CASUALTY PROTOCOL

Guidelines for Casualty Medical

Officer
• All the emergency patients (actual / potential)
after duty hours should be routed through
casualty department.
• All the patients who need observation should
be registered then admitted if needed, in the
corresponding ward
 Critical Care
• All patients in need of critical care should be
directed for admission to ICU RH Perambur as
early as possible with cross intervention at
casualty if required & possible.
• Casualty helper and nurse should accompany
the patient
 Brought dead
• If a beneficiary is brought dead then his case file
should be checked for the clinical records. If the
prevalent clinical records justify the event of
death or if cause of death can be ascertained
from previous records e.g. in a case of terminal
malignancy, then the certificate can be issued.
• This is possible only if the patient has been on
regular treatment at our hospital and there is no
doubt about the cause of death
 Inquest
• If the cause of death cannot be confirmed, death
certificate cannot be issued & then the Police
should be informed, so that they can arrange for
inquest & body can be sent to coroner with all
the medical records available for post mortem.
• Relatives do not have a say in deciding whether
postmortem should be done or not.
• Reports to be Xeroxed from the office and given
along with body for postmortem
 Shifting Dead body
• The certified dead body should not be kept in
casualty for longer time & shifted to mortuary
RH / Perambur, as early as possible, with
proper clothing
 Non railway patient
• If a non railway patient reports to casualty, first aid
should be offered with in-house facilities.
• Temporary registration number
Admission in the casualty.
• If necessary transfer to nearby hospital once the
patient is fit for transfer.
• A note of treatment given should be sent along with
• If patient is not stable enough for independent transfer,
then ambulance along with attendant will be provided
from the hospital.
 Non railway patient is brought dead
• Police should be informed and the entry
should be made with temporary registration
number and admission registered in casualty.
• Neither the death certificate should be issued
nor should the body be shifted to our
mortuary waiting for death certificate by
external authorities
 Non railway patient is brought dead
• In such cases the relatives must arrange death
certificate by the treating doctor.
• If death certificate brought then the copy of
death certificate should be kept in our
records.
• If death certificate is not brought then post
mortem should be arranged by registering a
medico-legal case.
Alcohol on Duty
 Alcohol on duty
• Employee brought with alleged h / o ‘under influence of alcohol
on duty’ following details are to be mentioned
• Who has brought the employee?
• Is there any written complaint from division / section about the
employee regarding violent behavior, irritability, drowsy / sleeping
/ vomiting / fall / injury etc?
• Clinical examination with vital parameters
• CNS examination
• Look for injury/rule out organic neurological /metabolic problems.
• Admit in the ward.
• Breath analyzer test for alcohol. If tested positive, alcohol levels in
the blood should be checked.
 Alcohol levels
• Confirmatory test by taking blood & urine
samples for alcohol levels.
• Two sets of sample must be collected. One set in
bottle containing fluoride & the other without.
• The sample collected in fluoride bottle is kept in
safe custody for cross reference, in case of need.
• It should be retained till the case is finalized &
then disposed off
 Sample collection
• 5cc of blood & 30 ml of urine is to be collected
• to be sealed with wax & labeled with all
relevant details.
• Name and Employee’s number is to be
mentioned on the label and the bottle to be
sent to forensic laboratory.
• In mean time the sample can be kept in the
door compartment of the fridge but not to be
frozen. This can be stored for upto 6 hours
 Form filling
• The prescribed form is filled with all details &
four copies are made. One copy is for the
department which had refereed the person,
one for the forensic lab & rest is retained.
•
INJURY ON DUTY
 INJURY ON DUTY (IOD)
• Injury on duty is to be given a special
consideration and is to be registered as IOD.
 Medico-legal
• In following circumstances, it should also be
registered as Medico-legal case
• 1. Death of the Employee while on duty
• 2. Vehicular/ road traffic accident while on
duty
• 3. Electrical burns
 IOD-Forms
• IOD form [G 352] is filled by the concerned
department and sent along with the patient in
triplicate.
• Injury on Duty report has to be generated
from respective division/section to which the
employee belongs to, only the medical details
are to be filled in by medical officer.
• Treatment should not be withheld due to non
availability of above mentioned forms
 Registering an IOD
• Details to be paid attention to while registering
an IOD
• Detailed h/o Accident
• Exact time & place where it occurred
• What was the employee doing at the time of
accident (exact nature work /job which employee
was doing when the accident occurred)
• Was he using Personal Protective Equipment
(PPE)?
• Was any first aid given before arrival?
 Death on duty

• Death of an employee on duty

• Accidental – Medico-legal - inform police &
send for post mortem.
• If employee is brought dead
• To be treated as MLC since cause of death
cannot to confirmed.
 MEDICO-LEGAL CASES

• What is a medico-legal case (MLC)?

• A medico-legal case is one where besides the
medical treatment; investigations by law
enforcing agencies are essential to fix the
responsibility regarding the present state /
condition of the patient.
• The case therefore has both medical and legal
implications.
 Registering MLC is a MUST

• Attending casualty medical officer has the

authority to decide whether the case is to be
registered as medico-legal or not.
• There is no scope for acceding to request /
pressure from the relatives, patient himself or his
colleagues regarding the registration of MLC.
• Even if the incident (e.g. trauma) has happened
several days ago, if the complaints merit an MLC,
then MLC should be registered.
• A case should be registered medico-legal even if
the patient requires an OPD treatment.
Which cases qualify as medico-legal
cases?
• Cases of accidental deaths, injuries, poisoning or unnatural events
under suspicious circumstances must be reported to the police
whenever such cases are brought to the notice of Casualty, OPD or
dispensaries for treatment.
• Police should be immediately informed after patient is declared
“Dead on Arrival” in casualty or dispensary, so that, an inquest can
be arranged.
• A patient may suddenly die after admission to the Hospital. It is the
duty of the Medical officer to inform such a case of death to the
Police, immediately.
• The intimation to be given to the Police should be to the effect that
the patient died suddenly and the cause of death is not known. The
date and time of the intimation must also invariably be recorded on
the case papers
 MLC
• The death of a patient within 24 hours of admission should be
reported to the Police, so that, they can arrange for an inquest and
a postmortem examination, if necessary.
• There may be certain occasions when cause of death of a patient
attending the hospital, is not clearly mentioned in the report and
there may also be suspicious circumstance. It is customary in such
case to inform the Police so that, they can arrange for the necessary
inquest and give instructions for postmortem examination..
• Deaths in the Operation Theatre during Medical Termination of
Pregnancy, delivery, following sterilization or any other surgical
procedure should also be reported to Police.
• The Police should be informed about drug or alcohol related death
(including deaths of drug addicts).
 MLC
• Whenever a medico-legal case is admitted in the ward, the
concerned consultant on call and the head of the unit
should be informed, about such admission.
• All burns cases should be registered as medico-legal. The
Medical Officers should record on the case paper, the
statement of the woman (if she is married) about the
circumstances under which she had sustained burns. The
Police should be informed to arrange for a dying
declaration in severe cases.
• If a patient is found absconding from the wards, MLC
should be registered immediately.
• MLC should be registered when a patient has a fall or
trauma during the hospital admission and treatment
INDOOR PATIENTS
 INDOOR PATIENTS

• Record Keeping Guidelines

• Records should be – Follow the 5 ‘c’
– Correct
– Clear
– Comprehensive
– Chronological
– Contemporaneous
 Indoor records
• All entries should bear Date and Time
• Handwriting should be legible
• Each continuation sheet should bear the name and IP
& employee’s number of the patient and page number.
• Canceling the record should be done with a single
strike through with signature of the doctor modifying
the records.
• General consent or Undertaking Form should be filled
by the patient and duly signed on admission
• Patients should be admitted in respective ward under
the concerned specialist.
 Discharge
• All discharged patients should be given
discharge summary and with follow up details
and explained to the patients.
• X-rays should be handed over and
acknowledgements taken.
 Discharge against medical advice
DAMA
• When the patient’s condition does not permit the
discharge but he is not willing for continuing the
indoor stay, discharge against medical advice
should be issued.
• The consequence of this could be a major
complication including death hence adequate
precaution should be taken.
• The attending doctor should take patient’s
signature on the given form along with a witness.
The witness should be patient’s relative/ friend
 DAMA
Also it is encouraged that patient writes in his
own handwriting on the case file and he and
his relatives sign the statement.
• Date and time of discharge should be
mentioned.
• This statement should mention the patient’s
condition at that moment and their insistence
on discharge in spite of all the possibilities
been explained to them
 Transfer to other hospitals-1

• It is the responsibility of the treating doctor to

shift the patient safely to other hospital.
• Give a clear idea to the patient and relatives
as to why the transfer is necessary.
• Give them a choice of place amongst the
panel hospitals, keeping in mind the patient’s
condition and proximity of the hospital.
• Check the facilities and equipment in the
ambulance
 Transfer to other hospitals-2
• If patient’s condition is unstable, a qualified
person should accompany the patient in the
ambulance.
• All relevant reports, documents and case
summary including treatment given should be
handed over to the relatives or accompanying
doctor and acknowledgment taken.
• A document that the need of transfer was
explained to the patient and their consent was
obtained to shift to another hospital should be
kept in the file
INFECTION CONTROL GUIDELINES
 INFECTION CONTROL GUIDELINES

• Head of units and M.O. Incharge are

responsible for implementation of these
policies.
• In-charges should assure that employees are
educated, the supplies are available in
accessible locations and compliance is
evaluated from time to time.
 Needle Stick Injury / Exposure to
Blood or Body Fluids-1
• Wash the part with soap and water
immediately
• Splashes to nose, mouth or skin should be
flushed with water and eyes should be
irrigated with clean water
• Arrange for PEP
• Take blood samples for testing
 Needle Stick Injury-2
• Forms
• One copy in patient’s record file
• One copy to Sister-in-charge – casualty
• One copy to Convener-Infection control
committee
 Guidelines for Antibiotic Usage

• Have a working knowledge of the spectrum of

pathogens involved in common infections and
spectrum of activity of commonly used antibiotics.
• Treat early and treat aggressively.
• In the absence of microbiological diagnosis, treat the
most resistant of possible pathogens. This is
particularly important in patients with serious life
threatening infections.
• If and when infection is microbiologically documented,
use the most narrow spectrum antibiotic agent
possible
 Antibiotic
• Use combination therapy with agents known to have
synergistic activity against the infecting organism.
• Use bactericidal agents whenever possible. Bacteriostatic
agents, particularly in the absence of normal host defense
mechanisms, contribute to suboptimal therapy.
• Understand the role of pharmacokinetics of the agent. Among
the appropriate agents available for the infecting organisms,
use those with high bioavailability, higher volume of
distribution and better tissue/ pathogen penetration.
• Use the optimal dose for optimal duration. Sub inhibitory
concentration of antibiotics for even a short period is highly
likely to induce resistance in the pathogens as well as normal
flora.
 Antibiotic
• Use local resistance surveillance date to guide initial antibiotic
selection and to decide on the most appropriate choices for
presumptive therapy when cultures are not helpful.
• Follow infection control practices for designated organisms
stringently and consistently.
• The least that should be done for all patients is to wash hands
between patient contacts.
• Use available vaccines for children and adults optimally with
initial immunization and periodic boosters as needed.
Vaccines not only offer protection against infections. They also
reduce the need for antibiotic use and thereby prevent
antibiotic resistance.
•
 ANTIBIOTIC POLICY FOR SURGICAL
PROPHYLAXIS
• Standard Protocol
• Cefuroxime 1.5 gram I.V. just prior to induction
of Anaesthesia. 1 gram I.V. 4 hrs. after the
previous dose
• Children -according to wt. (50 mg. / kg.)
• Gynaec surgeries –Metronidazole 500 mg. I.V.
3 doses 8 hrly.
• Colonic surgeries -Metronidazole and
Gentamycin.
Standard Precautions
 Standard Precautions
• Standard Precautions represents a system of
barrier precautions to be used by all personnel
for contact with blood, all body fluids, secretions,
excretions, non-intact skin and mucous
membranes of ALL patients, regardless of the
patient’s diagnosis.
• The purpose is to reduce transmission of
infectious agents between patients, caregivers
and others in the medical center environment
and to reduce the incidence of nosocomial
infections among patients.
 Hand washing-1

• Policies & Procedures

• Because nosocomial infections are most
frequently spread by contact and the most
common form of contact is hand contact,
HANDWASHING is the most important and
most effective means of preventing
nosocomial transmission of organisms.
 Hand washing-2
• When to Wash hands
• Before patient contact.
• Before invasive procedures, Use alcohol based agents
in between patient contact.
• After removing gloves or other personal protective
equipment.
• After contact with body substances or articles/surfaces
contaminated with bodysubstances.
• Before preparing or eating food after personal contact
that may contaminate hands. (e.g. covering sneeze,
blowing nose, using bathroom
 HAND WASH

• Wet hands first with water.

• Apply 3 to 5 ml of soap to hands.
• Rub hands together for at least 15 seconds.
• Cover all surfaces of hands and fingers.
• Rinse hands with water & dry thoroughly.
Towels to be changed frequently. Wet towels
should not be used for wiping hands. Sister
Incharge to take note of it.
 Techniques for hand hygiene –
Alcohol Rubs
• Do not use if hands are visibly soiled or
contaminated with blood or body fluids.
• Apply 2-3 ml of alcohol prep to hands.
• Be sure to cover all surfaces.
• Rub hands until alcohol dries (at least 15 seconds)
• Be sure hands are completely dry prior to putting
on gloves.
•
Personal Protective Equipment
Personal Protective Equipment (PPE)-
1
• 1. Glove
• Gloves must be worn for
– anticipated contact with moist body substances,
mucous membranes, tissue, and nonintact skin of all
patients;
– contact with surfaces and articles visibly
soiled/contaminated by body substances;
– performing venipuncture or other vascular access
procedures (IV starts, phlebotomy, in-line blood
draws);
– Handling specimens when contamination of hands is
anticipated.
 PPE-2
• Caution: Gloves do not provide protection
from needle sticks or other puncture wounds
caused by sharp objects. Use extreme caution
when handling needles etc.
 PPE-3

• Masks
• Masks are worn to protect personnel from
transmission of infectious droplets during close contact
with the symptomatic patient
• Trauma care.
• Surgery or delivery of newborn.
• Intubation / suctioning / extubation
• Bronchoscopy / endoscopy.
• Emptying bedpans/suction canisters etc.
• Patient care of coughing patient with suspected
infectious etiology
 PPE-4

• Aprons / Gowns
• Wear plastic gowns during patient care where
there is likelihood of soiling their clothes with
body substances.
• Lab coats in Lab settings.
• In surgical areas and during invasive procedures
protective and sterile attire is required.
• Remove protective body clothing before leaving
the immediate work area
Infection control
 Patient Placement
Infection control-1
– Those who soil the environment with body
substances. For example, children or adults with
altered mental status.
– Airborne diseases.
– Severely immune suppressed.
– Patients with the same infectious disease /
organism may be housed in the same room.
 Environment
Spill Management- Infection control-2
• Spills of body substances should be cleaned
up promptly.
• Workers should wear gloves and use other
protective equipments if there is risk of
splash.
• Area should then be disinfected with hospital
grade disinfect / detergent
 Soiled Linen Handling- Infection
control-3
• Wear gloves to handle moist or visibly soiled
linen.
• Place soiled linen in plastic laundry bags.
• Securely close laundry bag when bag is three-
fourth full.
• Laundry workers must always wear gloves
while handling the laundry
 Work Practices -Infection control-4

• Eating ,applying cosmetics etc in work areas is

prohibited. Prior to the consumption of food or drink
and exit from immediate work area, employees should
wash their hands.
• Food and drink will not be kept in freezers,
refrigerators, counter tops, shelves and cabinets where
blood or other potentially infectious materials are
stored and handled.
• Skin under the rings is more heavily colonized. Nursing
staff should not wear rings while on work. There has
been a study that 40% of nurses harbor gram-negative
bacilli under their rings.
• Dispensary In-Charges should frequently
check the dispensing methods in Dispensary.
• Doctors should randomly check the medicines
after they are dispensed to the Patients.
• DISPOSAL OF RECORDS
 GUIDELINES FOR DISPOSAL OF
RECORDS -1
• No specific clear cut guidelines were available
for disposal/ weeding out old records
maintained for various activities in the
Medical division
• Records were accumulating leading to
wastage of space.
• The committee has formulated the following
guidelines for the same.
 Identification of Records-2
Category A
• Permanent Records - Not to be destroyed
• Rules and regulations of Hospital
• Licenses records, e.g., spirits, morphine, fentanyl etc.
• Vaccination records
• Case Files showing the summary of in patients/out patients etc.
• Operation registers
• Death reports/registers
• Birth registers
• Statistical Records
• Procured Books,
• Procured Equipment / Capital Items Indented including furniture
• Minutes of advisory medical records
• Code numbers
• Legal opinion and proceedings
 Category B-3
• Casualty and Medico-Legal - Records to be
maintained for 30 years
• All Homicidal, Suicidal and Accidental Cases
Records-
• Non specific - example. Snake/insect bites etc.
 Category C-4
• General Records - Records to be maintained for 10 years
• All OPD records
• Minor operation registers
• Certificates of birth and death
• Medical relief records
• Purchase Records of books and magazines in Library
• Certificate of cause of death
• 69
• Duplicate license records
• Correspondence related to cholera, leprosy, plague,
tuberculosis and other infectious disease.
• DNB records
 Category D-5
• Yearly records - Papers to be maintained for 1
-2 years
• Muster Roll
• CL / EL / ML Papers (Not Registers) one year
• Late attendance one year
• Overtime one year
• Optional holidays one year
 Miscellaneous records-6
• Transfer of file registers -1 year
• No Dues Certificate -2 years
• Inward /Outward register-2 years
• Locum helper record -2 years
• Circulars /Amendment -current year only
• Indent copies (RClV’s and CV copies)-1 year
• Monthly report Statistics / Staff position-1 year
• Prescription Papers-2 years
• Purchase and claim forms covering letters with registers -1
year
• Over time details -1 year
• Admission / Discharge slips of admitted patients -2 years
 Ambulance services-1

• Ambulance services will be provided upto 10

kms. distance from the Hospital
• Patients coming fromplaces beyond 10 kms.
from Hospital can hire ambulance/taxi during
an emergency but
• Reimbursement will be made only if certified
by the concerned doctor as “Emergency
 Ambulance services-2
• The request for the ambulance will be co-
ordinated by Matron and Security.
• No payment shall be made if any patients
• hire ambulance/taxi for coming to Hospital
after discharging from the panel hospital
 Ambulance services-3

• If Ambulance is not Available, Head of the Unit

of the concerned department can
• sanction use of private ambulance, to be
claimed by patient later for reimbursement.
•
 THANK YOU

• THANK YOU
 Collection and transportation of
specimens
• Ensure that the outside of the specimen
container is clean and uncontaminated.
• Close the container tightly so that its contents
do not leak during transportation.
• Label and date the container appropriately
and complete the requisition form.
• Arrange for immediate transportation of the
specimen to the laboratory.
 Collection and transportation of
specimens
• Use standard precautions for collecting and
handling all specimens
• Wash hands before and after the collection.
• Collect at the appropriate phase of disease.
• Make certain that the specimen is representative
of the infectious process (e.g. sputum is the
specimen for pneumonia and not saliva) and is
adequate in quantity for the desired tests to be
performed.
• Collect or place the specimen aseptically in a
sterile and/or appropriate container.
• Handling of Different Specimens
 Blood-1

• Whole blood is required for bacteriological

examination
• Careful skin preparation before procedure is
essential.
• Blood for culture-
– Collect blood during the early stages of disease since
the number of bacteria in blood is higher in the acute
and early stages of disease.
– Collect blood during paroxysm of fever since the
number of bacteria is higher at high temperatures
 Blood-2

• Specimen Volume
• Direct relationship between the volume of
blood and the yield,
• For Adults-Three sets of blood cultures
collected within a 24 hour period will detect
96.9 - 98.3% of BSIs
• Infants and small children generally have high
levels of bacteremia, hence smaller volumes
are acceptable
 Cerebrospinal fluid (CSF)-1
• Essential for diagnosis of any patient with
evidence of meningeal irritation or affected
cerebrum.
• About 3-10 ml of CSF is collected and part of it
is used for biochemical, immunological and
microscopic examination and remaining for
bacteriological or fungal examination.
 Precautions for CSF collection-2
• Collect before antimicrobial therapy is started.
• Collect CSF in a sterile container and do not
delay transport and laboratory investigations.
• The carrier should place the specimen in the
hands of the person in charge of processing
the culture and NOT in the refrigerator or on
the bench.
• Store at 37 ° C, if delay in processing is
inevitable. Do not refrigerate
 Sputum

– Select a good wide-mouthed sputum container, which

is preferably disposable, made of clear thin plastic,
unbreakable and leak proof material.
– Give the patient a sputum container with the
laboratory serial number written on it.
– Instruct the patient to inhale deeply 2-3 times, cough
up deeply from the chest and spit in the sputum
container by bringing it closer to the mouth.
– A good sputum sample is thick, purulent and
sufficient in amount (2-3 ml
 Surgical Material-1

• Material from Biopsy, Abscess, Ulcers, Fistulae,

Sinuses, Wound Remove the tissue aseptically
from the lesion, including the wall and center of
the lesion.
• Curette sinus tracts so as to include the wall of
the tract. Collect tissue in sterile tubes. Tissue or
aspirates are always superior to swab specimens.
• Remove surface exudates by wiping with sterile
saline or 70% alcohol.
 Stool

• Faecal specimens for diarrhoeas should be collected in the

early stage of illness and prior to treatment with
antimicrobials.
• Specimen should not be contaminated with urine.
• 1 to 2 gm quantity is sufficient.
• If possible, submit more than one specimen on different
days.
• The fresh stool specimen must be received within 1-2 hours
of passage.
• Store at 2-8° C.
• In cases of suspected cholera, the faeces specimen may be
sent in Alkaline peptone water as it enhances the growth of
vibrios
 Surgical Material-2
• Aspirate with needle and syringe. If a swab
must be used, pass the swab deep into the
base of the lesion to firmly sample the fresh
border.
• Deliver all specimens to the laboratory
immediately after collection.
• Do not add water, saline or formaldehyde to
the sample
 Transportation of Specimens-1

• Ideally within 30 minutes of collection.

• Many micro-organisms are susceptible to
environmental conditions such as the presence of
oxygen (anaerobic bacteria), changes in
temperature (Neisseria meningitis) or changes in
pH (shigella).

• Thus use of special preservatives or holding

media for transportation of specimens delayed
for more than 30 minutes is important in
ensuring organism viability.
 Transportation of Specimens-2
• Specimens to be sent to other laboratories
require special attention for safe packing of
the material.
• Guidelines are usually issued by national
authorities and the same should be strictly
followed.
• For hand-carried transportation over a short
distance, the specimen should be placed
upright in appropriate racks.
• GUIDELINES RELATED TO BLOOD BANK
 1-W.H.O. strategies
• The W.H.O. has developed following integrated strategies to
promote global blood safety and minimize the risks
associated with transfusion.
• 1. The establishment of nationally – coordinated blood
transfusion services.
• 2. Collection of blood only from voluntary non-
remunerated donors from low-risk population.
• 3. Screening of all donated blood for transfusion
transmissible infections and good lab practices in
• all aspects of blood grouping, compatibility testing, storage
and transportation of blood.
• 4. A reduction in unnecessary transfusion through
appropriate clinical use of blood and bloodproducts.
 2-Blood Bank

• It is a compact unit where blood is accepted

from donors, processed, stored and finally
issued to needy patients on the
recommendation of Doctors.
• Only healthy donors are selected for donation,
after detailed history / physical examination,
• 300 ml of blood is withdrawn from each
donor.
 3-Guideline for Crossmatch

• Requisition form should be filled up

completely and complete name should be in
bold letter.
• The name and CHSS number of patient should
be exactly same on form and sample tube.
• Requisition form should be filled only by
doctors on duty.
• Relatives of patients should be sent to Blood
Bank to discuss regarding donation
 4-Guideline for Crossmatch
• X-matching in cases of planned operation
should be sent in normal working hours
between 10.00 am to 2.30 pm and not in shift
duty timings.
• Patient’s correct blood group should be
mentioned in the crossmatch form, whenever
known.
• Donors should be sent in advance a week
before for routine and planned cases.
• GUIDELINES FOR PHARMACISTS
 GUIDELINES FOR PHARMACISTS
• Tell patients to check the label on medicines
with prescription.
• If, any doubts, consult the prescribing Doctor
immediately for clarifications.
• The drugs with names which read/sound
similar should be kept in compartments of
drug box away from each other.
• For illiterate patients extra efforts should be
taken to explain the medicines, doses etc