N.

4
Policies
Batch:
....18....HCQM
By:Esraa
Mohammed El
Shemy
Under
supervision
of Dr
Ahmed
Salah
.
Sent by E-mail at 23-9-2016

Emergency Department Policies Index

Seria
Polic
l
y
No.
1.
Triage

Polic
y
No.
ER 1

2.

ER Mangment of Trauma Patient

ER 2

3.

Obtaining an Emergncy CAT Scan

ER 3

4.

Patients Who Leave Against

Medical
Advice
Emergency Assessmen For m

ER 4

ER 6

7.

Emergency X-Rays Ordered

reading
Response Time to ER Call

8.

Transfer to Another Hospital

ER 8

9.

Ambulance Checking

ER 9

10.

Call Consultants For Opinions

ER 10

11.

Patient Who Leave Without Being

Seen

ER 11

5.
6.

ER 5

ER 7

12.

Emergency Lab. Results

ER 12

13.

On Call Rotas In ER

ER 13

14.

Patients With Potential Medicolegal

ER 14

15.

Infection Control in ER

ER 15

Sue z Hos pital

policy 1&2
( Triage
)

SZ-H \ ER 1

ER Mangment of Trauma
Patient
SZ-H \ ER 2

P urpose :
It is to put the outline and guideline to manage
polytrauma patients in
ER.
Definit ions:
Polytrauma patients are those patients co ming to
the hospital with more than two systems involved
in trauma, e.g. Accidents
P olicy:
1- It is the ER responsibility to resuscitate all
polytrauma patients effectively as guided by ATLS.
2- The ER doctor is the person responsible for the
assessment and resuscitating the polytrauma

patient and to call specialists and consultants as

needed.
3- If the case is behind the hospital capability, it
must be referred to a
higher hospital urgently.
4- Any referred poly trauma case must be combined
with ER doctor and
Nurse.
P rocedure:
P HASE I :
a) Airway:
Oral toilet to remove blood or dentures
Oropharyngeal airway to clear o bstructed
tongue
Endotracheal intubation if indicated.
b) Breathing:
100 % oxygen by mask or endotracheal
intubation.
Assisted respiration by ambubag
Under water seal in case of
pneumo/haemothorax
c) Circulation:
External cardiac massage when pulse not
detected.
ECG & defibrillation in readiness.
Establish large-bore IV lines.
Blood (O ve) life threatening co ndition.
Ionotro phic su pport
Haemostatic measures by pressure dressing.
P HASE II :
a)

Initial rapid o verall assessment of patients

Baseline mo nitoring level of co nsciousness
Pupillary size and reaction
Blood samples for grouping/crossmatching
Blood gas analyses, CBC, chemistry, CVP.
Urethral catheter (hourly urine output)

b) Organized Fluid Replacement:

 Continue whole blood transfusion preferrably

(cross-matched)
Sodium Bicarbonate: according to blood gas
c) Analgesia/Sedation:
Narcotics in titrated doses
d) Splint fracture as appropriate. e) Wound
debridement/dressing
f) Re-assurance in detail (special consideration to
pre-existing disease,
coronary/diabetic etc.)
g) X-ray and other investigation (USG/CT)
h) Drug Therapy:
Anti tetanic seru m
Antibiotic if indicated
Methyl prednisolone i) Transfer to ICU
P HASE III :
Specific surgical i ntervention:
a) Compound fracture
b) Deco mpressio n of brain
c) Deco mpressio n of cardiac tamponade
d) Acl. Abdo men (laparotomy and proceeding)
Accountabilit ies:
ER doctor and Nurses
Surgical consultant or Specialist
X- ray Consultant or Specialist
Laboratory
Ref ranc e:
Dr. Ali ELshery -ER Co nsultant of HIO

Policy n.3

Policy Title:
Obtaining an Emergncy CAT Scan
Policy No3. Related departement
ER 3
ER
P olicy :
It is the process to be taken when obtaining an
emergency CAT scan for trauma cases within 30
minutes or as soon as possible .

P urpose :
To obtain CAT scan for trauma cases immediately .
P rocedure :
1. A consultant is the person who determine that
the patient with trauma in ER needs to do CAT scan
after examining him.
2. The Specialist & consultant will inform the
patient and/or relatives the procedure to be done .
3. After the approval from the patient and/or
relatives, the physician who ordered the CAT scan
will filled and complete the request form with his
signature .
4. Send the patient to the (CAT scan Room) with
the nurse on wheel chair .
5. The radiology technician will receive the
patient and do the procedure .
6. After duty hours , and there is a patient need to
under go CAT scan , the ER physician will ask the
Radiology Dep. to call the scheduled on call
technician .
7. Within 10 minutes , the technician has to be
onsite to do the CAT
scan .
8. The radiology specialist will be also called to
write the report of the scan.
9. The ER department
and the radiology
department try as much as possible to do the
CAT scan within 30 minutes right after the
attending physician determine the needs for CAT
scan .
Responsiblit ies
Specialist or Consultant in ER
Technician&Specialist in Radiology Dep.
Ref ra nce:
Dr. Ali Elshehry -ER Co nsultant of HIO

Policy Title
Policy No.
Related
departement

Patients Who Leave Against

Medical Advice
4
ER

De f i n i t i o n :
It is discharging a patient from the hospital upon
his/her own desire and responsibility .
P urpose :
1. To deal with the patient who wants to be
discharged against the medical advice .
2. To explain to the patient and/or relatives the
complications might happen .
P olicy :
1- A consent for discharge against medical advice
should be completed and signed by the patient
and/or relatives .
2- The responsible doctor must be notified
before discharging any
patient against medical advice.
P rocedure :
1. The nurse on duty will do the
appropriate
assessment for any patient admitted to ER and
document this assessment in ER form, and then
the patient will be examined by the physician .
2. The attending physician will explain to the
patient and/or relatives the treatment should be
given , the investigations or procedures should
be done (if there is) , and the needs of
admission if the condition and case of the patient
needs to be treated in the hospital and all
complications will be discussed to them .

3. If the patient and/or relatives refused to take

the treatment , or the procedures or investigations
to be done or refused to admit in the hospital ,
the attending physician will document it in the
patient's file and also the treatment to be taken at
home .
4. A consent for discharge against medical
advice will be filled, and completed by the
attending physician and signed by the patient
and/or relatives .
5. The attending physician will write the treatment
to be taken at home in a prescription and given
to the patient and/or relatives after explaining to
them how to use it and any relevant instructions to
be followed at home .
6. If the patient wants to take the treatment , or do
the investigations or procedure or to be admitted in
other hospital , a referral form will be
completed and signed by the attending physician
then given to the patient and/or relatives .
7. A consent will be completed by the attending
physician
and
signed by the patient and/or
relatives that they want to take the appropriate
treatment and procedures in other hospital and
a copy from the referral form will be kept in
patient's file .
8. If the condition of the patient needs to be
discharged
by the ambulance , a nurse or a
nurse and a physician
(depends
upon the
seriousness of the patient) will accompany the

patient to the desired hospital .

Accountabilit ies:
ER doctors
ER nurse
Refra nces:
Dr. Ali ELshehry -ER Co nsultant of HIO
Patient Assessment
Policy Title
Policy No.
5
Related
ER
departement
Definition:
It is the documentation of the assessment done in
the ER department for every patient.
P urpose :
1. To ensure that every patient coming to the
ER department has a complete assessment done
and this assessment is documented .
2. To obtain data for statics done about the
cases attend the ER
department.
3. To ensure the presence of data for quality
activities done for ER
department.
P olicy & P rocedure :
1. 1.ER assessment form should be completed for
every patient attend the ER. Either before
Discharge or Addmision.
2. The ER nurse on duty must document the
following information in the ER form for every
patient :
-Time of arrival
-Mean of arrival

-Vital signs
3. The ER physician on duty must document the
following information in the ER form for every
patient :
- Time of Start the Examination
- History of illness
- Allergies to medications, environment and food
- Physical assessment and reassessment
- Suspected diagnosis
- Any investigations requested
- Treatment given
- Time of the consultation, per arrival of consulting
service.
- Time of admission to a unit and\or discharge
from ER
Patient condition at time of discharge or
transfer to unit or other facility.
4. All ER forms must be filed in the patient file to
be retrieved with any future visits.
5. A copy of ER form must be saved at the ER
department.
Accountabilit ies :
Ref ra nces:
ER Physician
ER Nurse
Dr.Ali ELshehery -ER
Consultant of
HIO
MR Staff
Emergency X-Rays Ordered
Policy Title
reading
6
Policy No.
Related
departement

ER

Definition :
It is reading of the emergency ordered x-ray by the

radiologist.
Purpose :
1. To read and make a report for the x-ray done.
2. To give the appro priate treatment and
management to the patient .
Policy :
1. Patient's x-ray should be read by the radiologist
within 30 minute
2. X-ray technician should be called when x-ray
ordered after duty hours through( technician
24bhours Rota)
3. Radiologist should be called when immediate
reading is needed.
Procedure :
1. When the attending physician ordered x-ray, the
physician will complete and sign the x-ray request
form and mark the x-ray needed
.
2. The patient will go to the x-ray department with
the x-ray request.
3. The patient will be sent to the x-ray by the worker
and/or the nurse either by wheel chair or stretcher
depends upo n the condition of the patient .
Sue z Hos pital
4. The x-ray technician will receive the patient and
do the x-ray .
5. The x-ray film will be sent to the radiologist to
read and make a report .
6. The x-ray film together with the report will be
given to the patient or will be sent to the attending
physician.
7. When x-ray ordered after duty hours, the
attending physician will ask central to call the
scheduled o n call x-ray technician.
8. The x-ray technician will come within 10 minutes
and do the x -ray.
9. When immediate reading is needed or radiologist
opinion is needed, the attending physician will ask
the central to call the scheduled on call radiologist,

and within 10 minutes he will arrive.

Accountabilities:
Technician of X.Ray
Radiology Specialist
Refrances:
Dr. Ali Elshehry -ER Consultant of HIO

Response Time to ER Call

Policy Title
7
Policy No.
Related
ER
departement
Purpose :
To standardize the time of response to ER calls.
Definition:
It is the process of determining the time between
the call of the specialist or consultant
for
consultation
in ER and the arrival of this
specialist or consultant
Policy and Procedure:
1. Every patient coming to ER must be
assessed firstly by the ER
physician .
2. If the case needs to be seen by another
specialist or consultant the ER
physician will call the required physician.
3. The ER physician will inform the required
specialist
or
consultant about the case to
determine the capability of the hospital to receive
this case .
4. If the case included in the scope of service of
the hospital the called

physician will be come.

5. The maximum time permitted to the called
physician for arrival to
ER is 30 min.
6.
The central clerk will register in the on call
record the time of calling and the time of arrival of
the called physician.
7. The central clerk will submit a monthly report
for response time to the ER Director.
Accountabilities:
ER Director
ER in duty ( Specialist&Consultant)
Central clerk
Refra nces:
Dr.Ali ELshehry ER Co nsultant of HIO

Policy Title
Policy No.
Related
departement

Transfer to Another Hospital

8
ER

Tra nsfe r to A not he r Hospital

PURPOSE:
To transfer the patient to another institution when
there are no available specific health services or
there is no vacant bed in the hospital.
PROCEDURE:
- The treating physician will write a detailed report
inclu ding the:
History
Physical examination
Investigations done
Initial diagnosis and diagnosis reached
Cause of referral

- This report will be send by fax to the respective

institution for approval of acceptance, or the
treating physician will contact directly the
respective doctor in the needed institution for
referral.
- The patient and/or his family should be informed
about the transfer and explain to them the cause of
referral.
- The treating physician must assess the patient
before transfer.
- The treating physician must determine the
condition of the patient before transfer.
- And the type of transfer needed - ambulance or
Medieval
-And who will acco mpany the patient
Doctor
Or both Doctor &Nurse
RESPONSIBILITIES:
o Treating physician or his team
o In-charge nurse
o Admissio n officer
Refra nces:
Dr.Ali ELshehry ER Co nsultant of HIO
Policy Title
Policy No.
Related
departement

Ambulance Checking
9
ER

De f i n i t i o n :
It is the process of checking the medical ambulance
bag.
P urpose :
To ensure the availability and expiry date of all
drugs needed in the ambulance & to ensure the
functionality of all ambulance equipments.

P olicy :
1. Medical ambulance bag should be checked daily
and after each use.
2. Equipments in the ambulance should be checked
daily.
3. Male ER head nurse is responsible for
checking
the
medical ambulance bag and all
equipments available in the ambulance.
P rocedure :
1. The head nurse of the ER department will
checked
the
medical ambulance bag for the
availability of all drugs needed and if all equipments
available in the ambulance are functioning well
every day and after each used.
2. The head nurse of the ER department will
checked the availability and functionality of the
following equipments :
- Oxygen supply
- Intubation set
- C-Spine cuff
- Spinal board
- Suction equipment
3. When the medical ambulance bag is used, all
drugs will be replaced immediately from the
pharmacy.
4. When any equipment found not functioning,
the head nurse will remove it from the
ambulance ;and the hospital maintenance or
engineer will be informed After checking, the head
nurse who did the checking will document and sign
in the checklist form .
Accountabilities:
ER Head Nurse
Refrances:
Dr.Ali ELshehry ER Consultant of HIO
Policy Title
Policy No.

Call Consultants For Opinions

10

Related
departement

ER

De f i n i t i o n :
It is the process of calling the consultant when
needed.
P urpose :
To do the proper way of calling the consultant
when his/her presence or opinion is needed .
P olicy :
The on duty ER physician who can decide
and determine when a consultant should be
called .
P rocedure :
1. After admitting the patient in ER, the on duty
ER physician will examine the patient.
2. If the ER physician found out that the patient
should be seen by the consultant and/or the
specialist or an opinion of the consultant and/or
specialist is needed the ER physician will inform
the patient and/or relatives.
3. During duty hours, the ER physician will call the
consultant and/or specialist in his/her clinic to
inform his/her regarding the patient then he will
send the patient along with the file to the clinic
4. If the patient is very ill and cannot go to the
clinic, the ER physician will call the consultant
and/or the specialist and inform him/her regarding
the patient and ask him/her to examine the patient
in ER .
5. After duty hours, the ER physician will call each
Depart. and ask to call the consultant and/or the
specialist in (duty rota)

6. The central will refer the call to ER department

and ER
physician will inform the consultant
and/or specialist regarding the patient to take
his/her opinion.
7. The consultant and/or specialist needs to come
and see the patient by him/her self within 30
minutes, the consultant and/or specialist will arrive
at ER to examine the patient and to do the proper
management to be given to the patient.
Accountabilities:
Refrances:
ER physician
Dr.
Ali ELshehry
ER specialist&Consultant o n duty
ER
Consultant of HIO
Policy Title
Policy No.
Related
departement

Patient Who Leave Without Being

Seen
11
ER

DEFINITION:
It is situation in which the patient leaves the ER
department wi thout being seen
PURPOSE:
To know the proper procedure to be done when
patient leave without being seen and to prevent any
legal consequences.
POLICY PROCEDURE:
1. Department head nurse should be informed when
any patient leave without being seen.
2. The attending nurse should document in
patient's file that the patient leave without being

seen and the reason for leave.

3. The attending nurse should sign in patient file.
4. The ER doctor on duty should be informed about
this patient and must sign in the patient's file.
5. The attending nurse should register in the
department logbook that the patient leaves without
being seen by the physician.
Accountabilit ies:
ER Physician
ER Nurse
Refra nces:
Dr.Ali ELshehry ER Co nsultant of HI
Policy Title
Policy No.
Related
departement

Emergency Lab. Results

12
ER

Definition:
It is the process to be followed when lab results is
needed urgently.
Purpose:
1. To urgently diagnose the patient disease.
2. To provide the proper treatment and
management urgently.
Policy:
1. Lab result should be provided as soon less
than"1" hour for urgent cases.
2. Lab result should be provided within "30" min. not
more for critical cases.
Procedure:
1. When laboratory investigations needed, the
attending
physician
will mark the laboratory
investigations needed in the lab request form and
will complete and sign the request form.

2. The attending physician will inform the lab

technician regarding the investigations needed and
on urgent result is a must.
3. The attending nurse will see the lab
request
then
choice
the appropriate tube or
container for the requested investigations.
4. The attending nurse will extract blood form
the patient with the amount needed, then he/she
will put the blood in the proper tubes.
Sue z Hos pital
5. If urine and/or stool analysis are requested,
the patient will be assessed to go to bathroom
and a container for urine and/or stool will be given
to the patient and asked to put little amount of
urine and/ or stool, if the patient cannot go to
bathroom, a bedpan will be provided to the patient .
6. The blood samples, urine and/or stool sample
will be sent to the laboratory immediately either
by health giver or a nurse .
7. The lab technician will receive the sample and do
the investigations needed as soon as possible within
30 minutes 1 hour or less than ( depends upon the
investigations needed and the patient's case ) .
8. If lab physician's needed either to see the lab
results and/or to do the investigations by himself,
the central will call him ( see how to call consultants
procedure ) .
Accountabilit ies:
ER physician& ER specialist
Lab. Technician
Refra nces:
Dr. Ali ELshehry ER Consultant of HIO
Policy Title
Policy No.
Related
departement

On Call Rotas In ER
12
ER

Definition:
It is the process of putting the on call rotas of all
specialties in the ER to be posted and available for
ER physicians.
P urpose :
To ensure that the rot's of all specialties are
available to the ER physician to use them when he
wants to call for consultation in any specialty .
P olicy& P rocedure :
1. Every department
head must
make a
schedule for the on call physicians during all
days of the month including weekend .
2. The schedule of on call physicians during
the month of every department must be prepared
before the end of the previous month.
3. The prepared schedules of all departments
then sent to the medical director to be signed.
4. Assistant, Medical Director will then make
a copy from the schedules of all departments
and send it to be posted in the ER in the story board
of the ER.
5. At the first of every month, the Head of ER must
ensure that all on call rotas for all specialties are
available and posted in the emergency room.
Accountabilities:

Department Heads
Head of ER
Medical Director
Ass. Medical Director

Refra nces:
Dr.Ali ELshehry ER Co nsultant of HIO
Policy Title

Patients With Potential Medicolegal

Implications

Policy No.
Related
departement

14
ER

PURPOSE OF POLICY:
To outline the guidelines to be followed in dealing
with cases that could potentially have medico-legal
implications. These guidelines should be followed
in the technical and administrative departments.
Potential medico-legal cases include: alcohol and
narcotic abuse, sexual abuse, murder, suicide, rape,
and all kinds of poisoning.
POLICY PROCEDURE:
The hospital receives and resuscitate patients with
potential medico -legal implications only through
the ER department and the following guidelines
should be carefully observed.
1- If the patient needs life saving procedure, the ER
doctor will dealing primarily with the case and call
the consultant in charge according to the case.
2- The police is notified by the administratio n.
3- Safety and Security Department should be
notified of the incident to undergo the following:
a. Notification of the Hospital Administration via the
Security
Supervisor.
b. The Administration will notify the Police.
c. A Committee should be formed to examine the
patient and write a detailed medical report (after
receiving a letter from the police), a treatment plan
should be outlined when necessary.
d. A co py of the medical report is sent to the police
via the administration
4- The administration will arrange with the police to
refer the patient to another governmental hospital.

5- If any case of medico-legal implication is

referred to the hospital from any other hospital, it is
not accepted in the hospital but the police will be
notified.
6- In all cases with potential medico-legal
implications, information about the patient or
results of medical investigations are considered
confidential and are not to be displayed except to
the concerned authorities.
7- In all such cases, the patient cannot be
discharged except after notification of the police to
receive the patient.
Accountabilit ies:
High Administration
Department of safety & Security
Emergency Department
Refrances:
Dr.Ali ELshehry ER Consultant of HIO