Emergency department checklist and quality indicators for NABH accreditation preparation

Emergency department checklist and quality indicators for NABH accreditation preparation

      Emergency is an integral part of any hospital. Quality of emergency care depends upon several factors related to its infrastructure, design and processes. In NABH standards, there are several requirements that relates to the functioning of emergency and it must be taken care of by a hospital while preparing for accreditation. Below is the list of all such requirements which has been picked from NABH standards and observations made during assessments.

1. Requirements related to Infrastructure and design of emergency department

a. Emergency department should be on ground floor OR its entrance should be easily accessible by ambulance
b. It should have a separate and dedicated entry. The road should reach till the emergency entrance for making it accessible to ambulance. The road should also allow for easy U-turn of the ambulance. (Please also see the checklist of Ambulance)
c. The main entrance of the emergency should be wide enough for easily moving 2 or more stretchers at the same time
d. If there are stairs to access emergency a ramp should also be there to facilitate movement of wheelchair and stretchers. The width of the ramp should be sufficient to easily accommodate a wheelchair or a stretcher.
e. The doors of the emergency should not be locked from inside. It should open wide enough to accommodate stretchers and wheelchairs
f. The stretchers and wheelchairs should be kept available in a dedicated bay immediately outside the main entrance. A signboard can be put for the same
g. Inside the emergency, there should be dedicated areas for triage, emergency processes (like wound care, gastric lavage, fracture handling etc.) and for emergency observation. Others support areas that should be there in
emergency includes, nursing station, store (separately for clean and dirty items) and duty doctor’s chamber
h. As emergency plays an important role in handling of mass casualty. Necessary arrangement for the same is required in emergency department. They include dedicated storage of medicines and consumables required during mass casualty and identification of a place where mass casualty patients can be accommodated. 
i. The emergency department and ward should have sufficient space for carrying out patient care activities and circulation
j. Facility should be safe, for eg. Non-slippery, safe electrical fittings, no accidental spots etc.
k. Inter-bed distance in emergency ward to be maintained at around 6 feet in emergency observation ward
l. Hand washing area easily accessible to healthcare staff
m. Accessibility of fire-fighting equipment
n. Crash cart placed at a location from where it could be immediately accessed when required
o. Patient’s washroom should have safety arrangements (anti-skid mats, emergency call button, grab bars, disabled friendliness, door opening outside, latch type locking which can be opened from outside)
p. Adequate privacy arrangement for patient
q. Availability of all necessary emergency care equipment
r. Bio-medical waste bins as per BMW rules
s. Separate or segregated storage area for clean and dirty supplies
t. Emergency exit route and its display
u. If emergency department has a separate operation theatre, the requirements related to operation theatre becomes applicable to it


2. Requirements related to staffing

a. Emergency medical officer, who should at-least be MBBS and preferably have training in emergency care. In a higher level emergency department, a critical care specialist or an anaesthesiologist should be the in-charge of emergency department.
b. Nurses who are trained in emergency nursing care
c. Specialist (on call) in case, emergency related to their field comes. List of on-call specialist depends upon kinds of emergencies frequented at the hospital. However, doctors of few basic specialities such as paediatrics, orthopaedics, obstetrics should be always kept on call
d. Support staff
e. Emergency department should be functional round the clock. Staff should be posted in all shifts.
f. Number of staff depends upon the workload of the emergency and should be determined by the hospital


3. Requirements related to management of emergency department and its ward: 


Since emergency has many activities similar to ward, several requirements related to ward management are also applicable here. Specifically, they are

a. Linen on patients’ beds to be changed daily and as and when required (or as defined by hospital’s policy)
b. Periodic cleaning of mattresses, pillow and other bed items
c. All emergency medicines should be available as per defined quantity
d. Mechanism of replenishing emergency medicines to be followed
e. The stored medicines should follow protocols for lookalike sound alike medicines
f. High risk medicines to be identified and stored separately
g. Multi-use open vials to have labels of date of opening and date of expiry
h. If NDPS are temporarily stored, it should be under lock and key. NDPS regulations to be followed
i. If spirit is stored in higher quantity, it should be kept under lock
j. Proper identification of patient before carrying out any patient care activity
k. Maintenance of patient’s records as per hospital’s policy
l. Reporting of adverse patient events
m. List of hazardous materials in the emergency to be identified and MSDS sheet for them should be available
n. Temperature of refrigerator in which medicines are stored should be monitored and recorded, at-least once in each shift
o. Crash cart should have all life-saving drugs and equipment. It should be replenished whenever used
p. Bio-medical waste should be segregated as per regulation
q. All areas of emergency, including washrooms should be maintained neat and clean
r. Clean supplies and dirty used items should be stored separately
s. Maintenance of necessary registers (admission-discharge-transfer, stock, laundry, adverse incident register etc.)


4. Policies and protocols applicable to emergency

a. Emergency handling protocol for commonly visiting emergencies such as snake bite, poisoning, accidental cases etc.
b. Emergency handling protocol for paediatric cases
c. Triaging of patients
d. Medico-legal cases handling
e. Handling of brought in dead cases
f. Handling of mass casualty situation
g. Admission, discharge and transfer from emergency. A discharge/transfer note to be provided to patients
h. Transfer of stable and unstable patient

5. Staff to be aware of following

a.  All applicable policies listed above
b. Components and time-frame for initial assessment of emergency patients
c. Uniform care policy and patient care processes that falls under it
d. Patients’ rights
e. Dealing with HIV +ve patients and maintaining confidentiality
f. Provision of basic cardiac life support
g. Code blue policy and procedure
h. Other emergency codes (such as code pink, code red, code yellow etc.)
i. Identification and care of vulnerable patients
j. Safe medication practices (things to check before administration, monitoring, verbal orders, administering high risk medicines etc.)
k. Safe blood transfusion practices
l. Policy and procedure of patient’s restraint
m. Pain management policy and protocol
n. Standard precautions for infection control (hand hygiene, use of PPE etc.)
o. Safe injection practices
p. Medical errors, its types and reporting (such as near miss, sentinel, adverse drug reaction etc.)
q. Emergency evacuation plan
r. Their role during any disastrous situation
s. Quality indicators of emergency department


6. Quality Indicators of emergency department

a. Average time taken for initial assessment of emergency patient and outliers
b. Percentage of patients returning to emergency within 72 hours with similar complaints
c. Incidence of medication errors
d. Percentage of adverse drug reactions
e. Percentage of patients receiving high risk medicines and developing adverse drug reaction
f. Percentage of transfusion reaction
g. Percentage of near miss events
h. Incidence of patient falls
i. Percentage of non-compliance observed related to infection control practices

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