BMQR

                                                   Policy and procedure on care of obstetric patients 1.0 PURPOSE: To define policies guiding the care of Obstetric patients.   2.0 SCOPE: All obstetric patients, including high risk cases, undergoing treatment.   3.0 RESPONSIBILTY: Anesthesiologist, Gynecologist, Pediatrician, Labour Room staff NICU staff, Nursing Superintendent, Dietician   4.0 ABBREVIATION: NABH: National Accreditation Board for Hospitals and Healthcare providers COP: Care of Patients   5.0 REFERENCE: Pre Accreditation Entry Level Standards for Hospitals, First Edition, April 2014.   6.0 POLICY: 6.1 Gynecologist shall train medical officers and staff nurses in care of obstetric cases. 6.2 The assessment of obstetric cases shall include maternal nutrition, immunizations and education. 6.3 High risk obstetrical care shall be provided to required cases by Gynecologist and Trained Medical Officers and nurses. 6.4 Definit

                                                                                                CARE OF VULNERABLE PATIENT                        Policy: The hospital ensures that vulnerable patients (elderly, physically and / or mentally challenged and children) are protected from abuse, which we define as a violation of an individual’s human or civil rights by any other person or persons. A coordinated approach is used to manage any reported instance or suspicion of abuse against vulnerable patients admitted to the hospital.   Hospital has a sensitive, multi professional approach in dealing with disclosures of abuse or possible abuse. This is aimed to •       Protect the vulnerable patients from abuse •       Respond quickly and sensitively to any incident or suspected case of abuse to enable joint working of hospital personnel with external services when necessary.   Safe and Secure environment for vulnerable patient •       To ensure a safe environment for all vuln

                                                      CARE OF PATIENT UNDER SURGICAL PROCEDURE  Purpose: To promote patient safety by providing guidelines for verification of correct site, correct procedure, and correct patient for invasive/surgical procedure(s).   Scope: This policy applies to all invasive/surgical procedure including bedside invasive procedures performed. This policy does not apply to vein puncture, peripheral IV placement, insertion of nasogastric tube or insertion of a catheter.   Policy: Surgical /invasive procedures shall be performed by surgeons/physician who are privileged after necessary credentialing, by the hospital for that procedure.   All patients who have to undergo surgical procedure (planned or emergency) shall have a pre-operative assessment done and a provisional diagnosis written, prior to surgery. The pre-operative assessment and provisional diagnosis shall be done by the operating surgeon. Pre-operative orders shall be explained proper

                         POLICY AND PROCEDURE ON BED MANAGEMENT IN ICU   Policy: ICU shall try to keep 10% of its beds vacant at all times to meet any unexpected emergency situations.   ICU beds shall be used only for patients who require Intensive care. Admission to ICU shall be guided by admission criteria as given in document ‘admission and discharge criteria’. Patient shall be discharged from ICU as soon as discharged criteria are fulfilled.   In case of bed shortage in ICU, patient requiring Intensive care shall be managed in ER ICU. Every effort shall be made to arrange a bed for the patient by discharging the patient from ICU who meets the discharge criteria. (TRIAGE policy may be considered in selecting patients requiring ICU care)