Health Insurance organization

Suez Hospital

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Emergency Department Policies Index

Serial Policy Policy
No. No.
1. Triage ER 1

2. ER Mangment of Trauma Patient ER 2

3. Obtaining an Emergncy CAT Scan ER 3

4. Patients Who Leave Against Medical ER 4

Advice
5. Emergency Assessmen Form ER 5

6. Emergency X-Rays Ordered reading ER 6

7. Response Time to ER Call ER 7

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

12. Emergency Lab. Results ER 12

13. On Call Rota”s In ER ER 13

14. Patients With Potential Medicolegal ER 14

15. Infection Control in ER ER 15

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( Triage )
SZ-H \ ER 1

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








4
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-
-
-
-
-
-

-
-
-
-
-
-
-

-
-
-
5
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-
Shock -

-
-
-
-
-
-

-
-
-
-
-

-
-
-

6
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-
-
-
-
-

-
-
-

-
-
-

7
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



GCS

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









-
-
-

shunt

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10
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-
-
-





11
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GCS








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GCS




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ER Mangment of Trauma Patient

SZ-H \ ER 2

Purpose:
It is to put the outline and guideline to manage polytrauma patients in
ER.

Definitions:
Polytrauma patients are those patients coming to the hospital with more than
two systems involved in trauma, e.g. Accidents

Policy:
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.

Procedure:

PHASE I :

a) Airway:
 Oral toilet to remove blood or dentures
 Oropharyngeal airway to clear obstructed tongue
 Endotracheal intubation if indicated.

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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 condition.
 Ionotrophic support
 Haemostatic measures by pressure dressing.

PHASE II :

a) Initial rapid overall assessment of patients

 Baseline monitoring – level of consciousness
 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,
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coronary/diabetic etc.)
g) X-ray and other investigation (USG/CT)
h) Drug Therapy:
 Anti tetanic serum
 Antibiotic if indicated
 Methyl prednisolone

i) Transfer to ICU

PHASE III :

Specific surgical intervention:

a) Compound fracture
b) Decompression of brain
c) Decompression of cardiac tamponade
d) Acl. Abdomen (laparotomy and proceeding)

Accountabilities:
 ER doctor and Nurses
 Surgical consultant or Specialist
 X- ray Consultant or Specialist
 Laboratory
Refrance:
Dr. Ali ELshery -ER Consultant of HIO

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Policy Title Obtaining an Emergncy CAT

Scan
Policy No. ER 3
Related ER
departement Policy :
It is the process to be taken when obtaining an emergency CAT scan for
trauma cases within 30 minutes or as soon as possible .

Purpose :
To obtain CAT scan for trauma cases immediately .

Procedure :
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 .

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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 .

Responsiblities

 Specialist or Consultant in ER
 Technician&Specialist in Radiology Dep.

Refrance:

Dr. Ali Elshehry -ER Consultant of HIO

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Policy Title Patients Who Leave Against Medical Advice

Policy No. ER 4
Related ER
departement

Definition :
It is discharging a patient from the hospital upon his/her own desire and
responsibility .

Purpose :
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 .

Policy :
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.

Procedure :
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 .

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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

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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 .

Accountabilities:

 ER doctors
 ER nurse

Refrances:
Dr. Ali ELshehry -ER Consultant of HIO

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Policy Title Patient Assessment

Policy No. ER 5
Related ER
departement

Definition:
It is the documentation of the assessment done in the ER department for
every patient.

Purpose :
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.

Policy & Procedure :

1. 1.ER assessment form should be completed for every patient attend

the ER. Either before –Discharge or – Addmite
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

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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.

Accountabilities : Refrances:
- ER Physician
- ER Nurse Dr.Ali ELshehery -ER Consultant of
HIO
- MR Staff

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Policy Title Emergency X-Rays Ordered reading

Policy No. ER
Related ER
departement
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 appropriate 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 upon the condition of the
patient .

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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 on 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

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Policy Title Response Time to ER Call

Policy No. ER
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.

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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

Refrances:

Dr.Ali ELshehry –ER Consultant of HIO

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Policy Title Transfer to Another Hospital


Policy No. ER 
Related ER 
departement 
 Transfer to Another 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 including 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 accompany the patient
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 Doctor
 Or both Doctor &Nurse

RESPONSIBILITIES:
o Treating physician or his team
o In-charge nurse
o Admission officer

Refrances:
Dr.Ali ELshehry –ER Consultant of HIO

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Policy Title Ambulance Checking

Policy No. ER
Related ER
departement

Definition :
It is the process of checking the medical ambulance bag.

Purpose :
To ensure the availability and expiry date of all drugs needed in the
ambulance & to ensure the functionality of all ambulance equipments.

Policy :
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.

Procedure :
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
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- 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

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Policy Title Call Consultants For Opinions

Policy No. ER10
Related ER
departement

Definition :
It is the process of calling the consultant when needed.

Purpose :
To do the proper way of calling the consultant when his/her presence or
opinion is needed .

Policy :
The on duty ER physician who can decide and determine when a
consultant should be called .

Procedure :
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.

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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 on duty ER Consultant of HIO

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Policy Title Patient Who Leave Without Being Seen

Policy No. ER1
Related ER
departement

DEFINITION:
It is situation in which the patient leaves the ER department without 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.

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Accountabilities:

 ER Physician

 ER Nurse

Refrances:
Dr.Ali ELshehry –ER Consultant of HIO

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Policy Title Emergency Lab. Results

Policy No. ER12
Related ER
departement

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.

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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 ) .

Accountabilities:
 ER physician& ER specialist
 Lab. Technician

Refrances:
Dr. Ali ELshehry –ER Consultant of HIO

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Policy Title On Call Rota”s In ER

Policy No. ER1
Related ER
departement

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.

Purpose:
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 .

Policy& Procedure :
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:
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 Department Heads
 Head of ER
 Medical Director
 Ass. Medical Director

Refrances:

Dr.Ali ELshehry –ER Consultant of HIO

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Policy Title Patients With Potential Medicolegal Implications

Policy No. ER14
Related ER
departement

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 administration.

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.
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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 copy 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.

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Accountabilities:

 High Administration
 Department of safety & Security
 Emergency Department

Refrances:

Dr.Ali ELshehry –ER Consultant of HIO

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