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KINGDOM OF SAUDI ARABIA

MINISTRY OF HEALTH
AL CIASSIM REGION
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BDGH ti-r,al I <il ljg
ALBADAYA GENERAL HOSPITAL \4inistry ()l'[-lcalth

ADMINISTRATIVE POLICY AND PROCEDURE (APP)

DEPARTMENT: EMERGENCY ROOM
TITLE/DESCRIPTION POLICY NUMBER
HOSPITAL TRANSFER POLICY APP-ERD.OO4.V3
EFFECTTVE DATE REVISION DUE REPLACES NUMBER NO. OF PAGES
09-06-1440H 09-06-r443H APP-ERD.OO4-Y2 4
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR ER Staffs, Medical, Nursing,Transportation

PURPOSE
This policy is to set the guidelines for the procedure to be followed whenever a patient is to be
referred both within and outside the hospital.
DEFINITION
1. Internal Referral - is the referral of a patient within the facility; this may be intra-or
interdepartmental.
2. External Referral - is the referral of a patient from BDGH to any other health care
facility or vice- versa.
RESPONSIBILITIES
Specialist /Consultant (Medical, Surgical , Ortho , ,pediatrics)
POLTCY
It is the policy of BDGH that all referrals (internal & external) to & from the hospital should be according to
the approved process implemented by the Ministry Of Health
PROCEDURES
A- Internal referral : The ED Doctor may refer patients directly to any Specialty on call team
or to the specialty clinics. Where possible, before referring the patient
to another specialty, the Consultant in charge of ED should be asked to
review the patient. This allows for more definitive diagnosis and may
prevent unnecessary delays for the patient.
l- Same dav appointment should be made only after doctor-to-doctor
communications . This ensures that the patient prioritized according to need and
that the full information regarding the need for urgent appointment is known.
Once an agreed appointment is made the Central Appointment desk will
pull the patient's Medical file in the case of a new patient ensure that file is
opened.
2- Anpointment for latu date should be made through Central appointments.
The referral must state the name of the Specialty Clinic.
3- referral to obstetrics & wnecologv
A. All patients should have their initial assessment by E.R. physician, when indicated.
E.R. physician will initiate all stabilizing measures (LV. fluids, oxygen, draw

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huarty
KINGDC,M OF SAUDI ARABIA
MINISTRY OF HEALTH atc
4IF
BDGH
AL CIASSIM REGION
ALBADAYA GENERAL HOSPITAL
li -'., ll <illjg
t'tinisl r-l' oi' Hcalllr

ADMINISTRATIVE POLICY AND PROCEDURE (APP)

DEPARTMENT: EMERGENCY ROOM
TITLE/DESCRIPTION POLICY NUMBER
HOSPITAL TRANSFER POLICY APP-ERD-OO4.V3
EFFECTTVE DATE REVISION DIIE REPLACES NUMBER NO. OF PAGES
09-06-1440H 09-06-1443H APP.ERD.OO4-V2 4
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR ER Staffs, Medical, Nursing,Transportation

appropriate blood tubes for type cross-match, monitor, etc.) as the condition may
require.
B. Pelvic examination WILL NOT be performed by E.R. Physician.
C. All pregnant patients over 20 weeks of pregnancy regardless of their complaints
should have fetal heart monitored and recorded on the patient's file.
D. The E.R. Physician is responsible for any patient in the Emergency Department
from the time of arrival until the patient is seen by OB /GYN. Physician and he/she
assumes care of the patient.
E. No referral of Emergency patient to OB /GYN Clinic.
F. All the above ( A,B,C ) are guidelines that should be followed. Please use
your best medical judgment for the maximum benefit of your patient.
G. Please refer to Consultant if you have any questions or you need any help

MANDATORY CONSULTATION TO OB/GY\

The E.R. Physicians shall get OB/GYN. Consultation after examination
and evaluation of every pregnant patient in the following categories:
a. The Pregnant with history of hypertension or any pregnant will BP 140 Svstolic or
90 Diastolic or above.
b. Pregnant with history of diabetes mellitus whether on treatment or not.
Pregnant with blood sugar over 150 mg/dl without a history of diabetes mellitus.
d. All febrile Pregnant women.
e. All cases with vaginal bleeding.
f. Patient in Labor.

COMMUNICATION WITH OB/GYI\E

a. The E.R. Physician or his designee (Resident or a Nurse) may bleep or call the
OB/GYN. Resident to report to Emergency department.
B If there is no answer after five minutes, another call is placed. If there is no answer
after another five minutes, the E.R. personnel should call the OB/GYN Specialist on-
call.
c. If the OB/GYN Specialist does not respond within 5 min., the Consultant
OB/GYN. Should be called.

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 ,4IF
fL KINGDOM OF SAUDI ARABIA
a'src
Wudity MINISTRY OF HEALTH
BDGH
AL CIASSIM REGION ri r, ll <i1ljg
ALBADAYA GENERAL HOSPITAL \4i11ist r) ()l' l-lealllr

ADMINISTRATIVE POLICY AND PROCEDURE (APP)

DEPARTMENT: EMERGENCY ROOM
TITLE/DESCRIPTION POLICY NUMBER
HOSPITAL TRANSFER POLICY APP.ERD.OO4-V3
EFtr'ECTIVE DATE REVISION DUE REPLAcEs NUMBER i No. oF PAGES
09-06-1440H 09-06-t443H APP.ERD-OO4.Y2 4
BY APPLIES TO
HOSPITAL DIRECTOR ER Staffs, Medical, Nursing,Transportation

d. The OB/GYN Specialist should report to Emergency Department within 15 minutes

of answering the call. He / She will evaluate the patient and communicate with her/his
Specialist or Consultant. They will be in charge of that patient and the responsibility
of E.R. Physician will cease.
e.If patient's condition is very urgent, that an immediate action should be
taken the on-call OB/GYN Team (Consultant, Specialist, Resident) will be
called an immediate response is expected while patient is being stabilized in
E.R. pending further definitive management
B- External referral :
l. In some cases it may be necessary to transfer an E.R. patient to other hospital. In
such cases the physician who made the decisions to transfer will be responsible for
coordinating arrangements with the accepting hospital.
2. All transfer to higher center should have a prior acceptance either by fax or
telephone by the responsible doctor. For patients requiring ambulance transport the
normal transport iurangement apply. All ambulance before leaving should be
thoroughly checked for equipments.
3. In all cases, the Referral Form should be completed and sent with transferred patient,
in addition to copies of laboratory results and X-rays if available.
4. The referral form should include reason of referral with current patient situation
including history, physical examination with vital signs, all medication & IV fluid
taken.
5. No patient will be transferred without such transfer being approved by the
responsible practitioner
BQUIPMENTS
Fax / Telephone I

'

REFERENCES
CBAHI STANDARDS
MINISTRY OF HEALTH
FORMS
Referral Form ER referral form / O.P.D referral form

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hualitv
KINGDOM OF SAUD! ARABIA
MINISTRY OF HEALTH
AL CIASSIM REGION
aic 'rtIF

BDGH ti-:.,al I <i1ljg

ALBADAYA GENERAL HOSPITAL tairristry <.rl' ltcirltlr

ADMINISTRATIVE POLICY AND PROCEDURE (APP)

DEPARTMENT: EMERGENCY ROOM
TITLE/DESCRIPTION POLICY NUMBER
HOSPITAL TRANSFER POLICY APP.ERD.OO4.Y3
EFFECTM DATE REVTSION DUE REPLA@ NO.OFPAGES _
09-06-1440H 09-06-1443H APP.ERD-OO4-Y2 4
APPROVED BY APPLIES TO
HOSPITAL DIRECTOR ER Staffs, Medical, Nursing,Transportation

APPROVAL

Name Designation Signature Date

Prepared by:
Mrs. Hasnaa Al Shafee ER supervisor 9t6t1440H
I
Reviewed by: 9l6lt440H

w
Dr. Maged Abd Rabu Head of ER
*-"\€ )r
Reviewed by: 9l6lt440H
Mr.Sultan Bajid Al Muteiri Nursing Director

Reviewed by: Asst Hospital Director 9l6lt440H

.r 6-
Dr. AliMohd Ali for Medical Services (J-/

Reviewed by: 9l6lt440H

Mr,Hamed Al Khoweitir QPS Director
H
Approved By:
Mr.Mousa Hamoud Al
Shuwayeb
Hospital Director
/ I 9l6lr440H

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