Assessment of Patients in Emergency Department

1. Patient presents to the reception registration desk and the Arrival activity is used to search for the
patient’s record using all of the following demographics: Valid ID- Emirates ID/Passport, Patient
Name, Birth date, Gender, Mobile Number, Medical Record Number.
2. Patient record is identified in Salama based on the demographic search.
‐ If the patient already has a record at DHA, the registration clerk will create a new encounter
for the patient and mark an arrival time.
‐ If a matching record does not exist, registration clerk will create a new patient record with a
new ED encounter and arrival time.
3. Patient is being assessed by Tirage Nurse based on patient’s needs and condition and using the
minimum content of nursing assessment in Emergency Department.
4. Ensure by the end of the triage assessment, the following elements are complete on SALAMA
- Chief Complaint
- Acuity
- ED Speciality
- Triage Complete
5. Inform the patient/family member of anticipated length of time prior to being directed to the
physician and the reason for any delay that may occur.
6. Re-assessment for patients
- Re-assess Patients attending Emergency Department, while waiting to see doctor
 Triaged as Immediate T1 Blue , monitor continuously
 Triaged as Immediate T2 Red , monitor every 15 minutes
 Triaged as Immediate T3 Yellow, monitor every 30 minutes
 Triaged as Immediate T4 Green, monitor every 60 minutes
 Triaged as Immediate T5 White , monitor every 120 minutes

7. Identify patients whose condition is deteriorating and reassign acuity and indicate the reason for
reassigning on SALAMA system.
8. Patient is being directed to the physician according to the speciality and shall be assessed based on
the patient’s needs and conditions and using the minimum content of physician’s assessment in ED.
9. Physicians shall ensure to complete the following elements on SALAMA by the end of the ED visit
- Evaluation time
- Signed physician note
- Disposition
- Diagnosis
10. If the patient is being admitted to ED Short Stay, he/she shall be reassessed within 6hours by the
physician and reassessed as per the doctors’ orders by the nurse.
11. Physician shall review all investigations and diagnostic tests requested and mark them as reviewed
on SALAMA system.
12. Incase patient requires urgent nutritional assessment in ED, Nutirtionist shall assess patients in ED
as per their policy.
13. In case the patient needs emergency surgery and there is no time to document the complete
medical and nursing assessment, Physician shall create a case order with a brief note and pre op
orders if needed and call OT.
14. Patient’s family and next of kin are appropriately included in the decision process.
15. In case a patient decides to leave the ED without treatment ensure
• Information is given to the patient or care giver regarding the need to stay for treatment.
• Advice given regarding alternative or ongoing care

- Document the Patient Electronic medical record by entering AMA in the Disposition tab.

- Ensure patient Signs the AMA as per DHA/LWCH/ACC/004 Patients Leaving Against Medical
Advice.

16. - Patients who arrive from PHC as a prearranged case shall be referred through SALAMA system and
are triaged up on arrival by triage nurses and assessed by the Emergency Physician.
- Patients who arrive from outside the organization with a medical report with or without
arrangement with LWCH physicians, shall be triaged and assessed as per this policy in ED by the
Emergency Doctor and Triage nurse.

17. As per the scope of service of LWCH, the following specialties will be seen in Emergency
Department: Pediatric Medical, Pediatric Surgery, Neonatology and Obstetrics & Gynecology

- Any patient who does not fit into the above criteria has to be assessed and treated as Out of
Scope Service
Physician Assessment and Reassessment of Inpatients
1. Assess inpatients including health history and physical examination, within 24 hours from
admission or sooner according to patients’ condition in H&P note in Electronic Medical Record
(SALAMA).
2. Patients who arrive from outside the hospital as a referral case:
- Direct admission as inpatients shall be assessed on arrival by the “on call/Ward
doctor” of the concerned specialty who accepted the patient
- Referred for further assessment from PHC and other health facilities will be assessed
by the emergency physician
3. Patients referred for admission from outpatient clinics of LWCH whether a planned admission or
emergency admission, shall be assessed by the Ward/on call doctor using the minimum content
of history and physical examination required.
4. Patients having assessment reports from other hospitals or outpatient facilities shall be re-
assessed if admitted as inpatients, using minimum content of history and physical examination
required.
5. Diagnostic tests from out of LWCH facilities, will be repeated based on the patient’s condition
and physicians judgement.
6. Specialized assessments
- Patients are screened for nutritional status, functional needs, social needs and other
special needs and are referred for further assessment in case needed.
- Assessment is performed according to the patient’s special needs and conditions
and special populations shall be assessed according to their individualized needs and
characteristics.
7. Assessment findings shall be documented in patient’s Electronic Medical record by the physician
and completed within 24 hours.
8. Patients undergoing a procedure/ surgery will be assessed preoperatively by the
surgeon/Physician using the minimum content.
9. Patients that are to be undergoing a procedure/ surgery that requires anaesthesia will be
assessed by the Anaesthetist prior to anaesthesia using the minimum content.
10. - Re-assessments are done within 12 to 24 hours (including weekends) except for critical cases
where reassessment shall be done within 8 hours.
- Re-assessments of Chronic (stable patients) in ICU will be done once weekly However,
whenever condition of the patient changes and becomes acute then, he/she will be reassessed
accordingly.
- Reassessments are conducted also:
 In response to a significant change in the patient’s condition
 If the patient’s diagnosis is changed and the care needs revised planning
-Re-assessments will be documented in Progress notes in SALAMA.
11. Patient’s family and next of kin are appropriately included in the decision process.
Physician Assessment and Reassessment of Outpatients
Purpose

 To define the set of health related information to be obtained and documented for
outpatients.
 To define who performs the assessment and the minimum content of assessments performed
in outpatient settings
 To ensure that assessments are completed in the time frame set by the hospital.
 To ensure that assessment findings are documented in the patient’s electronic medical record
and are readily available to those responsible for the patient’s care.
 To ensure that each patient’s initial assessment includes an evaluation of physical,
psychological, nutritional, social, functional and economic factors.
 To ensure that individualized initial assessments for special populations are conducted.
 To ensure that the initial assessment of outpatients are appropriate to their needs and
conditions.

Procedure

1. Initial assessment shall be carried out for all the patients attending the outpatient clinic by the
physician from the concerned specialty.
2. The assessment shall be completed within 4 hours by the treating doctor.
3. Treating physician shall perform complete initial assessment with minimal content.
4. Re-assessment shall be done on each visit according to the condition of the patient and shall
include the minimal content.
5. Patient’s family and next of kin are appropriately included in the decision process.
Rehabilitation Therapists’ Assessment of Patients

1. Patients referred for Rehabilitation services are identified through the referral/order including
interdepartmental or cross referrals within the various disciplines of rehabilitation services.
2. Assessment
- Conduct patient’s assessment as per defined criteria.
- Complete & document patient’s evaluation within the first 24 hours of referral for
the inpatient, and the first two visits for the outpatient.
- Document the planned care in the assigned rehabilitation treatment flowsheet in
the patient record in the form of measurable progress goals based on the patient’s
initial assessment data
- Sign the assessment flowsheet by the responsible rehabilitation therapist (Sign
Visit).

3. Reassessment

- For Chronic inpatients, reassessment is done once a month.

- For neuropediatric outpatients, reassessment is done every 6 months.

- For adult outpatients reassessment is done every sixth visit.

- Reassessment of all patients shall be documented in physical medicine and Rehabilitation

Evaluation flowsheet as per changes in patient’s condition and when indicated.

- According to the reassessment of the patient, the plan of care and anticipated goals are
reviewed and updated accordingly.

4. Discharge

- On discharging the patient, a discharge summary shall be written and shall include
Physiotherapy intervention.

 Treatment outcome
 Functional status of the patient
 Impairments/Environmental Limitations
 Activity limitations

- Discharge summary for the inpatient to be written within 24 hours after the patient is being
discharged

- Discharge summary for the outpatient to be written once the patient discontinues treatment at
the rehabilitation section.
Collaborative review of patients’ assessments
1. Purpose/ Scope:
To promote that all healthcare providers responsible for the patient, work together to analyze
the assessment findings and combine the information obtained into a comprehensive picture of
the patient condition. 1.2 To ensure that from this collaboration, the patients’ needs are
identified, the order of their importance is established, and the care decisions are made.
2. Policy statement:
Latifa Hospital shall develop a policy and procedure to promote collaborative review of patients
in order to analyze and integrate patient assessments, identify and prioritize his/her needs and
develop a plan of care. 2.2. Collaborative review of patients will be done by all health care
providers working at Latifa Hospital and involved in the patients care and might include health
care providers from other Dubai Health Authorities facilities when other specialty consultation is
needed.

Procedure:

1. All health care providers concerned collaborate to analyze and integrate patient’s assessment data
to form a comprehensive picture of the patient’s condition.
2. Patient’s needs shall be identified and prioritized based on the results of the data analysis and care
of plan shall be decided accordingly.
3. In case, the patient’s needs are unclear or complex, arrange for formal team meetings, more clinical
rounds and meetings with the patient in order to clarify needs and discuss treatment/intervention
options.
4. Documentation:
 Collaborative review of patient assessment shall be documented along with any meetings,
clinical rounds, plan of care decisions.
 Care plan shall be documented under the title Multidisciplinary Care Plan
(MCP)/Multidisciplinary Management Plan (MMP).
5. Include the patient, his or her family, and others who make decisions on the patient’s behalf in the
decision process when it is needed and document it in the patients’ medical record.
Radiation Safety
1. Definitions / Key Terms:
 Radiation: Ionizing Radiation i.e. X-ray.
 System of Work: A set of rules govern day-to-day practice of using X-ray machine.
 Local Rules: A set of instructions for handling specific X-ray machine to ensure radiographers and
radiology nurse.
 Controlled Area:
 It is a defined area where the access is limited to the authorized radiation employees and
accompanying visitors (patients, patient escort, others….). This implies that a controlled area is
one that requires control of access, occupancy, and working conditions for radiation safety
purposes.
 No persons (other than the patient) may enter a controlled area unless they are acting in
accordance with the written System of work and activity appropriate to that area.
 Non-radiographic staff and members of the public should not remain in the controlled area,
unless their presence is essential and they are supervised by a radiographer or a radiologist.
 Supervised Area :
 It is an immediate neighboring area to the controlled area, where occupational exposure
conditions may need to be kept under review even though specific protection measures and
safety provisions are not normally needed. Supervised areas are mainly required in facilities
using radiation sources. Individual dosimeters are not mandatory.
 Entry to a supervised area is not restricted for authorized staff (i.e., staff carrying out essential
duties).
 A supervised area is under the supervision of the radiographer assigned to that area, who may
instruct people where to stand, refuse access to the area and not permit certain actions, if they
constitute an unnecessary radiation hazard.
2. Purpose
 To ensure that workers and public are not exposed to radiation in excess of the operational
limits specified under the federal law No. (1) of 2002 regarding the regulations and control
the use of radiation sources and protection against their hazards.
 To ensure availability of appropriate equipment, personnel and expertise for patient safety.
 To ensure timely detection and prompt rectification of radiation safety related or
malfunctioning of the equipment.
 To provide information and guidance on safety procedures & practices for those staff
involved either directly or indirectly with the use of ionizing radiation for diagnostic
purpose.
3. Scope of application
 3-1 This policy commences for all the outpatients and inpatients who need radiology
services.
4. Applicable To
 All radiation workers, healthcare providers (who are assisting the patients for radiology
procedures), patients, escorts and the public who are visiting the radiology section.
5. Procedure/Steps
I. Location of Controlled & Supervised Areas
 Room 1 (General Radiography & Tomography)
 The whole of X-ray room is designated as a controlled area which includes the area
behind the protective screen.
 The entrance to the controlled area is clearly indicated. Warning light indicates
when the X-ray generator is switched on and exposure is in progress.
 No supervised area is designated.
 Mobile X-ray Unit
 The controlled area around a mobile X-ray unit extends to 2 meters from the
scattering center (i.e., the exposed part of the patient).
 No supervised area is designated.
 Mobile Radiograph Intensifier Unit (C-arm)
 The controlled area extends to 2.5meters from the exposed region of the patient if
a permanent solid barrier (e.g., the walls of the room) lies within the 2.5 meters, the
controlled area ends at the barrier.
 A supervised area exists up to 4 meters from the exposed part of the patient if a
permanent solid barrier (walls of the rooms) lies within the 4 meters, the supervised
area ends at the barrier.
 The Radiation Protection Unit should be consulted if there is any doubt as to the
attenuation offered by the barriers.
II. SYSTEM OF WORK
All staff and visitors (including X-ray service engineers) who are required to work within
the controlled area may do so only in accordance with the System of Work. The System
of Work is designed to ensure that non-classified radiation workers do not receive more
than 30% of the adult occupational dose limits.
 All Staff
 Only suitably trained and qualified staff should operate the X-ray equipment.
 Only essential staff should remain in the controlled area during an X-ray exposure.
 All radiation workers should wear the Personal Radiation dosimeters and if
protective lead clothing is worn, the dosimeters should be under the lead clothing.
 During X-ray exposures staff must wear a protective lead apron unless positioned
behind a permanent protective screen.
 No one should enter the x-ray room when the warning light is lit.
 The doors must remain closed during an X-ray exposure.
 All radiation workers should avoid restraining, positioning or comforting patient
during the exposure. Support for patients undergoing an X-ray procedure, if
required, should be achieved by mechanical means where possible. If assistance is
required, the patient’s relative or non-radiation worker can assist by using lead
protection clothing.
 Portering Staff
 Should enter the controlled area only under supervision of the radiographer
present in the room.
 Must leave the controlled area before X-ray procedures commence
 Works & Maintenance Staff
 Maintenance work should only be done when the X-ray equipment is switched off
at the mains. During this time, the room is not a controlled area.
 Maintenance staff should only enter the controlled area with the permission of
the clinical supervisor or the concerned radiographer present during the time.
 Domestic Staff
 Domestic staff should not enter the controlled area unless accompanied by a
radiographer or any other professional.
 Visitors
 Visitors should not enter the controlled area unless supervised by a radiographer.
 Visitors who support the patient must wear appropriate protective clothing, as
directed by the radiographer.
 Pregnant Staff
 Staff who are pregnant or who are suspecting pregnancy must inform the facility
radiation protection officer.
 The pregnant staff should fill "Staff Pregnancy Form" and forward it to the
Radiation Protection Unit.
 Pregnant staff should not perform all fluoroscopic procedures.
 Pregnant staff should not work in controlled areas unless a permanent protective
lead screen is used.
 DIS reading for pregnant staff should be processed (read) each month, until the
end of pregnancy.
 Students and Trainees
 Students and trainees must adhere to the system of work appropriate to the
occupation while they are being trained.
 While the student technologists are on placement, the responsibility of their
protection rests on the hospital. They come under the supervision of the senior staff
and must report any radiation safety problems to the Superintendent Radiographer
and Facility radiation protection officer immediately.
 Students and trainees should follow the health and safety requirements made by
the Educational Establishment to which they are attached. They must inform their
clinical tutor if they are pregnant or suspect pregnancy.
 Protection of Staff:
 All staff should consider the following when working in the controlled area:
 Presence: Do not remain in the controlled area unless your presence is
essential.
 Barriers: Always remain behind the protective lead screen during exposure.
 Clothing: Always wear protective lead clothing during an exposure if the
staff is not standing behind the lead screen.
  Distance: Move as far as possible from the exposed part of the patient
during an exposure.
 Time: Total time of exposure of staff to x-rays must be strictly minimized,
especially during the fluoroscopic procedures.
 All radiation workers are required to gain familiarity with local rules pertinent to
their work area.
 All radiation workers shall be provided with personal monitoring devices and
should abide to the following:
- The radiation workers should ensure that he/she never wears a monitor that
has been issued to someone else.
- Use the monitor only for the purpose for which it was issued.
- All radiation workers must submit their DIS to the facility radiation protection
officer before proceeding for their leave.
- DIS should be stored properly in the provided trays.
- DIS should be checked every two months to monitor staff radiation dose which
has to be documented and the result to be displayed on the notice board.
- Ensure that the monitor is not worn while receiving any medical or dental
treatment involving ionizing radiation.
- All students should be provided with personal Radiation Monitoring Devices
from their institution.
 The radiation workers’ Occupational Dose Reports once received will be
forwarded to the Quality Control for documentation. These reports should be
sent to FANR every six months.
 Dose Limits for Radiation Workers
- An effective dose of 20mSv/year averaged over 5 consecutive years.
- An effective dose of 50mSv in any single year.
- An equivalent dose of 500mSv to skin in any single year.
 In any situation where a radiation worker has a high does reading, the facility
radiation protection officer must inform RPU to initiate appropriate action.
 Loss/Damage of Monitor Device
- In case a monitoring device is reported lost/damaged, the dose will be
estimated according to the job nature of the staff and depending on the last
three records. This estimate is to be made in conjunction with the Radiation
Protection Unit, and the appropriate record should be documented.
 Protection of the Patient
 Protection of the patients require the following
 Justification - No practice involving the use of ionizing radiation shall be
authorized unless it is justified by its medical benefit through official imaging
request.
 Optimization - The radiation dose to the patient should be optimized so as to
achieve the desired objective without unnecessary irradiation of radiosensitive
organs (*ALARA principle).
 Dose limitation - Exposure should be minimized and should be in accordance
with the diagnostic practice.
  The personnel handling ionizing radiation should be adequately trained.
 Examination of female patients
- The “28-day rule” rule should be strictly applied to all the female
patients of childbearing age for all radiology examination except the
examination that involve high radiation dose to the pelvis (MCU, IVU, HSG and
Barium Enema).
- The “ten-day” rule should be strictly applied to all procedures
delivering high radiation dose to the female pelvis at childbearing age (MCU,
IVU, HSG, and Barium Enema). If the examination falls outside the “ten-day”
from the onset of her menstrual period, pregnancy test should be requested for
the patient by the referring physician.
- If a pregnant woman needs to be examined, the consultant should
countersign the referring physician's order and the request should be scanned
and documented in the Radiology Information System (RIS).
III. OPERATING PROCEDURE
- To ensure good practice for the protection of the staff and patients certain local
operational procedures should be adhered to. Some of these apply to specific types
of equipment.
 Local Rules for Specific Equipment
All X-ray Equipment
 Only suitably trained and qualified staff or students acting under the supervision
of a professional radiographer should operate the X-ray equipment.
 The primary beam should not be directed at doors or any protective screen.
 Any equipment fault must be reported to clinical supervisor immediately.
 Each radiographer should show evidence of appropriate collimation in the image.
 None of the staff is required to provide service as a patient holder.
 The holder’s body part should not be exposed to the primary beam.
 Patient’s holder should not be pregnant or under 18 years of age.
 Cover the patient’s gonad area with the lead shield whenever possible.
 Protective clothing must be worn by the patient’s holder in the controlled area.

All Fixed X-ray Equipment

 All rooms containing fixed X-ray equipment are controlled areas except when
isolated from the main electricity supply. Access is restricted to patients undergoing
radiological examination and staff operating under the system of work.
 Doors which open directly into the controlled area must remain closed during X-
ray exposures.
 Adequate lead apron, gonad shield, lead gloves and thyroid shield, each with lead
equivalent of at least 0.25mm shall be provided in the procedure rooms.

Mobile Radiographic X-ray Units

 Portable X-ray examinations will be undertaken when the patient cannot be
brought to the department for medical reason.
 Only radiographers should make patient exposures.
 Protective clothing must be worn by patient’s holder in the controlled area. The
radiographer will advise appropriately.
 Those who are not required for essential patient care or support must withdraw
from the controlled area during an exposure.
 Clear audible warning to other staff in the vicinity must be given by the
radiographer before commencing an exposure.

Fluoroscopy
 Fluoroscopic X-ray exposures on patients should be made only under the
supervision of a radiographer or radiologist who must control the fluoroscopic
exposure factors.
 The grid should be avoided for fluoroscopic procedures if possible.
 Protective gloves with a lead equivalence of at least 0.25mm should be used
whenever manipulation is required under fluoroscopy.
 Pulsed fluoroscopy should be used and store radiographs whenever possible in
preference to live continuous fluoroscopy.
 Protective clothing must be worn by the patient’s holder and the clinical team in
the controlled area during an exposure.

Mobile Fluoroscopy (C-arm)

 Fluoroscopic X-ray exposures on patients must be made only under the
supervision of a radiographer who must control the fluoroscopic exposure factors.
 Access to the controlled and supervised areas is restricted as for fixed X-ray
rooms. Staff coming within the controlled area may do so only in accordance with
the system of work.
 The face of the intensifier should be positioned as close as practicable to the
patient.
 Pulsed fluoroscopy should be used and store radiographs whenever possible in
preference to live continuous fluoroscopy.
 Protective gloves with a lead equivalence of at least 0.25mm should be used
whenever manipulation is required under fluoroscopy.
 Protective clothing must be worn by the clinical team in the controlled area
during an exposure.

X-ray Equipment
 The Radiation Protection Unit (RPU) and Federal Authority of Nuclear Regulation
(FANR) should be notified of any new X-ray producing equipment installed in the
hospital.
 Conduct acceptance tests on new x-ray machine (or new x-ray tube) before it is
commissioned to ensure that all imaging and dose parameters are in agreement
with the manufacture’s specifications. The report should be documented.
 Malfunction and misuse should be reported immediately to the Superintendent
Radiographer
 Quality assurance of the machines will be carried out annually by the radiation
protection unit staff and the report will be forwarded to Superintendent
Radiographer, the Facility radiation protection officer and the biomedical unit.
 If all measured parameters are found acceptable i.e., within the specified margins
against the baseline values, no corrective action is required.
 If one or more parameters are found disagreeable with the baseline figures, a
report is immediately send by the radiology department to the biomedical
department requesting for corrective action. Biomedical will contact the supplier to
take necessary steps for intervention.
 After rectification, the radiation protection unit will perform QC again to ensure
quality with the set standards. All QC results should be documented.
 The RPU and FANR should be notified of any significant change in working
practices with regard to ionizing radiation.
 The biomedical should inform Radiology department and FANR regarding the
trade out of any x-ray machines.

Checks and Maintenance of Safety Features

Protective Equipment
 Visual defects in lead protective clothing must be reported to the Superintendent
Radiographer Facility radiation protection officer.
 Lead aprons must never be folded. They must be stored in appropriate manner.
 Lead protective clothing should be inspected visually and radiographically every
year.
 Defective aprons should be sent to radiation protection unit for disposal.
Emergency Procedures
 Continuous Exposure
 If the X-ray machine fails to terminate an exposure by normal or automatic
means resulting in a continuous exposure, the machine is to be isolated
from the main power supply immediately by pressing the Red Emergency
Button and call the control room on EXT: 3222 to state the case.
Immediately record all important parameters such as KVP, mAs, FFD, nature
& duration of the possible exposures and all who were involved during the
time. The fault must be reported immediately to the Superintendent
Radiographer or her designee. An incident report should be sent to RPU,
FANR and Quality Office of Latifa Hospital, for investigation, within 24 hours.
No further exposures should be attempted using the equipment until it has
been checked by a service engineer & Radiation Protection Unit.
 Over-exposure to Radiation
 Cases of over-exposure of staff or patients must be reported immediately to
the Superintendent Radiographer or her designee and the Director of
Clinical Support Services. An incident report should be sent to RPU, FANR
and Quality Office of Latifa Hospital within 24 hours.
  Fire and other Adverse Circumstances

 In the event of fire, flooding or other adverse circumstances patients and

staff should evacuate the controlled areas. If possible, without incurring risk
of hazard, the X-ray equipment should be isolated from the mains. Inform
the Fire Safety Officer through the hospital operator.

Declaration

 All staffs who work in the Radiology Department and are required to enter X-ray rooms
must be oriented to the Safety procedures and practice mentioned in this Policy and
must familiarize themselves with the relevant Systems of Work appropriate to their
duties.
 In addition, staffs who are operating or directing the operation of X-ray equipment must
familiarize themselves with the Operational Procedures and local rules relevant to the
equipment type.
INTERPRETING RADIOGRAPHS IN EMERGENCY UNIT
1. Purpose/ Scope
 To ensure safe and quality patient care.
 1.2 To ensure proper management and treatment of the patient, so as to provide
comprehensive care.
2. Policy Statement:
 Latifa hospital shall develop a policy and procedure of interpreting the radiographs
taken in Pediatric Emergency Room.
3. Procedure and Responsibility
a. A register will be maintained of all Pediatric cases seen in Emergency Unit who
underwent imaging procedures.
b. The urgent reports of images will be available online within 24 hours. Refer to
DHA/LH/AOP/015 Turnaround time for Radiology Reports
c. Daily X-ray reports will be reviewed (within 24 hours during weekdays and 48 hours
during weekends) and will be endorsed in the Emergency case record.
d. If there is any change in the management plan, the patients’ parents will be called
for the same and the Doctor concerned will be informed
e. Monthly statistics about the outcome of the procedure will be reported to the Head
of Pediatric Department for any needed actions.
Infection Control & Management of Hazardous Waste
1. Definitions / Key Terms
 Contamination: Soiling or pollution of inanimate or living material with harmful, potentially
infectious or other unwanted substances eg., organic material (blood and body substances),
microorganisms, dust, chemical residues, etc.
 Disinfection: Removal or destruction of microorganisms from inanimate surfaces.
Disinfection does not necessarily kill all organisms, but reduces them to a level which is not
harmful to health.
 Hazardous Waste: Material that is identified as hazardous by the hospital’s Hazardous
Waste Management Program.
 Infection: The deposition and multiplication of bacteria and other microorganisms in tissues
or crevices of the body with an associated host response.
 Pharmaceutical Waste: Is a type of hazardous waste which include pharmaceutical products,
drugs, vaccines and chemicals.
 Radiology Special Investigations: Any radiological examination involving administration of
contrast media.
 Sharps: Items that have corners, edges or projections that can cut or puncture human skin.
 Special procedure: Any radiological examination requiring insertion of catheter, guide wire,
sterile tubing or needle.
2. 2- Purpose:
 To promote safe environment for staff and patients.
 To minimize the risks of acquired infection from contact with the patient.
 To prevent accidental spread of disease.
 To impose strict control over disposal of hazardous waste generated by the department.
 To ensure proper management and disposal of waste.
 To prevent disease transmission from waste products.
3. Procedure/Steps

INFECTION CONTROL

 Ensure availability of hand washing supplies and disposable paper towels.

 Ensure you wash your hands:
 When soiled.
 Before and after handling patients.
 Immediately after the use of toilet.
 After handling of dressing, soiled linens, bedpans etc.
 Wear clean uniforms.
 Use proper personal protective equipment for the isolation cases.
 Keep unnecessary personnel out of the examination room during sterile procedures.
 Schedule isolations cases, if possible, at the end of morning shift to minimize contact with
others.
 Follow sterile techniques during all procedures involving the use of sterile materials.
 Clean ultrasound probes after each patient using the probe disinfectant.
  Cover vaginal probes with disposable cover, and disinfect the probes with available
germicidal disinfectant after each patient.
 Wipe the surfaces of the Ultrasound / X-ray machines with germicidal disinfectant wipes on
weekly basis and whenever necessary.
 Clean image plates of the x-ray machines and frequently touched areas with disinfectant
after each patient.
 Wipe the tables with appropriate disinfectant after any procedure in which body secretions,
excretions or fluids are handled, or come in contact with the table
 Wipe the stretcher with appropriate disinfectant and change the linen after each use.
 Dispose soiled linens, wet linen or linen contaminated with blood or body fluid in red bag
lined with water- soluble bag before sending it to soiled linen collection room.
 Wash any non-disposable patient equipment and trays with detergent solution before
sending for decontamination.
 Ensure to do the following:
 Dispose needles and sharp objects in sharps’ box.
 Do not recap or remove needles from syringes.
 Change sharp containers when it is two-third full and send it for incineration.
 Discard all the used disposable items, such as catheters, and needles
 Check sterile supplies monthly for outdate.
 Use damp mop to wipe all horizontal surfaces and floor in the department on daily basis
including dressing rooms, patients’ toilets and lounge areas.

FOR ISOLATED PATIENTS

 Wipe the used X-ray table with germicide (70% alcohol).

 Clean equipment, in contact with isolation patients, using detergent and then germicide
(70% alcohol) before reuse.
 Notify the radiology department about the proper precautions required for handling the
patients.
 Discard linen into special red bag lined with water-soluble bag. Secure the bag before
placing into linen bag.
 Observe standard precautions/ transmission-based precautions for isolation patients coming
to the department.
 Do not transport known or suspected communicable disease patients to the department
unless absolutely necessary.
 If needed, provide the patient with clean gown and mask before leaving the patient room.
 Take the patient into the examination room as soon as the patient arrive and if possible
keep patients in the changing room, following proper precautions.

STERILE TECHNIQUE

 Perform the sterile techniques for all radiology special investigations.

 Perform the following sterile techniques
 Opening sterile packs.
 Opening sterile contrast medium.
 Opening sterile catheter and guide wires.
  Assisting the radiologist during special procedures.

HAZARDOUS WASTES

 Maintain & update the safety data sheet log book.

 Ensure all the hazardous material are labelled.
 Store all the hazardous materials in accordance with the hazardous material and waste
management program.
 Hazardous Waste Disposal
 Dispose all contaminated or uncontaminated sharps items into the sharp safe
container.
 Dispose tissues, gloves, bandages, condoms contaminated with blood into the
yellow bag.
 Dispose linen/gowns contaminated with blood into the red bag.
 Send pharmaceutical wastes to the pharmacy department.
 Collect all the household alkaline batteries in a designated box and send it to
the engineering department when it is full.

NEEDLE STICK AND SHARPS INJURIES

 Take proper precautions to prevent injuries caused by needles and other sharp
instruments during procedures, cleaning, disposal, and during handling.
 In case of any needle stick and sharps injuries refer to the Policy of “Prevention of
Occupational Exposures to Percutaneous Injuries/ Splashes to Mucous Membrane and
Post Exposure Prophylaxis.
Initial Nursing Assessment and Reassessment of Patients
1. Definitions / Key Terms
a. Inpatient - Includes any patient admitted to the hospital for diagnostic procedures or
surgical/medical treatments that require overnight stay
b. Special population - includes the following group of patients –Newborn, Children,
Adolescents, frail elderly, terminally ill/dying patients, women during antenatal period,
postnatal, and in labor, patients with emotional or psychiatric disorders, patients
suspected of substance abuse, victims of abuse and neglect, patients with intense or
chronic pain, patients receiving chemotherapy or radiation therapy, patients with
communicable or infectious diseases, patients whose systems are immunocompromised
and comatosed patients
c. Outpatient - An outpatient is a patient who is not hospitalized overnight but who visits
the hospital, clinics or associated facility for diagnosis or treatment.
2. Purpose
 To ensure all patients attending Latifa Women and Children Hospital receive
consistent and timely nursing assessment
 To promote patient safety and quality of care.
 To ensure care provided to patients is based on an assessment of the patient’s
relevant physical, psychological, spiritual, economical, educational and social needs
 To identify patient’s healthcare nursing needs and formulate plan of care and nursing
interventions accordingly.
3. Policy
 Latifa Women and Children Hospital is committed to ensure that all patients, both
inpatients and outpatients, are being assessed by the assigned nurse upon
admission/visit according to the patient’s condition.
 Initial assessment of patients shall include physical, psychological, social and economical
assessments along with the history and physical examination.
 For Intensive and Critical Care Units, initial assessment shall be initiated immediately
following admission and shall be completed within 8 hours, while, For General Wards,
initial assessment shall be initiated within one hour from admission and shall be
completed within 8 hours
 The Nurses at Latifa Women and Children Hospital shall use the results of the initial
nursing assessment /reassessment to plan and update the patient’s nursing care
including interventions and/or monitoring according to the patient’s specific nursing
needs.
 All patients attending Latifa Women and Children Hospital shall be reassessed by their
assigned nurses,
4. Procedure/Steps

Outpatient Department

 All outpatients shall be assessed by Outpatient department (OPD) nurse upon their first
visit to the clinic and all information documented in Electronic Medical Record –
SALAMA
 Ensure that the Assessment tab Elements and the Screening tab elements are complete.
 All patients attending the outpatient department shall be reassessed every visit by
clicking on the revisit assessment and reviewing the initial assessment done and adding
any new changes from the previous visit.

Inpatient Department

 All Inpatients shall be assessed by the nurse upon admission and assessment data
recorded through the nursing admission navigator.
o 1 For Intensive and Critical Care Units, initial assessment shall be initiated
immediately following admission and shall be completed within 8 hours.
o For General Wards, initial assessment shall be initiated within one hour from
admission and shall be completed within 8 hours.
 The Registered Nurse/ midwife shall be responsible to complete the assessment form.
She/ He shall delegate to an Assistant Nurse or Health Care Attendant relevant
responsibilities in documenting the demographic data, vital signs.
 Check if there are signed and held orders that needs to be released and release them as
needed.
 Ensure that blood collection status is selected as Unit/ Lab collection based on clinical
area.
 Document the assessments
o The Glasgow Coma Scale shall be used upon admission when necessary
o The Braden Scale shall be used upon admission and when necessary
o 3 Oral assessment score shall be assessed on admission and reassessed as
required based on the scores
o 4 IV assessment / reassessment shall be done for all inpatients with intravenous
access device
o The Fall Assessment shall be used for all inpatients and outpatients
o The Pain assessment shall be done for all inpatients and outpatients using the
appropriate pain scale
 Assigned nurse shall notify the physician of any significant finding/ Abnormality and
document in the Provider Notification group of the complex / Peds assessment or
assessment flowsheet
 Inpatients shall be reassessed as follow in wards
o Once every shift
o Whenever the condition of the patient changes
o Before and after any invasive procedure
o Upon transfer to other unit by the receving unit staff
o Upon discharge
o Immediate post-operative patients/ patients undergoing procedures under
moderate or deep sedation who are transferred to wards will be reassessed as
follow
a. Every 15 minutes for the first hour
b. Half hourly for the next two hours
c. Hourly for the next four hours till the patient is stable
 oImmediate post-operative patients shifted to ICU and NICU vital signs must be
assessed as follow
a. Every 5 minutes in the first 15 minutes
b. Every 15 minutes for the next half an hour
c. half hourly for the next 2 hours
d. Hourly thereafter till the immediate post-operative period is over (first 8
hours after surgery)
o For patients in High Dependency Unit: Reassessment of vital signs as per
Disease protocol and medication
o When patient’s condition warrants, vital signs must be taken every 5 minutes
 For Pediatric Patients the following has to be followed:

Monitoring Vital Signs

oMonitoring of children admitted in high dependency

a. HR, RR & SPO2- 2 hourly
b. TEMPERATURE- 4 hourly
c. BLOODPRESSURE- 8 hourly or more frequent if clinically indicated.
o Monitoring of children admitted in general ward
a. HR, RR, SPO2, TEMP -8 hourly or more frequent if clinically indicated
b. BLOOD PRESSURE- once in a day
o Monitoring daily weight
a. Monitoring weight for all children upon admission and on discharge. Children
with special indication as per physician order [Eg: Cardiac patients, failure to
thrive, nephrotic syndrome etc.]
b. Monitor daily weight for children age group 0-6 months.
o Monitoring Height
a. Monitor height for all children upon admission
o Monitoring head circumference for pediatric patients
a. Head circumference on admission for all children from 0-2 years.
b. Children with specific needs /as per physician order. [Eg:Hydrocephalus,
Meningitis]
o Urine Routine test ( PH, Albumin, Sugar, Heam, Ketone, Bilirubin, Urobilinogen)
Urine dipstick can be done as per physician Order/ case related.
 For NICU Patients the following has to be followed:
o Level III patients
a. HR, RR & SPO2- hourly
b. TEMPERATURE- 3 hourly and hourly if indicated.
c. BLOODPRESSURE- 3 hourly and hourly for critically ill babies.
o 2 Level II patients(High dependency)
a. HR, RR & SPO2- hourly
b. TEMPERATURE- 3 hourly.
c. BLOODPRESSURE- Once a shift
o 3 Level I Patients
a. HR, RR & SPO2- hourly
 b. TEMPERATURE- 3 hourly
c. BLOODPRESSURE- Once a shift
o Monitoring weight:
a. Upon admission, alternative day for stable patients and daily if indicated.
o Monitoring Height
a. Upon discharge.
o Monitoring head circumference
a. On admission and then weekly.
b. Patients with hydrocephalus and microcephaly head circumference should
be checked as per physician order
o Urine Routine test
a. Urine dipstick once a day for patient on NPO until patient reaches 50% of
total oral intake and as indicated.
 The nursing care plan shall be initiated from the initial nursing assessment and
reviewed every shift and/or if any significant change in patient’s condition
 The Assigned nurse/ midwife shall initiate the discharge plan after all the relevant
formalities completed. Discharge planning is documented in Patient’s Electronic
medical record – SALAMA