lives.

However, in a country like ours, with problems of financial constraints, insufficient grants for health
care, lack of adequate money for improvisation of theatres and recovery rooms, and social factors, we
are not able to cash on all the advantages of day care surgery in our hospitals.

Benefits

Cost containment

In USA a saving of 15-30% and in UK a saving of 40% in the cost has been reported with the day care
surgery. The expenditure incurred by the civic authorities in India on a patient occupying a bed is
around Rs.800-900/- per day.4 this does not take into account the drugs, medication and the
material used for surgery. The estimated expenditure in Postgraduate Institute of Medical Education
and Research, Chandigarh is Rs. 1000/- per bed per day.
 Decongestion of hospitals

 Decrease in morbidity
  Decrease in Hospital Acquired Infection

Types Setting For Ambulatory Care Surgery

The designs of a prototypical ambulatory surgical unit could be:

 Hospital integrated

 Hospital separated (but accessible to the hospital)

 Satellite ambulatory unit (which works under the same administration)

 Free standing unit (which is totally independent) and office based

The majority of outpatient surgeries are still being performed in a hospital setting, either in integrated
or separated units. Although 15-20% of all outpatient operations are being done as office based
surgeries in the USA5, however, because of largely unregulated setting, serious questions are being
asked about the safety of office-based surgeries. The decision as to where should the surgery be
performed depends upon the:
Levels of Ambulatory Surgery: The levels of ambulatory surgery is classified as follows:

a) Minor ambulatory surgery (under local anesthesia)

b) Major ambulatory surgery (under G.A., central neuroaxial block with or without I.V. sedation).

c) In-patient ambulatory surgery.

Because of the topographical variations, and the absence of strict laws and the quality control,
outpatient surgery in India is performed in chemist’s shops, private clinics, nursing homes, primary
health centers, civil hospitals, peripheral medical colleges as well as tertiary care centers. Extra
surveillance is required while screening patients for outpatient surgery.

Modalities of pre-anesthetic assessment are:

 Pre-anesthesia clinics
 Health questionnaire
 Telephonic interviews

Pre-anesthesia clinics: These clinics are useful to get the necessary consultations and laboratory tests
done and cut down the unnecessary delays and cancellations.
Health questionnaires: Standardized questionnaires are completed in surgeon’s office or with primary
care physician. The data is subsequently reviewed by the anesthesia staff prior to administration of
anesthesia.

Telephonic interviews: This is not feasible at the moment in our country.

13.6 REQUIREMENTS FOR AMBULATORY CARE SURGERY

Factors relevant for the success of day care surgery

Day care surgery demands the highest standards of professional skills and organization. Although, the
operations could be minor, an anesthetic is never minor. Listed below are some of the factors relevant
for the success of day care surgery.
 Patient selection
 Patient information
 Preoperative assessment / tests.
 Proper anesthetic and postanaesthetic care
 Patient acceptability
 Audit
Patient Selection
This is the key to the successful day care surgery. Selection is not simply a matter of choosing patients
with conditions that may be treated on a day care basis, but also involves shifting out those patients
who are unsuitable for medical and social reasons. The current exclusion criteria for patient selection
are shown in Table 1. There are some controversial exclusion criteria also
Exclusion Criteria for Outpatient Surgery.
Medical
 Unfit ASA IV, ASA III
 Obese : Body mass index > 35
 Nature of pathology: Large scrotal hernias, major intrathoracic, intraabdominal or intracranial
surgery
 Procedures requiring more than one hour
 Surgery expected to have major fluid or blood loss.
Patient
 Concept of day care surgery unacceptable to the patient.
 Psychologically unstable
 If patient lives far away from the hospital
  Infants <3 months of age and preterm babies

Social: No competent relative or friend to

 Accompany or drive patient home after operation
 Look after him or her at home for the next 24-48 hrs.

Controversial exclusion criteria

 Morbid obesity
 Significant sleep apnoea
 Fragile diabetes
 COPD
 Severe asthma
 Significant epilepsy
 Patients prone to malignant hyperpyrexia
 Alcohol

Patient Information
Comprehensive and well-presented information using lay terminologies for patients and their
relatives is essential for the success of day surgery. Day Care patients, unlike in-patients, do not have
ready access preoperatively and postoperatively to health care professionals to answer their
questions and deal with their queries. As suggested by Baskerville et al, 7 the information given to
patients should commence with a brief description of the condition for which they are being treated
and the procedure being undertaken. This is followed by instructions regarding what patients must do
before coming to the unit, the postoperative analgesic regimen, what they should do at home, and
what is expected in the days following their operation. Finally, patients need advice on when they can
return to various activities. Perhaps the utmost information that must be given to the patients is
related to the problems that might arise at home following surgery and how to deal with those. This
will include advice on self-medication and when to seek professional help.

Preoperative Assessment / tests

An asymptomatic low risk patient does not need a battery of screening tests unless the medical history
or the physical examination suggests otherwise. In pediatrics, routine hemoglobin (Hb) evaluation and
urine examination are done. In adults above 40 years, in addition to Hb and urine, ECG is also required.
In older patients (patients >50 years, chest X-ray and serum glucose are also advised. The preoperative
assessment should be detailed and similar to in-patients.

Post Anesthetic Care

Several recent innovative facilities for post-anesthesia care after outpatient surgery have allowed
surgeons to do more complicated surgeries on sicker patients as outpatient procedures and have
made outpatient anesthesia less risky.

In an overnight stay unit (23-hour admission unit):-post-surgery patients are observed overnight but
discharged the next morning, within 23 hours of surgery. This course overcomes the arbitrary limit to
quality for reimbursement as an outpatient procedure.

Free standing recovery units / surgical hospitals are new concepts. These are private entrepreneurial
units for those patients who prefer not to go home soon after surgery. More recently, the concept of
surgical hospital has replaced the Free Standing Recovery Units. These surgical hospitals have beds for
postoperative recovery for a few days.

Hospital hotels and home health care are other options not available in India at the moment. However,
most of the above mentioned facilities are not currently available in India. After the operation, vital
signs are monitored till the patients are ready to be discharged. A detailed discharge slip is given,
including the details of the procedure / postoperative analgesia, when to remove sutures and on
follow up appointment.

Patient acceptability
Methods of gauging the acceptability of day care surgery in patients is to look for a number of
Unsolicited complaints, incidence of readmission after patients have returned home, and
postoperative complication rates.

Audit
As in other areas of practice, audit is essential to maintain and improve standards. Each unit should
audit its own complication rates and patients opinion to determine the relevance of regional or
general anesthesia.
WORK FLOW PROCESS FOR AMBULATORY CARE SURGERY (ACS)

PATIENT COMES TO
AMBULATORY
CARE SURGERY
CENTRE

INTERVIEW
INVESTIGATIO SCREENING PREANESTHET
NS EXAMINATION IC CHECK UP
CLINIC (PAC)

FIT FOR WARD

SURGERY
TAKEN TO
SURGERY

HOME

RECOVERY
ROOM
13.7 PHYSICAL FACILITY

The Following physical facilities are essential in an Ambulatory Care Surgery.

Facility Area in SQM
Reception/registration counter 15-20
Waiting area 25-30
Consulting rooms(2) 15 each
Sample collection area(room with documentation area 20
PAC 15
Staff change rooms(2-3) 10 each
Nurse’s room 10
Doctor’s lounge 15
Plaster room 20
Theatre sterile supply room 20
Clean utility room 10
Dirty utility room 10
Generator room 15 s
Pre-operative ward 40
Post op ward 40
Lab complex 10
USG room 15
Endoscopy room 22
X-ray/allied facility 15
Store room 15
Operating rooms and lay up room 28 each
Scrub up room 7
Medical records/administrative office 10
Sanitary facilities(separate for patients/relatives/staff 5.5 sq. Met. each(at least 2 for each)
Janitor’ close 5.5
Staff lounge 10

Post anesthesia care unit (PACU) bypass or fast tracking

PACU bypass, also called “fast-tracking” is another recent innovation in outpatient anesthesia. In the
normal set up the patients go from the waiting room to the operating room (OR) and then to the
PACU, and an hour or so later, when established clinical criteria are met, patients go to a step-down
recovery unit (Phase 2 PACU) before discharge. With the introduction of modern anesthetics and
depth of anesthesia monitoring, it is possible that many patients will actually meet the clinical criteria
in the OR itself and will be able to go directly to the step-down unit, bypassing the PACU, a high
intensity and high-cost.

13.8 DEVELOPING THE FUTURE AMBULATORY CARE MODEL

Each organization must establish both a design process and ambulatory care operating model that
aligns with its own strategic plan, clinical goals and priorities, as well as unique, market-specific factors.
That said, there are specific operating model components that are shared amongst successful
ambulatory care models:
Organization Structure and Clinical Operations Oversight: For many ambulatory networks, the
organizational structure and oversight function has not been fully developed. To transform care across
multiple, and often disparate entities, new attention must be given to how the entities relate to one
another and to how clinical operations are managed across the network. Overarching operational
authority must be established to support consistency around determining how and by whom key
clinical operating decisions will be made, including policies and procedures, standardization and
centralization.
Designation of Centralized versus Distributed Nature of Core Processes: In the evolution of an
ambulatory network, it is essential to determine which aspects of operations could be more effectively
managed centrally and which should remain within the purview of each practice. Key processes and
roles, such as scheduling and registration, performance measurement and reporting, and shared
services staffing, are often evaluated for centralization as organizations seek to benefit from
economies of scale and appropriate standardization. This type of targeted centralization can strongly
support an organization’s cost management strategy of delivering affordable care.
Care Delivery Process: The new operating model rests on a foundational set of core processes and
roles that come together to transform care delivery. The principles of standardization, reliability and
customization to the patient are essential in creating a new care delivery process that will meet patient
and referring physician needs.

13.9 SUMMARY
Day surgery is a cost-effective, quality approach to surgery that has expanded rapidly in recent years.
Multiple factors have contributed to this transition, including economic forces, improved anesthetic
and surgical techniques, better pre-operative planning, better patient education and an enhanced
ability to deliver adequate analgesia in the outpatient setting. The popularity of outpatient surgery
can be attributed to the development of preanaesthesia clinics, changed patterns of preoperative oral
intake, use of newer anesthetics, antiemetic and analgesics and better monitoring in preoperative
period.
At the moment there is lack of any standard practice and uniform policy. Outpatient surgery is being
carried out at chemist’s shops, private clinics, primary health centers, peripheral medical colleges and
also in tertiary hospital. The hospitalization concept of ’23 hours’ hospital stay with strong insurance
back up has not picked up in India. An ideal setting for day care surgery would be hospital based /
supported with well-equipped theatres, recovery rooms, post anesthesia care rooms and specially
trained staff. In addition, a strong social backup with satisfactory transport and telecommunications
system and recuperating hotels near the hospitals, social worker’s visit / follow up and audit is desired.
Regional anesthesia offers many advantages for the day care surgery patients. In general, peripheral
nerve blocks are under-used for ambulatory surgery. The success of day-care surgery depends, to a
large extent, on both effective control of postoperative pain and minimization of side-effects such as
sedation, nausea and vomiting. Inadequate analgesia after surgery is a problem. Side effects that
might be regarded as minor in the inpatients may contribute to unexpected admissions in the day-
care setting. Prolonged recovery may disrupt patient flow and increase institutional costs per patient.

13.10 KEY WORDS

Ambulatory Care: This is an innovative method of health care delivery by which various modalities
and specific types of investigations, treatment and surgeries are provided to patients in a separate
and well organizes unit without admitting the patient and discharging the patient on the same
day.(within 24 hours)

Ambulatory Surgery Centers—known as ASCs—are modern health care facilities focused on providing
same-day surgical care, including diagnostic and preventive procedures. ASCs treat only patients who
have already seen a health care provider and selected surgery as the appropriate treatment for their
condition

ACSCs are defined as “conditions for which good outpatient care can potentially prevent the need for
hospitalization, or for which early intervention can prevent complications or more severe disease.”
UNIT 14 OBSTETRICS CARE AND NEONATAL CARE SERVICES

Objectives
After going through this unit, you will be able to:

1. Understand the concepts of obstetrics unit;

2. Know the importance of obstetrics care services;
3. Understand the importance of neonatal care services;
4. Understand the various requirements of obstetrics and neonatal care services.

Structure

14.1 Introduction
14.2 Physical Facilities (Obstetrical Facilities)
14.3 Types
14.4 Physical Facilities
14.5 Infant Resuscitation/Stabilization Areas
14.6 NICU
14.7 Ambient, lighting in Infant Care Areas
14.8 Acoustic Environment
14.9 Summary
14.10 Key Words

14.1 INTRODUCTION

Prenatal care, observation and comfort of the patient in labour, delivery room assistance and the
nursing care of the newborn are important responsibilities of obstetrics department. The obstetrics
department must cater for all these requirements in a comprehensive manner.

14.2 PHYSICAL FACILITIES (OBSTETRICAL FACILITIES)

Location
The obstetrical unit should be located and designed to exclude non-related passage through the unit.
When delivery and operating rooms are in the same access and service arrangements should be such
that neither staff nor patients need to travel through one area to reach the other. It should always be
in the same level of the operative unit.

14.3 TYPES

There are three types of obstetric unit:

Traditional Model

Labor, delivery, recovery, and postpartum occur in separate areas. The woman is treated as the
moving part. She is moved through these functional areas depending on the status of the birth
process. The functional areas are separate rooms consisting of the labor room, delivery room,
recovery room, postpartum bedroom, and infant nurseries.

Labor-Delivery-Recovery Model

All labor delivery recovery rooms are designed to accommodate the delivery process from labor
through delivery and recovery of mother and baby. They are equipped to handle most complications,
with the exception of cesarean sections. The birthing woman moves only as a postpartum patient to
her bedroom or to a cesarean section delivery room if delivery complications occur.

Labor-Delivery-Recovery-Postpartum Model

Single Room Maternity Care in Labor-Delivery-Recovery-Postpartum Rooms:

Room design and capability to handle most emergencies remain the same as the labor-delivery-
recovery rooms. However, the (LDRP) Labor-Delivery-Recovery-Postpartum model eliminates a move
to postpartum after delivery. Labor-Delivery-Recovery-Postpartum uses one private room for labor,
delivery, recovery, and postpartum stay. Equipment is moved into the room as needed, rather than
moving the patient to the equipped room. Certain deliveries are handled in a cesarean section delivery
room (surgical operative room) should delivery complications occur.

Number of Obstetric Suite

A simple thumb rule for determining the size of an obstetrical suite is 2 labour rooms and one delivery
room per 20 postpartum beds. In many countries a combined labour and delivery room is used. In
Sweden there are 3-4 such rooms per 28 postpartum beds. In the current medical practice, the labour
or first stage only room, the delivery room and the recovery room are arranged in sequence.

14.4 PHYSICAL FACILITIES

Family Waiting Room: This facility should be in close proximity to the labour room. It should
be attractively furnished.

Admitting Room: In this room the patient is examined to determine whether she is in labour
or not. This room should have an area of 17sqm.It should have the following facilities:
  Examination table with stationary adjustable ceiling light.’
 A small lab for urine and blood tests
 Toilet complex.

Labour Lounge: The inability of the pregnant women to move around freely during the first
stage of labour is one of the unnecessary restrictions on her. It has been proved that in an
ambulant patient during first stage of labour the duration of labour is significantly shorter.
Therefore, comfortable lounges with privacy and away from the main traffic flow to be
provided next to the labour room. It should have facilities for light refreshment, TV, music and
should be homely.

Labour Room
Labour room should be of single occupancy with an area of 12 sq.mt. It should be comfortably
furnished and tastefully decorated. It should have
 Labour cum delivery bed with hydraulic system
 Bed head unit with oxygen and suction.
 Washbasin
 Toilet complex
 Overhead adjustable light
 Resuscitation/crash trolley
 Mobile anesthesia trolley.
 Labor rooms should have controlled access with doors that are arranged for observation
from a nursing station.

Each room should be designed for either one or two beds, with a minimum clear area of 120 square
feet (11.15 square meters) per bed.

Each labor room should contain a hand-washing station.

Delivery Rooms
These should have a minimum clear area of 300 square feet (27.87 square meters). It should have
the following facilities:-
 An emergency communication system shall be connected with the obstetrical suite control
station. Labour cum delivery bed with hydraulic system
  Bed head unit with oxygen and suction
 Washbasin
 Toilet complex
 Overhead adjustable light
 Resuscitation/crash trolley
 Mobile anesthesia trolley

Cesarean Section Rooms

 There should be a minimum of one such room in every obstetrical unit.
 These should have a minimum clear floor area of 360 square feet (33.45 square meters) with
a minimum dimension of 16 feet (4.88 meters).
 It should have all the facilities of an OT complex.

Infant Resuscitation Space

Infant resuscitation should be provided within cesarean/delivery rooms and delivery rooms or in a
separate but immediately accessible room.

A minimum clear floor area of 40 square feet (3.72 square meters) shall be provided for the infant
resuscitation space in addition to the required area of each delivery or cesarean/delivery room.

Infant resuscitation space provided in a separate but immediately accessible room shall have a
minimum clear floor area of 150 square feet (13.94 square meters).

Recover y Rooms
Recovery rooms should contain at least 50% beds from the whole bed in the delivery room. Recovery
room should have a nurse station with charting facilities located to permit visual control of all beds.
Each room should have a hand-washing station. Each room shall include facilities for dispensing
medicine. Storage for sup- plies and equipment shall be available.
There shall be enough space for baby and crib and a chair.

Postpartum Unit
An airborne infection isolation room is not required for the obstetrical unit.
Examination and Treatment Room should have a minimum clear floor area of 120 square feet (11.15
square meters). When used as a multi-patient diagnostic testing room, a minimum clear floor area of
80 square feet (7.43 square meters) per patient should be provided.
An adjoining toilet room should be provided for patient use.

Nursing Station
This should be ideally located within the suite. It should have table, desks, shelves, filing cabinet,
bulletin board, and a couch. The ideal space is 12 sq.mt.

Doctor’s Room:

Formula room: A space of 12 sq.mt. Is a deal. It should heating arrangement and facility for preparing
feed for neonate

Sanitary Complex

14.5 INFANT RESUSCITATION/STABILIZATION AREAS

Space for infant resuscitation/stabilization shall be provided within operative delivery rooms and
within Labor/Delivery/Recovery (LDR), Labor/Delivery/Recovery/Post-partum (LDRP) rooms, and
other non-operative delivery rooms. Delivery rooms may directly connect to nursery or Newborn ICU
(NICU) space via pass-through windows or doors. The ventilation system for each delivery and
resuscitation room shall be designed to control the ambient temperature between 72-78 degrees
Fahrenheit (22-26 degrees Centigrade) during the delivery, resuscitation, and

Specific recommendations for each location where infant resuscitation or stabilization occurs are as
follows:

Operative Delivery Rooms

Recommendations for operating rooms intended for use by NICU patients (Standard 8) shall be
followed with these exceptions:

 A minimum clear floor area of 80 square feet (7.5 square meters) for the infant shall be
provided in addition to the area required for other functions.
  3 oxygen, 3 air, 3 vacuum and 12 simultaneously-accessible electrical outlets shall be provided
for the infant and shall comply with all specifications for these outlets described in NICU
Standard 9.
 The infant space may not be omitted from the operative delivery room(s) when a separate
infant resuscitation/stabilization room is provided.

LDR, LDRP or other Non-operative Delivery Rooms

 A minimum clear floor area of 40 square feet (3.7 square meters) shall be provided for infant
space. This space may be used for multiple purposes including resuscitation, stabilization,
observation, exam, sleep or other infant needs.
 1 oxygen, 1 air, 1 vacuum and 6 simultaneously-accessible electrical outlets shall be provided
for the infant in addition to the facilities required for the mother.
 The infant space may not be omitted from the LDR, LDRP or non-operative delivery room
when a separate infant resuscitation/stabilization room is provided.

Pass-Through Windows and Doors

 Windows and doors shall be designed for visual and acoustical privacy and shall allow easy
exchange of an infant between personnel.
 When an operative delivery room is equipped with a pass-through window or door, it shall
have positive pressure so that air flows out to the infant room when the window or door is
opened.

Interpretation: Today's delivery rooms (operative and non-operative) are required to have separate
resuscitation space and outlets for infants. This space includes an acceptable environment for most
uncomplicated term infants, but may not support the optimal management of infants who will
become NICU patients.

Some term infants and most preterm infants are at greater thermal risk and often require additional
personnel, equipment and time to optimize resuscitation and stabilization. They are essentially NICU
patients from the time of delivery and would therefore be optimally managed in space designed to
NICU standards. The appropriate resuscitation/stabilization environment should be provided.
Providing it in each delivery room allows parents to be aware of staff's efforts to revive and care for
their infant before transport to the NICU. Providing ongoing support in a designated admission room
or within the NICU with infant transfer via pass-through windows or doors offers efficiencies for staff,
an environment designed for infants, and immediate access to all necessary equipment and supplies.
Infectious concerns for an opening into an operative room from a non-sterile (NICU) area are
addressed by designing airflow out of the sterile room when windows and doors are opened.
Provision of appropriate temperature for delivery room resuscitation of high-risk preterm infants is
vital to their stabilization. While lower temperatures are often more comfortable for gowned
attendants, the needs of the high-risk infant must take priority. It is also essential that these
appropriate ambient temperatures can be achieved within a short time frame, since many high-risk
deliveries occur with little warning.

Since many of the higher risk patients are delivered in operative delivery rooms, the operative room
minimums should be greater than the minimum standards for LDRs or LDRPs. If a hospital serves a
predominantly high-risk perinatal population, the hospital is encouraged to exceed the minimum
standards.

Equipment storage may be best provided by a wall-hung board or other suitable technique to allow
ready visibility and access to all needed resuscitation equipment.

14.6 NEONATAL INTENSIVE CARE UNIT

The NICU design shall be driven by systematically developed program goals and objectives that define
the purpose of the unit, service provision, space utilization, projected bed space demand, staffing
requirements and other basic information related to the mission of the unit. Design strategies to
achieve program goals and objectives shall address the medical, developmental, educational,
emotional, and social needs of infants, families and staff. The design shall allow for flexibility and
creativity to achieve the stated objectives.

The NICU shall be configured to individualize the care giving environment and services for each
infant and family, including families of twins or higher-order multiples.

The NICU shall be located within space designed for that purpose. It shall provide effective
circulation of staff, family, and equipment. Traffic to other services shall not pass through the unit.

The NICU shall be in close and controlled proximity to the area of the hospital where births occur.
When obstetric and neonatal services must be on separate floors of the Hospital, an elevator located
adjacent to the units with priority call and controlled access by keyed operation shall be provided for
service between the birthing unit and the NICU. Units receiving infants from other facilities shall have
ready access to the hospital's transport receiving area and shall designate a space for transport
equipment.

Family Entry and Reception Area

The NICU shall have a clearly identified entrance and reception area for families. Families shall have
immediate and direct contact with staff when they arrive at this entrance and reception area. The
design of this area should contribute to positive first impressions for families and foster the concept
that families are important members of their infant's health care team, not visitors. Facilitating contact
with staff will also enhance security for infants in the NICU. This area should have lockable storage
facilities for families' personal belongings (unless provided elsewhere).

Safety/Infant Security
The NICU shall be designed as part of an overall security program to protect the physical safety of
infants, families and staff in the NICU. The NICU shall be designed to minimize the risk of infant
abduction. Because facility design significantly affects security, it should be a priority in the planning
for renovation of an existing unit or a new unit. Care should be taken to limit the number of exits
and entrances to the unit. Control station(s) should be located within close proximity and direct
visibility of the entrance to the infant care area. The control point should be situated so that all
visitors must walk past the station to enter the unit. The design should provide for maximum
visibility of the nursery from the workroom or charting area. However, security considerations
should not adversely affect the quality of spaces for families in the NICU. The need for security
should be balanced with the needs for comfort and privacy of families and their infants.

Technological devices can be utilized in flexible and innovative manners within the design of the
multiple-bed or single infant room NICU schematic. Such technology, when utilized in conjunction with
the thoughtful planning of the traffic patterns to/from and within the NICU space, support areas and
family space, can facilitate a safe, yet open family-friendly area.

Minimum Space, Clearance, and Privacy Requirements for the

Infant Space
Each infant space shall contain a minimum of 120 square feet (11.2 square meters) of clear floor
space, excluding hand washing stations, columns, and aisles (see Glossary). Within this space, there
shall be sufficient furnishing to allow a parent to stay seated, reclining, or fully recumbent at the
bedside. There shall be an aisle adjacent to each infant space with a minimum width of 4 feet (1.2
meters) in multiple bed rooms. When single infant rooms or fixed cubicle partitions are utilized in
the design, there shall be an adjacent aisle of not less than 8 feet (2.4 meters) in clear and
unobstructed width to permit passage of equipment and personnel.

Multiple bed rooms shall have a minimum of 8 feet (2.4 meters) between infant beds. There shall be
provision for visual privacy for each bed, and the design shall support speech privacy at a distance of
12 feet (3.6 meters).
The width of aisles in multiple bed rooms should allow for easy movement of all equipment that
might be brought to the infant's bedside, as well as easy access for a maternal bed. The width of the
corridors or aisles outside single infant rooms or infant spaces designed with permanent cubicle
partitions should allow for simultaneous passage of two such items as mandated by state and
federal architectural and fire codes.

The need for privacy for infants and families should be addressed not only in design of each bed
space, but also in the overall unit design - for example, by minimizing traffic flow past each bed.

Private (Single-Family) Rooms

 Minimum size shall be no less than 165 square feet (15.3 square meters) of clear floor area.
 An outside window is not required (see Standard 25 for further specifics).
 The requirement for wireless monitor and communication devices shall be identical to that
described for isolation rooms (see Standard 7).
 Each room shall be designed to allow visual and speech privacy for the infant and family.
 Family space shall be designated and be able to include, at a minimum:

- A comfortable reclining chair suitable for kangaroo/skin-to-skin care

- A recumbent sleep surface for at least one parent
- A desk or surface suitable for writing and/or use of a laptop computer
- At least four electrical outlets for use and charging of electronic devices.
- No less than 6 cubic feet (0.2 cubic meter) of storage space

Staff space shall be designated and include, at a minimum:

 A work surface of no less than 6 square feet (0.6 square meters)

 A charting surface of no less than 3 square feet (0.3 square meters)
 Supply storage of no less than 30 cubic feet (0.85 cubic meters).

Airborne Infection Isolation Room(s)

An airborne infection isolation room shall be available for NICU infants, and shall provide a minimum
of 150 square feet (14 square meters) of clear floor space, excluding the entry work area. A hands-
free handwashing station for hand hygiene and areas for gowning and storage of clean and soiled
materials shall be provided near the entrance to the room. Ventilation systems for isolation rooms
shall be engineered to have negative air pressure with air 100% exhausted to the outside, and shall
meet acoustic standards for infant rooms (Standard 27). Airborne infection isolation room perimeter
walls, ceilings, and floors, including penetrations, shall be sealed tightly so that air does not infiltrate
the environment from the outside or from other airspaces.

Airborne infection isolation rooms shall have self-closing devices on all room exit doors. An emergency
communication system and remote patient monitoring capability shall be provided within the
airborne infection isolation room.

Airborne infection isolation rooms shall have observation windows with internal blinds or switchable
privacy (opaque) glass for privacy. Placement of windows and other structural items shall allow for
ease of operation and cleaning.

Airborne infection isolation rooms shall have a permanently installed visual mechanism to constantly
monitor the pressure status of the room when occupied by a patient with an airborne infectious
disease. The mechanism shall continuously monitor the direction of the airflow.

At least one single-occupancy isolation room should be available for any infant with a suspected
airborne infection. A space within the NICU should also be available to safely cohort a group of infants
infected with or exposed to a common airborne pathogen.

When not used for isolation, these rooms may be used for care of non-infectious infants and other
clinical purposes.

Turbulence attendant to high air-exchange rates can result in unacceptable levels of background noise
in airborne infection isolation rooms. Such levels result in speech interference, annoyance, and
physiologic responses typical of noise exposure for adults and infants. Specific attention is required,
therefore, to the design of noise-attenuating devices in the heating/ventilation/air-conditioning
(HVAC) ductwork and to washable acoustic surfaces on the walls and ceilings to ensure that sound
levels meet the Standard in these rooms. Glass partitions should be limited to that which is actually
necessary for safe visualization. Proportional amounts of acoustically absorptive and acoustically
reflective surfaces should be appropriate to achieve greater than 25% sound absorption.

Laminar flow diffusers over the surgical bed shall be set at the low end of the air velocity range
(approximately 25 ft. /min) and balanced with the surrounding slot diffuser air curtain to minimize
convective and evaporative heat and water loss from higher air flow onto the infant. In addition,
ambient temperature and humidity shall be adjustable into the range of 72-78° F (22 to 26° C) with a
relative humidity of at least 30%.

The acoustic environment set forth in Standard 27 shall be the basis for all design choices except for
the necessary hard (cleanable) room surfaces. No effort need be made to achieve this standard in
adjacent spaces if doors are expected to remain closed during most of the procedures.

Specialized Procedure Spaces or Rooms within the Newborn ICU

Specialized procedure spaces or rooms within the NICU shall be constructed to achieve all of the
above, as well as all of the requirements for an infant bed space elsewhere in these Recommended
Standards, except for the following additional modifications:

Each procedure area must be physically separated from other areas so that during surgery or
procedures patient and staff flow may be strictly controlled. Air flow must be designed so as to not
disrupt the air curtain around the surgical field, and shall be adjustable so as to be able to increase to
15 changes/hr. during procedures, then return to baseline values set forth in Standard 10. A
scavenging system to vent waste inhalation anesthesia and analgesia gases is required. HVAC
equipment shall be of a type that minimizes the need for maintenance within the room.

Procedure rooms designed for surgery or ECMO shall have a minimum clear floor area of 360 square
feet (33.5 square meters) with a minimum dimension of 16 feet (4.9 square meters) exclusive of built-
in shelves or cabinets, hand washing stations, and columns. These rooms shall be designed to comply
with safety requirements for performance of laser surgical procedures. The space requirements for
these functions in multi-bed rooms shall have a minimum clear floor area of 225 square feet (21 square
meters) exclusive of built-in shelves or cabinets, hand washing stations, columns and aisles.

It is assumed that infants having surgery in the NICU will be operated on and recover in their own beds
and that surgical personnel will bring needed sterile surgical equipment and supplies to the NICU.
Therefore, no additional recovery or post-anesthesia areas are required nor are work areas for storage
and processing of surgical instruments and separate corridors leading to the operative area. However,
support areas for storage of clean and sterile surgical supplies shall be provided, and a scrub station
shall be provided near the entrance to each procedure room in a corridor limited to authorized
personnel and patients.

Ambient lighting recommendations set forth in Standard 22 shall be followed except where higher
illuminances are required as set forth in IES recommendations for operating rooms5. Increased
ambient lighting must still be adjustable and indirect.
Electrical, Gas Supply, and Mechanical Needs

Mechanical requirements at each infant bed, such as electrical and gas outlets, shall be organized to
ensure safety, easy access and maintenance.

There shall be a minimum of 20 simultaneously accessible electrical outlets. The minimum number
of simultaneously accessible gas outlets is: Air 3, Oxygen 3, and Vacuum 3.

There shall be a mixture of emergency and normal power for all electrical outlets per current National
Fire Protection Association recommendations6.

A system that includes easily accessible raceways for electrical conduit and gas piping, work space,
and equipment placement is recommended because it permits flexibility to modify or upgrade
mechanical, electrical or equipment features. All outlets should be positioned to maximize access and
flexibility and minimize repetitive movements such as bending and stretching by the staff. Standard
duplex electrical outlets may not be suitable, since each outlet may not be simultaneously accessible
for oversized equipment plugs. The number of electrical, gas, and suction outlets specified is a
minimum; access to more may be necessary for critically ill infants. This area should also include
communication devices, supply storage, and charting space, resulting in an efficient, organized, and
self-contained workstation around the infant.

Ambient Temperature and Ventilation

The NICU shall be designed to provide an air temperature of 72°F to 78°F (22-26° C) and a relative
humidity of 30-60%, while avoiding condensation on wall and window surfaces.

A minimum of six air changes per hour is required, with a minimum of two changes being outside air.

The ventilation pattern shall inhibit particulate matter from moving freely in the space, and intake and
exhaust vents shall be situated to minimize drafts on or near the infant beds. Ventilation air delivered
to the NICU shall be filtered with at least the efficiency specified in the FGI Guidelines3. Filters shall
be located outside the infant care area so they can be changed easily and safely.

Fresh air intake shall be located at least 25 feet (7.6 meters) from exhaust outlets of ventilating
systems, combustion equipment stacks, medical/surgical vacuum systems, plumbing vents, or areas
that may collect vehicular exhausts or other noxious fumes. Prevailing winds or proximity to other
structures may require greater clearance.
Heat sources near the exterior wall, if applicable, should be considered to ameliorate the "cold wall"
condition, which in turn can be a source of convection drafts. This application of heat may also
alleviate the conditions leading to condensation on these walls.

The air flow pattern should be at low velocity and designed to minimize drafts, noise levels, and
airborne particulate matter. A HEPA filtration system may provide improved infection control for
immune compromised patients.

Because a regular maintenance program is necessary to assure that systems continue to function as
designed after occupancy, NICU design should attempt to maximize the ease of maintenance.

Hand washing

Every infant bed, whether in a single or multiple-bed room, shall be within 20 feet (6 meters) of a
hands-free hand washing station. Hand washing stations shall be no closer than 3 feet (0.9 meter)
from an infant bed, clean supply storage, or counter/work surface unless a splashguard is provided.

Hand washing sinks shall be large enough to control splashing and designed to avoid standing or
retained water. Minimum dimensions for a hand washing sink are 24 inches wide x 16 inches front to
back x 10 inches deep (61 cm x 41 cm x 25 cm) from the bottom of the sink to the top of its rim. Space
for pictorial hand washing instructions shall be provided above all sinks. There shall be no aerator on
the faucet. Walls adjacent to hand washing sinks shall be constructed of non-porous material. Space
shall also be provided for soap and towel dispensers and for appropriate trash receptacles. Towel
dispensers shall operate so that only the towel itself need be touched in the process of dispensing,
and constructed in such a fashion as to control noise .Handwashing facilities located at a level where
they can be used by people in wheelchairs shall be available in the NICU. Separate receptacles for
biohazardous and non-biohazardous waste shall be available.

Proper hand hygiene is a key component in the prevention and reduction of spread of infection in
health care settings. Alcohol-based hand rubs (ABHR) have been shown to be more effective than
soap-and-water hand washing in decontaminating hands that are not visibly soiled. ABHR dispensers
can be easily located at sites where hand hygiene is required. Hand washing sinks are also required in
close proximity to infant spaces to be used when hands or soiled or contaminated with body fluids.

Sinks for hand washing should not be built into counters. Sink location, construction material and
related hardware (paper towel and soap dispensers) should be chosen with durability, ease of
operation, ease of cleaning, and noise control in mind. Non-absorbent wall material should be used
around sinks to prevent the growth of mold on cellulose material. Local, state, and federal regulatory
agencies dictate what healthcare-generated waste is biohazardous or non-biohazardous and
appropriate disposal methods that are dependent on the type of waste. Depending upon the
jurisdiction, biohazard signage may need to be affixed.

General Support Space

Distinct facilities shall be provided for clean and soiled utilities, medical equipment storage, and unit
management services.

Clean Utility/Holding Area(s): For storage of supplies frequently used in the care of newborns.

Soiled Utility/Holding Room: Essential for storing used and contaminated material before its removal
from the care area. Unless used only as a holding room, this room shall contain a counter and a hands-
free handwashing station separate from any utility sinks. The handwashing station shall have hot and
cold running water that is turned on and off by hands-free controls, soap and paper towel dispensers,
and a covered waste receptacle with foot control.

The ventilation system in the soiled utility/holding room shall be engineered to have negative air
pressure with air 100% exhausted to the outside. The soiled utility/holding room shall be situated to
allow removal of soiled materials without passing through the infant care area.

A designated area for collection of recyclable materials used in the NICU shall be established. This area
shall measure at least one square foot per patient bed and be located outside the patient care area.

Charting/Staff Work Areas: Provision for charting space at each bedside shall be provided. An
additional separate area or desk for tasks such as compiling more detailed records, completing
requisitions, and telephone communication shall be provided in an area acoustically separated from
the infant and family areas. Dedicated space shall be allocated as necessary for electronic medical
record keeping within infant care areas.

A three zone storage area is desirable. The first storage area should be the central supply department
of the hospital.

The second storage zone is the clean utility area described in the standard; it should be adjacent to
and acoustically separated from the infant care area. Routinely used supplies such as diapers, formula,
linen, cover gowns, charts, and information booklets may be stored in this space. There should be at
least 8 cubic feet (0.22 cubic meters) for each infant for secondary storage of syringes, needles,
intravenous infusion sets, and sterile trays.
There should also be at least 18 square feet (1.7 square meters) of floor space allocated for equipment
storage per infant in intermediate care, and 30 square feet (2.8 square meters) for each infant bed in
intensive care. Total storage space may vary by unit size and storage system.

Easily accessible electrical outlets are desirable in this area for recharging equipment.

The third storage zone is for items frequently used at the infant's bedside. Bedside cabinet storage
should be at least 16 cubic feet (0.45 cubic meters) for each infant in the intermediate care area and
24 cubic feet (0.67 cubic meters) for each infant in the intensive care area. Bedside storage should be
designed for quiet operation.

Hospitals contribute significant waste each year to incinerators and landfills. This creates not only an
environmental hazard, but also conditions that are harmful to human health. Providing a designated
collection area enables staff to separate and store for collection waste such as paper, newsprint,
corrugated cardboard, plastics, metals, batteries, fluorescent lamps, and glass to either facilitate
existing hospital procedures for recycling or initiate a recycling system. Space within the designated
collection area also may be used for collection of medical supplies for distribution to hospitals or clinics
in need of such materials.

Charting/Staff Work Areas: A clerical area should be located near the entrance to the NICU so
personnel can supervise traffic into the unit. In addition, there should be one or more staff work areas,
each serving 8 to 16 beds. These areas will allow groups of 3-6 caregivers to congregate immediately
adjacent to the infant care area for report, collaboration, and socialization without impinging on infant
or family privacy. Infants' charts, computer terminals, and hospital forms may be located in this space.

Laundry Room: If laundry facilities for infant materials are provided, a separate laundry room can
serve the functions of laundry and toy cleaning within the NICU. Infant clothing and the cloth covers
of positioning aids should be laundered on a regular schedule and as needed. In addition, toys utilized
by infants or siblings are required to be cleaned on a regular schedule for each infant and between
infants. Space for a commercial-grade washer and dryer should be accommodated. The dryer should
be vented through an outside wall. The placement of a commercial-grade dishwasher could promote
the efficiency and effectiveness.

The ventilation system in the soiled utility/holding room shall be engineered to have negative air
pressure with air 100% exhausted to the outside. The soiled utility/holding room shall be situated to
allow removal of soiled materials without passing through the infant care area.

A designated area for collection of recyclable materials used in the NICU shall be established. This area
shall measure at least one square foot per patient bed and be located outside the patient care area.
Support Space for Ancillary Services

Distinct support space shall be provided for all clinical services that are routinely performed in the
NICU.

Space for preparation and storage of formula and additives to human milk and formula shall be
provided within the unit or other location that is away from the bedside7. When a separate room for
infant feeding preparation is not merited due to infrequency of need, commercial preparation off
premises or other reasons, a separate area in the food services area or in the patient unit shall be
designated for infant feeding preparation. Hospital food preparation design guidelines shall be
followed.

When the functional program requires a separate room, the room shall include the following areas
that can be separated in individual rooms or combined: Ante area, Preparation area, Storage space
for supplies, formula, and both refrigerated and frozen breast milk, Clean-up area.

To minimize contamination, the ventilation system should have a minimum filtration of 90% based on
the American Society of Heating, Ventilation and Air Conditioning Engineers standards or have a HEPA
forced air filtration system.

Provisions shall be included for human milk storage. Human milk may be stored in a designated space
in the infant feeding preparation room, and in designated spaces on the patient unit.

Ancillary services such as (but not necessarily limited to) respiratory therapy, laboratory, pharmacy,
radiology, developmental therapy, and specialized feeding preparation are common in the NICU.
Distance, size, and access are important considerations when designing space for each of these
functions. Satellite facilities may be required to provide these services in a timely manner.

Unless performed elsewhere in the hospital, a specialized feedings preparation area or room should
be provided in the NICU, away from the bedside, to permit mixing of additives to breast milk or
formula. The cleanliness of the floor surface, walls and ceilings should be easily maintained. Floor
drains are not recommended unless required by local code. Adequate sinks, electrical outlets and
storage should be provided based on the individual hospital facility needs. The use of a laminar flow
hood is a decision that each hospital should make. Pharmacies are not required to use laminar flow
hoods to prepare oral medications. Powdered formulas are not sterile, and preparing them under a
laminar flow hood does not improve the sterility of the product. All water supplied for feeding
preparation should meet Federal Standards for drinking water and be commercially sterile.
Commercially sterile water is preferred because it has eliminated pathogenic and other organisms,
that if present, could grow in the product and produce spoilage under normal conditions of handling
and storage.

Administrative Space
A wide range of personnel are assigned to the NICU, many of whom require office or administrative
space. When planning the NICU, administrative space should be considered for each discipline that
provides service to the unit on a daily basis and needs a distinct area for carrying out their
responsibilities, even if that individual has additional office space elsewhere.

Family Support Space

Space shall be provided in or immediately adjacent to the NICU for the following functions: family
lounge area, lockable storage, telephone(s), and toilet facilities.

Separate, dedicated rooms shall also be provided for lactation support and consultation in or
immediately adjacent to the NICU. A family library or education area shall be provided within the
hospital. Access to the Internet and educational materials shall be provided via a computer station in
the family lounge or at the infant's bedside.

Interpretation: Family Lounge Area: This should include comfortable and moveable seating, as well
as a play area stocked with entertainment materials for children. A nourishment area should also be
considered, as well as external windows or skylights.

Lockable Storage: Secure storage for personal items should be provided at each infant space.

Lactation Support: Comfortable seating, a handwashing sink, and a means of communication to the
NICU should be provided.

Family Education Area: This should include publications, audiovisual resources, and Internet access so
that families can learn about health conditions, child development, parenting issues, and parent-to-
parent support. This area might also include space and supplies to learn about and practice care giving
techniques.

Telephones: Telephones should be provided that offer privacy and that enable an individual to sit
down while talking.

Consultation Room: This should include comfortable seating and allow complete visual and acoustic
privacy.
Family Transition

Family-infant room(s) shall be provided within or immediately adjacent to the NICU that allow(s)
families and infants extended private time together. The room(s) shall have direct, private access to
sink, toilet and shower facilities, emergency call and telephone or intercom linkage with the NICU
staff, sleeping facilities for at least one parent, and sufficient space for the infant's bed and equipment.
Each room shall also have at least four electrical outlets for use and charging of the family's electronic
devices. The room(s) can be used for other family support, educational, counseling, or demonstration
purposes when unoccupied.

Interpretation: Access to family-infant room(s) encourages overnight stays by parents and the infant
in the NICU. The room(s) should be sufficiently equipped and sized to accommodate the parents, with
additional space for a physician, nurse, social worker, chaplain, or other individuals who may need to
meet with the parents and baby in private. For security reasons, transition room(s) should be situated
within an area of controlled public access. Sufficient family-infant rooms should be provided to allow
those families who wish to room in with their infants the opportunity to do so. The appropriate
number of rooms will depend on each hospital's practice pattern, the number of single infant rooms
with parent sleeping facilities, the availability of other rooms nearby, the size of the region served,
and other variables.

Ceiling Finishes

Ceilings shall be easily cleanable and constructed in a manner to prohibit the passage of particles from
the cavity above the ceiling plane into the clinical environment. The ceiling construction in infant
rooms and adult sleep areas and the spaces opening onto them shall not be friable and shall have a
noise reduction coefficient (NRC) of at least 0.90 for 80% of the entire surface area or an average NRC
of 0.85 for the whole ceiling including solid and acoustically absorptive surfaces. To ensure protection
from noise intrusion, ceilings in infant rooms and adult sleep areas shall be specified with a ceiling
articulation class (CAC)-29.

Finishes shall be free of substances known to be teratogenic, mutagenic, carcinogenic, or otherwise

harmful to human health.

Interpretation: Since sound abatement is a high priority in the NICU, acoustical ceiling systems are
desirable, but must be selected and designed carefully to meet this standard. In most NICUs, the
ceiling offers the largest available area for sound absorption. The Standard for ceiling finishes includes
areas that communicate with infant rooms and adult sleep areas (e.g., hallways, corridors, storage,
and staff work areas) when doors are opened in the course of daily activity.
Ceilings with high acoustical absorption (i.e., high NRC ratings) do not necessarily have a significant
barrier effect (i.e., offer protection from sounds transmitted between adjacent areas). A CAC-29
provides a moderate barrier effect and allows a broad range of ceiling products. Poor barrier effects
can result if room-dividing partitions are discontinued above the ceiling allowing room-to-room cross-
talk or if there are noise-producing elements in the ceiling plenum. If the ceiling plenum contains noise
sources such as fan-powered boxes, in-line exhaust fans, variable air volume devices, etc. then a higher
CAC than CAC-29 may be necessary.

VOCs and PBTs such as cadmium are often found in paints and ceiling tiles and should be avoided.
Specify low- or no-VOC paints and coatings.

Wall Surfaces

Wall surfaces shall be easily cleanable and provide protection at points where contact with movable
equipment is likely to occur. Surfaces shall be free of substances known to be teratogenic, mutagenic,
carcinogenic, or otherwise harmful to human health.

As with floors, the ease of cleaning, durability, and acoustical properties of wall surfaces must be
considered. Although commonly used, many vinyl wall coverings contain PVC and will degrade indoor
air quality, and thus should be avoided. VOCs and PBTs such as cadmium often are found in paints,
wall-coverings, acoustical wall panels, and wood paneling systems and also should be avoided. Specify
low- or no-VOC paints and coatings.

Floor Surfaces
Floor surfaces shall be easily cleanable and shall minimize the growth of microorganisms.

Flooring material with a reflectance of no greater than 40%8 and a gloss value of no greater than 30
gloss units shall be used5, to minimize the possibility that glare reflected from a bright procedure or
work-area light will impinge on the eyes of infants or caregivers.

Floors shall be highly durable to withstand frequent cleaning and heavy traffic.

Flooring materials shall be free of substances known to be teratogenic, mutagenic, carcinogenic, or

otherwise harmful to human health.
Interpretation: While ease of cleaning and durability of NICU surfaces are of primary importance,
consideration should also be given to their glossiness (the mirror-like reflectivity of a surface), their
acoustical properties, and the density of the materials used. Reduced glossiness will reduce the risks
from bright reflected glare; acoustic and density properties will directly affect noise and comfort.

Materials should permit cleaning without the use of chemicals that may be hazardous, since it may
not be possible to vacate the space during cleaning.

Transition surfaces that do not obstruct mobility, are durable, and minimize noise and jarring of
equipment should be provided at the intersection of different flooring materials.

Materials suitable to these criteria include resilient sheet flooring (medical grade rubber or linoleum)
and carpeting with an impermeable backing, heat- or chemically-welded seams, and antimicrobial and
antistatic properties. Carpeting has been shown to be an acceptable floor covering in the hospital and
the NICU and has obvious aesthetic and noise reduction appeal, but it is not suitable in all areas (e.g.,
around sinks or in isolation or soiling utility/holding areas). Small floor tiles (e.g., 12 inch squares) have
myriad seams and areas of non-adherence to the sub-floor. These harbor dirt and fluids and are a
potential source of bacterial and fungal growth.

Much is known regarding the effects of chemicals such as mercury on human health and development.
Additional efforts should be made to exclude persistent, bio accumulative toxic chemicals (PBTs) such
as polyvinyl chloride (PVC) from healthcare environments. PVC or vinyl is common in flooring materials
including sheet goods, tiles, and carpet. The production of PVC generates dioxin, a potent carcinogen,
and fumes emitted from vinyl degrade indoor air quality. Dioxin releases are not associated with
materials such as polyolefin, rubber (latex), or linoleum.

Volatile organic compounds (VOCs) such as formaldehyde and chlorinated compounds such as
neoprene also should be avoided when selecting adhesives or sealants for floor coverings. Specify low-
or no-VOC and non-toxic and non- carcinogenic materials. Flooring containing natural rubber (latex)
should be certified non-allergenic by the manufacturer.

Infants should not be moved into an area of newly installed flooring for a minimum of two weeks to
permit off-gassing of adhesives and flooring materials.

FURNISHINGS
Built-in and freestanding furnishings such as cabinets and carts, especially those in the infant care
areas, shall be easily cleanable with the fewest possible seams in the integral construction.
Exposed surface seams shall be sealed. Furnishings shall be of durable construction to withstand
impact by movable equipment without significant damage. Furnishings and materials shall be free
of substances known to be teratogenic, mutagenic, carcinogenic, or otherwise harmful to human
health.

Countertops should have the fewest possible seams. Edges exposed to impact should be "soft"
(i.e., bull-nosed). Corners created at wall or backsplash intersections should be coved.
Intersections with sinks or other devices should be sealed or made integral with the top.
Casework construction should not chip or flake when struck by objects in the normal routine of
infant care, and should be of sufficient moisture resistance to prevent deterioration.

Furnishings in the NICU are often composite pieces made of various parts and layers of
materials that are assembled with glue or adhesives. Materials and substances typically used in
these furnishings often contain volatile organic compounds (VOCs) such as formaldehyde, which
is frequently found in pressed wood products including plywood and particle board. Vinyl-based
laminates, which often are applied to the surface of pressed wood products, also contain VOCs
such as polyvinyl chloride (PVC). Specify low- or no-VOC materials, including urea-formaldehyde-
free adhesives, for all furnishings in the NICU. Specifying furnishings and materials from regional
sources (within a 300 - 500 mile radius) not only provides support for the local community, but
also reduces the amounts of fossil fuels necessary for transport.

14.7 AMBIENT, LIGHTING IN INFANT CARE AREAS

Ambient lighting levels in infant spaces shall be adjustable through a range of at least 10 to no more
than 600 lux (approximately 1 to 60 foot candles), as measured on a horizontal plane at each bedside.
Both natural and electric light sources shall have controls that allow immediate darkening of any bed
position sufficient for Tran’s illumination when necessary.

Electric light sources shall have a color rendering index (CRI) of no less than 80, and a gamut area index
(GAI) 9 of no less than 80 and no greater than 100. The optical reflectors in the luminaires (light fixture)
shall have a neutral finish so that the color rendering properties of the light source are maintained.
The sources shall avoid unnecessary ultraviolet or infrared radiation by the use of appropriate lamps,
lens, or filters.

No direct view of the electric light source or sun shall be permitted in the infant space (as described
in Standard 5): this does not exclude direct procedure lighting, as described in Standard 23. Any
lighting used outside the infant care area shall be located so as to avoid any infant's direct line of sight
to the fixture.
The electric light sources that are supplied by 60 Hz alternating current shall not flicker more than a
common 40 W incandescent light source. Specifically, the frequency and the depth of the light
modulation produced by the source shall be no less than 120 Hz and no more than 13%, respectively.

Lighting fixtures shall be easily cleaned.

Substantial flexibility in lighting levels is required by this standard so that the disparate needs of
infants at various stages of development and at various times of day can be accommodated, as well
as the needs of caregivers. In very preterm infants, there has been no demonstrable benefit to
exposure to light. After 28 weeks gestation, there is some evidence that diurnally-cycled lighting has
potential benefit to the infant. Caregivers benefit from moderate levels of ambient light in order to
perform tasks and maintain wakefulness.

Control of illumination should be accessible to staff and families, and capable of adjustment across
the recommended range of lighting levels. Use of multiple light switches to allow different levels of
illumination is one method helpful in this regard, but can pose serious difficulties when rapid
darkening of the room is required to permit Trans illumination, so a master switch should also be
provided.

Perception of skin tones is critical in the NICU; light sources that meet the CRI and GA values identified
above provide accurate skin-tone recognition. Light sources should be as free as possible of glare or
veiling reflections. When the light sources to be used are linear fluorescent lamps, these color criteria
can be met by using lamps that carry the color designation "RE80".

Procedure Lighting in Infant Care Areas

Separate procedure lighting shall be mounted at each infant bed. The luminaire shall be capable of
providing no less than 2000 lux at the plane of the infant bed, and must be framed so that no more
than 2% of the light output of the luminaire extends beyond its illumination field. This lighting shall be
adjustable so that lighting at less than maximal levels can be provided whenever possible.

Temporary increases in illumination necessary to evaluate a baby or to perform a procedure should

be possible without increasing lighting levels for other babies in the same room.

Since intense light may be unpleasant and harmful to the developing retina, every effort should be
made to prevent direct light from reaching the infant's eyes. Procedure lights with adjustable intensity,
field size, and direction will help protect the infant's eyes from direct exposure and provide the best
visual support to staff. It is preferable that the procedure light be either mounted on the headwall or
incubator in lieu of a floor stand. This will maximize the space around the infant work area and
minimize trip hazards.

Illumination of Support Areas

Illumination of support areas within the NICU, including the charting areas, medication preparation
area, the reception desk, and hand washing areas, shall conform to IES specifications.

Illumination should be adequate in areas of the NICU where staff performs important or critical tasks;
the IES specifications in these areas are similar to but somewhat more specific than the general
guidelines recommended by AAP/ACOG.

In locations where these functions overlap with infant care areas (e.g., close proximity of the staff
charting area to infant beds), the design should nevertheless permit separate light sources with
independent controls so the very different needs of sleeping infants and working staff can be
accommodated to the greatest possible extent. Care must be taken, however, to insure that bright
light from these locations does not reach the infants' eyes.

Daylighting

At least one source of natural daylight shall be visible from an infant space or room, either from an
exterior window or exterior clerestory located at each infant space or in each room, or from an
exterior window or exterior clerestory in the staff work area adjacent to the infant space or room.
When provided, exterior window(s) located at an infant space or in a room shall be glazed with
insulating glass to minimize heat gain or loss, and shall be situated at least 2 feet (0.6 meter) away
from any part of an infant's bed to minimize radiant heat gain or loss. All external windows shall be
equipped with shading devices that are neutral color to minimize color distortion from transmitted
light.

The provision of daylight and windows shall be guided by the recommendations outlined in LEED
(Leadership in Energy and Environmental Design) for Healthcare12; IEQ Credit 8:1 Daylight and Views,
except in cases where the provision of daylight and windows interferes with the recommendations
provided elsewhere in this document. Windows provide an important psychological benefit to staff
and families in the NICU. Properly designed daylighting is the most desirable illumination for nearly all
caregiving tasks, including charting and evaluation of infant skin tone.

However, placing infants too close to external windows can cause problems with radiant heat loss or
gain and glare, so provision of windows in the NICU requires careful planning and design. Shading
devices should be easily controlled to allow flexibility at various times of day, and should either be
contained within the window or easily cleanable. These should be designed to avoid direct sunlight
from striking the infant, IV fluids, or monitor screens.

Access to Nature and Other Positive Distractions

Views of nature shall be provided in the unit in at least one space that is accessible to all families and
one space that is accessible to all staff. Other forms of positive distraction shall be provided for families
in infant and family spaces, and for staff in staff spaces.

The provision of views via windows shall be guided by the recommendations outlined in LEED
(Leadership in Energy and Environmental Design) for Healthcare12; IEQ Credit 8:1 Daylight and Views,
except in cases where the provision of daylight and windows interferes with the recommendations
provided elsewhere in this document.

Culturally appropriate positive distractions provide important psychological benefits to staff and
families in the NICU. Looking out a window, viewing psychologically supportive art, or taking a stroll
in a garden may help to reduce stress or increase productivity. When possible, windows should have
views of nature environments. These environments might consist of trees, plants, human and animal
activity, gardens, and landscapes. In urban settings, appropriate nature elements might include
planters or water features. When such views are not possible, artwork with nature images or other
nature simulations (e.g., video and artificial representations) should be provided throughout the unit.
Family and staff lounge spaces are ideal locations for views of nature and other positive distractions.

Provision should be made for direct access to nature and other positive distractions within the hospital
complex. These nature environments may consist of outdoor spaces such as gardens or walking paths
or indoor spaces such as greenhouses and atria. Amenities within the nature environment might
include water features, plant and animal life and solitary and group seating. Other positive distractions
might include fitness centers and access to music.

14.8 ACOUSTIC ENVIRONMENT

Infant rooms (including airborne infection isolation rooms), staff work areas, family areas, and staff
lounge and sleeping areas and the spaces opening onto them shall be designed to produce minimal
background noise and to contain and absorb much of the transient noise that arises within them.

 In infant rooms and adult sleep areas, the combination of continuous background sound and
operational sound shall not exceed an hourly Leq of 45 dB and an hourly L10 of 50 dB, both A-
weighted slow response. Transient sounds or Lmaxshall not exceed 65 dB, A-weighted, slow
response in these rooms/areas.
  In staff work areas, family areas, and staff lounge areas, the combination of continuous
background sound and operational sound shall not exceed an hourly Leq of 50 dB and an hourly
L10 of 55 dB, both A-weighted slow response. Transient sounds or Lmax shall not exceed 70 dB,
A-weighted, slow response in these areas.

To achieve the required noise levels in infant rooms and adult sleep rooms, building mechanical
systems and permanent equipment in those areas shall conform to Noise Criteria (NC) -25 based on
manufacturers' noise ratings with allowance for other sound sources and adjustment for room loss if
less than 10 db. Areas in open communication with infant rooms and adult sleep rooms shall conform
to NC-30. Building mechanical systems and permanent equipment in other areas specified in the
Standard shall conform to a maximum of NC-35. Building mechanical systems include heating,
ventilation, and air conditioning systems (HVAC) and other mechanical systems (e.g., plumbing,
electrical, vacuum tube systems, and door mechanisms). Permanent equipment includes refrigerators,
freezers, ice machines, storage/supply units, and other large non-medical equipment that is rarely
replaced.

Where personal address speakers are located in sensitive areas, announcing systems shall have
adjustable volume controls for the speakers in each room and for each microphone that sends signal
through the system.

Speech privacy and freedom from intrusive sounds shall be provided by acoustic seals for doors and
building to meet STC criteria (below) for demising partitions in infant rooms, on-call and sleep rooms,
family transition rooms, and conference rooms or offices in which sensitive staff and family
information is discussed. All other penetrations for conduits, inset boxes, pipes, ducts, and other
elements in sound demising partitions shall be sealed airtight to prevent noise flanking (leakage)
through gaps and openings.

: The acoustic environment is a function of both the facility (e.g., building mechanical systems and
permanent equipment, the intrusion of exterior sounds, the sound containment afforded by doors
and walls, and the sound absorption afforded by surface finishes) and operations (e.g., the activities
of people and function of medical equipment and furnishings).The acoustic conditions of the NICU
should favor speech intelligibility, normal or relaxed vocal effort, speech privacy for staff and parents,
and physiologic stability, uninterrupted sleep, and freedom from acoustic distraction for infants and
adults. Such favorable conditions encompass more than the absence of noise and require specific
planning for their achievement. Speech Intelligibility ratings in infant areas, parent areas, and staff
work areas should be "good" to "excellent" as defined by the International Organization for
Standardization ISO 9921:2003. Speech intelligibility for non-native but fluent speakers and listeners
of a second language requires a 4 to 5 dB improvement in signal-to-noise ratio for similar intelligibility
with native speakers. The Leq, L10 and Lmaxlimits will safeguard this intelligibility and also protect infant
sleep.

The permissible noise criteria of an hourly Leq of 45 dB, A-weighted, slow response in infant rooms and
adult sleep areas is more likely to be met in the fully operational NICU if building mechanical systems
and permanent equipment in those areas and the areas in open communication with them conform
to NC-25 or less. NC-25 translates to approximately 35 dBA of facility noise. A realistic addition of 10
dB of operational noise above this background will result in a Leq of about 45 dBA. Limiting operational
noise to only 10 dBA above the background will require conscientious effort.

Acoustically absorptive surfaces reduce reverberation and, therefore, sound levels at a distance from
the sound source. When possible, two perpendicular walls should be covered with sound absorptive
surface materials with an NRC of at least 0.65. Where this is not possible the upper portions of all four
walls (above areas likely to be damaged by the movement of equipment) should be covered with such
material. Glass should be limited to the area actually required for visualization in order to leave wall
surface available for absorptive surface treatment. While a variety of flooring will limit impact noise
somewhat, specialized carpeting offers the most protection.

Fire alarms in the infant area should be restricted to flashing lights without an audible signal. The
audible alarm level in other occupied areas must be adjustable. Telephones audible from the infant
area should have adjustable announcing signals. The type of water supply and faucets in infant areas
should be selected so as to minimize noise, and should provide instant warm water in order to
minimize time "on".

Noise-generating activities (e.g., linen and supply carts, conference areas, clerk's areas, multiple-
person work stations, and travel paths not essential to infant care), permanent equipment and office
equipment should be acoustically isolated from the infant area. Vibration isolation pads are
recommended under leveling feet of permanent equipment and appliances in noise-sensitive areas or
areas in open or frequent communication with them.

Post-construction validation of specifications for the building mechanical systems and permanent
equipment should include noise and vibration measurement, reporting, and remediation.
Measurement of NC levels should be made at the location of the infant or adult bed or at the
anticipated level of the adult head in other areas. Each bed space must conform to the Standard. With
space at a premium, many incompatible adjacencies are possible in NICU designs (e.g., break area,
meeting room, or mechanical room sharing a wall with an infant room or adult sleep room).
Specialized wall and floor/ceiling treatments will help to meet criteria in these non-optimal conditions.
The criteria below are for sound transmission loss (TL) or attenuation through horizontal barriers (e.g.,
walls, doors, windows) and vertical barriers (e.g., between floors). The Sound Transmission Class (STC)
rating spans speech frequencies and is relevant for separation of spaces with conversational and other
occupant-generated noise. The Noise Reduction (NR) rating, which covers a wider frequency span, is
more relevant for mechanical noise dominated by low frequencies. The recommended criteria for TL
below apply to barriers between adjacent spaces and infant areas or adult rest or sleep rooms13.

Adjacent Spaces

Pedestrian-only corridor STC 45

Equipment corridor STC 55

Infant area STC 40

Reception STC 55

Meeting room with amplified sound STC 55

Staff work area STC 55

Administrative office, conference STC 45

Non-related area STC 50

Mechanical area NR 60-65

Electrical area NR 50-55

Sound transmission from the exterior of the building should meet the NC criteria inside all spaces
identified in the Standard. It is advisable to enlist the services of an acoustical engineer from the onset
of the project through post-construction validation. This specialty service is usually not covered by
architectural fees and can assist in program and design development, design of mechanical systems,
specification of equipment and building construction, and test and balance validation. Enlistment of
acoustical services late in the design process often results in fewer and more costly options for
meeting performance standards.

14.9 SUMMARY

The birth entails an extensive adjustment process for the mother as it involves and reflects changes in
not only her physical state but also in her ability to cope and adapt .Delivery of the baby has to take
place in an informal and relaxed and comfortable atmosphere. Also the time of maximum
vulnerability in the life of an individual is during the transition from intrauterine to extra uterine life.
This critical period commands prompt and efficient resuscitative medical acre which is provided in
neonatal resuscitative area.

14.10 KEY WORDS

Labour Lounge: - The inability of the pregnant women to move around freely during the first stage of
labour is one of the unnecessary restrictions on her. It has been proved that in an ambulant patient
during first stage of labour the duration of labour is significantly shorter. Therefore, a comfortable
lounge with privacy and away from the main traffic flows to be provided next to the labour room. It
should have facilities for light refreshment, TV, music and should be homely.

Labour Room
Labour room should be of single occupancy with an area of 12 sq.mt. It should be comfortably
furnished and tastefully decorated. It should have

 Labour cum delivery bed with hydraulic system

 Bed head unit with oxygen and suction.
 Washbasin
 Toilet complex
 Overhead adjustable light
 Resuscitation/crash trolley
 Mobile anesthesia trolley.