Manual of Standards and Guidelines on the Management of the Hospital Emergency Department Second Edition Department of Health Health Facility Development Bureau

MANUAL OF STANDARDS AND GUIDELINES ON THE MANAGEMENT OF THE HOSPITAL EMERGENCY DEPARTMENT SECOND EDITION CY 2022

DEPARTMENT OF HEALTH HEALTH FACILITY DEVELOPMENT BUREAU

MANUAL OF STANDARDS AND GUIDELINES ON THE MANAGEMENT OF THE HOSPITAL EMERGENCY DEPARTMENT

Copyright 2022 by the Department of Health. All rights reserved. Subject to the acknowledgement of the Health Facility Development Bureau (HFDB), Department of Health, the Manual may be freely abstracted, reproduced or translated in part or in whole for non-commercial purposes only. If the entire Manual or substantial portions will be translated or reproduced, permission should be requested from the HFDB. Printed in the Republic of the Philippines.

National Library Cataloging-in-Publication Data

ISBN

Published by:

Department of Health San Lazaro Compound Rizal Avenue, Sta. Cruz, Manila 1003 PHILIPPINES

PRODUCTION CREDITS Project Leaders:
Dr. Terence John M. Antonio Dr. Ma. Bituin S. Reyes Ms. Madeliene Gabrielle M. Doromal Copy Editor:

Mr. Glenn A. Cruz

The development of this Manual was initiated, completed, and subsequently published through the HFDB. For inquiries, contact the Bureau:

Phone: +63 2 9651 7800 locals 1401, 1403, 1407 Email Address: hfdb@doh.gov.ph

PREFACE

In the Philippines, access to health care is challenged by blocks and inequity in emergency care. The disparity in emergency department standards of care is apparent not only in the marginalized and the disadvantaged rural areas, but it also manifests across cities and highly developed urbanized areas of the country due to and despite its geopolitical landscape. The COVID-19 pandemic has highlighted pre-existing inequities and insufficient attention accorded to emergency care in the Philippines.

With the release of the World Health Assembly Resolution 72.16, “Emergency Care Systems for Universal Health Coverage: Ensuring Timely Care for the Acutely Ill and Injured” and the passage of the Republic Act No. 11223, emergency care is highlighted as an integral component towards the realization of Universal Health Care. In consonance with the provisions of these pronouncements and in alignment with the priorities of the Health Facility Development Bureau of the Department of Health, the release of the second edition of the DOH Manual of Standards and Guidelines on the Management of the Hospital Emergency Department is both timely and long overdue. This Manual’s emphasis addresses the need for standards and processes to deliver seamless quality emergency care in each level of the healthcare system across all settings.

This edition underscores the strengths of the earlier edition, investing in the principles and ideals of emergency department management, and it is also cognizant of the need to future- proof the guidelines based on current emergency care evidence and practice. The country needs to ensure a functional emergency care system with the emergency departments at the forefront in the event of disasters and epidemics, or when the demands are high despite resource limitations. Emergency departments are no-discrimination zones demanding a specialty of both breadth and depth, functioning as a gate-keeping structure bridging public health and primary health to the hospital health system, and expected to treat patients in times of peace and, more so, in adversity.

Chapter 1, the introductory chapter, sets the tone of the rest of the manual: it includes the principles of emergency care as a basic human right and the emergency care system framework, where emergency care is meant to be seamless, not siloed and not defined by a confined space. This manual’s ten chapters streamlined the earlier edition; each chapter may be read in isolation but best utilized with cross-reference to the other chapters as the challenge of taking infrastructure (form) and system (function) cannot be seen as mutually exclusive of each other.

There are several new chapters added including one on “Governance - Leadership and Management” (Chapter 3) and “ED Guide on Special Situations” (Chapter 7), which address unique issues in the ED such as the emerging and re-emerging infectious diseases (EREIDs), women and children protection unit, mass casualty incidents, surge capacity, combative and aggressive patients, bullying and violence, among others. This manual attempts to address the

challenges of the dynamic emergency care landscape and ensure establishment of structures and systems that withstand and adapt with demands of the injuries and illnesses of EREIDs, globalization and climate change.

The manual is intended for the ED’s health care professionals: encompassing the administrative and management operations of an emergency unit and with due consideration of all settings from Level 1 to Level 3, private and public facilities. It is intended to present the developmental standards of emergency units/emergency departments across all health care facilities with stratification as to the applicability within the facility’s context in accordance with the Administrative Order No. 2012-0012, “Rules and Regulations Governing the New Classification of Hospitals and Other Health Facilities in the Philippines” as amended. It is further envisioned that the manual be used as an indispensable reference for institutional policies and guidelines within nationally or globally set standards for regulations and total quality management towards ensuring the best emergency care that all Filipinos deserve.

PAULINE F. CONVOCAR, MD, MCHM, DPBEM, FPCEM, DPCOM Chairperson Emergency Department Manual Development TWG

ACKNOWLEDGEMENT

Sincerest gratitude to the Health Facility Development Bureau (HFDB) Director Dr. Ma. Theresa G. Vera, and to the Health Facilities and Infrastructure Development Team (HFIDT) Undersecretary Dr. Lilibeth C. David, for their support in the completion of this manual.

Special recognition is provided to the hardworking and dedicated members of the Technical Working Group for the review, revision, and crafting of the Second Edition of the Hospital Emergency Department Manual of Standards and Guidelines. They have patiently reviewed relevant resources and meticulously crafted the manual to serve the needs of Emergency Departments in the country, during an ongoing pandemic.

Chairperson:

Dr. Pauline Convocar Medical Specialist III, Corazon Locsin Montelibano Memorial Regional Center Medical Specialist III, Southern Philippines Medical Center President, Philippine College of Emergency Medicine (2019-2021)

Co-Chairperson:

Dr. Terence John Antonio OIC-Division Chief, Health Facility Development Bureau

Members:

Arch. Jean Paolo Policarpo Architect II, Health Facility Development Bureau

Ms. Zenaida Villaluna (Former) Development Management Officer IV, Health Facility Development Bureau

Dr. Arnel Rivera OIC-Director IV, Health Emergency Management Bureau

Ms. Maria Belinda Evangelista
Nurse VI, Health Emergency Management Bureau

Dr. Maria Rosa Abad (Former) Medical Specialist III, Health Facilities and Services Regulation Bureau

Dr. Mary Jane Paez (Former) Medical Specialist IV, Health Facilities and Services Regulation Bureau

Dr. John Paul Ner Medical Specialist II, East Avenue Medical Center Chair, Committee on Standards of Practice, Philippine College of Emergency Medicine
(2019-2021) Dr. Dave Gamboa Medical Specialist III, Philippine General Hospital Chair, Committee on Constitution and By-Laws, Philippine College of Emergency Medicine
(2019-2021)

Dr. Myrna Rivera
Medical Specialist IV, Tondo Medical Center

Dr. Jesus Maniago Medical Specialist IV, Tondo Medical Center

Dr. Ralph Cabaddu
Medical Specialist III, Quirino Memorial Medical Center Dr. Referino Lingating Medical Officer IV, Quirino Memorial Medical Center

Ms. Mylene Mangalindan Nurse III, Quirino Memorial Medical Center

Dr. Enrico Ian Deliso Medical Officer IV, Southern Philippines Medical Center

Ms. Michelle Anne Mudanza Nurse III, Southern Philippines Medical Center

Mr. Peter Paul Tutor Nurse III, Southern Philippines Medical Center

Dr. Cherie Grace Quingking Medical Specialist III, Corazon Locsin Montelibano Memorial Regional Center

Ms. Gemmarie Cabrera
Nurse III, Corazon Locsin Montelibano Memorial Regional Center

Dr. Halima O. Mokamad-Romancap Medical Specialist III, Cotabato Regional Medical Center

Ms. Maria Kristine Go Portaje Nurse V, Cotabato Regional Medical Center

Dr. Willie Saludares
Medical Specialist III, East Avenue Medical Center

Ms. Mary Jane Cruz Nurse III, East Avenue Medical Center

Dr. Amor Buragay Jr. Medical Officer IV, Las Piñas General Hospital and Satellite Trauma Center

Dr. Obdin De Guzman Medical Officer IV, Las Piñas General Hospital and Satellite Trauma Center

Technical Secretariat:

Dr. Ma. Bituin S. Reyes Medical Officer IV, Health Facility Development Bureau

Administrative Support Staff:

Ms. Rhod-Ann Lebrino Administrative Assistant V, Health Facility Development Bureau

Appreciation is extended to the following technical staff from DOH Central Office for sharing their time in reviewing these standards and providing valuable inputs: • Dr. Braylien W. Siy, Medical Specialist II (Former), Health Facility Development Bureau • Mr. Erickson A. Feliciano, Development Management Officer IV, HFDB • Ms. Faye Diana C. Chua, Development Management Officer IV, HFDB • Dr. Gian Carlo L. Infante, Medical Officer III, HFDB • Ar. Katrine Aira A. Veridiano, Development Management Officer III, HFDB

List of Abbreviations and Acronyms

ACLS Advanced Cardiovascular Life Support AED Automated External Defibrillator ATLS Advanced Trauma Life Support BLS Basic Life Support BPA Best Practice Advisory CBRNE Chemical, Biological, Radiological, Nuclear, and high yield Explosives CEDAW Convention on the Elimination of All Forms of Discrimination Against Women CPD Continued Professional Development CSC Civil Service Commission CSR Central Supply Room CTAS Canadian Triage and Acuity Scale DEDAW Declaration on the Elimination of Discrimination Against Women DEM Department of Emergency Medicine ED Emergency Department EDIS Emergency Department Information Systems EDMAO Emergency Department Management and Administrative Officer EMR Electronic Medical Record EMS Emergency Medical Services EMT Emergency Medical Technician DAMA Discharge Against Medical Advice DOA Dead on Arrival DOH Department of Health HCP Health Care Professional HFDB Health Facility Development Bureau HICS Hospital Incident Command System (HICS) Infection Control Committee ICS Incident Command System (ICS)

IFEM International Federation for Emergency Medicine IHCA In-Hospital Cardiac Arrest ISO International Organization for Standardization NA Nursing Attendant NAOD Nursing Attendant on Duty
NOD Nurse on Duty NRP Neonatal Resuscitation Program OHCA Out-of-Hospital Cardiac Arrest PALS Pediatric Advanced Life Support PAPR Powered Air Purifying Respirator PGS Performance Governance System PHTLS Pre-Hospital Trauma Life Support POCS Point-of-Care Studies POCUS Point-of-Care Ultrasound RSF Resource Stratified Framework ROSC Return of Spontaneous Circulation SAEK Sexual Assault Examination Kit SARS Severe Acute Respiratory Syndrome SWOD Social Worker on Duty VAWC Violence Against Women and Children VAWC-RS Violence Against Women and Children Registry System WCPU Women and Children Protection Unit

Table of Contents

1 Introduction ................................................................................................................................. 1 Emergency Care as a Human Right ............................................................................................ 1 Legal Framework .......................................................................................................................... 1 Emergency Care and the Emergency Care Systems Framework .............................................. 1 Resource Stratified Framework in Provision of Emergency Care .............................................. 3 Emergency Department or Unit.................................................................................................... 3 Scope of the Management of the Hospital Emergency Department Manual .............................. 5 2 Emergency Department Services.............................................................................................. 6 Case and Condition: The Emergency Department Patient .......................................................... 6 Care and Interventions: Emergency and Acute Care .................................................................. 7 Stratified Delivery of Emergency and Acute Care Services ........................................................ 7 Overview of Other Services in the Emergency Department ........................................................ 8 3 Governance: Leadership and Management ........................................................................... 11 General Overview ....................................................................................................................... 11 Organizational Structure and Staffing Pattern ........................................................................... 13 Roles, Responsibilities, and Qualifications of Staff in the ED.................................................... 16 4 Infrastructure Standards .......................................................................................................... 29 General Considerations for Infrastructure and Design .............................................................. 29 Description of Spaces and Planning and Design Considerations ............................................. 30 Space Planning and Design Considerations for Special Services in the Emergency Department ................................................................................................................................. 45 Space Planning and Design Considerations for Ancillary Services in the Emergency Department ................................................................................................................................. 46 5 Medicines and Supplies ........................................................................................................... 51 Medications and Supplies in the Emergency Department for Levels 1, 2, and 3 ...................... 51 Medication Standards in the Emergency Department ............................................................... 56 6 Systems and Procedures ......................................................................................................... 61 Approach to Standardization ...................................................................................................... 61 Definition of Terms ..................................................................................................................... 61 Emergency Department Services and Overview of Patient Flow .............................................. 62 Triage and Medical Screening Examination .............................................................................. 65 Patients requiring Immediate Resuscitation .............................................................................. 71 General Care of the Emergency Department Patient ................................................................ 73 Care of Patients in the Waiting Area .......................................................................................... 74 Care of the Patient in the Acute Care and Treatment Areas .................................................... 75 Diagnostic and Ancillary Procedures in the ED ......................................................................... 76 Conduct of Referral and Hand-over Communication between Healthcare Professionals in the ED ............................................................................................................................................... 78

Intra-Hospital Transfer of Critically Ill Patients ........................................................................... 79 Disposition of Patients in the ED ................................................................................................ 80 Disposition of the Cadaver and Dismembered Body Parts ....................................................... 85 Special Emergency Department Principles ............................................................................... 87 Special Populations in the Emergency Department .................................................................. 94 Ethics in the Emergency Department ........................................................................................ 95 7 Guide on Special Situations .................................................................................................... 97 Special Situations in the Emergency Department ..................................................................... 97 Women and Child Protection Unit .............................................................................................. 97 Mass Casualty Incidents .......................................................................................................... 104 Emerging and Re-Emerging Infectious Diseases (EREID) ..................................................... 106 Surge Capacity ......................................................................................................................... 107 Medical Examinations of Apprehended Persons in the Emergency Department.................... 111 Management of Aggressive/Combative Patients ..................................................................... 111 8 Ancillary Services and Clinical Support of the ED .............................................................. 116 Satellite Pharmacy ................................................................................................................... 117 Clinical Laboratory .................................................................................................................... 117 Diagnostic Radiology................................................................................................................ 117 Clinical Support Units ............................................................................................................... 118 9 Medico-Legal Cases in the Emergency Department ........................................................... 120 Medico-Legal Cases Defined ................................................................................................... 120 Policies and Mandates relative to Medico-Legal Cases .......................................................... 121 Health Information Management for Medico-Legal Cases in the Emergency Department ..... 122 Consent for Examination .......................................................................................................... 123 Medico-Legal Documentation and Reporting .......................................................................... 123 Medico-Legal Evidence Guidelines .......................................................................................... 124 Medico-Legal Aspects of Poisoning ......................................................................................... 125 Medical Negligence and Reckless Imprudence ....................................................................... 125 10 Continuous Quality Improvement in the ED ...................................................................... 128 General Principles of Continuous Quality Improvement .......................................................... 128 Tools and Strategies for CQI in the ED.................................................................................... 129 Implementation of CQI in the Emergency Department Setting................................................ 132 Emergency Department Quality Metrics/ Indicators ................................................................ 135 APPENDICES .............................................................................................................................. 143

1. INTRODUCTION

1.1 Emergency Care as a Human Right

Emergency Care encompasses that of the provision of first-contact care, comprehensive (non-organ, non-patient and non-disease specific) care, and the practice of gate-keeping. As such, Emergency Care is an integral part of Universal Health Care (UHC) and is considered a health human right (Office of the United Nations High Commissioner for Human Rights; World Health Organization. It should be provided without any discrimination and within the limits of resources, manpower, and competence available for emergency care.

1.2 Legal Framework

Under the Department of Health FOURmula One Plus For Health (F1 Plus For Health) which envisions Filipinos as among the healthiest people in Southeast Asia by 2022, and in Asia by 2040, the Emergency Department is tasked as a key intervention in the Service Delivery Pillar through the provision of resilient health systems and provision of essential health goods and services during times of disasters and emergencies (Department of Health, 2020). In the Philippines, all government and private hospitals or clinics duly licensed to operate as such are required to render non-discriminatory and immediate emergency medical assistance and provide facilities and medicines within its capabilities to patients in emergency cases who are in danger of dying and/or who may have suffered serious physical injuries. The following legal mandates, among others, serve to ensure access of all patients to emergency care: Republic Act No. 6615 An Act Requiring Government and Private Hospitals and Clinics to Extend Medical Assistance in Emergency Cases Republic Act No. 83441 An Act Penalizing the Refusal of Hospitals and Medical Clinics to Administer Appropriate Initial Treatment and Support in Emergency or Serious Cases Republic Act No. 10932 An Act Strengthening the Anti-Hospital Deposit Law by Increasing the Penalties for the Refusal of Hospitals and Medical Clinics to Administer Appropriate Initial Medical Treatment and Support in Emergency or Serious Cases, Amending for the Purpose Batas Pambansa Bilang 702, Otherwise Known as “An Act Prohibiting the Demand of Deposits or Advance Payments for the Confinement or Treatment of Patients in Hospitals and Medical Clinics in Certain Cases.” As Amended by Republic Act No. 8344, and for Other Purposes

1.3 Emergency Care and the Emergency Care Systems Framework

Emergency medical care is the provision of immediate medical intervention aimed to stabilize patients with life-threatening or limb-threatening injury or illness such as patients with time-critical conditions of any age, gender, location, or severity (Razzak and Kellermann, 2002).

The Emergency Care System Framework The emergency care spectrum should be continuous and seamless as illustrated in the World Health Organization's Emergency Care System Framework (Figure 1), after the 72nd World Health Assembly resolution on "Emergency Care Systems for Universal Health Coverage: Ensuring Timely Care for the Acutely ill and Injured."

Figure 1. WHO Emergency Care System Framework Infographic. Reprinted from the World Health Organization. (2018, May 2). WHO Emergency care system framework. World Health Organization / Publications. https://www.who.int/publications/i/item/who-emergency-c Health Care Provider Network (HCPN) The ED is a safety net and gatekeeper. It serves as a link and entry point of the public health system to the hospital system and is part of the Health Care Provider Network (HCPN). Emergency Care Services
The ED is an in-hospital gatekeeper, and in effect, a temporary primary care coordinator for emergencies and acute care. The core concepts and strategies of emergency medicine care focus on reducing preventable mortality, morbidity, and disability from time-sensitive disease processes through integrated systems for accessing emergency care, providing emergency care in the community, care during transportation, and care on arrival at receiving facilities. Based on WHO universal care standards, depending on resource availability, emergency care systems is comprised of (1) being receiving facilities inclusive of processes of triage, resuscitation and stabilization, initial diagnostic evaluation and treatment, observation and consultation, communication of results and documentation of care, and planning for follow-up care, and (2) being providers of emergency care access and out-of-hospital care such as basic first aid and transportation through emergency medical services (EMS).

1.4 Resource Stratified Framework in Provision of Emergency Care

The Philippines utilizes a Resource Stratified Framework wherein services expected from health facilities, including Emergency Department services are based on the resources available to the facility and their corresponding Level.
Facilities are classified into three levels from Level 1 to Level 3, where Level 3 facilities are considered referral facilities. Specific services expected from Emergency Departments from each level are outlined and discussed in Chapter 2: Emergency Department Services of this manual.

1.5 Emergency Department or Unit

The Emergency Unit (EU) or Emergency Department (ED) is a specialized area in the hospital that provides initial treatment for patients with a broad spectrum of illness and injuries, some of which may be life-and-limb threatening, requiring immediate medical or surgical attention.
The Emergency Department was developed during the 20th century in response to the increased need for rapid assessment and management of critical illness and injury. While this department provides initial medical management for patients with varying severity of illness and injury, this also serves as an entry point for those patients without access to medical care. The old term Emergency Room is a misnomer and is advocated to be abandoned as the department or unit is not really just a room and is, in fact, a complex area in the hospital with distinct structures and systems and emergency care services may even extend beyond the physical structure of the ED/EU. The perspective and paradigm shift is essential to understand the complexity and the wide scope of emergency care services considered as part of primary care services.

1.5.1 General and Specific Functions of the Emergency Department

The general function of the ED is to provide quality emergency care services to patients in the Emergency Department. The specific functions of the ED include provision of emergency services, building the critical capacity of the ED personnel, and institutionalization of the standard system and procedure on emergency care. Services • Complete assessment of all patients who seek help in the ED for a rational and accurate diagnosis of their medical problems • Provision of immediate resuscitative measures to patients with life-and-limb-threatening conditions • Coordination for appropriate and timely disposition of ED cases for further inpatient care or transfer as warranted based on the institution’s level of care capability • Acute care service delivery during mass casualty incidents and disasters • Promotion of patient's rights through informed consent • Counseling for cases that may require managed home care • Provision of ED documentation for medico-legal cases and other medico-legal services

• Provision of quality, effective and efficient emergency care services Capacity Building • Continuing professional education to all staff including paramedical staff handling emergency care services • Orientation and competency-based training on ED policy and procedures among ED personnel and student affiliates • Provision of competent, well-trained and committed staff for acute services Institutional Emergency Care Standards and Systems Development • Provision of quality standards for emergency care • Provision of policies and guidelines on administrative procedures • Strengthening of the ED health information management • Provision of policies and procedures of an efficient Triage System • Compliance to standards on physical plans and equipment • Provision of adequate supplies, medicines and equipment • Implementation of a Continuous Quality Improvement (CQI) and Patient Safety Program • Strengthening of a referral system/network • Institutionalizing patient-centered care • Development of a monitoring and evaluation system • Conduct research and development

1.5.2 Emergency Department as a Specialized Area

The Emergency Department is the show-window of a hospital providing 24-hour, seven (7) days a week service. Adequate resources are made available for the provision of quality care to patients in an emergency situation. The care provided to each patient is carefully planned, written on the patient's record and effectively carried out in a timely and responsive manner. Only qualified and competent personnel with minimum training on basic and advanced cardiac life support (BLS and ACLS) should be assigned at the ED.
The policies and procedures guide the care of ED patients to ensure that they receive quality care. Clinical Practice Guidelines and Clinical Pathways developed by the hospital and/or specialty societies are used to guide patient assessment and management. They can be reviewed and adapted on a regular basis after implementation to ensure its continued relevance for a pro-active quality improvement approach. Patients categorized as emergent, urgent, or non-urgent examined at the ED are identified through its established clinical assessment processes that may include diagnostic services to clearly define their appropriate disposition. Periodic assessment at appropriate intervals according to their condition, plan of care and individual needs are performed and documented in the patient’s record. Plan of care is modified relative to the changes in the patient’s emerging condition. The hospital processes are designed to provide continuous patient care services within the ED through interdepartmental referral or to appropriate levels of care through an established inter-hospital networking and referral system. Institutionalized criteria or policies determine the appropriateness of transfer of patients to other hospitals to meet their continuing needs.

The disposition to discharge patients at the ED considers the need for support service and continuity of care with the follow-up instructions that include diagnosis and interventions done; medications; pertinent medical advice; and date, time and service where to obtain follow-up care. Physicians should explain all possible options of treatment and intervention. Patients and their families likewise, participate in decision-making as to the extent of care they choose. Thus, benefits are maximized, risks are minimized and potential complications are prevented.

1.6 Scope of the Management of the Hospital Emergency Department Manual

The scope of the second edition of the Manual of Standards and Guidelines on the Management of the Hospital Emergency Department includes services provided within the physical structure of the Emergency Department or Unit in accordance with the intent of the Health Facility Development Bureau of the Department of Health. While the technical working group recognizes that the Department of Emergency Medicine and Emergency Care extend beyond the physical structure, the manual's scope will remain within the structure of the ED/EU. These services will be further discussed in the succeeding chapters.

References

Department of Health. (2020). 2019 Annual Report Department of Health Philippines. Health Policy Development and Planning Bureau. https://doh.gov.ph/sites/default/files/publications/2019-DOH-Annual-Report.pdf Office of the United Nations High Commissioner for Human Rights; World Health Organization. (2000). The Right to Health. Retrieved June 03, 2021, from https://www.ohchr.org/documents/publications/factsheet31.pdf Razzak, J. A., & Kellermann, A. L. (2002). Emergency medical care in developing countries: is it worthwhile? Bulletin of the World Health Organization, 80(11), 900-905. https://www.who.int/bulletin/archives/80(11)900.pdf Republic Act No. 6615 An Act Requiring Government and Private Hospitals and Clinics to Extend Medical Assistance in Emergency Cases. (1972, October 23). Philippines. https://www.chanrobles.com/republicacts/republicactno6615.html#.YLh0JvkzY2w Seventy-Second World Health Assembly. (2019, May 28). Emergency care systems for universal health coverage: ensuring timely care for the acutely ill and injured [WHA72.16 Agenda item 12.9]. World Health Organization. (2018, May 2). WHO Emergency care system framework. World Health Organization / Publications. https://www.who.int/publications/i/item/who-emergency-care-system-framework.

2. EMERGENCY DEPARTMENT SERVICES

The Emergency Department (ED) is an area of the hospital with special equipment and staffed by specially-trained personnel that provides acute care and resuscitation. It is usually identified by a prominent signage with the word “EMERGENCY” in white text on a red background and with arrows to guide where patients should proceed. The services are intended for a broad spectrum of clinical cases, some of which are acute limb or life-threatening conditions requiring immediate resuscitation and stabilization. The ED provides services 24 hours a day, 7 days a week (24/7).
The ED is an important interface to the many inpatient and outpatient services. It plays a pivotal role in providing the public access to acute care, support to primary health care and community services. It can provide targeted primary preventative interventions to populations at risk, such as post-exposure prophylaxis for tetanus and rabies, injury prevention, and early detection of chronic diseases. Emergency Departments are also vital in the response of mass casualty incidents as well as population- based epidemiologic data for use in disease surveillance (International Federation for Emergency Medicine).

2.1 Case and Condition: The Emergency Department Patient

The ED receives a wide range of patients from those requiring resuscitation, to emergent, urgent, and less urgent conditions. The purpose of the ED is to receive, triage, assess, stabilize and provide acute health care to these patients. Hence, care provided is not only limited to individual level patient care services but must also have the capacity to deal with mass casualty incidents and disasters. Conditions seen at the ED are defined as follows: Emergency case is a condition or state of a patient wherein based on the objective findings of a prudent medical officer on duty for the day there is immediate danger and where delay in initial support and treatment may cause loss of life or cause permanent disability to the patient. Section 2(a), Republic Act No. 8344. Serious case refers to a condition of a patient characterized by gravity or danger wherein based on the objective findings of a prudent medical officer on duty for the day when left unattended to, may cause loss of life or cause permanent disability to the patient. Section 2(b), Republic Act No. 8344 Emergency refers to a condition or state of a patient wherein based on the objective findings of a prudent medical officer on duty, there is immediate danger and where delay in initial support and

treatment may cause loss of life or permanent disability to the patient, or in the case of a pregnant woman, permanent injury or loss of her unborn child or a non-institutional delivery. Section 4(g), Republic Act No. 11223 Emergency Department Patient Patients seen at the ED may be self-referred or referred by primary care practitioners via self-conduction or ambulance conduction. Patients of any age and background arrive at the ED with varying severity of conditions. Some will have acute events due to their chronic illness, others come due to trauma, while others come due to infection. These patients presenting at the ED may be classified as, but not limited to the following: • Major and minor trauma patients • Patients with acute and critical medical needs • Children and adolescents • Elderly patients • Patients with mental health issues • Victims of child, domestic violence, or sexual assault • Patients affected by chemical, biological and radiological contaminants • Patients with emerging and re-emerging infectious diseases • Obstetrics and gynecologic patients

2.2 Care and Interventions: Emergency and Acute Care

Emergency medical care, also known as acute care is defined by the World Health Organization as health care which includes all promotive, preventive, curative, rehabilitative or palliative actions, whether oriented towards individuals or populations, whose primary purpose is to improve health and whose effectiveness largely depends on time-sensitive and, frequently, rapid intervention (Reynolds). In this case, the purpose of the ED is to provide such emergency care which includes receiving, triaging, stabilizing and providing acute care itself to patients. Services include managing patients requiring resuscitation, emergent, urgent, and less urgent conditions. Care provided is not only limited to individual level patient care services but also the capacity to manage mass casualty incidents and disasters (Australasian College of Emergency Medicine).

2.3 Stratified Delivery of Emergency and Acute Care Services

Services provided by the Emergency Department are guided by the Resource Stratified Framework where the expected minimum ED services are based on the health facility classification between Levels 1, 2, and 3. Special services may be provided by the ED such as Emergency Medical Services, Ambulatory Care Services, Animal Bite Centers, Poison Control Centers or Toxicology Treatment Services. Emergency Departments of Level 1 and 2 hospitals may refer to higher level facilities as required by their patients. Depending on the resources available, special services may be provided by the Emergency Department especially among Level 2 and Level 3 hospitals. EDs of Level 1 and 2 hospitals may refer their patients to higher level facilities as required.

Table 1. Resource Stratified Framework Based Functional Areas of the Emergency Department Level 1 Level 2 Level 3 • Triage Area • Decontamination Area • Resuscitation Room • Trauma Bay • Acute Care area • Isolation Room • Examination Area • Waiting Area • Counseling/Bereavement Room • VAWC Unit • Psychosocial and Neurological Services Area All functional areas of L1 plus: • Acute Adult and Pediatric Care Areas • Trauma Unit • High Risk Obstetrics and Complicated Gynecology cases
All functional areas of L2 plus: Areas of Special Services • Ambulatory Care/Fast Track Services • ABTC area • Minor Operating Room • Observation Unit

2.4 Overview of Other Services in the Emergency Department

In addition to the prime function of the ED to provide acute care services, the ED also provides services like medico-legal and Emergency Medical Services (EMS) coordination during disasters and mass casualty incidents. However, since the ED is a 24/7 hospital department, it has often been prone to abuse brought about by an overburdened healthcare delivery system. Some individuals would seek ED consult for non-emergency cases because they could not go to a general practice clinic for consultation. The ED then aims to educate the community on proper utilization of its acute care services. Doing so would result in improved ED services through optimized, appropriate specialty care for patients in need of such.

2.4.1 Ambulance Transport and Emergency Pre-Hospital Response or Interfacility Transfers

Pre-hospital care is vital in safely transporting patients with critical conditions to first contact Emergency Departments or for inter-facility transfers. Emergency Medical Services (EMS) may be outsourced to private entities with supervision from EMTs and MDs while others are provided by Local Government Units. These pre-hospital services include ambulance transport and emergency pre- hospital response.

2.4.2 Mass Casualty Incidents Services

The ED also plays a crucial coordinating role during disaster situations, both external to the hospital and in the event of exceeding its surge capacity. The ED shall develop the hospital’s emergency preparedness plan in collaboration with the other departments in the hospital and plan for its activation based on an alert system in place. This plan identifies the different functions and relationships of the ED to the local police and fire department, media, government, and non-governmental organizations during its activation.

2.4.3 Medico-Legal Services

The ED also provides services for the medical cases with legal implications. The emergency physician, surgeon, or gynecologist assigned has the mandate of conducting a thorough medical examination,

complete, and accurate documentation for reporting of medico-legal cases to the proper authorities. These services are discussed further in Chapter 9: Medico-Legal Cases in the Emergency Department.

2.4.4 Ambulatory Care Services

Ambulatory care service is for non-critically ill patients who present themselves as non-urgent cases in the ED, and can be given appropriate care and discharge instructions for home care and follow-up. Ideally, they will receive treatment in the designated ambulatory care unit of the ER complex or in the out-patient department.

2.4.5 Animal Bite Services

In specialty hospitals with a unit known as ‘Animal Bite Center”, the ED shall cater to Category III animal bite cases where emergent management is needed. Categories I and II cases shall be triaged as non-urgent and referred to the OPD for management. Category III Animal Bites are classified based on the following criteria: • Injuries involving the Head and Neck, and Finger areas • Deep, lacerated wounds • Multiple bites • Bites from the stray, killed, sick animals and those which died within 10 days from the date of bite • Patients from places highly endemic for rabies

2.4.6 Toxicology Treatment Services

Toxicology Treatment Services in the ED focus on cases of poisoning due to medications, biological agents, occupational or environmental agents. The ED is expected to provide the following services relative to the resources available per hospital facility level. Referrals may be made to the identified Poison Control Centers based on the DOH Department Circular No. 2020-0081. Table 2. Emergency Department Toxicological Services based on Resource Stratified Framework Level 1 Level 2 Level 3 • Identification of poisoning case • Acute medical care for poisoning patients • Acute medical care including critical care
• Poison information services
• Acute medical care of all poisoning cases, including antidote administration

References

Anderson, P. D., Suter, R.E., Mulligan, T., Bodiwala, G., Razzak, J.A., Mock, C., & International Federation for Emergency Medicine (IFEM) Task Force on Access and Availability of Emergency Care. (2012). World Health Assembly Resolution 60.22 and its importance as a health care policy tool for improving emergency care access and availability. Annals of Emergency Medicine, 60(1), 35-44. https://europepmc.org/article/med/22326860

Australasian College of Emergency Medicine. (2014). Emergency Department Design Guidelines. Australasian College of Emergency Medicine. https://acem.org.au/getmedia/faf63c3b-c896-4a7e-aa1f- 226b49d62f94/G15_v03_ED_Design_Guidelines_Dec-14.aspx International Federation for Emergency Medicine. (2012). Framework for Quality and Safety in the Emergency Department. International Federation for Emergency Medicine. https://www.ifem.cc/wp- content/uploads/2016/03/Framework-for-Quality-and-Safety-in-the-Emergency-Department-2012.doc.pdf Razzak, J. A., & Kellermann, A. L. (2002). Emergency medical care in developing countries: is it worthwhile? Bulletin of the World Health Organization, 80(11), 900-905. https://www.who.int/bulletin/archives/80(11)900.pdf Reynolds, T. (n.d.). WHO | Emergency Care [Department for Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention]. World Health Organization.

3. GOVERNANCE: Leadership and Management

3.1 General Overview

Given its mandate of providing the best quality care to every Filipino patient who needs emergency attention, the Emergency Department (ED) has to be complemented by highly skilled staff with defined duties and responsibilities. EDs should have a centralized organizational structure with the chairperson as head of its leadership and management operations for the medical, nursing, and administrative staff. The ED shall have a mission-vision, with the patient at its core and which shall be communicated to all the staff. Aligned with this mission-vision should be the following duties and responsibilities:

1. To render timely care to all patients with life-threatening or limb-threatening situations;
2. To exercise the highest level of courtesy and ethical standards in the performance of duties;
3. To empower the Filipino patient by making them partners their healthcare decision-making; and
4. To support the community (government, local authorities, media, household) mitigate the effects of disasters during the mass casualty incidents.

3.1.1 Guidelines for ED Operations in Hospitals of All Levels

1. The Emergency Department should have clinical and administrative staff in order to ensure provision of emergency and urgent care services, and provide oversight of the crucial services based on hospital level. Table 3 outlines the minimum prescribed ED administrative staff per hospital level, but are not limited to the following: Table 3. Emergency Department Administrative Staff based on Hospital Level Level 1 Level 2 Level 3 • ED Chair (Medical Officer or Medical Specialist) • ED Nurse Manager (Nurse Supervisor)
   • ED/DEM Chair (Medical Officer or Medical Specialist) • Vice Chair • ED Nurse Manager (Nurse Supervisor) • ED/DEM Chair (Medical Officer or Medical Specialist) • Vice Chair • DEM Training Officer • ED Nurse Manager (Nurse Supervisor)

2. The ED chair or head should have the centralized administrative supervision over all operations in the ED regardless if the hospital has an Emergency Medicine (EM) training program or not.

3. All hospitals having departmentalized services should exercise some form of autonomy in the ED. Clinical supervision means specialist inputs to the medical management of the patients for those with specialist training programs.

4. The technical (clinical) supervision may be under the responsibilities of the respective clinical departments in non-EM training hospitals. Respective department chairs of rotating services shall ensure that service delivery practiced in the ED is in accordance with the specialty guidelines.

5. For hospitals with non-EM training programs, all rotating personnel in the ED shall be provided with necessary training and orientation related to emergency care to ensure that they are equipped with the competency needed, so as not to disrupt the services being provided. Residents and interns should have a fixed time frame of rotation e.g. 2-3 months and not be pulled out anytime by different departments or units. In the same manner, emergency equipment should be solely for ED use only.

6. Rotation in the ED should be primarily service-oriented. Seminars and training on Value Reorientation, Rights of Patients, Client Satisfaction, Art of Communication, etc. are suggested topics during ED orientation.

7. The ED shall be staffed by no less than a second-year resident for EDs with no EM or FM training program. If there will be a first-year resident of a non-EM training program, he/she will not be a frontliner.

8. All health personnel and staff stationed at the ED should be provided with the necessary orientation or briefing on the essential operations of the ED.

9. All health personnel and staff stationed at the ED should have the minimum required training to ensure provision of quality services: basic emergency care, training in pediatric, medical and trauma resuscitation as follows:

Table 4. Minimum Required Training for Emergency Department Staff Personnel Training Level Physicians (Based on training competencies of clinical training) Training in Triaging Basic Emergency Care Basic Life Support 4Rs (Training in WCPU) ACLS L1 and L2 All L1 and L2 PLUS PALS/NRP
ATLS
POCUS
L3 Nurses Basic Emergency Care including training in Triaging Basic Life Support
4Rs (Training in WCPU) L1 All L1 PLUS
ACLS
PALS/NRP L2 and L3 All staff including administrative staff Basic Life Support All levels

3.1.2 ED Operations for Hospitals with Emergency Medicine Training Programs

1. For emergency departments with Emergency Medicine training and consultancy staff shall develop administrative and clinical protocols relevant to the delivery of services of the ED.
2. Residents in training should be supervised by the EM consultant/staff on duty especially for emergent processes.

3.2 Organizational Structure and Staffing Pattern

Table 5. Emergency Department Manpower Requirements and Organizational Chart Level 1 Level 2 Level 3 Medical Officers Medical Specialists: Emergency Medicine Medicine, Pediatrics, Obstetrics and Gynecology, Surgery

Medical Officer (Training or non-trainees) Without EM Residency Training Without EM Residency Training but with EM Specialist With EM Residency Training EM Specialist

Medical Specialists from Level 2 PLUS Medical Specialists from other services such as, but not limited to Family Medicine, ENT, and Ophthalmology

Medical Officers (Training) corresponding to Medical Specialists pool Emergency Medicine Specialists; Specialist Same with Level 2 including but with Specialist not limited to Family Medicine, ENT, Ophthalmology

Medical Officers same with Level 2 Same with Level 2 including but with Emergency Medicine Training plus Family Medicine, ENT, Ophthalmology

Medical Officers

Medical Officers same with Level and with Emergency Medicine Residents and Level 3 training MOs Nurses Nurse II Nursing Attendant Nurse III Nurse II Nursing Attendants Nurse III Nurse II Nursing Attendant Midwife Midwife Midwife Support Services Midwife Support Services Midwife Support Services

Support Services Support Services (Emergency Medical Technicians) (Emergency Medical Technicians)

3.2.1 Proposed Organizational Structure for Hospital Level 1-3

All Emergency Departments shall follow the prescribed organizational structures as described in Figures 2, 3, 4 and 5. Roles and responsibilities of positions indicated in the organizational structures are outlined from section 3.3.1 to 3.3.4.

Figure 2. ED Structure for Level 1 Hospitals

Figure 3. ED Structure for Level 2 and Level 3 Hospitals without Emergency Medicine Training without EM consultants

Figure 4. ED Structure for Level 2 and Level 3 Hospitals without Emergency Medicine Training with EM consultants

Figure 5. ED Structure for Level 3 Hospitals with Emergency Medicine Training

3.3 Roles, Responsibilities, and Qualifications of Staff in the ED

3.3.1 Medical Staff in the ED

The Medical staff shall exercise the highest standard of patient care and extend utmost courtesy to the patient and their relatives during management at the Emergency Department. Table 6. Roles, Responsibilities, and Qualifications of the Emergency Department Chair Roles/ Responsibilities Qualifications

1. Oversees the management of the nursing, administrative, ancillary, and allied medical operations of the Emergency Department
2. Shall have an administrative supervision of all staff in the Emergency Department in close coordination with their respective clinical supervisors or heads of department/ section.
3. Designates a Vice Chairperson and a Training Officer among the pool of Consultants.
4. Ensures that the professional care rendered to patients conforms to the highest quality of care standards possible.
5. Makes recommendations as to the qualifications of the ED staff.
6. Recommends to the medical director/ chief of hospital/ medical center chief the essential drugs, supplies, instruments, and equipment for procurement. For a Hospital with EM Specialist/ Training: • Diplomate or Fellow of the Philippine College of Emergency Medicine For Hospitals without EM Specialist / Training • Diplomate or Fellow of a duly recognized non-EM specialty/subspecialty society • Training in Emergency Care
   • Training in ED management

Mandatory Training Training in Triaging Basic Emergency Care Basic Life Support 4Rs (Training in WCPU)

7. Formulates policies to standardize the daily operations of patient care.
8. Participates in inter- department meetings.
9. Conducts regular conferences, attended by all its members to address clinical, operational and organizational problems peculiar to the service.
10. Activates the hospital’s emergency and incident command system (disaster management plan) during disaster situations and provides recommendations to the medical director/ chief of hospital/ medical center chief during the implementation of contingency plans.

ACLS
PALS/NRP
ATLS
POCUS

Table 7. Roles, Responsibilities, and Qualifications of the Emergency Department Vice-Chair Roles/ Responsibilities Qualifications

1. Assists the Chair in the implementation of policies and guidelines within the department and with other clinical services.
2. Attends regular department and inter-departmental hospital meetings.
3. Assumes positions and assumes functions as assigned by the Chair. The Vice-Chair of the Emergency Department should be a Diplomate or Fellow of the Philippine College of Emergency Medicine or that of a duly recognized non-EM specialty/ subspecialty society.

Table 8. Roles, Responsibilities, and Qualifications of the Emergency Department Training Officer Roles/ Responsibilities Qualifications

1. Ensures that the residents, medical student clerks, and interns follow the prescribed training modules as part of their pre- qualification for graduation. The Training Officer of the Emergency Department should be a Diplomate or Fellow of the Philippine College of Emergency Medicine

Table 9. Roles, Responsibilities, and Qualifications of the Emergency Department Consultant Staff Roles/ Responsibilities Qualifications

1. Assumes on-call status for 24 hours and provides supervision to the ED Officer and residents-on-duty especially when difficult and equivocal cases cannot be decided on by residents in the Emergency Department. The consultant physicians of the Emergency Department should be Board-Eligible, Diplomates or Fellows of the Philippine College of Emergency Medicine or that of

2. Supervises the training of residents (or medical interns and clerks) and conducts thorough regular rounds and conferences for continuing medical education.

3. For L3 and L2 hospitals with no EM training but with EM consultants, consultant staff will assume as the Charge Physicians/ED Attending Physicians.
   a duly recognized specialty/ subspecialty society.

Table 10. Roles, Responsibilities, and Qualifications of the Chief Residents - For Hospitals with Residency Training Programs Roles/ Responsibilities Qualifications For Hospitals with EM Specialty Training

1. Assists the Chair and Consultant Staff in the daily operations of the ED.
2. Performs pertinent administrative functions for the department.
3. Conducts regular rounds with the residents (and medical interns, clerks, and students).
4. Monitors the delivery of patient care in the ED.
5. Coordinates with other medical services rotating in the ED.
6. Acts as liaison between the other Departments and the Hospital Administration. The Chief Resident is the most senior resident usually in his 4th year of residency. For Hospitals without EM Specialty Training:
7. Coordinates with the ED chair on the daily operations of the ED.
8. Monitors the delivery of patient care in the ED.
9. Ensures that an adequate number of residents are assigned in the ED.
   Assumed by Consultant/Charge Physician or Attending EM if with EM Consultants in consultancy staff

Table 11. Roles, Responsibilities, and Qualifications of the ED Charge or Attending Physicians Roles/ Responsibilities Qualifications

1. Reports to the Head of Emergency Services or Assistant Head of Emergency Services.
2. Assumes clinical and administrative duties in the ED at least 40 hours per week (160 hours per month) for full time appointments/contracts or 20 hours per week (80 hours per month) for part time appointments/contracts or as on-duty in the ED at least 40 hours per week and depending on roster shall cover the ED for 24/7.
3. Ensures 24/7 coverage of ED duties.
4. Oversees all medical care in the ED and coordinates through external communication with hospital administration and those not covered by the ED Applicable for L2 and L3 hospitals with EM Consultants

All attendings/charge physicians in Emergency Medicine are members of the medical staff in good standing.

Attendings in Emergency Medicine must have completed a residency in either

Management and Administrative Officer (EDMAO)’s coordination/reporting.
5. Ensures professional and timely communication between the emergency department physicians and the following: a. Nursing and Private Medical Staff
b. Administration c. Emergency Medical Services
d. Patients and Families
e. Community
f. Media
6. Supervises all resident physicians, physician assistants, nurse practitioners, EMS and student
7. Oversees the overall communication between the Emergency Medical Services (EMS) agencies/stakeholders and the Emergency Department EMS-related activities must be coordinated and reported firsthand by the EDMAO/Senior ED resident on-duty to the Charge Physician. 8. Serves as EMS Medical Director during tour of duty. Indirect or offline medical direction in relation to EMS include but not limited to the following: a. Adherence to existing ED Work Instructions and SOPs and education/dissemination as such to prehospital care and field responders when necessary. b. Oversight of proper execution of Interfacility Referrals, Intra-facility Transfers and Ambulance operation concerns. c. Direct or online medical direction on the other hand include interaction between Charge Physician and EMS Provider regarding patient referrals and transfer. Direction will also include prepositioning of appropriate logistics (staffing, equipment, supplies, treatment spaces) that will involve during patient care and transfer. 9. Manages mass casualty incidents, surge capacities, internal disasters concerning ED operations and activates/alerts the ED Staff and existing Hospital ICS for immediate assistance and response. 10. Oversees triaging, medical screening and assigns resuscitation response by nurses when appropriate.
11. Ensures that assigned department tasks are completed by designated staff and signed off on a daily checklist.
12. Facilitates rapid patient flow through the department by making frequent rounds.
13. Assists with patient care as needed and coordinates help for nurses who need assistance.
14. Coordinates crisis intervention for families with social workers and clergy.
15. Documents significant occurrences or interventions on shift reports.
Emergency Medicine, 4 years ED experience.

Attendings in Emergency Medicine must be Board Eligible or Board Certified
Mandatory Training for Emergency Department Attending Physicians ACLS PHTLS ATLS Or equivalent training such as residency training in Emergency Medicine or initial course training in ACLS and ATLS and board certification in Emergency Medicine.

16. Facilitates and ensures proper endorsements and hand over by EM resident physicians through bedside and daily endorsements.

Table 12. Roles, Responsibilities, and Qualifications of the Emergency Department Officers Roles/ Responsibilities Qualifications

1. Ensures timely disposition (admit, discharge, or transfer) of all patients to avoid or minimize congestion of ED.
2. Goes on 24-hour duty and shall be physically present during his/her tour of duty.
3. Updates the consultant-on-duty of the status of the ED on a regular basis (and the Chairperson/ Hospital Director in cases of mass casualty incidents).
4. Receives telephone referrals of patients for possible transfer from other hospitals/ health facilities and documents said referrals (whether accepted or referred further) in a patient logbook.
5. Checks the attendance of the residents (and medical interns and clerks).
6. Follows up cases referred by the respective ED residents-on- duty for proper disposition.
7. Follows up interdepartmental referrals of the residents-on-duty to facilitate the disposition of patients.
8. Oversees the proper conduct of residents (and medical students) at the ED. All infractions/ offenses must be reported to the Head of the Department.
9. Ensures that the ED register is complete at the conclusion of duty with regards to: a. Signature of resident over a printed name and/or stamp b. Impression/diagnosis with appropriate management c. Accurate documentation of patients in accordance with the ER 24-hour Report Form before admission.
10. Supervises the operations of the ambulance with the assistance from the Nursing Service. Physicians accompanying the patient for ambulance transport shall come from the ward where the patient is admitted. The ED Officer of the day shall facilitate the process.
11. Conducts regular disposition rounds with the residents-on-duty and medical students. Designated team leader of the residents per clinical department every tour of duty.

Applies to L2 and L3 hospitals with non-EM Consultants.

For hospitals with EM training, roles and responsibilities outlined are applicable for senior EM residents.

Table 13. Roles, Responsibilities, and Qualifications of the Triage Officer Roles/ Responsibilities Qualifications

1. Assesses the vital signs, cardiopulmonary function, and the chief complaint of the patient.
2. Performs a primary assessment of the patient and facilitates issuance of patient blotter and chart.
3. Conduct a rapid classification of patients into following categories: resuscitative, emergent, urgent, non-urgent and then directs the patient to the most appropriate service.
4. Ensures that patients seen at the Triage Bay are properly documented in the triage registry.
5. Secures consent for emergency treatment/management.
6. Initiates emergency treatment when the patient's condition is life threatening.
7. Communicates and acts as liaison with patients, relatives, and healthcare professionals with respect to confidentiality and dignity.
8. Provides education to patients and relatives when necessary.
9. Reports directly to the ED Officer any concern that may arise from the Triage Bay. The Triage Officer may be any of the following: a. Second year (or higher) resident from ED or from other rotating clinical department b. Senior nurse or a nurse trained to perform triage. c. Shall have at least the following trainings: i. Basic and Advanced Cardiac Life Support. ii. Other pertinent training may be deemed necessary per clinical department such as Advanced Trauma Life Support, Pediatric Advanced Life Support, Triaging, Mass Casualty Incidents (MCI)

Table 14. Roles, Responsibilities, and Qualifications of Residents in the Emergency Department Roles/ Responsibilities Qualifications Emergency Medicine Residents

1. Attends to all emergency patients, as directed by the Triage Officer, who need acute care stabilization.
2. Institutes time-bound management and disposition.
3. Refers to the appropriate specialty service for further management and for possible admission of patients initially stabilized.

Rotating Residents from other Clinical Departments.

1. Surgery a. Attends to all surgical patients and, as part of the Trauma team, participates in initial resuscitation of all Trauma patients. The patient may be referred by the Triage Officer for management or by the Emergency Medicine, Medicine, Pediatric, or Licensed physicians undergoing Residency Training Programs

Obstetric residents for further management or co-management, as the need arises. b. Receives referrals from other specialty services in the ED for surgical evaluation. 2. Internal Medicine a. Attends to all medical patients seen at the ED (as may be directed by the Triage or the other specialty service in the ED). b. Receives referrals from Emergency Medicine or other specialty residents for medical evaluation. 3. Pediatrics a. Attends to all pediatric cases (whether with medical or surgical conditions). b. Receives pediatric patient referrals from the Emergency Medicine, Internal Medicine or Surgery for evaluation. 4. Obstetrics-Gynecology
a. Attends to all patients seen at the ED (as may be directed by the Triage or the other specialty service in the ED) for obstetric or gynecological problems.

Table 15. Roles, Responsibilities, and Qualifications of Medical Interns and Clerks in the Emergency Department Roles/ Responsibilities Qualifications

1. Assists the residents stationed in the ED during patient care and observes patient disposition.
2. Provides care and disposition of patients under the direct supervision of residents or the ED Officers.
3. Observes utmost courtesy with the patients, the medical staff and the other ED staff. Interns should not treat and dispose of patients without the direct supervision of residents or the ER Officer. At no time should the interns (or medical clerks) be allowed to cover for the ER Officer or the RODs in the latter’s discharge of their duties and responsibilities. Clerks

4th Year Medical Students
Interns - Post Graduate Interns or 5th Year Medical Students

3.3.2 Nursing Staff in the ED

The Emergency Department Nurses are organic employees of the hospital under the Nursing Service and as an integral part of emergency care, must ensure to give quality emergency nursing care to all patients who come into the Emergency department. According to the Administrative Order FAE 007, s. 1998 (dated August 10, 1988), nurses shall be permanently assigned in the Emergency Department so as to not disrupt the services and provide continuity of emergency care. They shall be provided with continuous training to further develop their clinical skills and competencies in emergency care. Other qualifications and requirements shall be in alignment with Republic Act No. 9173 The Philippine Nursing Act of 1991.

All Nursing personnel in the Emergency Department shall be trained but not limited to BLS, ACLS, PALS, ATLS, Triaging, and Mass Casualty Incidents. Table 16. Roles, Responsibilities, and Qualifications of the ED Unit Manager Roles/ Responsibilities Qualifications Under the supervision of ED Chair, oversees the management of the nursing care services, ED equipment, patient and staff safety.

1. Plans and supervises nursing related activities in the ED.
2. Coordinates administrative duties to ensure proper function of staff.
3. Plans and develops objectives, policies, program, schedule of duties of the unit.
4. Prepares annual work and financial plan and PPMP of the ED.
5. Communicates and interprets to the staff the policies, objectives and strategies of the DOH, the institution, and the Nursing department.
6. Coordinates with other departments regarding patients' needs.
7. Monitors and evaluates staff performance based on nursing standards in the delivery of quality nursing care.
8. Ensures implementation of E3N (efficient, effective, equitable nursing) program for continuous quality improvement and research.
9. Conducts learning development and interventions to increase competence of nursing staff.
10. Conducts continuous quality improvement activities in the unit/department to ensure provision of safe and quality nursing care.
11. Prepares and ensures safekeeping of ED records and reports.
12. Determines needs of staff related to professional growth and development and participates in the orientation, training of new staff, trainees and student affiliates.
13. Participates in nursing audits and patient charts, and other nursing quality records quarterly.
14. Directs arrangement of schedule of work hours, off duties, and leaves of all nursing personnel in the ED.
15. Coordinates with housekeeping and janitorial services for maintenance of cleanliness and orderliness of the unit.
16. Delegates authority and responsibility and makes clear the extent of which to improve work performance.
17. Encourages staff to promote positive values and attitude.
18. Responsible for ensuring patient and staff satisfaction.
19. Performs other functions as may be assigned.

Applicable for L3 Hospitals with more than 1 Nurse Supervisor Education Master of Arts in Nursing
or equivalent

Table 17. Roles, Responsibilities, and Qualifications of ED Nurse Manager Roles/ Responsibilities Qualifications Under general supervision of ED Unit manager, the ED clinical supervisor shall supervise the nursing care service unit/s through mentoring and monitoring of work performance of nursing staff and nursing school affiliates in the hospital, Education Master of Arts in Nursing

performs clinical functions, and participates in the development of policies, rules, and regulations for the hospital with the following functions:

1. Plans and supervises nursing related activities.
2. Assists in the development of plans, policies, procedures and standards related to the delivery of nursing care.
3. Serves as mentor/preceptor to staff directly involved in patient care.
4. Monitors performance of nurses and other nursing personnel in the unit.
5. Identifies training needs of nursing staff and personnel in the unit.
6. Prepares monthly nursing and health programs reports.
7. Coordinates with other departments relative to patient care.
8. Plans and implements patient safety programs in the unit.
9. Ensures adequate medical supplies and functional equipment in the area.
10. Ensures adherence to established policies and procedures in the unit.
11. Evaluates the performance of nursing personnel in the unit.
12. Does other duties as directed. or equivalent

Table 18. Roles, Responsibilities, and Qualifications of ED Charge Nurse Roles/ Responsibilities Qualifications A more senior clinician who has knowledge of intradepartmental and inter- hospital policies and procedures, usually a senior head nurse on duty. This nurse monitors the quality of patient care in the department by matching patient needs with departmental resources while on duty shift with the following responsibilities:

1. Makes management decisions in the absence of the supervisors

2. Coordinates and maintains communications with other units: inpatient units, operating room, EMS, admitting section, pharmacy and other units to facilitate inpatient flow and service support for the ED from ancillary services.

3. Maintains communication with the Charge Physician on duty or ED Officer on duty

4. Makes decisions with regard to use of on-call nurses and relays information to Unit Manager and Supervisors.

5. Assigns resuscitation team from the nursing staff

6. Ensures that assigned department tasks are completed by designated staff and signed off on a daily checklist.

7. Facilitates rapid patient flow through the department by making frequent rounds.

8. Assists with patient care as needed and coordinates help for nurses who need assistance.

9. Coordinates crisis intervention for families with social workers and clergy.

10. Documents significant occurrences or interventions on 24-hour shift reports.

11. Checks staffing numbers on graphic sheets to facilitate department coverage for 24 hours and make appropriate calls to cover staff call- ins. Education Bachelor of Science in Nursing with 15 MAN Units or equivalent

12. Becomes the main source of communication for nursing in the emergency department in a disaster situation.

13. At the beginning of each shift, sees to it that narcotics, ED equipment and supplies are counted accurately and that all sets of keys are in the department before the previous shift leaves.

14. Assigns staff mealtimes and facilitates breaks.

15. Receives reports from on-going charge nurses and makes walking rounds.

16. Sees that all personal property is returned to owner or that it is sent to Lost Property Department according to hospital policy

17. Responsible for supervision of nurses while on shift

18. Responsible for leaving and routing appropriate documentation of incidents, employee accidents, quality committee reports and transfer forms.

Table 19. Roles, Responsibilities, and Qualifications of ED Senior Nurse or Charge Nurse Roles/ Responsibilities Qualifications Under general supervision, the ED Supervisor provides direct nursing care through mentoring and monitoring nursing staff and students. Performs regular staff functions when necessary. Acts as charge nurse and with the following functions: 1. Provides guidance and support for ward staff a. Using coaching and mentoring technique with individual staff b. Promoting a work environment conducive to harmonious work relationship and high staff morale 2. Ensures emergency care is provided to patients in accordance with the appropriate professional and hospital standards.
3. Ensures that all patients' contacts are documented, treatment plans are implemented and evaluated in a timely manner consistent with the evidence-based practice. 4. Monitors and evaluates performance of nursing staff and non- professional staff in providing care.
5. Provides a safe environment to patient’s visitors and other staff. a. Understanding and promoting emergency procedures such as fire response and evacuation b. Observing and promoting all professional graduates for practice regarding infection control 6. Promotes, monitors, and participates in all quality improvement activities. 7. Maximizes the education and development of staff and self. a. Participating in a performance appraisal and identifying personal goals and strategies 8. Manages all treatment and care related resources in an effective and cost-efficient manner.
9. Performs other related functions: Education Bachelor of Science in Nursing with 15 MAN Units or equivalent

a. Direct nursing procedures which includes bedside nursing, peri-operative nursing care, admission and discharge duties. b. Administering medication and noting of reaction c. Maintaining records reflecting patient’s condition, on medication and treatment d. Coordinating with other section in the hospital regarding client care e. Assisting in the education and rehabilitation of patients and their families related to physical and mental health.

Table 20. Roles, Responsibilities, and Qualifications of ED Nursing Staff Roles/ Responsibilities Qualifications Under general supervision, performs direct nursing care services and assist physicians in diagnostic and therapeutic procedures in order to provide proper patient care with the following functions:

1. Utilizes assessment skills and techniques to identify patients’ problems and needs.
2. Prioritizes care based on the critical nature and severity of the patient's condition.
3. Maintains accurate documentation of the plan of care based on the patient's condition/needs.
4. Provides safe, effective and efficient emergency care according to standards of nursing practice.
5. Performs emergency nursing care procedures which include admission and discharge duties.
6. Monitors, records and reports patients’ symptoms, condition and progress of treatment and therapies.
7. Administers medications adhering to the 12 rights of medication administration.
8. Prepares patients for, and assists physicians with emergency diagnostic and therapeutic procedures.
9. Monitors the progress of patients' health conditions.
10. Refers critical laboratory/diagnostic results.
11. Assists in the education of patients and their families related to treatment options and advance directives.
12. Conducts/participates in research/evidence-based practice studies.
13. Maintains the confidentiality of patients’ data and privacy.
14. Evaluates effectiveness of nursing care plan
15. Coordinates with other sections in the hospital regarding patient’s care.
16. Acts as a patient's advocate.
17. Respects the patient's bill of rights.
18. Performs other related functions. Education Bachelor of Science in Nursing

Table 21. Roles, Responsibilities, and Qualifications of ED Nursing Attendant Roles/ Responsibilities Qualifications Under the direct supervision of the ED Nurse Supervisor. The ED Nursing Attendants are the second-line nursing care providers who are responsible for giving assistance to patients with the following functions:

1. Checks and receives hospital supplies from outgoing staff.
2. Requisitions supplies from the Central Supply Room (CSR).
3. Maintains updated record of monitoring and inventory of supplies, equipment.
4. Performs emergency patient care with supervision.
5. Takes and records vital signs, height and weight of patients including anthropometric measurements of newborns.
6. Performs application and removal of catheterization.
7. Administers gastric tube feeding.
8. Assists in the preparation of patients for emergency treatment, examination and surgery.
9. Assists in specimen collection (e.g. urine, stool, wound discharge, etc.)
10. Administers postnatal nursing care procedures to infants.
11. Assists patients in self-care activities.
12. Conducts post mortem care.
13. Ensures the condition of a safe and therapeutic environment.
14. Checks and maintains cleanliness of equipment, instruments, linens and other properties within the unit through disinfection and sterilization methods.
15. Assists physicians with minor procedures and physical examination of patients.
16. Ensure privacy of patients during procedures
17. Ensures safe transport and transfer of patients.
18. Maintains proper waste segregation and disposal of hospital and pathologic wastes adhering to the infection prevention and control policies.
19. Performs other housekeeping duties.
20. Performs other related functions as may be assigned. Education

Bachelor of Science in Midwifery

Or

Graduate in Midwifery

Trained in the following: • Basic Life Support • Lifting and Moving of Patients

Table 22. Roles, Responsibilities, and Qualifications of Institutional Worker Roles/ Responsibilities Qualifications Nursing support personnel who work under the nursing service department, whose main function is to transport patients to and from the ED safely Trained in the following: • Basic Life Support • Lifting and Moving of Patients

3.3.3 Other ED Staff

Table 231. Roles, Responsibilities, and Qualifications of Ambulance Driver Roles/ Responsibilities Qualifications

1. Dispatches patients to homes or other locations to ensure the day to day care and maintenance of Ambulances of the hospital. Trained in the following: • Basic Life Support • Standard First Aid • Ambulance Driving With Valid Drivers’ License

Table 24. Roles, Responsibilities, and Qualifications of Security Guard Roles/ Responsibilities Qualifications

1. Ensures the safety and security of both patients, relatives, and ED staff.
2. Reports all medico-legal patients to the nearest police station not later than 24 hours after alleged injury.
3. Secures the emergency treatment area and its personnel of looters and other bad elements.
4. Controls the influx and egress of the patient's visitor/ companions (one companion per patient).
5. Conducts regular rounds in every section of the ED.

References

Department of Health. (1998). Administrative Order No. FAE 007 s 1998: Policies and Guidelines on the Transfer and Referral of Patients Between DOH Metro Manila Hospitals. Department of Health. (2013). Organizational Structure and Staffing Standards for Government Hospitals CY 2013 Edition. Department of Health. (2022). Proposed Revised Organizational Structure and Staffing Standards for Level 3 Government Hospitals with 200 to 1,500 beds CY 2021 Edition. Strauss, R. W., & Mayer, T. A. (Eds.). (2014). Strauss & Mayer's Emergency Department Management. McGraw- Hill.

4. INFRASTRUCTURE STANDARDS

4.1 General Considerations for Infrastructure and Design

The Emergency Department (ED) plays a crucial role in providing patients appropriate and effective acute clinical care (Abdelsamad, 2018). It serves as an entry point to the provision of both inpatient and outpatient services provided by the hospital.

In order to address the needs of such complex system while ensuring an effective and people-centered delivery of health services in the ED, the following principles shall be considered in its planning and the design:

Functionality and Form
The design of the ED needs to be practical, and needs to reflect how health professionals manage and treat patients with different clinical conditions. It should be designed to optimize the interaction between the hospital staff, patients, relatives and carers throughout the course of the delivery of health services (Australasian College for Emergency Medicine, 2014). Designing the ED must take into consideration provisions for IT/ICT infrastructure, as technology in general has continued to play an important role in acute care service provision.

Integrated People-Centered Care With the issuance of the Administrative Order No. 2020-0003 entitled, Strategic Framework for the Adoption of Integrated People-Centered Health Services in All Health Facilities, Hospitals are called to ensure that the infrastructure and design of the different units of the hospitals shall consider the overall patient experience and promoting a healing environment for them through:

1. Ensuring adequate space for movement;
2. Ensuring acoustic and thermal control;
3. Use of appropriate color palette in accordance with Administrative Order 2020-0011 Guidelines in the Implementation of the Unified Color Signage, Features, and Design of Identified Interior Spaces for Health Facilities Enhancement Program (HFEP)-funded and coordinated Health Facilities and Medical Transport Vehicles;
4. Clear signages to ensure proper wayfinding;
5. Provisions for the population with special needs such as persons with disability and the elderly;
6. Accessibility to key entry points in the health facility and other areas; and
7. Access to facilities for communication (e.g. public phone, internet connection/Wi-Fi)

Infection Prevention and Control (IPC)
The design of the ED should likewise consider the following IPC measures to control the spread of infection in the ED.

1. Adequate and functional hand hygiene stations at point of care, and alcohol-based hand rubs at appropriate locations
2. Application of zoning
3. Unidirectional foot traffic
4. Cleanliness and disinfection
5. Adequate ventilation (natural or mechanical, as needed) to prevent the spread of infectious pathogens
6. Availability of safe and adequate quantity of water for IPC activities
7. Sufficient and appropriately labeled trash bins that would allow segregation of waste (include disposal of needles/ sharps)
8. Isolation rooms or a single room for cohorting patients with same pathogen

Safety and Security
At the minimum, the ED shall comply with the standards set by the National Building Code, Accessibility Law, Fire Code, National Structural Code of the Philippines, and Philippine Electrical Code. Additional security features such as CCTV cameras, metal detectors at points of entry, and others may be considered to ensure the security of patients and staff entering the ED. In addition, there must be provision for duress alarm buttons throughout the ED, to ensure access to these at any point within the ED. Other aspects of safety and security related to processes will be discussed in subsequent chapters beyond the infrastructure standards.

4.2 Description of Spaces and Planning and Design Considerations

4.2.1 Ambulance Bay / Access

Purpose/ Function: The ambulance bay serves as a special receiving area, with a specially marked pavement, exclusive for ambulances. It should also have a dedicated space for transient parking where the ambulance must leave the area after disembarkation. The ambulance space should be designed in conjunction with the Ambulance Service and facilitate turning circles (IEAM, 2007).

Specification
Description
Developmental Standards

1. Access/ Location
   • Should be designed in conjunction with the Ambulance Service and parking.
   • Direct access to trauma/ resuscitation rooms and Decontamination Area • There shall be separate and unobstructed access/egress to the emergency department, and shall be directly accessible from the main road/street
2. Size

• Size is dependent on the potential number of ambulances attending the Emergency Department at any given time.

• Allowance should be provided for an unloading space at the back of the vehicle’s door opening and the pedestrian access along both sides of a parked vehicle. • Adequate space for turning circles 3. Design/Functional requirements • Dedicated and separate ambulance vehicle access and egress, separate from pedestrian access • Provision for accessibility for PWDS (e.g. ramps, stairs, signages) in the pedestrian access to ED • Signage including ground markings for vehicle bays should be clearly visible • Adequate lighting • Adequate overhead weather protection • Non-slip surfaces 4. Equipment Requirements

N/A

Variations in across the level of care:
Level 3 Level 2 Level 1 Separate access to Crash/ Resuscitation and or Trauma Bay of the hospital.

4.2.2 Triage

Purpose/ Function This area serves as the first contact of all patients in the ED. It serves as an area for the registration of patients and initial clinical assessment of patients by the designated triage officer of the ED.

Specification
Description
Developmental Standards

1. Access/ Location • Should be designed in conjunction with the following • Ambulance and walk-in entrance • Waiting room • Acute treatment and assessment areas • Resuscitation bays

2. Size • Dedicate 1.8 sqm/ 1000 patient attendance per annum

3. Design/ Functional Requirements • Space for triage assessment where space allocation for personnel and patient/s involved based on statutory code of practice e.g 5.02sqm/staff
   • Security for staff and patients
   • Design should allow clear line of sight from the perspective of the staff • Ability to accommodate additional triage officers and equipment during surge of patients
   • Provision for a separate triage area for highly infectious patients or use of pre-triage/fever areas.

4. Equipment Requirement
   • Equipment for registering patients and or queuing (ie. computers, registrations desks/ tables, patient tags)
   • Equipment for taking vital signs and anthropometrics (sphygmomanometer, thermometers, stethoscopes, weighing scale) • Wheel-type stretchers or scoop stretchers • Communication system

Variations across the Levels of Care Level 3 Level 2 Level 1 Triage Room Triage Area

4.2.3 Waiting Area / Room

Purpose/ Function Waiting areas are intended to hold patients, while awaiting their turn to be seen and examined by the triage officer, or while waiting to be transferred to their respective treatment areas. This also serves as a holding area for other relatives and carers that accompanies the patient in the ED.

Specification Description
Developmental Standards

1. Access/ Location • Should be designed in conjunction with
   • Triage area and reception
   • Ambulance and walk-in entrances • Clinical areas of the ED
2. Size/ Space • The size of the waiting room is influenced by the load of potential patients being catered to by the ED. In general, 0.65 sqm should be allotted per person in the waiting area.

• 4.4 sqm / 1000 attendances per annum and up to 6 sqm/ 1000

attendance for pediatric areas to accommodate at least 1 guardian and child.
3. Functional requirements • Aside from those stated in the general considerations, the following should be considered: • Access to food and drink • Access to toilet with emergency call system • Seating to accommodate for mobility aids/ wheelchairs • Space/alcove for wheeled stretcher area • Adequate size to accommodate all waiting patients and relatives, or carers during peak times.

4. Equipment Requirements • Benches/ chairs to accommodate patient and companion • Infotainment and communication systems
5. Other Considerations • Color coded seating for zoning or Sub-waiting areas within th ED (for larger hospitals) • Electronic display with current waiting times and other announcements/ reminders • Facilities for charging mobile phones and electronic devices

Variations in across the level of Care

Not applicable

4.2.4 Decontamination Area

Purpose and Function This area of the ED serves as the external decontamination of patients for toxicological management is performed before being directed to the Acute Care Unit. In cases of nuclear, biological, and chemical incidents, exposed patients and/or personnel are also decontaminated in this area. The doors are unidirectional for entrance and exit. The exit door directly opens toward the Acute Care Unit.

Specification
Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in conjunction with
   • Ambulance Bay • Critical Care Unit - the exit door should directly open towards the Acute Care or Critical Care Unit
2. Size/ Space • Dependent on the role in the regional or state of emergency response to Mass Casualty Incidents. (see variation across levels of care)

• Provision for the following areas: • Disrobing area, • Decontamination area • Drying off area; and • Entry to ED 3. Functional Requirements • High pressure showers and/ or retractable hoses with a water drain that does not connect with the main hospital sewage. • Water heaters should be made available in the decontamination area for appropriate water thermal control.
4. Equipment Requirements • Apron or water- and aerosol-proof suits • Mildly alkaline soap • Patient gown • Personal protective equipment

Variation across the level of Care Level 3 Level 2 Level 1 Large Decontamination of more than 10 people Decontamination of up to 5- 10 people Decontamination of 1 to two persons

4.2.5 Ambulatory Treatment Area

Purpose and Function Serves as consultation areas for the assessment, treatment, management of patients without major illness, non-complex, injuries or conditions. These patients are expected to be sent home after consultation.

Specification
Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in conjunction with the triage area and waiting area
2. Size/ Space • At least 5.02 sqm/ staff • Provision of 1-2 patient beds for examination • At least 7.43 sqm/ bed
3. Functional Requirements • The design should consider rapid turnover of patients.
4. Equipment Requirements • Consultation desk with computer/ forms • Lavatory/ sink for handwashing • Examination bed

• Diagnostic set

Variation across the level of Care Level 3 Level 2 Level 1 Lower level facilities may defer this unit depending on expected patient load.

4.2.6 Acute Care / General Treatment Area

Purpose and Function These areas serve to assess, manage and initiate treatment on patients entering the ED. The ventilation of the acute care unit has to be a one-way laminar airflow type that recycles air on a periodic basis. The patient assignment per bed has to be clustered in such a way that all critical patients are grouped together for ease of patient tracking. The disposition time of each patient in the acute care unit has to be closely monitored so as to prevent overcrowding in the area.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in conjunction with the following • Dirty Utility Rooms • Medication Room • Patient toilets • Nurse Station
2. Size/ Space • Each cubicle or treatment area should be at least 7.43 sqm/ bed to accommodate the following: • Space for at least 1 companion • Space for bedside equipment
3. Functional Requirements • Provision to ensure privacy such as Polyvinyl Chloride (PVC) accordion or walls. The use of cloth curtains may be used provided that the frequency of changing these curtains will be considered to ensure infection prevention and control.
   • Should be designed to ensure direct observation from the staff position
4. Equipment Requirements • Wheeled-type stretcher or bed with IV pole.
   • Nurse call/ emergency alarm/ button • Monitoring equipment • Light source adequate for examination
   • Storage for any bedside equipment • Service panel for each treatment bed

Variation across the level of Care Level 3 Level 2 Level 1 For larger hospitals, a separate ED may be allowed to cater to specific needs/ population.
For departmentalized hospitals, treatment area may further be sectioned based on the four (4) major departments namely • Adult/ Medicine • Surgery/ Trauma • Pediatric • Obstetrics and Gynecology Generally divided into two (2) sections based on population • Adult • Pediatric

4.2.7 Crash / Resuscitation Unit / Area

Purpose and Function The crash/ resuscitation unit/ area is a special area in the acute care/ treatment area which provides reception, assessment, and initiation of treatment to patients with life threatening or time critical illness or trauma.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in conjunction with the following • Access from the waiting room, ambulance bay • Ready access to the radiology department
   • Access to areas where medication and other equipment are stored.
2. Size/ Space • The number of beds dedicated for resuscitation areas is dependent on patient attendance, patient acuity, and case-mix and services offered.
   • 2 resuscitation areas per 20,000 patients per year • 1 additional ambulance bay and resuscitation area per additional 10,000 patients per year • The following should be considered in the design of the resuscitation area: • Adequate floor space to accommodate mobile equipment such as portable x-rays and the like.
   • Adequate shelving to accommodate medication and equipment required for trauma care
3. Functional Requirements • The resuscitation area should be adequate to accommodate the resuscitation team

• There is a seamless transition from ambulance bay and triage
4. Equipment Requirements • Basic and Advanced Cardiac Life Support Equipment • Advance airway kit and surgical airway kit • Mechanical Ventilators • Defibrillator with adult and pediatric paddles • Emergency cart • Fitted oxygen outlets and High-pressure oxygen supply • Wall mounted suction
• Equipment for Minor procedures • Cut down set • Minor surgical set • Thoracostomy set • Tracheostomy set • Full monitoring equipment and invasive monitoring systems which include but are not limited to ECG, NIBP, oxygen saturation, core temperature, invasive monitoring, end-tidal CO2 monitoring and the like (ideally 1 per bed), Stethoscopes and thermometers (thermoscans) • Imaging Equipment • Portable ultrasound machine (especially for focused abdominal sonography in trauma patients) • Immobilization devices such as cervical collars (ideally semi-rigid type) and splints • Nurse call/ emergency alarm • Biological refrigerator • Personal protective equipment • Public announcement system • Procedure lights adequate to illuminate all parts of the patient • Hand-hygiene facilities • Puncture-proof sharp containers (located strategically in the crash room, pantry and patient areas) • Supplies and drugs as indicated in Chapter 5.
• Trash can per patient bed • Weighing scale

Variation across the level of Care Level 3 Level 2 Level 1 Separate Resuscitation Bay and Trauma Bay
May be a dedicated bed/ area specific in each section

4.2.8 Isolation Rooms

Purpose and Function Isolation rooms in the ED are intended to cater to patients suspected to have a highly communicable disease. This area connects to the main ED through an ante-room where PPE’s can be accessed and standard precaution is strictly observed.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in conjunction with the following: • Entrance of the ED • Triage
   • Ante-room
2. Size/ Space • At least 9.29 sqm • Should have its ensuite toilet that is PWD accessible
3. Functional Requirements • Should be a negative pressure room, with at least 6 air changes per hour or twelve (12) air changes per hour for newly constructed or renovated rooms. • Air exhaust should be directed away from people and air intakes. If this is not possible, air must be filtered through a HEPA filter before recirculation. • Air handling system designed for airborne infectious diseases are to be connected to emergency backup power, in case of power failure. • Provision of an Ante-room to serve for hand-hygiene and donning and doffing of Personal Protective Equipment with PPE rack and sink • Provision of a communication system for staff and patients to be able to communicate with people outside the room, without having to leave the room.
4. Equipment Requirements Ante Room • Hand hygiene station, preferably hands free • Single use hand towels
   • Cabinet/ rack for PPE Isolation Room • Hospital Bed • Foot stool • Chair • Waste Bin (both for infectious and general waste) • Console, bedhead: For nurse call, Medical gas exchange, power outlets, lamps etc

• Dedicated Monitoring Equipment (ie sphygmomanometer, stethoscopes)

Variation across the level of care

Not applicable

4.2.9 Procedure (Examination) Room / Area

Purpose and Function The Procedure (Examination) Area serves as a special area for the treatment and examination of patients requiring further examination of other specialty services such as ORL-NHS, Ophthalmology, or Orthopedics.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in conjunction with the acute care unit/ treatment areas
2. Size/ Space • At least 7.43 sqm/ bed
3. Functional Requirements • Adequate space to perform procedures • Adequate space to store immobilization devices
   • Provision for sink/ lavatory
   • Adequate lighting to perform procedures.
4. Equipment Requirements Equipment and Fixtures • 10 Nasal packs • Diagnostic set (otoscope/ ophthalmoscope) • Elastic bandages of different size • Electric saw • Eye gauze • Eye shield • Headset • Immobilization devices (skin traction, plaster of Paris) and splints
   • Equipment for rhinoscopy and Magill forceps • Pantry for casting area • Patient Referral and disposition logbook • Pinhole • Sit lamp • Snellen chart • Tongue depressors • Traction devices

Variation across the level of Care

Not applicable

4.2.10 Nurses’ Station in the ED

Purpose and Function The nurses’ station serves as an area where nurses and other staff work behind when not directly attending to the patient. Key functions performed here include secretarial work, chart processing and management, patient monitoring and medication preparation. Nurses’ station shall be located to permit observation of patients and control access to entrance, waiting area, and treatment area.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in conjunction with the treatment areas.
   • Ideally, the nurses’ station should be located at the center to facilitate monitoring and mobility of the nurses as well as the medical staff.

2. Size/ Space • 5.02 sqm/ staff

3. Functional Requirements • Adequate work surface for medical staff (i.e. for writing or encoding) • Adequate space to prepare medication

4. Equipment Requirements • Computers and printers • Shelves for patient charts and medicines • Communication systems

Variation across the level of Care

Not applicable

4.2.11 Acute Mental Health Area

Purpose and Function This area serves as an area for the assessment, treatment, and management of patients in acute psychological or psychiatric crises. The main purpose of this area is to provide a safe and appropriate space for patient interview and stabilization.

In order to ensure the safety of both patient and staff, the room should not contain objects that could be thrown. The room should also be free from mobile or breakable equipment, sharps or hard surfaces that may injure an uncontrolled patient. The exit doors should open outwards. Ideally windows should not be present in these areas. Should windows be incorporated, it should be made from shatter-proof materials.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Should be separate enough from adjacent patient care areas to uphold privacy and safety of the patient and other people in the ED
2. Size/ Space • A minimum of 9.29 sqm
3. Functional Requirements • Area should be conducive for the assessment of patients with mental health concerns, and for discussion with carers. • Ensure patient and staff safety • Easy access to assistance should a threatening situation arise.
   • Ensure privacy of patients through: • Ensuring acoustic and visual separation from other areas
4. Equipment Requirements • Patient Bed • Smoke detector • Duress alarm • CCTV when applicable

Variation across the level of Care Level 3 Level 2 Level 1

In smaller facilities, this may be used to double as a counseling/ bereavement room.

4.2.12 Counseling / Bereavement Room

Purpose and Function This area serves as an avenue to where relatives of patients may be brought to ensure privacy when ED staff is managing them. In this area, the ED staff may discuss with the relatives when securing an informed consent, updating the patient's condition, and counseling in case the patient deteriorates or eventually dies. This room shall not be used as a waiting area for patient’s relatives. This room is an ideal addition to the ED but is ideal. Activities done in this room may also be done in the conference room.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in conjunction with resuscitation area

2. Size/ Space • Should be able to comfortably seat at least four persons as well as seating room for the ED staff that may enter and deliver news regarding the patient

3. Functional Requirements • Should be private and soundproofed space with visual and acoustic privacy • Space that is culturally neutral and inoffensive • Space should be aesthetically calming and peaceful

4. Equipment Requirements • Comfortable furnishings • Outlets for mobile charging

Variation across the level of Care Level 3 Level 2 Level 1 In smaller facilities, the Acute Mental Health Area may be used to double as a counseling/ bereavement room.

4.2.13 Staff Call Room

Purpose and Function Given the stressful clinical environment of the ED, adequate and well designed areas/ spaces should be provided for the ED staff for time out, relaxation, and to add morale and staff functioning. The staff room may be used by the staff to eat, and social events. A pantry may be provided for the staff so that they can prepare hot and cold drinks and food.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Should be located away from patient areas • Close proximity with toilets and other non clinical areas/ offices in the ED
2. Size/ Space • Size of the call room should be adequate enough to seat all staff on a rostered meal break
3. Functional Requirements • Preparation and consumption of meals • Secure • Provision for other aspects of relaxation (ie. television, music, internet connectivity)
4. Equipment Requirements • Pantry • Food Preparation Area • On demand hot and cold Water

• Tables and comfortable seating • Computer/ Wi-fi Access • Television • Microwave ovens • Refrigerator

Variation across the level of Care

Not applicable

4.2.14 Equipment and Supply Storage Room

Purpose and Function This area is used to store devices and other consumables and place buffer stocks. The Charge Nurse should regularly update the inventory of the stocks per shift, and make the necessary requisition before his/ her shift ends. Access to the supply room should be restricted to authorized personnel only. All supplies should be properly labeled and locked. Keys should be properly endorsed to Nurse on Duty (NOD) every shift.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Located near Staff Call room or other administrative areas in the ED
2. Size/ Space • At least 4.25 sqm in size • Should consider central and decentralized storage of equipment and disposables, in relation to the presence of the bedside
3. Functional Requirements • Should be secured with access to authorized personnel only.
   • Sufficient space and power sockets to store and charge battery powered equipment
4. Equipment Requirements • Shelves

Variation across the level of Care Level 3 Level 2 Level 1 Higher level facilities may consider larger storage areas depending on need.

4.2.15 Minor Operating Theater

Purpose and Function According to Administrative Order No. 2016-0042 Guidelines in the Application for DOH - Permit to Construct, all emergency departments must have a minor OR or area where minor surgical procedures may be performed safely. Dedicating operating theaters for emergency cases has shown an overall improvement in the quality of care by increasing the chances of patients to access care within the prescribed time and decreasing the cancellations and overruns for patients requiring elective surgeries (Heng et. al 2013).

Relative to the minor OR, the management should be able to consider the following:

1. Establishing the criteria for the use of the operating theater which may include urgency and the surgical procedure that will be conducted.
2. Dedicating a surgical team that will be stationed in the said operating theater.
3. Ensuring adequate equipment and supplies in the minor operating room

Specification Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in conjunction with the following: • Resuscitation areas/ units
2. Size/ Space • Adequate space to accommodate the operating theater team (minimum of 2 Physicians, 1 nurse, 1 nursing attendant) and the patient.
   • Adequate floor space for portable imaging equipment such as x-rays or ultrasound
3. Functional Requirements • Provision for dressing room and surgical hand scrubbing
   • Separate access for patients and staff
4. Equipment Requirements Operating room • Operating table
   • Operating light
   • Minor Surgical Set • Electrocautery machine • Instrument trays • Anesthesia machine with tanks of gases and gauges • Advanced Airway Equipment
   • Monitoring equipment (Pulse oximeter, Sphygmomanometer, stethoscope, cardiac monitor) • Emergency Medicines
   • Defibrillator
   • Waste bins Scrub up
   • Sink and drainboard

• Counter • Scrub and sink w/ gooseneck • Spout and foot/elbow control • Waste bin w/ yellow lining • Clock
• Soap dispenser Dressing Room • Lockers and shelves

Variation across the level of Care

Not applicable

4.3 Space Planning and Design Considerations for Special Services in the

Emergency Department

4.3.1 Observation Units

Purpose / Function Serves as a holding area where admitted patients are placed until their respective service is ready to receive them. This unit serves as a buffer area of the Acute Care/ Treatment area to avoid crowding.

Specification
Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in proximity with Acute Care/ Treatment Area
2. Size/ Space • At least 7.43 sqm/ bed
3. Functional Requirements • Patients placed in this area are monitored less frequently as ED management has already been given.
4. Equipment Requirements • Basic monitoring equipment

Variation Across the levels of Care
Level 3 Level 2 Level 1 Higher level facilities may consider including observation units depending on need.

4.3.2 Women and Children Protection Unit (WCPU)

Purpose / Function This area caters to women and children who are victims of violence and other cases as stipulated in Republic Act 9262, also known as, Anti-Violence Against Women and Their Children Act of 2004.

Specification
Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in conjunction with the following • Counseling/ Bereavement room
   • OB-GYN treatment acute care/ treatment area
2. Size/ Space • Consultation area of at least 5.02 sqm/ staff • Provision for at least 1 examination table (7.43sqm/bed)
3. Functional Requirements • Should be private and soundproofed space with visual and acoustic privacy • Space that is culturally neutral and inoffensive • Space should be aesthetically calming and peaceful
4. Equipment Requirements • Doctors desk
   • Waste bins • Communication system • Lithotomy table for examination • Speculum set
   • Examination light

Variation Across the levels of Care
Level 3 Level 2 Level 1 For lower level facilities, bereavement/ counseling rooms may double as WCPU to conduct interviews.

4.4 Space Planning and Design Considerations for Ancillary Services in the

Emergency Department

4.4.1 Satellite Laboratory

Purpose and Function
In hospitals with a high volume of patients in the ED, a satellite laboratory may be beneficial to ensure the timely processing and release of laboratory results that will aid in clinical decision making. This may include but are not limited to Arterial Blood Gases (ABG), determination of Hemoglobin/ Hematocrit (Hgb/ Hct) or Complete Blood Count (CBC), urinalysis, serum electrolytes (sodium and potassium), and point of care (POC) testing for Troponin I, Troponin T and pregnancy test, among others.

In hospitals with a toxicology service/unit, the satellite laboratory is critical for the rapid identification of an unknown substance that a patient may have ingested.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Designed in conjunction with the following: • Resuscitation Bay • Acute Care/ Treatment Area
2. Size/ Space • 10-15 sqm
3. Functional Requirements • Able to process selected Hematology and Chemistry services in the ED • Capacity for rapid turn-around of laboratory testing
4. Equipment Requirements • Arterial blood gases analyzer • Centrifuge • Hemoglobin/ hematocrit analyzer or automated Hematology analyzer • Microscope • Point of care (POC) testing kits • Serum electrolyte analyzer • Urine dipsticks • Equipment for bedside toxicology kits

Variation across levels of Care Level 3 Level 2 Level 1 May be considered in higher level facilities with high volume of patients

4.4.2 Satellite Pharmacy

Purpose and Function
In larger hospitals where the Main Pharmacy is far from the ED, a satellite pharmacy may be considered to facilitate efficiency in hospital operations. The satellite pharmacy processes emergency and starting doses of selected medicines.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Should be designed in conjunction with other administrative units
2. Size/ Space • At least 10 sqm
   • Should provide at least 5.02 sqm of space per staff
3. Functional Requirements • Adequate space to store emergency and starting doses of selected medicines • Link to Main Pharmacy for recording and reporting of inventory
   • Adequate space for activities related to dispensing
   • Adequate space and equipment for securing high alert medications and regulated drugs
4. Equipment Requirements • Shelves • Computers with printer • Cabinets • Chairs

Variation across levels of Care Level 3 Level 2 Level 1 May be considered in higher level facilities with high volume of patient or distant main pharmacy

4.4.3 Satellite Billing and Cashier

Purpose and Function
Augments the role and function of the main billing and claims section and cash operations section of the hospital to process ED consults that did not require any admission.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Designed in conjunction with other administrative offices/ areas

2. Size/ Space • Should provide at least 5.02 sqm of space/ staff

3. Functional Requirements • Able to transact with client with ease
   • Link with main Billing and Cashier

4. Equipment Requirements • Computer • Printer • Money Verifier
   • Waste bins • Desks • Transparent Counter • Cashbox/ safe • Filing Cabinet • Stool/Chair

Variation across levels of Care Level 3 Level 2 Level 1 May be considered in higher level facilities with high volume of patients or if main Billing and Cashier is far from the ED

4.4.4 Satellite Medical Social Worker Office

Purpose and Function
A satellite Medical Social Worker Office may likewise be stationed in the ED to cater to patients requiring referral to the Medical Social Worker in cases where the MSWD is far from the ED. This satellite office shall focus on the following tasks:

1. Provides assistance to patients based on a patient classification and capability assessment tool.
2. Facilitates tracking of relatives of patients, as situation dictates.
3. Coordinates with the Women and Child Protection Unit (WCPU), the Department of Social Welfare Development (DSWD) and the local police regarding cases of violence against women and child abuse.
4. Others as deemed necessary.

Specification Description
Developmental Standards

1. Access/ Location Requirements • Designed in conjunction with the the following: • Admitting office • Other Administrative Satellite Offices

2. Size/ Space • 5.02 sqm/staff

3. Functional Requirements • Should be conducive for interview and counseling • Should be link to the Main MSWD office

4. Equipment Requirements • Computer • Printer

• Desks • Chairs
• Waste bins

Variation across levels of Care Level 3 Level 2 Level 1 May be considered in higher level facilities with high volume of patients or if main Billing and Cashier is far from the ED

References

Abdelsamad, Y., Rushdi, M., & Tawfik, B. (2018). Functional and Spatial Design of Emergency Departments Using Quality Function Deployment. Journal of Healthcare Engineering. https://www.researchgate.net/publication/328951430_Functional_and_Spatial_Design_of_Emergency_ Departments_Using_Quality_Function_Deployment Australasian College for Emergency Medicine. (2014). Emergency Department Design Guidelines. Australasian College for Emergency Medicine. https://acem.org.au/getmedia/faf63c3b-c896-4a7e-aa1f- 226b49d62f94/Emergency_Department_Design_Guidelines Department of Health. (2004). Hospital Planning and Design. Department of Health. Department of Health. (2020). Manual of Standards and Guidelines (1st ed.). Department of Health. Irish Association for Emergency Medicine. (2007). Standards for Emergency Department Design and Specification for Ireland 2007. https://iaem.ie/wp- content/uploads/2013/02/iaem_standards_for_ed_design__specification_for_ireland_300907.pdf

5. MEDICINES AND SUPPLIES

Operations of the ED depends largely on the extent of capability of the hospital in terms of skilled human resources and availability of medical supplies and functional equipment. In line with the Department of Health’s goals of ensuring that every Filipino receives the best possible quality care in emergency situations, this chapter presents a list of basic drugs, medicines, medical supplies, and equipment that are essential in the Emergency Department.

Based on the Administrative Order No. 2012-0012 also known as “Rules and Regulations Governing the New Classification of Hospitals and Other Health Facilities in the Philippines” and its amendments, hospitals are classified by Level 1, 2, and 3 based on their service capability. The same policy likewise provides guidance on the minimum medicines and medical supply for any hospital to be able to provide the necessary emergency care services regardless of level to be able to perform initial stabilization of patients. Additional medications and equipment above the licensing standards may vary depending on the case mix of the hospital and types of specialty care available in the hospital.

This is to reiterate that the lists contained below are based on developmental standards, which may be beyond the minimum required in the licensing standards for Emergency Departments.

5.1 Medications and Supplies in the Emergency Department for Levels 1 - 3

Table 25. Contents of a Crash Cart (PL – Philippine Licensing Requirement)

Prescribed ED Cart Meds PL L3 L2 L1 Adenosine 6mg/2ml vial

Amiodarone 150mg/3ml ampule

Aspirin USP grade (325mg/tablet)

Aspirin 100 mg/tab

Atropine sulfate 1mg/ml ampule

B-adrenergic agonists (i.e. salbutamol 2mg/ml)

Benzodiazepine (Diazepam 10mg/2ml ampule) – in high alert box

Calcium (usually calcium gluconate 10% solution in 10ml ampule)

Clonidine 75mcg/tablet or 150 mcg/tablet

Clopidogrel 75mg/tablet

D5W 250ml

D50W 50mg/vial

Dexamethasone 4mg/ml ampule

Digoxin 0.5mg/2ml ampule

Diphenhydramine 50mg/ml ampule

Dobutamine 250mg/5ml ampule or pre-mixed solution 250mg/250ml

Dopamine 200mg/5ml ampule/vial or pre-mixed solution 250mg/250ml

Epinephrine 1mg/ml ampule

Enoxaparin 2000/4000/6000 IU prefilled syringe

Furosemide 20mg/2ml ampule

Haloperidol 50mg/ml ampule - in high alert box

Hyoscine N-Butyl bromide 10mg ampule

Hydrocortisone 250mg/2ml vial

Insulin, Regular

Ipratropium + Salbutamol nebule

Isosorbide dinitrate 5 mg/tab

Lidocaine 10% in 50ml spray

Lidocaine 2% solution vial 1g/50ml

Magnesium sulfate 1g/2ml ampule

Mannitol 20% solution in 500ml/bottle

Metoclopramide 10mg/2ml ampule

IV Midazolam

Morphine Sulfate 10mg/ml ampule - in high alert box

Nicardipine 10mg/10ml ampule

Nitroglycerin 10mg/10ml ampule or Isosorbide dinitrate 5mg SL tablet

Noradrenaline/ Norepinephrine 2mg/2ml ampule

Paracetamol 300mg/ampule

Phenobarbital 120mg/ml ampule IV or 30mg tablet – in high alert box

Phenytoin 100mg/ capsule or 100mg/2ml ampule – in high alert box

Propofol 10mg/ml

Potassium Chloride 40mEq/20vial – in high alert box

Salbutamol nebule

Sodium bicarbonate 50mEq/50ml ampule

Tramadol ampule

Tranexamic acid 500mg/5ml ampule (Crash 2) Trial

Verapamil 5mg/2ml ampule

Vitamin B1/6/12 vial (1gB1, 1gB6, 0.01gB12 in 10ml vial)

Vitamin K (Phytomenadione) 10mg ampule

Table 16. Summary of Emergency Medications Available at the ED across the different levels of care. Emergency Department Medications PL L3 L2 L1 Tetanus Toxoid

Anti-Tetanus Serum (either equine based antiserum or human anti serum)

Heparin 5000IU/ vial

Hydralazine 20mg/1ml ampule

Methimazole

Methylprednisolone 4mg/tablet

Oral Rehydration Solution

Oxytocin

Propylthiouracil 50 mg/tab

Propranolol

Terbutaline ampule/tablet

FLUIDS PL L3 L2 L1 Plain LRS 1 liter/bottle

Plain NSS 1 liter/bottle – 0.9% Sodium Chloride

D5 LR 1 liter/bottle

D5 NSS 1 liter/bottle

D5 NM 1 liter/bottle

D5W 250ml

D5 0.3 NaCl 500ml/bottle and 1liter/bottle

D5 IMB NaCl 1liter/bottle

Dextran 500ml/bottle

D10 Water

In addition to the medications listed above, institutions are to have initial doses of antibiotics for common cases available in the Emergency Department. This is to ensure that appropriate antibiotics are initiated within three hours of recognition of sepsis, increasing survival rates of affected patients (Evans et al., 2021).

Table 27. Summary of Equipment and Supplies Available at the ED across the different levels of care.
Equipment and Supplies PL L3 L2 L1 Intubation Kit

Bag-valve-mask Unit • Adult • Pediatric • Neonate

Laryngoscope set with blade (0,1,2,3) with disposable stylet (Adult, Pediatric, Neonate)

Endotracheal Tubes of different Sizes and Guide wires.

Alcohol disinfectant

Aseptic bulb syringe

Blood transfusion set

Calculator

Cardiac board

Clinical Weighing Scale

Digital/Electronic Clocks

Defibrillator with paddles or AED

Dressing Tray and table

Delivery Set, Primigravid

Delivery Set, Multigravid

ECG Machine with leads

EENT Diagnostic Set with
Ophthalmoscope and Otoscope

Emergency cart

Examining Table

Examining table with Stirrups

Eye protective goggles or face shield

Fetal Heart Doppler

Feeding tubes (Fr. 8, 10, 12, 14,16)

Indwelling catheters (Fr. 8, 10,12,14,16,20,22)

Procedure Table

Gauze (steril, pre-folded, individually packed)

Gloves, non-sterile

Gloves, sterile

Glucometer with strips and lancet

Gooseneck lamp/ examining Light

High Flow Nasal Oxygen Therapy Machine

Instrument/ Mayo Table

Mask (respirator mask N95: small, medium, large) with fit testing as much as possible

Minor Instrument Set

Mechanical Ventilators

Portable Mechanical Ventilators

Nebulizer

Needles (disposable, different sizes)

Negatoscope (optional for institutions utilizing digital imaging)

Neurologic Hammer

OR light

Oxygen Unit (Pipeline Oxygen for Level 3)

Oxygen delivery devices (neonate, pedia, adult)

Simple rebreather mask with reservoir bag

Non-rebreather facemask with reservoir bag

Nasal cannula

Pulse Oximeter

Patient monitor

Pen light

Sphygmomanometer (Adult and Pedia)

Stethoscope

Sterilizer

Suction Apparatus

Suturing Set with suture materials Sutures: cutting/atraumatic sutures Silk, nylon, catgut

Surgical Blades

Thermometer (Digital/Infrared)

Vaginal Speculum, Different Sizes

Wheelchair

Wheeled stretcher with guard side rails

Cardiac Monitor

Magill Forceps (Adult and Pedia)

Bone rongeur forceps

IV infusor bags

IV cannula (G26,24,22,20,18)

IV infusion sets (microset, macroset, blood transfusion set,)

Infusion set with volumetric chamber (Soluset)

IV poles/stand

Cricothyroidotomy set

Oropharyngeal Airway (Size 000,00, 1,2,3,4,5,6)

Spine board with Head Block and straps

Cervical Collar

Plaster of Paris

Wadding Sheet

Splints for arm and leg

Orthopedic weights (sand bags)

Cesarean Section Set

ED Thoracotomy set

Tracheostomy set

Chest Tube Insertion equipment

Slit lamp with tonometer

Infusion pump

Syringe Pump

Fluid Warmer

Intraosseous devices

Central Line

Radiant Warmer

Point of Care Diagnostics: Troponin Markers | Serum electrolytes etc

Point of care testing: Portable/mobile X-ray

Point of care testing: Portable ultrasound

5.2 Medication Standards in the Emergency Department

Medications in the Emergency Department are administered in a timely, safe, appropriate, and controlled manner following the Medication Standards outlined below:

5.2.1 Medication Order Review and Verification

1. Verify Doctor’s Order in the Doctor’s Order Sheet through the read back method.
2. For High Alert Medication, comply with the Philippine Drug Enforcement Agency (PDEA) form and coordinate with the Pharmacy Section.
3. Prior to administration, medications are once again checked against the original prescription and administered as prescribed.
4. For verbal/telephone orders, these must be countersigned by the ordering physician not later than the standards set by the organization.

Verbal Orders

1. Verbal orders are accepted in the Emergency Department but are restricted to urgent and emergent situations including a “CODE”
2. All accepted verbal orders shall have the following information: a. Dated, timed, and authenticated promptly by the ordering physician b. Verbal orders must be signed within the shift they were ordered in c. Indication for ordered medication must be documented with the order
3. Only medications included in the drug formulary are accepted to be ordered verbally as names and dosages of unfamiliar drugs are more likely to be misheard and may lead to medication errors
4. Orders must be clearly enunciated by the ordering physician and be read back by the receiver for verification purposes
5. Abbreviations in drug name, route of administration (e.g. IV, IM, etc.), and frequency (e.g. QD, PRN, etc.) must be avoided
6. Only authorized staff may receive and record verbal orders
7. Receiving personnel must ensure that the verbal order is aligned with the context of the patient’s present health condition
8. The following situations in non-emergent conditions cannot be ordered verbally if the ordering physician is present and physically able to order
9. Modifying enteral nutrition a. Requests for laboratory or diagnostic test b. Infuse blood components c. Administer medications d. Admit or discharge a patient

Transcription of Orders to Medication Sheet Transcribe all medications ordered legibly and accurately in the patient’s medication sheet indicating dose, route, frequency, and duration of administration.

5.2.2 Process of Requisition, Storage, and Transportation of Medications

Requisition of Medications

1. In charging of requested medications, dose and frequency must be indicated.
2. Ensure correct name of patient, age, sex, and date

Storage and Transportation 1. Medications are properly stored and accessible only by authorized personnel. 2. Regulated drugs are stored in a cabinet of substantial construction for which only authorized staff have access. 3. Expiration dates of medications are checked periodically. 4. A refrigerator for medications that require storage at low temperature shall be available in the satellite pharmacy. 5. Medications are properly stored and labeled inside the refrigerator and an appropriate level of temperature must be maintained at all times. 6. Medications shall be labeled securely and stored in a clean environment in accordance with the manufacturer’s instructions relative to temperature, light, and humidity specifications. 7. Medications shall be inspected and those with visible contamination, cracks or leaks are discarded. 8. All medicines stored in the emergency cart shall be properly monitored, recorded and replaced using the Emergency Department Drug Checklist every shift. This ensures that the quantity in the checklist coincides with the actual number of medicines in the E-cart. For near expiry medicines (or one month before the expiry) shall be returned to the Pharmacy for replacement. 9. For safety reasons, all medicines in the emergency cart shall have a visible expiration date
10. High Alert Medicines (HAM) are stored in a cabinet key and properly endorsed every shift by the Head Nurse.
11. All medications use in the emergency cart are replaced at the end of the shift and shall be recorded utilizing the Emergency Department Emergency Cart Checklist

5.2.3 Twelve Rights of Administering Medications

Right Patient • Check and verify patient identification using at least two patient identifiers, every patient, every time medication is to be administered. Any two identifiers as listed below may be used to verify the patient identity: o Full name (given and family name) o Date of birth o Address o Medical record number

Right Medicine • Always verify with the other nurse to ensure that you are preparing the right medicine • Check medication label to confirm the name of the drug and the expiration date of the drug • Check the label in comparison with the prescription three (3) times before drug administration

Right Dose • Use an appropriate measurement system to determine the exact dose to be given to the patient. Take precautionary measures for pediatric patients • Always use appropriate measuring devices (e.g. dropper, calibrated medicine cup, syringe) • Shake all suspensions and emulsions before administering to the patient • Do not divide/crush/pulverize film/enteric-coated tablets
Right Route • Ensure to double check for the route of the drug to be administered • Assess swallowing reflex before administration of oral medications • Assess for signs of phlebitis and infiltration at the intravenous (IV) site before drug administration • Administer medications at appropriate sites • Rotate sites for insulin subcutaneous injections • When administering medications through an IV drip, flush the drip with approximately 10 cc of normal saline solution or until the tubing is clear to ensure that the remaining medications is flushed out of the IV tubings • During IV drug administration, flush 5 cc of normal saline solution to prime the IV access and ensure that the medication is completely infused into the vein and then flush another 5 cc of normal saline solution after the drug administration • To maintain the patency of the IV, the access shall be flushed with 2 cc of normal saline solution every six (6) hours Right Time • Use standard medication timing based on the hospital policy • Ensure drug administration follows the intended interval period between doses to optimize bioavailability of the drug

Right Assessment • Baseline assessment (e.g. vital signs) prior the drug administration • Ensure drug compatibility in case of multiple drug infusions. Right Reason • Confirm the rationale or indication for the ordered medications Right of the Patient to Refuse • Nurses have the responsibility and accountability to determine the reason for refusal • Explain to patient the risks for refusal to treatment and give vital information on the reason for drug administration • Refer to the Resident-in-Charge if patient refuses to receive medication especially if it will pose harm or delay his treatment • Document patient’s refusal to drug administration accurately Right of the Patient to Know the Reason for the Medication • Provide adequate information to the patient/folks regarding the indications and possible side/adverse effects of the medication prior to administration • The information should be based on the patient level of understanding • Document on the patient’s medical record the information provided to the patient/folks

Right Evaluation • Evaluate and document the effectiveness and adverse effects of the drug administered
Right Documentation • Record accurate information immediately as to: generic name (name of medication), dose, route, frequency, time and date, nurse’s/midwife’s name and signature • Document side/adverse effects to drug administration.
• Use universally accepted and standard abbreviations and symbols • Use a clear, accurate, timely record of all medicines administered, intentionally withheld by the Resident in charge or refused by the patient.
• Document in the nurse’s notes the reason for discontinuation and refusal of patients to drug administration
• Medications administered by the student affiliates shall be countersigned by their Clinical Instructor/Preceptor and assigned Head Nurse • Indicate date and time for all medications administered • Affix name and signature of the nurse who administered the medication on the Medication sheet and Doctors’ Order sheet
Right Medicine Preparation • Observe Hand Hygiene prior to and after drug administration • Stay focused during the preparation and administration • In Intravenous Medications: o Determine the exact volume of medicine to be administered o All IV medications prepared in syringe must have a proper label of patient’s name, name of medicine, timing or time due and the dosage • Drug titration o Medications with range of dosages, nurses shall titrate dosages according to patient’s response and symptoms control and to administer the drug within the prescribed range

References

AHIMA. (2012, August). Verbal/Telephone Order Authentication and Time Frames (2012 Update). American Health Information Management Association: HIM Body of Knowledge. https://library.ahima.org/doc?oid=105743#.YXjIiBpBw2w Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., Machado, F. R., Mcintyre, L., Ostermann, M., Prescott, H. C., Schorr, C., Simpson, S., Wiersinga, W. J., Alshamsi, F., Angus, D. C., Arabi, Y., Azevedo, L., Beale, R., Beilman, G., … Levy, M. (2021, October 2). Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Nature Public Health Emergency Collection, 47(11), 1181-1247. NCBI. 10.1007/s00134-021-06506-y

Hanson, A., & Haddad, L. M. (2021). Nursing Rights of Medication Administration. https://www.ncbi.nlm.nih.gov/books/NBK560654/ Moghaddasi, H., Farahbakshsh, M., & Zehtab, H. (2017, May 25). Verbal Orders in Medicine: Challenges; Problems and Solutions. JOJ Nursing and Health Care, 1(5). https://juniperpublishers.com/jojnhc/pdf/JOJNHC.MS.ID.555575.pdf

6. SYSTEMS AND PROCEDURES

6.1 Approach to Standardization

With the advances in medical technology, acute care provision in the Emergency Department has become increasingly complex. Placing these complex procedures in a fast paced, high tension environment, puts patients and healthcare teams at higher risk for patient safety events from preventable medical errors. With this in mind, systems and standardized procedures to be implemented must be thought out to protect all stakeholders present in the ED, including patients, medical, and non-medical staff. The recommended systems and procedures in this chapter are standards of care that promote the institutionalization of Patient Safety practices where patients seeking care at the ED will be able to receive appropriate and immediate care without compromising safety.

6.2 Definition of Terms

Triage The process of conducting a brief assessment of incoming ED patients with the aim to prioritize patient care based on illness or injury, severity, prognosis, and resource availability Arrival Time The recorded time of the first contact between the patient and the ED staff. Waiting Time This is the duration between the arrival time and the initial medical assessment and initiation of treatment. A recording accuracy of within the nearest minute is appropriate. Time of Medical Assessment and Treatment This is the recorded time representing the start of care to the patient as provided by the ED staff responsible. A recording accuracy of within the nearest minute is appropriate.
Assessment and Treatment Time

This is the difference between the time of initial medical assessment and treatment, and disposition. A recording accuracy of within the nearest minute is appropriate. This should not be more than 4 hours from the time of initial medical assessment. Must have disposition within 4 hours from time of arrival.

Access Block Refers to any of the factors affecting prolonged ED stay, where patients who have been admitted and awaiting transfer to their hospital bed are delayed from leaving the ED for more than 8 hours because of a lack of inpatient bed capacity. This includes patients who were admitted but were discharged from the ED without reaching an inpatient bed, or transferred to another hospital for admission, or who died in the ED.
ED Boarding Indicator Patients who have a disposition of admission, transfer, discharge but still in the ED for any reason, for more than 4 hours. This excludes patients admitted in the ED observation units, if applicable.
ED Crowding / Congestion ED crowding refers to the situation where ED function is impeded due to the number of patients exceeding either the physical and/or staffing capacity of the ED, whether they are waiting to be seen, undergoing assessment and treatment, or waiting for departure. ED reattendance Patients seen in the ED and discharged but presents again within 24 hours due to the same chief complaint. Overstaying Patients still without disposition, after 4 hours. Readmissions Patients who were previously admitted and discharged in the past 30 days presenting in the ED with indication for inpatient care. Primary Responder Services Refers to the deployment of any personnel in a vehicular unit that is able to arrive and retrieve victim(s) in the vicinity of emergency.

6.3 Emergency Department Services and Overview of Patient Flow

The Emergency Department should provide an integrated and seamless continuum of care — beginning from prehospital to ED/hospital settings. All EDs should have the following scope of services albeit limited to lower level of care facilities: Pre-hospital Care This covers ambulance services which can include primary responder services, ambulance services and inter-facility transfers based on facility capacity for medical direction. Emergency Clinical Care Services This covers the triaging and clinical/trauma care including resuscitation, stabilization and early definitive care. The scope of services to be provided is dependent on the type of facility. Medical Incident and Disaster Management EDs of tertiary and specialty centers should play a fundamental role in medical incidents and disaster management including response for the community they serve in accordance with national disaster response and management guidelines. Medical coverage may also be provided by EDs for mass gathering or major events with possibilities of emergency medical incidents or if with public figures.

Figure 6. Overview of the patient journey in the emergency unit/department. Reprinted from Strauss and Mayer’s Emergency Department Management, by R.W. Strauss and T.A. Mayer, 2014, McGraw- Hill. Copyright 2014.

6.3.1 Receiving Patients in the ED

6.3.2 Care of Patients requiring Immediate Resuscitation

6.3.3 General Care of the ED Patient

6.3.4 Nursing Process Flow

6.4 Triage and Medical Screening Examination

Triage is the prioritization of patient care based on illness/injury, severity, prognosis, and resource availability. Triaging ensures that the sickest patients are seen first and the least sick, last. Its essential function is the "sorting" of patients through a brief clinical assessment which in turn determines the time and sequence in which patients should be seen in the ED. All patients entering the ED are triaged. This is done without regard for the patient’s ability to pay, diagnosis, financial status, race, national origin, disability, sex, or age (Wang et al., 2011). The objectives of triaging are as follows: • To categorize patients coming to the ED based on the urgency and severity of their illness • To prioritize patient care corresponding to the above categorization with an emphasis on identifying patients in need of immediate and emergent resuscitation and care. • To assign patients to pre-designated areas where appropriate care can be given • To manage congestion in the ED treatment areas

Procedure Person-in- Charge Additional Information Upon arrival, the patient must be assessed immediately. Triage Officer/Nurse Upon arrival at the ED, all patients are to be triaged by a doctor, a senior nurse or a nurse trained to conduct triaging.

The triage assessment should generally take no more than two or five (2-5 minutes).

Assessment must be balanced in terms of speed and thoroughness Measure vital signs at triage, if required to estimate urgency and if time permits. Vital Signs include the following: • Blood Pressure • Heart Rate • Temperature • Respiratory Rate • O2 saturation • Pain Scale For patients triaged to the highest level of urgency, a complete set of vital signs may not be necessary for proper triaging. If time permits, vital signs are to be taken in the triage area. The triage assessment is not necessarily intended to diagnose the patient but it may sometimes be possible. Determine the clinical urgency of the patient. See quick look Australasian Triage Scale (ATS) in Table 28 Multiple patients seen must be assessed and categorized using the 5-tier triage scale Categorization is done prior to or concomitant with registration. Registration is filled out by the administering clerk.

6.4.1 Registration during Triage

Registration may be done in the triage area, provided that in no instance will registration hinder time sensitive interventions the patient may need. For patients requiring immediate resuscitation, treatment of the patient will be initiated prior to or concomitant with registration. Only the minimum demographic information, vital signs, and chief complaint of the patient will be taken in the triage areas. Complete registration may be done once the triage has been done. All patients seeking consultation or care in the ED are to be triaged and logged into the ED registry or Logbook.

6.4.2 Triage Area

Triage area shall occupy the front area nearest the entrance of the ED and shall comply with the infrastructure standards and facilities such as communication systems and infection prevention and control standards as outlined in Chapter 4. The triage area must be immediately accessible and clearly identifiable by signage. The area should offer patient privacy and security measures for staff and all individuals present in the said area.

6.4.3 Triaging ED Staff

Triaging should be done by an experienced healthcare worker or a healthcare worker with proper triage training. Mistriages i.e. wrongful assignment of triage categories - are potential causes of poor clinical

outcomes and should be avoided. Triaging may be assigned to the following ED staff (1) ED physician, (2) Senior Nurse, or (3) A nurse specifically trained in triaging.

6.4.4 Triaging Systems

A validated triaging system is to be adopted by the ED institution depending on their needs. A 5-tier triaging system is recommended for all hospital levels such as Australasian Triage Scale, Emergency Severity Index, or Canadian Triage and Acuity Scale however, a 3-tier triaging system can be utilized in L1 facilities.

Table 28. Sample of a Five Level Triage System. Adapted from Australian Government: Department of Health and Ageing. (2009). Emergency Triage Education Kit. Commonwealth of Australia. Level Response Description ATS Category 1 Immediate simultaneous assessment and treatment Immediately Life-Threatening Conditions that are threats to life (or imminent risk of deterioration) and require immediate aggressive intervention ATS Category 2 Assessment and treatment within 10 minutes (assessment and treatment often done simultaneously) Imminently Life-Threatening The patient's condition is serious enough or deteriorating so rapidly that there is the potential of threat to life, or organ system failure, if not treated within 10 minutes of arrival OR Important Time-Critical Treatment The potential for time-critical treatment (e.g. thrombolysis, antidote) to make a significant effect on clinical outcomes depending on treatment commencing within a few minutes of the patient's arrival in the ED OR Very Severe Pain Humane practice mandates the relief of very severe pain or distress within 10 minutes ATS Category 3 Assessment and treatment to start within 30 minutes Potentially Life-Threatening The patient's condition may progress to life or limb- threatening, or may lead to significant morbidity, if assessment and treatment are not commenced within 30 minutes of arrival OR Situational Urgency There is potential for adverse outcome if time-critical treatment is not commenced within 30 minutes OR Humane practice mandates the relief of severe discomfort or distress within 30 minutes

ATS Category 4

Assessment and treatment to start within 60 minutes Potentially Serious
The patient's condition may deteriorate, or adverse outcomes may result, if assessment and treatment is not commenced within one hour of arrival in ED. Symptoms are moderate or prolonged
OR
Situational Urgency
There is potential for adverse outcomes if time-critical treatment is not commenced within 60 minutes OR Significant complexity or Severity
Likely to require complex work-up and consultation and/or inpatient management
OR
Humane practice mandates the relief of discomfort or distress within 60 minutes ATS Category 5 Assessment and treatment to start within 120 minutes Less Urgent The patient's condition is chronic or minor enough that symptoms or clinical outcome will not be significantly affected if assessment and treatment are delayed up to 60 minutes from arrival OR Clinico-administrative problems Results review, medical certificates, prescriptions only

Table 29. Sample Adult Physiologic Predictors for the ATS Five Level Triage System. Adapted from Australian Government: Department of Health and Ageing. (2009). Emergency Triage Education Kit. Commonwealth of Australia. Category I Immediate Category 2 10 minutes Category 3 30 minutes Category 4 60 minutes Category 5 120 minutes Airway Obstructed/ partially obstructed Patent Patent Patent Patent Breathing Severe respiratory distress/absent respiration/ hypoventilation Moderate respiratory distress respiratory distress No respiratory distress No respiratory distress Circulation Severe haemodynamic compromise/ absent circulation
Moderate haemodynamic compromise haemodynamic compromise No haemodynamic compromise No haemodynamic compromise

Uncontrolled hemorrhage Disability GCS <9 GCS 9-12 GCS >12 Normal GCS Normal GCS Risk factors for serious illness/injury - age, high risk history, high risk mechanism of injury, cardiac risk factors, effects of drugs or alcohol, rash and alterations in body temperature - should be considered in the light of history of events and physiological data. Multiple risk factors = increased risk of serious injury/illness. Presence of one or more risk factors may result in allocation to a triage category of higher acuity.

Although it is desirable to use a single comprehensive triaging system, a facility catering to multiple population segments may require triaging systems specific to those populations. As such, multiple triaging systems may be utilized by these institutions. General Hospitals, for example, may use one triaging system for adult patients and another for pediatric patients. A facility catering to only one specific population may use a validated triaging system specific to that population.

Table 30. Sample Pediatric Physiologic Discriminators. Adapted from Australian Government: Department of Health and Ageing. (2009). Emergency Triage Education Kit. Commonwealth of Australia. Category 1 Immediate Category 2 Emergency 10 minutes Category 3 Urgent 30 minutes Category 4 Semi-urgent 60 minutes Category 5 Non-urgent 120 minutes Airway Obstructed

Partially obstructed with severe respiratory distress Patent

Partially obstructed with moderate respiratory distress Patent

Partially obstructed with mild respiratory distress Patent

Patent Breathing Absent respiration or hypoventilation Respiration present Respiration present Respiration present Respiration present Circulation s/s dehydration ↓LOC/activi ty cap refill <2 sec dry oral mucosa sunken eyes ↓tissue turgor Severe respiratory distress e.g. • Severe use of accessory muscles • Severe retraction • Acute cyanosis Moderate respiratory distress e.g. • Moderate use of accessory muscles • Moderate retraction • Skin pale Mild respiratory distress e.g. • Mild use of accessory muscles • Mild retraction • Skin pink No respiratory distress • No use of accessory muscles • No retraction No respiratory distress • No use of accessory muscles • No retraction Absent circulation
Significant bradycardia e.g. HR <60 in an infant Circulation present Circulation present Circulation present Circulation present

Absent tears deep respirations thready/we ak pulse Tachycardi a ↓ urine output

Severe haemodynamic compromise e.g. • Absent peripheral pulses • Skin pale, cold, moist, mottled • Significant tachycardia • Capillary refill

4 secs Moderate haemodynamic compromise e.g. • Weak/thready brachial pulse • Skin pale, cool • Moderate tachycardia • Capillary refill 2-4 secs Mild haemodynamic compromise e.g. • Palpable peripheral pulses • Skin pale, warm • tachycardia No haemodynamic compromise e.g. • Palpable peripheral pulses • Skin pink, warm, dry No haemodynamic compromise e.g. • Palpable peripheral pulses • Skin pink, warm, dry Uncontrolled hemorrhage 6 s/s dehydration 3-6 s/s dehydration <3 s/s dehydration No s/s dehydration Disability GCS <8 GCS 9-12 Severe decrease in activity e.g. • No eye contact • Decreased muscle tone GCS >13 Moderate decrease in activity e.g. • Lethargic • Eye contact when disturbed Normal GCS or no acute change to usual GCS Mild decrease in activity e.g. • Quiet but with eye contact • Interacts with parents Normal GCS or no acute change to usual GCS No alteration in activity e.g. • Playing • Smiling

Severe pain e.g. • patient/parents report severe pain • Skin pale, cool • Alteration in vital signs • Requests analgesia Moderate pain e.g. • patient/parents report moderate pain • Skin pale, warm • Alteration in vital signs • Requests analgesia Mild pain e.g. • patient/parents report mild pain • Skin pink, warm • No alteration in vital signs • Requests analgesia No or mild pain e.g. • patient/parents report mild pain • Skin pink, warm • No alteration in vital signs • Declines analgesia

Severe neurovascular compromise e.g. • Pulseless • Cold • Nil sensation • Nil movement • ↓capillary refill Moderate neurovascular compromise e.g. • Pulse present • Cool • Sensation • Movement • ↓capillary refill Mild neurovascular compromise e.g. • Pulse present • Normal/↓ sensation • Normal/↓move ment • Normal capillary refill No neurovascular compromise

Risk factors for serious illness or injury These should be considered in the light of history of events and physiologic data Multiple risk factors = increased risk of serious injury. The presence of one or more risk factors may result in allocation of triage category of higher acuity.

Mechanism of injury e.g. • Penetrating injury • Fall >2- height • MCA >60 kph • MBA/cyclist >30 kph • Pedestrian • Ejection/rollover
• Prolonged extrication (>30 minutes) • Death same car occupant • Explosion
Comorbidities e.g. Hx prematurity • Respiratory disease • Cardiovascular disease • Renal disease • Carcinoma • Diabetes • Substance abuse • Immuno- compromised • Congenital disease • Complex medical Hx Age <3 months and • Febrile • Acute change to feeding pattern • Acute change to sleeping pattern Victims of violence e.g. • Child at risk • Sexual assault • Neglect
Historical variables e.g. events preceding presentation to ED • Apnoeic/cyanotic episode • Seizure activity • Decreased intake • Decreased output • Red currant jelly stool • Bile stained vomiting Parental concern Other, e.g. • Rash • Actual/potential effects of drugs/alcohol • Chemical exposure • Envenomation • Immersion
• Alteration in body temperature

6.4.5 Medical Screening Examination

The goal of triage is to assign a level of priority to patients as they enter the ED. It sets an order in which they should be seen. It is not designed to determine whether the person has an emergency medical condition. Medical screening examinations, on the other hand, is an ED process used to determine whether an emergency medical condition exists in the patient presenting at the ED. All medical screening examinations shall be supervised by the most senior ED officer/attending. The following should be properly assessed and documented prior to transfer of patients or when waiting times are increased before the patient can be seen in the ED: • Review of chief complaints/symptoms • Assessment of vital signs • Assessment of general appearance • Assessment of pain level • Assessment of mental status • Assessment of hydration status • If pregnant, assessment of gestational status • Other tests to ascertain whether an emergency condition exists

6.5 Patients requiring Immediate Resuscitation

Patients requiring immediate resuscitation may come either from those being triaged upon entry into the ED or those patients whose condition unexpectedly deteriorate while in the ED. In both situations, care of these patients are prioritized to prevent death or disability. Resuscitation begins with recognition of the patient's condition. As such, the healthcare worker who first recognizes the need for resuscitation

initiates the resuscitative effort. Oftentimes, the resuscitative effort requires a team of healthcare workers, each with their own tasks and responsibilities. All Emergency Departments must be capable of treating patients requiring immediate resuscitative care regardless of level and specialty. All Emergency Departments are therefore mandated to prepare individualized protocols commensurate to their capability.

6.5.1 Resuscitation Team

The resuscitation team is tasked with the treatment of patients requiring immediate resuscitation. It shall be composed of the following members • ED Physician • Nurse Supervisor on Duty • Resuscitation Nurse • Staff Nurse • Attendant/ Orderlies

6.5.2 Conduct of Resuscitation

1. Once a patient requiring immediate resuscitation is recognized, the health workers will begin BLS and notify the resuscitation team.
2. The Team Leader of the resuscitation team will be the ED physician. The most senior nurse trained in BLS may act as Team Leader until the ED physician arrives.
3. All team members of the resuscitation team must have BLS training. The resuscitation team leader should be a certified Advanced Cardiac Life Support (ACLS) provider or Pediatric Advanced Life Support (PALS) provider or Neonatal Resuscitation program provider or its equivalent.
4. A defibrillator, either automated or manual, should always be functional and available. Any team member may perform defibrillation per physician's order or per institutional protocol.
5. The team leader in conjunction with the resuscitation team will decide regarding continued patient care.
6. The team leader may discontinue resuscitative efforts if deemed unsuccessful and/or futile by either the ED physician in-charge or per institutional protocol.
7. Nurse supervisor on duty or the treatment officer will inform the family of the patient. If the family is not present, the nurse supervisor will attempt to locate the family members by telephone or the security guard or inform the nearest police station.

6.5.3 Post-Resuscitation Care

Early definitive care may be initiated in the ED after a successful resuscitation or during the resuscitation effort. All diagnostics including laboratory or imaging studies will be prioritized by the institution with the goal of initiating early definitive care. Admission of these patients to the ICU or wards will also be prioritized. Patients who have been successfully resuscitated may require care not commensurate with capability of the current facility. In these situations, transfer to a more specialized facility may be required.

6.6 General Care of the Emergency Department Patient

Most patients will not be triaged to the highest level of urgency as the vast majority of ED patients will not require immediate resuscitation. Prioritization of these patients will follow from their triage categories, regardless of race, social, financial or political status. The designation to a triage category however does not preclude the need for immediate resuscitation should these patients deteriorate while in the ED.

6.6.1 Registration

Complete registration can be done after the patient has been safely triaged with their immediate needs having been addressed. This post-triage registration supplements the initial registration already done at the triage area and ensures that the registration process does not impede in the care of patients. Procedure Person-in-Charge Additional Information The following information is recorded in the chart: • Complete name
• Age • Sex • Address and contact Number • Next of kin/Companion and their contact numbers • Religion • Date of Birth • Date and time of consult • Chief Complaint • Weight and Height • Civil Status Triage Officer/ Nursing Staff/ Treatment Officer Additional information may be included in the registration process as dictated by institutional needs Other information that may be included during the registration • Allergies • NOI, POI, DOI, TOI • OB Scores This information may be taken during the registration process to facilitate a more efficient flow of patients in the ED or as part of the History and Physical Examination of the Treatment Officer.

6.6.2 Informed Consent

An informed consent refers to the voluntary agreement of a person to undergo or be subjected to a procedure based on full information, whether such permission is written, conveyed verbally, or expressed indirectly.

Patients who have reached the age of 18 and patients who have yet to attain majority but have been legally emancipated, with sound mind and consciousness shall give an informed consent for all interventions. The informed consent of minors who are not legally emancipated should be obtained from their parents or guardians. Consent for patients who have attained majority but do not have sound mind and consciousness shall be obtained from the patient's next of kin. In emergent cases, the doctrine of implied consent applies to all resuscitative interventions, unless revoked by the patient's nearest of kin.

Procedure Person-in-Charge Additional Information Explain to the patient, guardian or next of kin the need for informed consent Triage officer/ Treatment officer/ED Nurse Explanation must be in a language that is understandable to the patient, guardian, or next of kin Signature of the Patient/Guardian/ Next of kin is obtained Name of the signee and their relation to the patient must be indicated with the signature Witnesses must be included in the consent forms The witness may be the patients’ companion, a disinterested party or one not involved directly in the care of the patient

Person Who May Execute an Informed Consent for Incapacitated Patient, 18 years old and above (as adopted from Republic Act 7170, Section 4) Any of the following persons, in order of preference, in the absence of actual notice contrary intentions by the patient or actual notice of opposition by a member of the immediate family of the patient, may give consent for any purpose: • Spouse; • Son or daughter of legal age; • Either parent; • Brother or sister of legal age; or • Guardian

6.7 Care of Patients in the Waiting Area

Patients triaged to lower levels of urgency may be asked to stay in the waiting area before being seen by the attending physician. As patients are awaiting assessment and disposition, the safety of both the patient and the staff in this area is of paramount importance. Possible untoward scenarios in the waiting area include the following: • Patients clinically deteriorate while waiting to be seen by a physician • Patients become irate and aggressive, becoming a threat to the safety of others • Patients may abscond from the hospital only to return clinically worse

6.7.1 Staffing in the ED Waiting Area

The ED waiting area should be staffed by a nurse or other experienced healthcare professional whose main function shall be the following:

1. To detect and assess a deteriorating patient
2. To improve communication between patients and staff
3. To assess and initiate nurse-initiated protocol driven pathways

6.7.2 Monitoring of Patients in the ED Waiting Area

The nurse or healthcare worker assigned to the ED waiting area shall have the responsibility of monitoring patients triaged to this area. They may retriage patients to higher levels of urgency should the patient's condition worsen. The nurse in-charge acts as the communication bridge between the physician and the patient. They inform patients about the situation in the ED while updating the ED physician regarding the condition of the patients.

6.7.3 Initiation of Patients’ Assessment and Treatment

Emergency departments may opt to address long waiting times by adopting department/institution approved protocols for commonly seen conditions that nurses or other healthcare professionals can identify and initiate within their scope of practice. These nurse-initiated protocol-driven pathways may hasten the treatment and evaluation of patients and improve satisfaction outcomes among ED patients.

6.8 Care of the Patient in the Acute Care and Treatment Areas

All patients in the Emergency Department shall have an assigned nurse and an attending physician at all times. The attending physician shall be responsible for the assessment, treatment, and disposition of the patient but may delegate the same to his subordinates provided that there is supervision and oversight over the subordinates’ action. At no time shall the patient be without a physician or nurse responsible for their care.

6.8.1 Bed Allocation

Bed allocation in the Emergency Department shall be prioritized by the triage level of urgency with the sickest patient being prioritized first. Patients with the least level of urgency may be asked to stay in the waiting area after assessment by the physician.

6.8.2 Monitoring of Patients in the ED

Regular monitoring of vital signs of all patients in the ED is recommended but should be balanced with the staffing capability of the ED. The frequency of monitoring shall also be dependent upon the patients’ level of urgency with more frequent monitoring done for more critical patients. All patients exiting the ED shall have their vital signs monitored and documented prior to exit.

6.8.3 Disposition Decision

All patients seen in the ED should have a disposition before the 4th hour of stay in the ED with the exception of critically ill patients who should have a disposition by the 2nd hour of ED stay. Critically

ill patients will be prioritized in both admission and decking of bed in the Intensive Care Unit or ward as the case may be.

6.9 Diagnostic and Ancillary Procedures in the ED

All Emergency Department patients requiring diagnostic and ancillary procedures which are crucial and necessary for immediate decision-making and treatment, shall be done immediately without requiring prior payment. These shall include those studies that are done in the central laboratory or imaging departments and their satellite extensions or those done as point of care studies. Results of diagnostics should not delay admission and/or transfer of care to the different services/facility provided that said diagnostics are not necessary for the immediate and emergent treatment of a patient's condition and/or are not necessary for his clinical disposition. It is acceptable that routine diagnostic tests and X-ray procedures already requested at the ED but were not carried out, shall be done in the Ward.

Diagnostics and ancillary tests may be categorized as:

1. Routine where tests are done during the usual running time with the releasing of results within 3 hours. This is done on samples in which the result is not emergently needed
2. STAT where tests done are essential for a life-threatening condition. The turnaround time of

releasing the official result shall not be more than 1 hour. Stat test requests are given the highest priority by the laboratory for processing, analysis, and reporting. It shall be the responsibility of the hospital administration to establish a list of “STAT” laboratory tests as recommended by the Emergency Department and approved by the Laboratory Department. This is to avoid abuses made on the “STAT” laboratory tests.

6.9.1 Transport of Patients to the Diagnostic Departments

Patients being brought to the diagnostic departments are to be risk stratified based on their hemodynamic stability and their risk of deteriorating during the procedure. This determination shall be done either by the attending physician or as per institutional protocol. In all situations, the healthcare facility should have in place a protocol should a patient deteriorate while in transit to the diagnostic departments or while the procedure is being performed. All healthcare workers in the ED and the diagnostic departments should be briefed of this protocol and must be able to activate the same as the need arises. Patients who are hemodynamically stable but are at high risk of deteriorating should be brought to the diagnostic departments only with the supervision and consent of the attending physician and should be accompanied by a healthcare worker capable of recognizing the progression of the patient's condition. Patients who are hemodynamically unstable but require the diagnostic procedure in addressing their emergent needs, may be brought to the diagnostic departments provided that care and monitoring can be continued during the procedure. The transport of critically ill patients, either hemodynamically stable or not, to a diagnostic department shall follow the guidelines in the intra-hospital transfer of critically ill patients below.

6.9.2 Point of Care Studies (POCS)

Point of care studies refer to diagnostic studies that can be competently and accurately done at bedside even by a non-laboratory/non-medical imaging healthcare professional. Point of care studies may be done independent of the central laboratory/imaging department or its satellite extensions. It has the advantage of not having to transport the patient outside the ED and possibly having faster results. POCS provides the ED the ability to address a patient's clinical need immediately and accurately. All EDs are recommended to have POCS especially those in resource limited areas.
In healthcare facilities with POCS, the ED shall develop protocols and guidelines as to the following guidelines:

1. The indications for the use of these studies
2. Infection prevention and control and waste disposal
3. Training in the use and maintenance of equipment
4. Methods of recording results

6.9.3 Financial Considerations for Laboratory, X-ray and Other Ancillary Services at the

Emergency Department Considering the emergent or urgent need to institute proper and immediate care or treatment of ED patients, the diagnostics and ancillary services shall not ask for payment or deposit prior to performance of requested procedure. The tests shall be performed but charged and to be paid prior to discharge. For patients who have no capability to pay will be referred to the Medical Social Work Department for classification and must issue a promissory note prior to discharge in accordance to RA 9439 (An Act prohibiting the detention of patients in hospitals and medical clinics on the grounds of nonpayment of hospital bills or medical expenses). The procedure shall follow the hospital policy on this matter. Pursuant to RA 10932 (An Act Strengthening the Anti-Hospital Deposit Law by Increasing the Penalties for the Refusal of Hospitals and Medical Clinics to Administer Appropriate Initial Medical Treatment and Support in Emergency or Serious Cases, Amending for the Purpose Batas Pambansa Bilang 702, Otherwise Known as “An Act Prohibiting the Demand of Deposits or Advance Payments for the Confinement or Treatment of Patients in Hospitals and Medical Clinics in Certain Cases.” As Amended by Republic Act No. 8344, and for Other Purposes), laboratory procedures not necessary in the urgent or emergency needs, can be deferred and done while the patient is in the Ward/ or sent home, not necessitating delay or prolonging stay at the ER. The ER resident makes judicious use of the laboratories that are needed to aid in his management of the emergency case.

6.9.4 Labeling Specimen Container / Slide

Labels (at least five) should be used whenever possible. The label should be permanently affixed to the specimen container. Based on the Guidelines for Collection of Specimens for Laboratory Testing (World Health Organization, March 2003), it should contain: • Patient Name • Unique Patient Identification Number or Hospital Number • Specimen Type, Date, Time and Place of Collection • Name or Initials of Specimen Collector

Request Forms for Laboratory Tests shall contain a stamp of the requesting physician with the name and signature in addition to the above data. X-ray requests labeled as “STAT” shall have the approval of the Radiology department personnel.

6.10 Conduct of Referral and Hand-over Communication between Healthcare

Professionals in the ED It may be possible that multiple specialties and units will care for the patient in the ED. This is complicated by the instant flow of patients in and out of the ED all requiring some degree of care. Clear Communication between healthcare professionals and general policies thereof are essential to the well- being of patients.

6.10.1 General Policies in the Conduct of Patient Referral

• Referral by the Treatment Officer to another service for evaluation should be done within the first 2-4 hours from patient arrival. A ONE-WAY referral should be strictly followed if the patient still has no disposition. • Category 1 and 2 patients for admission must be referred to admitting service for admission within 2 hours from time of arrival and resuscitation. • Referrals should be endorsed personally by the physician-in-charge to the admitting specialty. • Referrals not answered within the designated period shall be referred to the Attending/Charge Physician or Senior EM resident for appropriate action. • Referrals shall be made at the resident’s level. In cases of conflict or issues regarding patient disposition, department consultants on-call shall be consulted to decide on the case. In case the issue remains unresolved, the matter is then elevated to higher hospital authority. • Previous patients readmitted to the ED for the same complaint or problem shall be referred and admitted to the previous service that last managed the patient. • Patients with emergent and urgent conditions referred for admission from the Outpatient Department (OPD) shall be examined at the ED prior to the hospital admission for initial stabilization. • Elective and non-urgent cases from the OPD that are for admission shall be admitted directly to the floors or wards. The ED will not serve as a holding area for elective and non-urgent cases when these patients cannot be accommodated at the wards or floors.

6.10.2 Hand-Over Communication through SBAR Method

According to the WHO Collaborating Center for Patient Safety Solutions, “hand-over communication pertains to the process of passing patient-specific information from one caregiver to another, from one team of caregivers to the next, or from caregivers to the patient and family for the purpose of ensuring patient care continuity and safety.” A standardized approach to hand-over communication between parties is recommended, such as the SBAR Method. This method provides a framework of communication between members of the healthcare team about a patient's condition that ensures all essential information is passed on.

Table 31. SBAR Method. Adapted from Institute for Healthcare Improvement. (n.d.). SBAR Tool: Situation-Background-Assessment-Recommendation. Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx SBAR Method Situation A concise statement of the problem Background Pertinent and brief information related to the situation Assessment Analysis and considerations of options — what you found/think Recommendation Action requested/recommended — what you want Implementation of a standardized tool should be supplemented by the following (WHO Collaborating Center for Patient Safety Solutions, 2007): • Hand-over communication should be given ample time for essential patient information to be discussed. This process must allow receiving and endorsing staff to ask and respond to questions and conduct repeat-back and read-back of relevant information. • This process must ensure that the following are discussed during hand-over: patient’s current status, medications, treatment plans, advanced directives, what to watch out for, and any significant status changes. • Ensure that the patient information discussed is limited to what is necessary to provide safe care to the patient.

6.11 Intra-Hospital Transfer of Critically Ill Patients

The transport of the critically ill patient outside of the ED either for admission or for a diagnostic procedure must follow an orderly and team-based approach in order to mediate the risk inherent with transport. The underlying principle in the transport of the critically ill patient is that the level of care and monitoring provided to the patient should not be impeded by the transport process (Warren et al., 2004).

6.11.1 Pre-Transport Coordination

Prior to any intra-hospital transport from the ED, pre-transport communication and coordination between representatives of the involved departments is a prerequisite. Receiving department must confirm that they are ready to receive the patient prior to transport. The attending physician and nurses in-charge must be made aware of, and consent to the transport. A pre-transport checklist shall be used to facilitate coordination between the departments and ensure that all equipment necessary for the transport is complete. Proper documentation should include the destination of the patient, the indication for transport, and status of the patient prior to transport.

6.11.2 Composition of the Transport Team

The transport team includes at least 2 health care professionals that will accompany the critically ill patient. This shall include at least one (1) nurse trained in emergency or critical care OR with training in advanced cardiac life support or its equivalent. All critically ill patients with hemodynamic instability

will be accompanied by a physician trained in airway management and advanced cardiac life support or its equivalent.

6.11.3 Equipment for Transport

The minimum equipment for intra-hospital transport of the critically ill patient shall include but shall not be limited to the following: • Blood pressure monitor • Pulse oximeter
• Cardiac monitor/defibrillator • Bag-valve mask/tube resuscitator • Oxygen source The following should be taken in consideration depending on the needs of the patient for transport: medications such as epinephrine, portable mechanical ventilators, and other devices. All members of the transport team should be familiar with the equipment and medications used by the team.

6.11.4 Monitoring during transport

Critically ill patients being transported outside of the ED shall be monitored through the following: • Continuous ECG monitoring • Continuous pulse oximetry monitoring • Regular measurements of o Blood pressure o Respiratory rate o Cardiac rate o GCS Other parameters may be considered as needed. Monitoring shall be done before transport, at regular intervals during transport, and after the transport, when either a different team has taken responsibility for the patient or when the patient has been brought back to the ED, as the case may be.

6.11.5 Responsibility of Care During the Transport

There shall be a clear and explicit delineation of responsibilities amongst the transport team during the transport process. Acceptance of responsibility and the termination thereof, must be explicit between parties involved. At no time shall the patient be without a physician or healthcare worker responsible for their care.

6.12 Disposition of Patients in the ED

There are only 3 dispositions at the end of every ED patient journey: • Admission • Transfer • Discharge
Mortality and Recovery are clinical outcomes and should be reported separate from the disposition.

6.12.1 Admission of Patients

Admission is the disposition given to a patient who will be placed in a potentially available inpatient bed within the current healthcare facility. These are patients whose continuity of care will be done in the

hospital setting and who have consented to be admitted in the current facility. Admission of patients shall have the following general guidelines:

1. Once the disposition for admission has been made, the attending physician, nursing staff and other members of the healthcare team must explain the need for admission and the plan of management. If an invasive procedure is contemplated, the doctor or physician in-charge must explain the procedure as to its risks and benefits based on evidence-based medicine so that the patient can render informed consent.
2. Consent secured from the patient and/or relatives for the contemplated admission and treatment plan must be well-understood by the consenting parties.
3. Results of diagnostics should not delay the admission of the patients and their subsequent transfer to an in-patient bed provided that said diagnostics are not necessary for the immediate and emergent treatment of a patient's condition. Routine diagnostic tests and X-ray procedures already requested at the ED but were not carried out, shall be done in the ward.
4. Referrals between healthcare staff such as those between ED physician to Ward physician and ED nurse to Ward nurse shall follow the guidelines for referral. Responsibility for the care of patients must always be clear and explicit. There shall always be a physician and a nurse responsible for the patient.

6.12.2 Transfer of Patients

The disposition to “transfer” is assigned to patients who are to be referred and transported directly to another healthcare facility for continuity of care. The underlying goal of transfer is the health and well- being of the patient. Transfer of patients shall have the following general guidelines:

1. All ED patients with the disposition for transfer shall still receive care through prompt and appropriate assessment, treatment, and stabilization, matched with the capability of the facility they presented in.

2. In the case where the patient or their next of kin request for transfer prior to the commencement or completion of stabilization, such care should still be offered by the ED while informed refusal from the patient or kin shall be documented.

3. Informed consent shall be secured prior to transport, with the attending physician and nurse in- charge having explained the risk and benefits of the transfer to the patient or their next of kin. Consent shall be documented accordingly.

4. All healthcare facilities shall identify individuals responsible for accepting and transferring patients on behalf of the hospital. In addition, the attending physician at the transferring hospital will use their best judgment regarding the condition of the patient when determining the timing of transfer, mode of transportation, level of care necessary during transfer, and the destination of the patient.

5. The attending physician and the nurse in-charge at the transferring hospital shall be responsible for endorsing the patient to the receiving physician/nurse of the receiving hospital. There must be explicit acceptance of the patient by the receiving healthcare facility. The names of the receiving physician and nurse, the name and location of the healthcare facility to receive the patient, the time and date of the referral, and the patient’s current condition shall be noted and documented.

6. When a patient requires a higher level of care other than that provided or available at the transferring facility, a receiving facility with the capability and capacity to provide a higher level of care MAY NOT REFUSE any request for transfer.

7. All pertinent records and copies of diagnostic studies should accompany the patient to the receiving facility or be electronically transferred as soon as is practical.

8. All networked referrals shall not be refused by the receiving hospital once properly coordinated.

9. Healthcare professionals should abide by applicable laws regarding patient transfer (Warren et al., 2004).

Procedure and Documentation of Transfer
All transfers should be properly networked with the admitting hospital accompanied with properly filled up forms in triplicate with acknowledgement form duly signed by the receiving hospital. All laboratory results, x-ray plates, etc. and abstract should go with the patient and properly endorsed and acknowledged. Patients transferred to the other hospitals are given an inter-hospital referral slip and required to sign a release of responsibility. Likewise, patients who refuse admission, procedure of treatment or medication should sign a release of responsibility with the ED physician and nurse as witness.

A clinical summary specifying the clinical evaluation and interventions done to include medication dosage, time administered and condition prior to transfer shall be accomplished and attached to the inter-hospital referral form. The patient’s vital signs and condition prior to the transfer shall be recorded in the ED record/ data sheet.

All coordinated and networked referrals shall be conducted by the referring health facility using an ambulance or EMS system. Hospitals without ambulance/ EMS transport shall make the necessary arrangement with their local government for assistance in patient transport.

Referrals of ambulatory and non-urgent cases require only the written inter-hospital referral form. For comprehensive guidelines related to the Health Care Provider Network, refer to Administrative Order No. 2020-0019 also known as “Guidelines on the Service Delivery Design of Health Care Provider Networks.”

Transfer of Patients with Highly Communicable Disease
Patients suspected to have highly communicable disease shall be referred immediately to the Infection Control Committee (ICC) after initial stabilization of ABCs and if deemed for transfer, the ICC shall make the necessary coordination with the receiving facility.

Patients with communicable diseases are advised to be transferred to end-referral hospitals (e.g. San Lazaro Hospital) by ambulance, unless the patient decides on personal conduction after being required to sign a release of responsibility. For hospitals outside the National Capital Region, communicable diseases are only admitted when the institution is fully equipped and capable to manage such cases. The table below outlines a list of highly communicable diseases to be referred to a capable facility.

Table 32. Minimum Requirements for Receiving Facilities of Patients with the Highly Communicable Diseases Listed Absolute contraindication for admission IN A NON- QUARANTINE OR UNDER EQUIPPED HOSPITAL Diseases Isolation Reverse Isolation – (Depends upon discretion of attending physician) Diphtheria Smallpox Poliomyelitis Rabies Psychiatric cases, violent PTB active, open cavity Bubonic Plague Chicken pox Meningococcemia Tetanus Mumps Scabies Measles Meningitis Meningo-coccal infections Gonorrhea Chaneroid Syphilis Gas gangrene Infectious hepatitis, Pre-comatose, comatose Pertussis Cholera Typhoid H-fever AIDS Postpartum and post abortal sepsis Premature and Newborn infants Leukemia Hypo-or-a-gamma-globulinemia Certain post surgical conditions Patients treated with a large doses of radiation, steroids or various immunosuppressive agents Severe burns (follow Burn Unit Policy)

6.12.3 Discharge of Patients

The Discharge of a patient patient may be categorized as follows: • Discharged and Sent Home • Discharge Against Medical Advice • Discharge – Absconded • Discharge – ED Death • Discharge - DOA

High Quality ED Discharge has Three Characteristics • It informs and educates patients on their diagnosis, prognosis, treatment plan, and expected course of illness. This includes informing patients of the details of their visit (treatments, tests, procedures). • It supports patients in receiving post-ED discharge care. This might include medications, home care of injuries, use of medical devices/equipment, further diagnostic testing, and further health care provider evaluation. • It coordinates ED care within the context of the healthcare system (other health care providers, social services, etc.).

Discharge and Sent Home This disposition is given to a patient who has completed the ED assessment and treatment and has been recommended for discharge by the attending physician. In most cases the continuity of care for these patients can be done in the outpatient care service.

Procedure of Discharge and Sent Home The Discharge of patients shall be facilitated by the ED physician and the nurse in-charge. The ED process for discharge shall include the following: 1. Communication and education of patients a. Communicate with patients what occurred during the ED visit (treatments, tests, procedures) b. Educate patient on diagnosis and treatment plan c. Communicate with patients about reconciled medication list d. Educate patient on expected course of illness e. Educate patient on signs and symptoms to watch for 2. Support Post-ED discharge Care a. Ensure patients appropriately take new medication b. Ensure patients stop or avoid taking certain medications (depending on condition) c. Ensure patients are capable and able to care for wounds d. Ensure patients understand and comply with dietary restrictions e. Ensure patients can receive the appropriate physical therapy (depending on the condition) f. Discuss use of medical devices (crutches, walker, neck brace, inhalers, glucometers, etc.) g. Discuss activity restrictions h. Facilitate further diagnostic testing i. Facilitate further health care provider evaluation and treatment 3. Communicate Care with Other providers and service a. Share records with primary care physician (PCP) and specialists b. Communicate further plans with PCP and specialists c. Make appointment with PCP and specialists if possible

A discharge note to be accomplished by the attending physician. The note shall contain the following information: name of patient, age, date examined, take home medications with the proper instructions, diagnosis, results of laboratory examination, date of follow-up visit and the name of the attending physician. CSR, supplies, medicines and procedures done to the patient may be charged accordingly if the patient can afford to pay. However, if not, they are referred to the Social Services for proper evaluation.

Discharge Against Medical Advice This disposition is given to a patient who has registered in the ED but has decided to leave prior to or against the recommendation of the attending physician.

General Policies Pertaining to the DAMA patients Refusal of admission and other treatments to be given to patients usually requires a form for release of responsibility. This should be signed by the patient himself. If the patient is a minor, the nearest of kin may sign. Proper and clear explanation of consequences that may arise after refusal of medical management must be made.

The person who signed the waiver must be the one to remove all the contraptions connected to the patients and should leave the hospital premises at once. All supplies and medicine used by the DAMA patient shall be replaced or charged (Abuzeyad et al., 2021).

Discharge - Absconded This disposition is given to a patient who has left the emergency department unexpectedly, without the knowledge of clinical staff, and in whom there remains a potential risk of harm to self or others either through neglect or deliberate means (Royal College of Emergency Medicine, 2020).

The Emergency Department should have a clear policy when a patient is discovered to have absconded. Actions should be taken to locate the patients and should include

1. Searching the ED and the surrounding area
2. Informing the Security and reviewing the CCTV if available
3. Calling the patient using his last known contact number
4. Informing the Next of Kin

Discharge – Hospital Death (ED Death)/ Community Death (DOA) Please see corresponding section below

6.13 Disposition of the Cadaver and Dismembered Body Parts

Death is the irreversible cessation of circulatory and respiratory functions or the irreversible cessation of all functions of the entire brain, including the brain stem. A person shall be medically and legally dead if either:

1. In the opinion of the attending physician, based on the acceptable standards of medical practice, there is an absence of natural respiratory and cardiac functions and attempts at resuscitation would not be successful in restoring those functions. In this case, death shall be deemed to have occurred at the time these functions ceased; or
2. In the opinion of the consulting physician, concurred in by the attending physician, that on the basis of acceptable standards or medical practice, there is an irreversible cessation of all brain functions; and considering the absence of such functions, further attempts at the resuscitation or continued supportive maintenance would not be successful in restoring such natural functions. In this case, death shall be deemed to have occurred at the time when these conditions first appeared. The death of the person shall be determined in accordance with the acceptable standards of medical practice and shall be diagnosed separately by the attending physician and another consulting physician, both of whom must be appropriately qualified and suitably experienced in the care of such patients. The death shall be recorded in the patient’s medical record (Republic Act 7170-Sec 2).

6.13.1 Dead on Arrival (DOA)

Patients brought to the Emergency Department without cardio-pulmonary and brain functions. This will include patients who did not respond to initial resuscitation (for 30 minutes). Resuscitation is no longer done to patients with signs of Rigor Mortis, Livor Mortis, Algor Mortis and Decapitation and advanced state of decomposition. A DOA Form shall be accomplished to indicate name, date, time of arrival, time of death, informant and attending physician.

6.13.2 ED Death

ED Death refers to the death that occurred in the ED of a patient who was not yet admitted. It includes patients who arrived at the ED with no detectable vital signs (BP, HR, and RR), revived by initial resuscitative measures, but eventually died, regardless of the time of stay. ED nursing personnel shall do postmortem care.

Death of an admitted patient at the ED and while on transport This refers to the death of an admitted patient who was not yet accepted or has not yet reached the assigned ward. For such cases, the mortality shall be counted to the census of the admitting ward. This also includes patients who arrived at the ED with no detectable vital signs (BP, HR, and RR), revived by initial resuscitative measures and sustained for more than 15 minutes, but eventually died regardless of time of stay. ED nursing personnel shall do postmortem care.

Admitted patient who died at the ER In this case, the death certificate shall be accomplished by the ER Officer. Postmortem care shall be done by the ER nursing personnel.

Admitted patient who died while on transport When the patient dies on transport, the patient shall be brought and resuscitated in the nearest unit which has an E-cart. The physician who pronounced the death of the patient shall accomplish the death certificate. The postmortem care shall be done by the nursing personnel in that unit.

Sample Case Scenario A patient is admitted to the 3rd floor but while on transport, the patient coded/ arrested at the 2nd floor, the patient shall be resuscitated in the nearest unit with E-cart at that floor. Even though the personnel who attended the patient are not from the admitting ward, the census shall be counter to the admitting ward.

For undifferentiated cases staying <24 hours at the ED but demised, Death Certificates may be accomplished by the Treatment Officers.

A patient’s death shall be accurately and appropriately documented upon declaration or pronouncement of the death. Postmortem care should be done by the nurse or nursing attendant and shall be brought to the morgue immediately after. The cadaver should not stay for more than two hours in the ED.

Documentation, release of certification/death report, and release of cadavers shall follow hospital guidelines.

6.13.3 Dismembered Body Part

All dismembered body parts, non-viable for attachment that are brought in the ED shall be forwarded to the Surgical Pathology section of the laboratory for gross microscopic examination and documentation for future reference, if the case has medico-legal implication. The surgical pathology report shall serve as the certificate of dismembered body part which is issued and duly signed by the pathologist. The certificate shall bear the name of the owner if the dismembered body part is claimed by the owner through identification of an identifying mark of malformation. This “Certificate of Dismembered Body Part” is issued for burial or proper disposal of the body part. If the ownership is uncertain, the body part shall be stored in the surgical pathology for a certain period for further studies; thereafter, it is released for proper disposal. The certificate shall not bear any name of person. Further documentation such as taking photographs, radiologic studies, and samples for possible DNA testing shall be done.

6.14 Special Emergency Department Principles

6.14.1 Infection Prevention and Control

Infection prevention is a major challenge in the rapid-paced, high-volume setting of emergency care. The ED is a complex and dynamic healthcare environment. Patients present with undifferentiated illnesses and variable acuity, ranging from the otherwise healthy to the critically ill. Risk recognition and medical decision-making are often based on limited and evolving data, under significant time and resource constraints.

Screening for Hazardous Exposure and Highly Communicable Diseases All patients coming to the ED should be screened for hazardous exposure or possible communicable diseases prior to entry into the ED. The aim of this screening is to prevent the inclusion of patients with potentially hazardous exposure or highly communicable diseases from the general ED patients. Once identified, patients with hazardous exposure or highly communicable diseases are brought to the decontamination or isolation area where assessment and treatment is initiated. Screening does not preclude the subsequent triaging, but flows continuously to it, with triaging being done in the decontamination/isolation area. Once identified, all healthcare workers are expected to strictly follow hospital safety protocols including but not limited to the use of PPEs and standard or transmission- based precautions as applicable. In pre-triaging and triaging, the following are recommended:

1. Staff comply with PPE recommendations according to current published guidance.
2. Staff must be fully attired in appropriate level PPE prior to triaging any patient.
3. Triaging for ambulatory patients and those arriving by ambulance will follow the same process.
4. Identification of patient cohorts should occur consistent with the COVID-19 risk groups based on DOH/Institution’s ICC guidelines.
5. Re-configuration of EDs will be required to safely accommodate arriving patients and ensure proper bed placements according to both their COVID-19 risk statuses and clinical priorities, as follows:

a. The movement of people shall follow the principle of establishing a contaminated zone, a potentially contaminated zone and a clean zone which are clearly demarcated, with buffer zones between the zones. b. Planning may include capacity to immediately stream higher dependency and critical COVID-19 high risk patients to negative pressure rooms within the hospital, with a COVID rapid response call to the facility Critical Care/Intubation team. c. Streaming out of the ED for specific patient groups who are clinically stable and have no or low identified COVID-19 risk should be a component of the ED zone planning. d. Consideration of transport of patients and equipment from each zone should be part of the design. e. Procedures for clinical staff to don and doff their protective equipment should be standardized and observed at all times. f. Flowcharts of different zones, donning and doffing areas, and staff walking routes should be displayed in plain view in critical areas and communicated widely. g. A pre-examination and triage area outside of the main ED may be separately established to perform preliminary screening of patients, depending on the volume of attendances to the ED; otherwise, this function may be performed by the existing Triage. Provision to upscale to a separate ED screening triage station should be planned and trigger points communicated. PREVENTING THE TRANSMISSION OF INFECTIOUS ORGANISMS
Hand Hygiene Hand hygiene remains the cornerstone of modern infection prevention and is the single most important strategy for curbing transmissions of infectious microorganisms between patients, healthcare professionals (HCP), and the healthcare environment. Alcohol-based gel and foam products are superior to regular and antimicrobial soap in reducing bacterial counts, and are therefore recommended for most routine hand hygiene. However, scrubbing and rinsing with soap and water is still preferred when caring for patients with C. difficile infection, as alcohol-based products are not effective against C. difficile spores, or when there is visible soiling of the hands. Proper steps and protocols in hand hygiene must be displayed in plain view in hygiene areas to influence HCP behavior. Immediate feedback about hand hygiene performance as well as regular reporting and dissemination of HCP adherence rates foster accountability and provide concrete benchmarks by which improvement can be measured. Standard Precautions ED HCP routinely comes in contact with blood and other potentially infectious body fluids (e.g. cerebrospinal, pleural, peritoneal, pericardial, synovial, amniotic) during patient care. Most exposures involve the hands. Exposure to the face of bodily fluids may occur during tube thoracostomy, lumbar puncture, or examination of a hemorrhaging patient. Face and eye protection are recommended for procedures and examinations where splashes or sprays of blood or other body fluids are likely. Eyewear must consist of a face shield, goggles, or glasses with side shields in order to be considered adequate protection. Standard precautions also encompass hand and respiratory hygiene as well as the safe handling and disposal of potentially contaminated equipment and environmental surfaces.
Transmission-based Precautions Communicable infectious diseases can be transmitted through airborne droplet nuclei, large particle droplets, or direct contact with patients and their immediate environment. Given that knowledge of

whether a patient is infected or colonized with a pathogen is seldom known at the time of presentation, empiric transmission-based precautions are crucial to preventing the spread of infectious microorganisms in the ED.

Airborne Precautions Airborne droplet nuclei measuring ≤5 µm can remain infective and suspended in the air for hours at a time, particularly in enclosed and poorly ventilated spaces. Airborne transmission of tuberculosis, measles, and severe acute respiratory syndrome (SARS) has been described in ED settings. Rapid identification and isolation of ED patients suspected of harboring airborne diseases hinges greatly upon heightened clinical suspicion, as in the case of tuberculosis. Proper HCP protection against airborne droplet nuclei requires use of either an N95 or Powered Air Purifying Respirator (PAPR). In COVID, source control options for HCP include a NIOSH-approved N95 or equivalent or higher-level respirator, a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators, or a well-fitting facemask. Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting. Engineering controls aimed at mitigating or eliminating workplace hazards factor prominently in preventing airborne transmission of pathogens in the ED. Single-occupancy airborne infection isolation rooms equipped with special air handling and ventilation systems to generate negative room pressure have been associated with significant reductions in tuberculosis conversion rates among urban ED HCP caring for high-risk populations.

Droplet Precautions Unlike airborne droplet nuclei, large particle droplets measuring >5µm neither travel nor remain suspended in air for long periods. Droplet transmission occurs with seasonal influenza and meningococcal disease, both of which have been associated with transmission to and infection of ED HCP. Donning a surgical mask as part of standard precautions provides sufficient droplet protection for HCP and is recommended when working within 3 feet of the patient. A more conservative radius for masking within 6 to 10 feet or upon entering the patient’s room has also been suggested.

Contact Precautions Transmission of these pathogens and others, including SARS and highly pathogenic influenza, can occur through direct contact with patients or their immediate surroundings. Contact precautions entail the use of protective gowns and gloves during patient care to prevent HCP acquisition and transmission of these pathogens to other patients. With the exception of patients presenting with diarrhea or bowel incontinence, the decision to initiate contact precautions in the ED can be difficult. The extent of HCP adherence to contact precautions once the need has been identified is not yet known.

6.14.2 Patient, Staff, and Facility Safety

Emergency departments are prone to making diagnostic, procedural, and medication errors that are an ever-present risk in patient care as well as for the staff. Risks include combative patients and relatives that can cause undue harm or harassment to staff.

The effective delivery of hospital services and patient care is significantly tied to the safety attitudes and practices of hospital staff and management. Indeed, issues related to patient health and safety in hospitals throughout the world have resulted in-patient deaths, prolonged hospitalizations, irreversible disabilities and significant financial costs.

Facility Management and Safety The hospital works to provide a safe, functional, and supportive facility for patients, families, and staff. To attain this goal, the physical facility, medical and other equipment, and people must be effectively managed. In particular, management must strive to: • Reduce and control hazards and risks • Prevent accidents and injuries, and • Maintain safe conditions

Effective management includes planning, education and monitoring. • Leaders plan the space, equipment and resources needed to safely and effectively support the clinical services provided.
• All staff are educated about the facility, how to reduce risks, and how to monitor and report situations that pose risk. • Performance criteria are used to monitor important systems and identify needed improvements.

Planning should consider the following seven areas, when appropriate to the facility and activities of the organization:
• Safety – buildings, grounds, equipment, and systems do not pose hazards to the occupants • Security – property and occupants are protected from harm and loss. • Management of Hazardous Materials – handling, storage, and use of radioactive and other materials are controlled and hazardous waste is safely disposed of. • Emergency Preparedness Plan – response to epidemics, disasters and emergencies is planned and effective. • Fire Safety – property and occupants are protected from fire and smoke and conduct fire drills
• Preventive Maintenance of Medical Equipment – equipment is selected, maintained and used in a manner to reduce risks.
• Management of Utility Systems – electrical, water, and other utility systems are maintained to minimize the risks of operating failures.

Standards in Facility Management and Safety • The organization complies with relevant laws, regulations, and facility inspection requirements. • Ensures qualified individuals oversee the planning and implementation of the program to provide a safe and effective physical facility. • Plans, budgets, and implements a program to manage the physical environment. o Plans include upgrading or replacing key systems, buildings or components o Plan to reduce evident risks and provide a safe physical facility for patients, relatives, and staff. • Plans and implements a program to ensure that all occupants are safe from fire, smoke, or other emergencies in the facility. o Plan includes prevention, early detection, suppression, abatement, and safe exit from the facility in response to fires and non-fire emergencies. o Inspects patient care buildings for fire safety. o Regular testing of its fire and smoke safety plan, including any devices related to early detection and suppression, and documents the results. o Develops and implements a no smoking policy of staff and patients

• Emergency processes to protect facility occupants in the event of water or electrical system disruption, contamination, or failure are in place. o Emergency water and electrical systems are checked and tested on a regular basis and documents the results. • Develops a plan to respond to likely community emergencies, epidemics, emerging infectious diseases and natural or other disasters. o Plans in response to emergencies, epidemics, and disasters are tested and updated periodically. o Access to any medical supplies, communication equipment, and other materials to support its response to emergencies, epidemics, and disasters is taken into consideration. • Develops processes and plans for the inventory, handling, storage, and use of hazardous materials and the control and disposal of hazardous materials and waste. • Plans and implements a program for inspecting, testing, and maintaining medical equipment and documenting the results. o Monitoring data are collected for the medical equipment management program. These data are used to plan the organization’s long term needs for upgrading or replacing equipment. o Staff is trained to operate and maintain medical equipment and utility systems.
• Potable water and electrical power are available 24 hours a day, seven days a week, through regular or alternate sources, to meet essential patient care needs. o Electrical, water, waste, ventilation, medical gas, and other key systems are regularly inspected, maintained, and when appropriate, improved.
o Designated individuals or authorities monitor water quality regularly. • All staff members are educated and trained about their roles in providing a safe and effective patient care facility such as their roles in fire safety, security, hazardous materials, and emergencies. o The organization periodically tests staff knowledge through demonstration, drills, and other suitable methods. This testing is then documented.

Safe Work Environment Establish policies and procedures for routine and targeted cleaning of the environmental surface as indicated by the level of patient contact and degree of soiling. • Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient (side rails, over bed table) and frequently touched surfaces in the patient care environment such as door knobs, surfaces in the toilet in or more frequent schedule compared to that for other surfaces (horizontal surfaces in waiting rooms). • Review the efficiency of in-use disinfectants when evidence of continuing transmission of an infectious agent (rotavirus and difficile norovirus) may indicate resistance to the in-use product and change to a more effective disinfectant as indicated. • Include multi use electronic equipment in policies and procedures for preventing contamination and for cleaning and disinfectant, especially those items that are used by the patients, those used during delivery of patient care, and mobile deliveries that are moved in and out of patient rooms frequently. • Include the potential for transmission of infectious agents in patient placement decisions. Place patients who pose a risk for transmission to others (uncontained secretions or wound drainage;

infants with suspected viral respiratory or gastrointestinal infections) in a single patient room when available.

6.14.3 Access Blocks

Access block is the principal factor responsible for ED crowding and adversely impacts on all aspects of acute medical system performance. This includes increased patient harm and mortality, increased patient waiting times, increased patient hospital length of stay and increased ambulance turnaround time. It is recommended that a whole-of-hospital and whole-of-system approach should be implemented as follows: • Mandatory notification must be made to the hospital executive for any patient with an emergency department length of stay greater than 24-hours and if ED boarding rate reaches

30% of critical bed capacity • Increasing hospital and alternative care capacity, including: o Increases in physical inpatient bed capacity o Improving hospital efficiency through clinical process redesign o Implementing over-capacity protocols to share the patient load more equally throughout the hospital o Improving, and transparent, bed management practices o Extending inpatient services outside of normal business hours, for example, increasing the availability of radiology services over weekends o Increasing inpatient staff specialists and/or senior decision makers working after hours and on weekends to ensure inpatient beds are made available in a timely and clinically appropriate fashion through timely discharge or step downs.

6.14.4 Emergency Department Crowding

Emergency department crowding is a major global healthcare issue. The ED is the gateway to the hospital. The negative consequences of ED crowding are well established, including poorer patient outcomes and the inability of staff to adhere to guideline-recommended treatment. The majority of identified causes related to the number and type of people attending ED and timely discharge from ED, while reported solutions focused on efficient patient flow within the ED. Although the problem of overcrowding is most visible in the ED, it is strongly associated with boarding of admitted patients due to inadequate hospital capacity. This problem cannot be overcome by process improvements limited to the ED nor by diverting low acuity patients, since they do not address the underlying problem caused by boarding.

ED overcrowding has true costs and has real consequences, in both patient care and the cost of medicine. Overcrowding causes delays in care for all patients, including the critically ill. ED boarding has been demonstrated to increase total hospital length of stay (LOS) by at least one day, with the longest borders having increased LOS of 3 days.

Cures to ED Crowding To address the problem of ED overcrowding, we must address the problem of hospital capacity.

1. Crowd Management Policy in the ED a. ONLY ONE (1) RELATIVE OR COMPANION per patient is allowed and bags and other bulky things should be deposited in a baggage counter.

b. The patient’s medical/ health records shall be treated with utmost confidentiality and all efforts made to ensure its completeness. c. Firearms and other deadly weapons ARE NOT ALLOWED to be brought inside ED premises and MUST be deposited at the security compound for safe-keeping.
2. Smoothing elective admissions - While the variability of emergency medicine admissions is uncontrollable, there comes a level of expectant predictability based on time, season, and epidemiology, resulting in a smooth pattern of admissions without a great deal of variability from day to day. The remainder of hospital admissions which, historically, have been scheduled early in the week to suit the needs of specialty practices that tend to follow a more regular schedule of working hours.
3. Early Discharge - As the volume within the ED increases throughout the course of the day, the volume of patients being admitted to the hospital increases. Without the early discharge of inpatients, newly admitted ED patients become ED boarders. A focus on early discharge before noon has been demonstrated to improve the flow of the ED by decompressing the number of ED boarders prior to the time the ED is at its busiest. 4. Weekend Discharge - Further variability occurs during the weekends, when the number of discharges is almost 50% less than the number of weekday discharges. Increasing weekend discharges can increase inpatient hospital capacity, decrease ED boarding, and decrease overall hospital LOS. 5. Full Capacity Action Plan - When capacity is exhausted, hospitals should utilize a program to handle excess admitted patients and reduce ED boarding, such as the full capacity protocol (FCP). The FCP redistributes boarders to inpatient units; these patients are placed in available areas of the inpatient floor (hallways, conference rooms, solarium, and exam room) instead of the ED hallway. The sickest patients requiring higher levels of care continue to board in the ED until an ICU or step-down bed is available.

6.14.5 Prehospital Care and Ambulance Services

There should be an existing protocol on prehospital care services and ambulance services that will cover patient interfacility transfers at a minimum in all EDs/EU at any level of facility. For Level 3 and specialty hospitals, protocols for primary responder services and ambulance responder services should be in place and may include aeromedical transport. Appropriate activation and interfacility transfer forms should be utilized to ensure proper documentation and aid in audits for quality improvement. Minimum documentation should be as follows and will be part of patient clinical record:

1. Reason for activation/transfer 
   

2. Departure time 
   

3. Arrival time 
   

4. Departure time from destination/health facility 
   

5. Arrival to ED 
   

For prehospital services, the EMS team should ensure information, assessment and outcome of care provided as well as request medical direction in emergency encounters.

6.14.6 Disaster Response

Disaster response for mass casualty incidents should be differentiated from disasters due to biologic/EIDs. A disaster from a pandemic is different from a Mass Casualty Incident (MCI) where an

event results in a number of casualties vastly exceeding local resources and capabilities in a short period of time. Nevertheless, planning for disaster response should include the following phases in Table 33. Table 33. Stages in Disaster/Crisis Care

6.15 Special Populations in the Emergency Department

6.15.1 Psychiatric Patients

In recent years, more patients are seeking care for psychiatric conditions in EDs. The duration of time spent in the ED is especially long for patients who require transfer to a different facility or who carry a diagnosis of significant mental illness. This patient may present in the ED as agitated. The etiology of agitation is broad and includes systemic medical, as well as psychiatric, causes. The calm patient may be able to participate better in care, while the sedated patient may awaken agitated, creating a cycle of sedation and agitation. Over-sedation is associated with prolonged ED visits and potentially compromises care. Verbal de-escalation, on the other hand, as well as targeted medications may be considered. Physical restraints should be used only as a last resort, with use limited to the least amount of time necessary. Restraints and seclusions can be quite traumatic for patients, and these interventions raise the risk for medical complications. Emergency Department guidelines on managing patients with psychiatric conditions must be in alignment with the provisions of Republic Act No. 11036 Mental Health Act.

6.15.2 Combative Patients

It is often difficult to predict which patients will become violent. The atmosphere in the Emergency Department is chaotic. Patients and families are under severe stress. Crowding and the boarding of inpatients, particularly those with mental health emergencies, aggravate the situation. Cues to escalating behavior include yelling or cursing and aggressive verbal and physical behavior. Pacing, avoiding eye contact, and being destructive to their space suggest escalating behavior. Sedation may be necessary. Commonly used drugs include benzodiazepines, haloperidol/droperidol, and ketamine. Chemical restraints are preferable to physical restraints.

6.16 Ethics in the Emergency Department

The ethical framework is underpinned by the fundamental premise that every person matters. In the same way that every person deserves respect and that the team never abandons a patient no matter how futile treatment may become. Emergency clinicians apply well-known and ethically rigorous principles to guide decision making. Autonomy The ability to choose but not in detriment to others. For example; patients may still choose to reject treatment and alternatively patients cannot demand treatment that does not have any capacity to benefit or that limits treatments of others. Beneficence The obligation to provide care that is for the good of the patient and others including staff. This includes being truthful to patients and communicating with relevant stakeholders, where feasible. Non-maleficence Where options of care offered must avoid harm. Examples include: futile treatment and exposing staff to risk without availability of personal protective equipment. Justice Allocating medical resources fairly, according to medical need and each patient’s capacity to benefit. This allocation should not be influenced by the race, culture, wealth or address of the person being treated. And lastly, that emergency clinicians supplement the above principles with use of an objective, evidence-based threshold test to guide decision making in times of resource scarcity.

References

Abuzeyad, F. H., Farooq, M., Alam, S. F., Ibrahim, M. I., Bashmi, L., Aljawder, S. S., Ellouze, N., Almusalam, A., Hsu, S., & Das, P. (2021). Discharge against medical advice from the emergency department in a university hospital. BMC Emergency Medicine. https://doi.org/10.1186/s12873-021-00422-6

American College of Emergency Physicians. (2016, January). Policy Statement: Appropriate Interfacility Patient Transfer. https://www.acep.org/globalassets/new-pdfs/policy-statements/appropriate-interfacility-patient- transfer.pdf Australian Government: Department of Health and Ageing. (2009). Emergency Triage Education Kit. Commonwealth of Australia. Forero, R., McCarthy, S., & Hillman, K. (2011, March 22). Access block and emergency department overcrowding. Critical Care, 15(2), 216. 10.1186/cc9998 Innes, K., Jackson, D., Plummer, V., & Elliot, D. (2015). Care of patients in emergency department waiting rooms

• an integrative review. Journal of Advanced Nursing. https://doi.org/10.1111/jan.12719 Institute for Healthcare Improvement. (n.d.). SBAR Tool: Situation-Background-Assessment-Recommendation. Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Tools/SBARToolkit.aspx Royal College of Emergency Medicine. (2020). The Patient Who Absconds:. The Royal College of Emergency Medicine: Best Practice Guideline. http://allcatsrgrey.org.uk/wp/download/health_services/urgent_and_emergency_care_services/RCEM- Absconding-Guidance-v2.pdf Strauss, R. W., & Mayer, T. A. (Eds.). (2014). Strauss and Mayer's Emergency Department Management. McGraw-Hill. Wang, L., Zhou, H., & Zhu, J. (2011). Application of emergency severity index in pediatric emergency department. World Journal of Emergency Medicine, 2(4), 279-282. 10.5847/wjem.j.1920- 8642.2011.04.006 Warren, J., Fromm, R. E., Orr, R. A., Rotello, L. C., Horst, H. M., & American College of Critical Care Medicine. (2004). Guidelines for the inter- and intrahospital transport of critically ill patients. Critical Care Medicine, 32(1), 256-62. 10.1097/01.CCM.0000104917.39204.0A WHO Collaborating Centre for Patient Safety Solutions. (2007, May). Communication During Patient Hand-Overs. Patient Safety Solutions, 1. https://cdn.who.int/media/docs/default-source/integrated-health-services- (ihs)/psf/patient-safety-solutions/ps-solution3-communication-during-patient- handovers.pdf?sfvrsn=7a54c664_4&ua=1

7. GUIDE ON SPECIAL SITUATIONS

7.1 Special Situations in the Emergency Department

The Emergency Department faces significant challenges in the delivery of high quality and timely care on the patient when he/she arrives. An emergency condition is one that can either permanently impair or endanger a patient's life. If not treated right away, the condition could cause death or serious harm. This chapter provides guidance on special situations in the ED such as women and children victims of violence, mass casualty incidents, surge capacity, and medical examination of apprehended persons. Nowadays, the ED is manned by highly educated and trained physicians, who can handle all forms of emergency situations, and can provide the best possible care. A patient's first stop in the ED would be the triage area where the condition is prioritized based on a category that either requires immediate care or less urgent care. The patient is then registered after assessment of vital signs and history-taking, and directed to the services for appropriate management and care.

7.2 Women and Children Protection Unit

Women and children are more particularly susceptible to all forms of violence because they have fewer rights and they may lack appropriate means of protection which makes them vulnerable to threats and violence. World Health Organization studies the growing global magnitude of violence against women and children resulting to high burden on global health.
The Philippines has its share of increasing cases of violence against women and children (VAWC). In 1997, the Department of Health responded to this serious public health issue with Administrative Order 1-B mandating DOH hospitals to establish the Women and Children Protection Unit (WCPU) that will cater to cases of VAWC like rape, incest, and other related cases. In addition, the Philippine government initiative to further protect victims and survivors of VAWC, several laws were passed to protect their rights and give access to immediate health care services as stipulated in the Republic Act No. 9262 of 2004, Magna Carta of Women of 2009, RA 7210, RA 8252, Anti-Sexual Harassment Law and other related laws. Since the creation of Administrative Order 1-B in 1997, only few Women and Children Protection Units were established therefore utmost care of VAWC patients was not delivered appropriately. Hence on 2013, in response to WHO and Philippine government initiatives to strengthen health care services for VAWC, the DOH issued Administrative Order 2013-0011 The Revised Policy on the Establishment of WCPU in All Hospitals) with the objective to institutionalize and standardize the quality of health care service delivery in all WCPUs. The AO 2013-0011 defined that The Women and Children Protection Unit is a multidisciplinary, multi- specialized, easily accessible and readily available unit that will cater to the holistic and appropriate

health care needs of victims and survivors of VAWC. It will address the biomedical, psychosocial and legal concerns of the patient in a gender sensitive environment specifically within the Emergency Room. It will be manned by trained doctors, nurses, social workers, mental health professionals and other personnel germane to the utmost delivery of health care to its patients.

7.2.1 Legal Basis on the Establishment of WCPU

International, the Philippines as a member of the United Nations: • Declaration on the Elimination of Discrimination Against Women (DEDAW), the Human Rights proclamation of the United Nations General Assembly outlining women’s rights. Adopted by the General Assembly in 1967, the precursor of CEDAW. • Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) adopted by the United Nations on 1979 and took effect on September 1981. Is an internal legal instrument that requires member countries to eliminate discrimination against women in all areas and promote women’s equal rights.

Table 34. Key Philippine Policies related to WCPU Policy Summary Republic Act No. 9262 Anti-Violence Against Women and Their Children Act of 2004 • Refers to an act committed by any person against a woman who is his wife/ a former wife. • A woman with whom the person has or had a sexual or dating relationship. • With whom he has a common child • Against the woman’s child whether legitimate or illegitimate. • Healthcare Provider Duties stipulated in Section 31. • The primary legal basis of violence against women and their children commonly and previously known as domestic violence. Administrative Order No. 1 – B of 1997
Establishment of a Women and Children Protection Unit in All Department of Health (DOH) Hospitals • Mandate to answer the MEDICAL and PSYCHOLOGICAL needs of victims of VAWC. • Goal is to provide a holistic, gender sensitive health care to women and children who are victims of violence. Republic Act No. 9710
Magna Carta of Women • Ensures women’s protection from all forms of violence as provided for in other existing laws • Addresses the particular needs of women from a gender perspective to ensure their full protection from sexual exploitation and other sexual and gender-based violence committed against them. Republic Act No. 7610
Anti-Child Abuse Law • An Act Providing for Stronger Deterrence • Special Protection Against Child Abuse • Exploitation and Discrimination, and for Other Purposes • As stipulated under Section 12 of the IRR, pertaining to Physical Examination, the child shall be referred to a government medical or health officer for physical / mental examination and / or medical treatment.

Republic Act No. 8353 Anti-Rape Law of 1997 • Man has a carnal knowledge of woman under the following circumstances: o Through forced, threat, or intimidation o When offended party is deprived of reasons or is unconscious o When offended party is under 12 years or demented.
o By means of fraudulent machination/grave abuse to authority Republic Act No. 77877 Anti-Sexual Harassment Act of 1995 • Address to the issues of sexual harassment committed at the work place and education and training environment • Any person who is in authority, influence or moral ascendancy over another. Republic Act No. 6955 Anti-Mail Order Bride Act of 1990 • An act to declare unlawful the practice of matching FILIPINO WOMEN for marriage to foreign national on a mail order basis
• And other similar practices, including the advertisement, publication and printing, or distribution of brochures fliers and other propaganda materials
Republic Act No. 9208
Anti-Trafficking in Persons Act of 2003 • Amended by the RA100364, Established the necessary institutional mechanism to protect and support trafficked persons and provide penalties for its violation. Republic Act No. 9344 Juvenile Justice Welfare Act of 2006 • An act establishing a comprehensive juvenile justice and welfare system Republic Act No. 9995 Anti-Photo and Video Voyeurism Act of 2009 • An act defining and penalizing the crime of photo and video voyeurism, prescribing penalties thereof, and other purposes Republic Act No. 9775
Anti-Child Pornography Act of 2009

• An act defining the crime of child pornography, prescribing penalties
Republic Act No. 7658 Anti-Child Labor Law • An act prohibiting the employment of a child below 15 years of aged in public and private undertakings Republic Act No. 11313 Safe Space Act of 2019 • An act defining gender base sexual harassment in the streets, public spaces, online, workplaces, educational or training institution. • Providing protective measures and prescribing penalties therefor. Republic Act No. 10627
Anti-Bullying Act of 2013 An act requiring all elementary and secondary schools to adopt the policies to prevent and address the acts of bullying in their institutions. • Any unwanted physical contact between the bully and the victim like punching, pushing, shoving, kicking, slapping, tickling, headlocks, inflicting school franks, teasing, fighting and the use of available objects as weapons.

• Any acts that causes damage to the victim’s psyche and/or emotional well-being; • Any slanderous statement or accusation that causes the victim undue emotional distress like directing foul language or profanity at the target, name – calling, tormenting and commenting negatively on the victim's looks, clothes and body. • Cyber-bullying or any bullying done through the use of technology or any electronic means. • Social bullying refers to any deliberate, repetitive, and aggressive social behavior intended to hurt or to belittle another individual or group.

7.2.2 Minimum Requirements

Based on the requirements of the law and AO No 2013-0011 for the biopsychosocial management and recovery of VAWC victim’s /survivors, all hospital based WCPUs must have the following minimum features:

1. The WCPU must be readily available and accessible 24 hours 7 days, located in the emergency room and has two doors as entrance and exit for the safety and security of clients. The Unit must be spacious enough to accommodate all services provided. To ensure privacy, a separate room for interview, medical examination, and crisis counseling shall be available. The reception area must have a culture- and gender- sensitive environment and have information materials on VAWC. The area must include a playroom for children with small chairs, a table, and toys. Filing cabinets must ensure security and confidentiality of files and records. It also must have its own comfort room with water from an improved source. Fixtures needed are an examination table, office desk and chairs, adequate light source and communication lines.
2. Non-traumatizing supplies and equipment for medical examination must always be readily available to include: colposcope, video camera for recording the forensic interview, Sexual Assault Examination Kit (SAEK), speculum of different sizes, pregnancy testing kits, basic medicines like analgesics and medicines for STI prophylaxis, WCPU forms.
3. The WCPU must have trained and competent service providers to include obstetrician- gynecologist, pediatrician, psychiatrist, mental health practitioners, nurse, social worker and other personnel relevant to services provided.

In cases when WCPU cannot be established in the hospital, at least a trained WCPU coordinator must be present to link the patient to the nearest available WCPU.

7.2.3 Definition of Terms related to WCPU

Physical Abuse Acts that include bodily or physical harm Sexual Abuse An act which is sexual in nature and committed against a woman or child Psychological / Emotional Abuse Acts or omissions causing mental or emotional suffering to a child or a woman

Financial / Economic Abuse Acts that make a woman financially dependent. Neglect Failure to give basic needs to a child causing harm, illness, or even death. Child Refers to a person below 18 years old (17 years and 364 days) or those over but are unable to fully take care of themselves from abuse, neglect, cruelty, exploitation, or discrimination because of a physical or mental disability or condition, includes biological children of the victim and others under her care (Republic Act No. 9262) Child Abuse Refers to the maltreatment whether habitual or not, of the child which include the following: a. Psychological or physical abuse, neglect, cruelty, sexual abuse and emotional maltreatment; b. Any act by deeds or words which debases, degrades or demeans the intrinsic worth and dignity of a child as a human being. c. Unreasonable deprivation of his/her basic needs for survival such as food and shelter; or d. Failure to immediately give medical treatment to an injured child resulting in a serious impairment of his growth and development of his permanent incapacity or death.

Dating Relationship Refers to the situation wherein the parties live as husband and wife without the benefit of marriage or are romantically involved over a time and on continuing basis during the relationship. A casual acquaintance or ordinary socialization between two (2) individuals in a business or social context is not a dating relationship. Sexual Relations Refers to single sexual acts which may or may not result in the bearing of a common child. Bullying Refers to any severe or repeated use by one or more students of written, verbal, or electronics expression, or a physical act or gesture, or any combination thereof, directed at another student that has the effect of actually causing or placing the latter in reasonable fear of physical or emotional harm or damage to his property; creating a hostile environment at school for the other students. infringing the rights of the other students at school, or materially and substantially disrupting the education process or the orderly operation of the school; such as, but not limited to the following: a. Any unwanted physical contact between the bully and the victim like punching, pushing, shoving, kicking, slapping, tickling, headlocks, inflicting school franks, teasing, fighting and the use of available objects as weapons. b. Any acts that causes damage to the victim’s psyche and/or emotional well-being; c. Any slanderous statement or accusation that causes the victim undue emotional distress like directing foul language or profanity at the target, name – calling, tormenting and commenting negatively on the victim's looks, clothes and body. Cyber Bullying Any bullying done through the use of technology or any electronic means.

Social Bullying Refers to any deliberate, repetitive, and aggressive social behavior intended to hurt or to belittle another individual or group. Gender Based Bullying Refers to any act that humiliates or excludes a person on the basis of perceived or actual sexual orientation and gender identity. Violence Against Women and their Children Any acts or series of acts committed by any persons against women and their children

7.2.4 Guidelines and Protocols

Principles and Policies The units shall contribute to the realization of the Department of Health’s goal of eliminating all forms of violence against women and children, as well as promoting social justice based on the following: A. Identification and treatment of violence against women and children are anchored on respect for and recognition of the rights of women and children as mandated by the Philippines Constitution, the Convention on the Elimination of all Forms of Discrimination Against Women, the Convention on the Rights of the Child and the Beijing Platform of Action. B. All actions concerning victims of abuse, neglect and maltreatment shall be taken in full account of the children’s best interests. All decisions regarding children shall be based upon the needs of individual children, taking into account their development and evolving capacities so that their welfare is of paramount importance. This necessitates careful consideration of the children’s physical, emotional/psychological developmental, mental and spiritual needs. Adequate care shall be provided by the Multidisciplinary Child Protection Teams when the parents and/or guardian fail to do so. In cases whether there is doubt or conflict, the principle of the best interest of the child shall prevail. C. Care should be focused on the whole person addressing the biomedical, psychosocial and legal concerns. D. Holistics and appropriate health care delivered shall be coupled with respect for diverse needs of patients. E. Regardless of cultural, religious, developmental (including special needs), gender and sexual orientation and socio-economic diversity, all women and children victims of violence shall have a right to receive medical treatment, care and psycho-social interventions. General Guidelines A. Recognition, reporting and care management of cases involving violence against women and children shall be through medical and psychosocial teamwork including the mental health interventions and local government unit response and cooperation, when necessary. B. The WCPU shall ensure to have competent and trained gender-responsive professionals who will coordinate the services needed by the women and children who were victims of violence. C. The quality of health care services shall be standardized and maintained by the Women and Children Protection Unit. D. A registry report shall be submitted daily to the Violence Against Women and Children Registry System of the Department of Health. E. Hospitals shall include in its annual proposed budget the funds needed to support the WCPU operations and services, such as technical assistance, monitoring and advocacy campaigns, and other related activities to its operations and services delivery.

7.2.5 Process Flow

From the Emergency Gate, the Security Guard will receive the patient and refer to the Triage Area for Triaging. 2. The ER Triage Doctor will conduct initial interview to get the patient’s primary information and on the circumstance of the illness/injury to determine if it is a case of Violence Against Women and Children/ Child Abuse. Vital signs will be taken and documented before encoding for ED blotter. Consent for medical management secured. 3. On instances where the injury is life threatening, the victim will be immediately managed by Surgery Resident-on-duty, once stabilized, the patient will be referred to Women and Children Protection Unit (WCPU) for co-management. 4. Once the patient has been determined to be a non-life threatening WCPU case, the patient will then be brought to the WCPU room by the Social Worker-on-duty (SWOD) for appropriate medical management ensuring patient safety and privacy. 5. At the WCPU room, the WCPU resident rotator shall secure the WCPU consent prior to WCPU management which includes forensic examination. In the absence of a relative or nearest kin, consent must be given by an authorized officer of DSWD or similar agency of a local government unit (city/barangay). 6. After the consent is obtained, the WCPU resident rotator, NOD and SWOD will now conduct the team interview and fill up required WCPU forms 7. All female sexual abuse or alleging sexual abuse cases, regardless of age will be seen by WCPU OB-GYN Resident Rotator, while male pediatric sexual abuse cases will be seen by WCPU Pediatric Resident Rotator and male adult sexual abuse case will be seen by the Surgery Resident on Duty. 8. Child patients as defined by RA 7610 and 9262 and/or alleging to have been physically, psychological abused and neglected shall be seen by the WCPU Pediatric Rotator. 9. All adult female patients as defined by RA 9262 and 8353 and/or alleging to have been abused shall be seen by OB WCPU Rotator. 10. All pertinent information, management and plans must be documented on prescribed WCPU forms by the first contact doctor ensuring accuracy and completeness prior to referral to other departments.
11. In case of medical procedure, the request slip should be signed by the SWOD before the NOD hands it to respective departments / sections. 12. Collection of specimens by laboratory personnel should be done in the WCPU room, employing standard precaution protocols and proper waste management procedures. In case of radiologic procedure, patients should be accompanied by a NOD or Nursing Attendant on Duty (NAOD) to designated radiologic area and should not be left without staff ensuring safety and privacy. 13. All supplies and medicines needed for the entire duration of management will be taken from the pharmacy by the NOD with request slip or prescription signed by the SWOD. Assistance from the SWOD and/or NAOD must be afforded when deemed needed. 14. The carbonized duplicate copy to be attached to the Official Medical Report, after appropriate referral and notification with their department consultants to ensure the accuracy and completeness. 15. Once medical management is processed and subsequently cleared for discharge by the WCPU rotator, the NOD will prepare necessary documents, get prescribed medicines from the

pharmacy with assistance from either SWOD and/or NAOD, check for the completeness of WCPU forms and ensure nursing management plan explained and appropriately executed. 16. Once medical management is completed, the SWOD will ensure that the patient is referred/reported to appropriate agencies such as the LSWD/DSWD, Law Enforcement Agencies and the Barangay.
17. After doctor’s orders carried out by the NOD, the SWOD with finality will check on the completeness of WCPU documents, ensure provided medicines, check utilization documents, issue a follow up and discharge clearance slip.
18. All expenses incurred by the victim, including but not limited to hospital bills, laboratory and/or medical imaging tests and medicines shall be free of charge and be charged to the GAD fund. 19. The security guard on duty will then ensure clearance from NOD, SWOD and encoder before consenting departure.
20. In case of admission, the patient will be admitted by the first contact doctor into their respective wards as co-management with WCPU. The NOD and SWOD must ensure that all WCPU forms are complete and accurate before transfer to the ward.

Special Considerations Patients who have serious or life-threatening injuries should be treated as an emergency case hence medical and / or surgical management should be prioritized over all other considerations.
In cases of non-life-threatening or less serious injuries where patients have to wait inside the WCPU room, the patient should not be left alone. There must be an ED personnel in the room for security and to offer comfort while the patient waits.
For further information on WCPU, please refer to the WCPU Manual as developed by Quirino Memorial Medical Center.

7.3 Mass Casualty Incident

A Mass Casualty Incident (MCI) is defined as any event resulting in a number of victims large enough to disrupt the normal course of emergency and health care services. This section aims to define specific terminologies related to MCIs, provide guidance in identifying MCIs, and offer strategies on how to manage them.

7.3.1 Definition of Terms

CBRNE Chemical, Biological, Radiological, Nuclear, and high yield Explosives Mass Casualty Incident A circumstance in which patient care resources are overextended but not overwhelmed Mass Casualty Event An event causing numbers of casualties large enough to disrupt the healthcare services of the affected community/region Mass Casualty Management
Handling of victims of a mass casualty incident, aimed at minimizing loss of lives and disabilities. There is a need to initiate fast, timely, coordinated, and adequate response to reduce morbidity, mortality, and disability among

the victims. The management of the incident spans from the disaster or impact site (pre-hospital care) to the transport of the last victim to the emergency room of the receiving hospital. It is directed at prompt and efficient bringing back of disrupted emergency and health care services to routine operation. The first five minutes' response will determine the response for the next five hours. Mass Casualty Management System
Refers to groups of units, organizations, sectors and agencies which work jointly through institutionalized procedures to minimize disabilities and loss of lives in a mass casualty event through the efficient use of all existing resources.
Incident Command System (ICS) An organizational structure that provides overall direction for management of the disaster response.
Hospital Incident Command System (HICS) A modification the ICS in hospitals (Hospitals typically adopt their own versions of this system)

Previously known as HEICS or Hospital Emergency Incident Command System MCI Triage Triage to be done by a separate triage officer specific for handling MCI patients
Multiple Vehicular Crash When more than one car, truck, or motorcycle or any other vehicles are involved in a collision. Shooting Incident Pertains to any weaponized projectile object causing injury. START Triage Stands for “Simple Triage and Rapid Treatment” which includes rapid assessment of patients into 4 categories with visible color-coded identifiers for rescuers. Surge Capacity Extra assets (personnel and equipment) that potentially can be used in mass-casualty even without consideration of the essential supporting assets (e.g. excess ventilators without adequate staff to actually care for patients) Surge Capability The extra assets (personnel and equipment) that can be deployed in a disaster (e.g. ventilators with adequate critical care staff to care for patients)

7.3.2 When to Declare MCI

The situation to call for a Mass Casualty Incident shall be dependent on the capacity and capability of the health facility. MCI may be declared when the specific facility reaches their critical level or when the number of casualties exceeds available resources.

7.3.3 Hospital Incident Command System

In situations of Mass Casualty Incidents, all sections of the hospital are involved, not only healthcare workers. Health facilities must prepare a Hospital Incident Command System applicable to their institution. All personnel involved, including housekeeping, security personnel, accounting, dietary services, etc, must be trained and aware of their particular roles in times of a Mass Casualty Incident. These protocols are put in place to support the ED to continue to provide safe, quality care to all patients in need.

Team Mobilization and Tasking Hospital personnel are assigned to specific teams in order to address the needs of the ED in times of a Mass Casualty Incident. Teams include the following but are not limited to: Decontamination, Triage, Treatment, Security, Trauma, or CBRNE.

Figure 7. Organizational Structure of Incident Command System Teams

7.4 Emerging and Re-Emerging Infectious Diseases (EREID)

Recently, the Philippines had many outbreaks of emerging infectious diseases, and it continues to be susceptible to the threat of re-emerging infections such as leptospirosis, dengue, meningococcemia, and tuberculosis, among others. There are several social determinants contributing to the emergence of novel infectious diseases and resurgence of controlled or eradicated infectious diseases in our country.

Therefore, as stated in Executive Order 168, s. 2014, the Department of Health was tasked to lead the National Task Force on Emerging Infectious Diseases. Subsequently, there is a need for the Emergency Department to come up with proactive systems that would ensure preparedness and response in anticipation to any surge of patients or any disruption of routine services.

Program strategies shall be implemented to address the different scenarios in attending to EREID. The organization or facility shall be working the development of policies, continuously updating the Hospital Disaster Risk Reduction Management Plan—also known as the Hospital Emergency Preparedness, Response, and Recovery Plan—to consider resources management and its mobilization, including the logistics aspect on non-human resources; capability and capacity building of human resources especially in the aspect of Infection Prevention and Control; gathering and managing information to enhance disease surveillance, and; improving risk communication.

In this regard, protocols related to Infection, Prevention, and Control may be found in Chapter 6. For a more thorough discussion on IPC principles, they may refer to the National Standards in Infection Prevention and Control for Health Facilities, 3rd Ed.

7.5 Surge Capacity

Surge capacity is defined as the ability of the health facility to expand its servicing capability when a patient surge or sudden increase in volume of ED patients occur whether due to a Mass Casualty Incident or infectious disease outbreak. This section aims to provide principles necessary in preparing plans for such events, for activation in the Emergency Department.

7.5.1 Core Principles for Surge Capacity Planning (Adapted from Department of Health - Health

Emergency Management Staff (DOH-HEMS), 2014) 4C’s Command Command refers to the Incident Command System which includes the organizational structure to be followed in times of patient surge, clearly defined roles and responsibilities, which uses a common nomenclature across emergency responders for improved cooperation and understanding between teams across health facilities. The ICS has the authority to direct the team in the operations. Control Control refers to the goals that the team wants to achieve when a surge occurs. This goes hand in hand with Command where the Command principle directs the team towards the intended goals.
Communication Involves communication with external partners such as, but not limited to the following: Emergency Management Services (EMS), Public Safety/Law enforcement, Healthcare Systems, etc. In communicating with external partners, consider nearby agencies and how they can support the facility experiencing the surge depending on the type of situation and where it happened. Coordination Coordination is essential as disasters or similar situations require the support of more than one health facility/institution. Coordination between institutions

allow patients to be transferred where they can be accommodated allowing a more seamless flow of receiving patients, without leaving any one institution seemingly isolated in their response.
4S’s Space In this principle, space must be allocated to prioritize patients in the ED. Strategies that may be implemented under this principle, include but are not limited to the following: • Elective and other outpatient appointments may be cancelled to accommodate incoming patients from the ED. Criteria for cancellation must be agreed upon by concerned services in the planning stage. • There must be an allocated discharge holding area as there is limited time to proceed with the discharge process o Patients for discharge may be placed in this holding area while awaiting actual discharge • Identify areas that may be converted into patient care areas e.g. lobby for triage, gym or conference rooms for cots, procedure center for trauma care/isolation area • Convert step-down beds to “ICU” beds by allowing more stable ICU patients to be on vents or medication drips in these areas • Procedure rooms and OR space can serve as temporary ICU areas Staff Generally, staff should be aware of their expected roles during a surge. In this principle, the following are taken into consideration: • Ensure staff know their roles and that they are reachable • Consider work clinical staff do that can be done by others. Free up clinical staff for patient assessment • Support staff are vital in these operations. Response to these situations must include staff to support the clinical staff.
• Transition from individual nursing to team nursing. Roles may change. • Non-healthcare providers or family members to do personal care or feeding of patients, as appropriate. Ensure non-healthcare providers are oriented, mentored, and supervised. Stuff There are four categories of supplies that must be considered: • Provider Protection o Refers to personal protective equipment such as masks, lab gowns, gloves, goggles/face shields o May refer to antidotes or antivirals • General Patient Care Supplies o Airway - disposable intubation blades, bags/masks o Surgical - chest tube trayes o Medications - Morphine, Valium, Atropine o Other disposables - catheters, dressings, linens o Durable - beds, vents, IV pumps, BP cuffs • Specialty Care Supplies (e.g. for burn patients) o Adaptic dressings o Silver sulfadiazine o Kerlix dressings o 50% BSA burn needs 14 liters LR/NS in 1st 24H, MS 250mg/24h • Support Supplies o Food, Water o Oxygen Supply o Office Supplies

o Utilities o Communications Special Ensure that special conditions have specified areas for them such as the following: • Burn • Chemical/Decontamination • Isolation • Pediatric • Blast Injury / Mass Trauma

7.5.2 Protocol for Surge Capacity

1. Gather basic information (Security Personnel from First Responders) a. MOI, POI, DOI, TOI b. Number of expected casualties, age, sex c. If available, gather duplicate copy of First Responder referral form
2. Activate Surge Capacity Plan a. Ensure that all ED has a Surge Capacity Plan in place i. Disaster Risk Reduction Management-Health Plan/Hospital Emergency Preparedness, Response and Recovery Plan in place
   ii. Use principles of 4Cs, 3Ts, and 4S in conducting the surge capacity plan b. Activation of Code Alert System (includes public address system)
3. Activate MCI Triage a. Use START Triage System (Figure 8) b. Simultaneous assessment of patients into the following characteristics: i. Emergent, Urgent, Non-urgent ii. Infectious vs Non-infectious iii. Medical vs Surgical
4. For Chemical, Biological (Communicable Disease), Radiological, Nuclear, Explosive (CBRNE) a. Set up of decontamination and disinfection system b. Donning and doffing (gearing up)

Figure 8. START Triage (Taken from Bhalla et al., 2015) Safety and Security during Surge

1. Regulate the entry and exit (ingress and egress protocol) of the un-authorized personnel
2. Augmentation of Security workforce
3. Designate waiting area for family and relatives according to Minimum Public Health Standards
4. Disarm any individual entering the ED

External Traffic Flow This requires the security personnel to direct the flow of responding ambulance teams. The aim is to maintain and secure a separate entrance and exit for these teams to have ample flow in the ambulance bay area of the Emergency Department and maintain access to the Emergency Department. A separate route should be provided for pedestrians away from ambulance routes.

Internal Traffic Flow Patients and responders must be able to navigate the areas within the Emergency Department. This can be prepared for through the inclusion of well-placed and easy to understand signs inside the facility. Likewise, security personnel must be able to maintain and secure separate entrance and exit doors. Patients and responders must be assisted and guided to appropriate areas to allow ample flow through the Emergency Department.

Crowd Control In cases of surge, security personnel shall control the flow of persons through the Emergency Department and ensure that only authorized personnel are allowed inside the cordoned area. Specific areas shall be designated for onlookers and crowds, away from the cordoned off area.

7.6 Medical Examinations of Apprehended Persons in the Emergency Department

During counter insurgency operations, a government doctor may be called upon to medically examine and render a physical fitness certificate before and after interrogation or handing over of an apprehended person to the police or on release. Medical examination prior to prison commitment of arrested persons must be detailed, taking more focus on external injuries.

7.7 Management of Aggressive/Combative Patients

Triage is the first point of public contact with the Emergency Department where patients with the whole spectrum of acute illness, injury, mental health problems and challenging behavior may present. Aggressive people presenting to the Emergency Department are usually patients or the relatives or friends of patients. Aggression is said to occur where a person is verbally or physically abused, threatened, assaulted or injured and can arise directly or indirectly as a consequence of the actions of another person. Aims • Maintain a safe work environment • Establish and maintain a positive client focus • Minimize the risk of escalation of aggression

7.7.1 Causes of Aggressive Behavior

If mentioned factors are present it may provoke or magnify aggressive behavior and create a risk of harm for triage nurses and other reception staff. • Pain • Fear and stress • Influence of drugs and/ or alcohol • Mental instability • History of Aggression • Irritation and frustration • A sense of loss of control • Perceived prejudice

Relatives/ friends can become quite anxious and upset when they see ‘their’ patient in pain or not being attended to by medical staff frequently enough. Usually this anger is expressed verbally.

7.7.2 Managing Immediate Threat

While some acutely-disturbed patients may require an immediate clinical intervention, other individuals who enter an emergency department and pose an immediate threat to staff (for example, brandishing a dangerous weapon, verbal assaults, etc.) should not receive a clinical response until the safety of staff can be secured. Where the safety of staff and/ or other patients is under threat, the staff and (other ED) patient safety should take priority over clinical assessment and treatment. The staff should obtain immediate intervention from security staff and/ or any concerned person so as to protect themselves. Once the situation is established, a clinical response can take place as (and if) required, and triage should then reflect clinical and situational urgency.

7.7.3 Verbal Strategies

• While not effective with all patients, verbal diffusion can be as effective as pharmacologic restraint. Encourage patients and relatives that due care would be rendered. • Offer food and drink to encourage cooperation of the agitated patient if not contraindicated with the presenting clinical symptoms. • Enforce limits and explain the consequences of the person’s unacceptable behavior.

7.7.4 Pharmacological Restraint

• More humane than physical restraint and most effective for severe aggression. • No one medication is appropriate for every situation. • Regular monitoring of patients will be required following sedation to detect adverse side effects.

7.7.5 Physical Restraint

Principles • Physical restraint and emergency sedation should only be used when other reasonable methods of calming the patient down are unsuccessful. If a patient who is acting out does not need acute medical or psychiatric care, he/ she should be discharged from the hospital rather than restrained. • When restraint is required a coordinated team approach is essential, with roles clearly defined and swift action taken. • Unless contraindicated, sedation upon physician’s order should usually accompany physical restraint. Indications Aggressive and combative behavior in a patient who requires urgent medical or psychiatric care, which is: • Compromising the provision of urgent medical treatment (physical or psychiatric); • Placing the patient at risk of self-harm; or • Placing staff at risk
Contra-indications to physical restraint and emergency sedation • Safe containment possible via alternative means. • Inadequate personnel, setting and equipment. • Situations judged as too dangerous e.g. patient has a weapon. • Known adverse reaction to drugs usually used (e.g. neuroleptic malignant syndrome) Key points
If the staff thinks they will not be able to safely restrain the patient or manage the threat, then the security staff should be called.

PROCEDURE ADDITIONAL INFORMATION Explain the procedure to the parents/ relatives, if possible

Establish roles, including defining person in charge This is usually the attending doctor

Assemble all available staff. Assign roles before approaching the patient.

Draw up drugs upon physician’s order Drugs will vary between patients. Secure the patient quickly and calmly.

Hold the patient supine, with hands and feet restrained to the stretcher with consent of the relative.

Once sedated, monitor O2 saturation continuously. Consider the need to transfer the patient to a specialty facility.

Observe conscious state, respirations, pulse, BP, and temperature as determined by the condition of the patient.

Patients who have been sedated may not be transferred into police custody.

If sedation other than their normal medication has been administered, a staff must accompany the patient being transferred to another health care facility. Complication of emergency sedation include: • Anaphylactic reactions • Respiratory depression • Cardiovascular symptoms such as hypotension, tachycardia. Extra pyramidal reactions (dystonia) may occur with major tranquilizers, particularly when medication wears off. These are treated with repeated small doses of diazepam. Follow up Following restraints, the patient must have a complete medical and mental health assessment by the physician to guide subsequent management.

In cases patients referred to Acute Psychiatric unit at OPD Consider the need for on-going physical restraint

Consider the need for on-going sedation.

Document fully in the patient’s unit record: The indication for chemical and physical restraint The patient’s responses to sedation On-going observations Plan for future management

7.7.6 Assessment Process

Alert security staff or any concerned as required to provide assistance during assessment. • It should be decided whether those who accompany the patient have an establishing or destabilizing influence. People who appear to provoke the patient should be requested by the security staff to leave the premises. • Staff who sense feelings of danger, however vague, should discontinue the assessment and seek assistance. So-called ‘gut feelings’ should not be ignored. • If a ‘dangerous’ person leaves the Emergency Department alert security staff or any concerned person immediately. Do not attempt to chase the person.

PROCEDURE ADDITIONAL INFORMATION Do not assess people in confined or isolated areas. Ensure that there is easy access to the door. Lessens the client’s feeling of being trapped and to create any easy escape route if necessary Consider • Whether the person’s anger is manageable or out of control • The need for another person to be present (e.g. nurse, security officer, etc.) • Any previous history of violence

One other person should be sufficient so as not to create an atmosphere of “them” and “us”. This may cause further anxiety. Establish the circumstances of presentation from: • Referring person/ letter • Other staff • Patient • Patient’s family/ friends

Patient’s old notes may provide additional information. Use a confident reassuring approach by staff without added stimuli.

Use a soft modulated tone of voice when speaking to the person It is difficult for angry people to maintain their anger when faced with calm, controlled people. Do not respond to verbal aggression with verbal aggression. If a person’s anger is specifically directed to you then hand over to another person Rarely will a person’s anger be directed at the staff member. It is more likely they are angry about a situation or event and you are targeted for ventilation and relief. If the person is rational, acknowledge their anger. • Be aware of your own body language • Minimize direct eye contact. • Attempt to relax the person by appearing calm. For instance, “you seem very angry about this… I’m wondering what’s causing this anger.” By engaging the client in thoughtful discussion, he/ she may mirror your sitting position and general demeanor.

7.7.7 Debriefing

The need to restrain an aggressive patient is fortunately a rare event, but can be extremely distressing, when the staff is involved. A formal debriefing session should be arranged, ideally chaired by an objective facilitator who was not involved in the restraint process.

References

American College of Surgeons. (2018). Advanced Trauma Life Support Student Course Manual (10th ed.). American College of Surgeons. Bhalla, M. C., Frey, J., Rider, C., Nord, M., & Hegerhorst, M. (2015). Simple Triage Algorithm and Rapid Treatment and Sort, Assess, Lifesaving, Interventions, Treatment, and Transportation mass casualty triage methods for sensitivity, specificity, and predictive values. The American Journal of Emergency Medicine, 33(11), 1687-1691. https://doi.org/10.1016/j.ajem.2015.08.021 Department of Health - Health Emergency Management Bureau & National Kidney and Transplant Institute. (2015). Hospital Emergency Preparedness, Response, and Recovery Plan. Department of Health - Health Emergency Management Staff (DOH-HEMS). (2014). Mass Casualty Incident Training Manual. Ramos-Go, E. (2021). WCPU Manual. Quirino Memorial Medical Center. U.S. Department of Health & Human Services. (2021). START Adult Triage Algorithm. Chemical Hazards Emergency Medical Management. https://chemm.hhs.gov/startadult.htm

8. ANCILLARY SERVICES AND CLINICAL SUPPORT

Ancillary care refers to the wide range of healthcare services provided to support the work of a primary physician. These services can be classified into three categories: diagnostic, therapeutic, and custodial. Diagnostic services include laboratory tests, radiology, and diagnostic imaging. With the Department Order 2021-0001, which designates select DOH hospitals as specialty centers as part of the healthcare provider network, the Emergency Department becomes the access point for the delivery of these specialty services. The following are identified specialty care services for Brain and Spine Care, Burn Care, Cancer Care, Cardiovascular Care, Dermatology Care, Eye Care, Geriatric Care, Infectious Disease and Tropical Medicine, Lung Care, Mental Health, Neonatal Care, Orthopedic Care, Physical and Rehabilitation Medicine, Renal Care and Kidney Transplant, Toxicology, and Trauma Care. With the provision of specialty care required, clinical support to the ED is mandatory to provide timely care. The following clinical support and ancillary services required by ED across levels are recommended:
Table 35. Recommended Clinical Support and Ancillary Services Required by the Emergency Department Across Hospital Levels Level 1 Level 2 Level 3 Specialty Hospital Hospital Pharmacy Support All of Level 1 with the following: Satellite Pharmacy

Basic Diagnostic Imaging
(Radiology) Cranial CT scan Ultrasound
All of level 2 Emergency Point-of- Care testing for Diagnostic Imaging such as Portable Ultrasound and Portable Chest X-ray

All of L3, depending on specialty center: Diagnostic and Interventional Angiography
Interventional Radiology

Hospital Laboratory support with minimum:
Capillary Blood Glucose Fasting Blood Glucose CBC Platelet Blood typing and Crossmatching Urinalysis Fecalysis
Gram stain
For clinical laboratory additional: arterial blood gas and pH determination
renal function tests coagulation studies including PT, PTT and platelets level
gram stain, culture and sensitivity
serum and urine osmolality
serum electrolytes

Emergency diagnostic Point of Care testing for cardiac markers, blood chemistry, and blood gases.

Basic Toxicologic Screening Kits Cardiac/infectious disease related markers as follows but not limited to:
ProBNP, calcitonin, lactate

Clinical Laboratory includes a Blood Station, which is staffed 24 hours a day and performs Blood Typing and Crossmatching procedures.

Provision for Massive Transfusion Protocols

Clinical Laboratory with Blood Bank

8.1 Satellite Pharmacy

An ideal ED should have its own pharmacy for essential emergency drugs included in the Philippine National Drug Formulary (PNDF). This saves time in obtaining medications without delay especially during resuscitation attempts. This promotes convenience and ready access to emergency drugs without the necessity of leaving the ED premises.

8.2 Clinical Laboratory

The clinical laboratory can be a satellite laboratory or on site in the hospital, and is capable and responsible for performing all routine analyses of blood, urine, and other body fluids at all times for ED patients. Minimum analyses are enumerated in Table 35. The Clinical Laboratory should include a Blood Bank, which is staffed 24 hours a day and performs typing and crossmatching procedures. The Blood Bank maintains an adequate supply of blood and blood components for ED patients. Point of care testing should be made available in the ED for Level 3 and specialty hospitals.

8.3 Diagnostic Radiology

Diagnostic Radiology should be available 24 hours a day to perform routine studies using equipment, both fixed and portable, located on site in the ED. An attending physician or resident physician in

Radiology is available in the hospital 24 hours a day to interpret all radiographs in the ED. An attending physician in Radiology is available 24 hours a day for consultation. Point-of-care testing with the use of ED ultrasound / point of care ultrasonography (POCUS) should be made available in the ED for Level 3 and specialty hospitals for Emergency Medicine and General Surgery training hospitals. The Radiology Department provides other specialty capabilities 24 hours a day. These specialty services are available within approximately 30 minutes of the initial request. A resident physician, fellow and attending physician in Radiology are available 24 hours a day for consultation regarding these services. These include:
• Computerized Tomography Scan
• Diagnostic and Interventional Angiography
• Interventional Radiology • Ultrasonography

8.4 Clinical Support Units

8.4.1 Operating Room (OR)/Theater

1. The OR is staffed and available 24 hours a day for all surgical emergencies arising in the ED.
2. Resident physicians and an attending physician in Anesthesiology are in-house and available 24 hours a day.
3. A senior resident physician in Surgery, Pediatric Surgery and Orthopedics is in- house and available 24 hours a day.
4. Attending physicians in Surgery and all surgical subspecialties are available 24 hours a day for consultation within approximately 30 minutes.
5. Depending on the level of hospital, the OR has the capability of the following services for any ED patient:
   a. Cardiopulmonary bypass pump oxygenator
   b. Craniotomy equipment c. Endoscopes for upper endoscopy, colonoscopy and bronchoscopy d. Fracture table
   e. Pacemaker insertion capability
   f. Temperature control equipment for blood
   g. Temperature control equipment for patient

8.4.2 ED Access to Special Care Units

The ED has access to the following Special Care Units of the hospital:
• Burn unit (BU)
• Cardiovascular Intensive Care Unit (CVICU)
• Coronary Care Unit (CCU)
• Labor and Delivery Suite (OB)
• Medical Intensive Care Unit (MICU)
• Newborn Intensive Care Unit (NICU)
• Pediatric Intensive Care Unit (PICU)
• Surgical Intensive Care Unit (SICU)
• Telemetry Unit (TU)

For cases wherein, special care units are needed by the patient but not available, they are to be referred to facilities able to provide access to these units.

8.4.3 Poison Control Unit/Poison Information Unit

The ED should have access either direct or through telemedicine to a Poison Control Unit or Poison Information services as designated by the Department of Health or to other academic poison control centers (e.g. UP PGH National Poison Management and Control Center). This will ensure support for management of poisoning cases, reporting and toxico- and pharmacosurveillance of cases and surveillance for possible chemical incidents or mass casualties related to poisoning.

8.4.4 Custodial Services

Medical Social Services The Medical Social Service Unit is an integral part of the Emergency Department. It subsumes the following functions and roles (but not limited to): • Provides assistance to patients based on a patient classification and capability assessment tool. • Facilitates tracking of relatives of patients, as situation dictates • Coordinates with the Women and Child Protection Unit (WCPU), the Department of Social Welfare Development (DSWD) and the local police regarding cases of violence against women and child abuse.

References

Department of Health. (2012, July 18). Administrative Order No. 2012-0012: Rules and Regulations Governing the New Classification of Hospitals and Other Health Facilities in the Philippines. Department of Health. (2021, January 4). Department Order No. 2021-0001 [Designation of Selected DOH Hospitals as Specialty Centers for Brain and Spine Care, Burn Care, Cancer Care, Cardiovascular Care, Dermatology Care, Eye Care, Geriatric Care, Infectious Disease and Tropical Medicine, Lung Care, Mental Health, Neonatal Care, Orthopedic Care, Physical Rehabilitation Medicine, Renal Care and Kidney Transplant, Toxicology, and Trauma Care].

9. MEDICO-LEGAL CASES IN THE EMERGENCY DEPARTMENT

9.1 Medico-Legal Cases Defined

A medico-legal case (MLC) is any case of injury or ailment where the physician, after history taking and clinical examination, considers that investigation by lawful authorities is warranted to ascertain justice and fix responsibility regarding the said injury or ailment according to the law. It is a medical case with legal implications or a legal case requiring medical expertise. Accordingly, a medico-legal report is one which is prepared for the purpose of any imminent or prospective litigation. The responsibility to label any case as an MLC rests solely with the attending physician.

The physician is mandated to report the following cases to the police as these are considered MCLs:

1. All forms of injuries- physical, thermal, chemical, and electrical, where the circumstances suggest commission of an offense by another person. Examples of which include but are not limited to: a. Vehicular accidents b. Unnatural accidents or disasters due to force majeure
   c. Industrial Accidents d. Mauling e. Fire arm or Gunshot injuries f. Assault and battery, including domestic violence, child abuse, and sexual assault/offenses g. Suspected self-inflicted injuries or attempted suicide
2. Cases of suspected or evident criminal abortion, poisoning or intoxication;
3. Cases referred from court, police, National Bureau of Investigation (NBI), or patients under police custody or otherwise for age estimation;
4. Cases of undiagnosed comatose/unconscious patients;
5. Cases brought dead with improper/ inconsistent medical history creating suspicion of an offense, which may include: a. Dead on Arrival - Patients brought to a health facility without cardio-pulmonary and brain functions, including patients who did not respond to initial resuscitation and patients with signs of Rigor Mortis, Livor Mortis but excluding cases of decapacitation

not susceptible for resuscitation and patients brought in an advanced state of decomposition.
b. Unnatural death
c. Death due to animal bite d. ED Deaths - refers to deaths of patients occurring in the ED, including patients who were revived by initial resuscitative measures at the ED but eventually died there, regardless of the time of stay in the ED.
e. Deaths within 24-hours of hospitalization without diagnosis 6. Any other case not falling under the categories stated but requires legal implications.

Reporting of injuries shall conform to the latest coding system of the International Classification of Diseases

9.2 Policies and Mandates relative to Medico-Legal Cases

Outlined below are the laws or legal mandates that provide guidance on Medico-Legal Cases.
Table 36. Summary of Key Policies related to Medico-Legal Cases Policy Summary Revised Penal Code Articles 263-266
Provides classification, description and penalties associated to injuries with medico-legal implication which includes:
• Slight Physical Injury • Less serious Physical Injury • Serious Physical Injury
Presidential Decree No. 169, April 4, 1973
Mandated the role of Physicians of any hospital, medical clinic, sanitarium or other medical establishments, or any medical practitioner, to report cases of serious or less serious physical injuries as those injuries are defined in Articles 262, 263, 264 and 265 of the Revised Penal Code.
Executive Order No. 212 of 1987 Amendment to the initial PD No. 169 which further defined the information needed for documenting Medico-Legal cases by the attending physician, and penalties for violation of the Act.
Republic Act No. 7610
Special Protection of Children Against Abuse, Exploitation and Discrimination Act and its Implementing Rules and Regulations
Mandates all attending physicians, and nurses the reporting of children who appear to have suffered abuse within the prescribed time from knowledge of the same with corresponding penalty for failure of reporting.
Republic Act Nos. 8353 and 8505
Anti-Rape Law of 1997
Mandates all Regional Hospital to dedicate a space for Rape Crisis Centers, developed and adopt uniform medical examination procedures including the accomplishment of forms/ report, such as the conduct of physical examination within 48 hours

Rape Victim Assistance and Protection Act of 1998

Ensure both the validity and confidentiality of the medical records required in cases of litigation.

Highlights the duties and responsibilities of examining physicians, taking into account gender sensitivity in its conduct. Republic Act No. 9262
Anti-Violence Against Women and Their Children Act of 2004 and its Implementing Rules and Regulations All records pertaining to cases of violence against women and their children including those in the barangay shall be confidential and all public officers and employees and public or private clinics to hospitals shall respect the right to privacy of the victim. Whoever publishes or causes to be published, in any format, the name, address, telephone number, school, business address, employer, or other identifying information of a victim or an immediate family member, without the latter's consent, shall be liable to the contempt power of the court. Administrative Order No. 2013-0011 Revised Policy on Establishment of Women and their Children Protection Units in All Government Hospitals Mandates the creation of a Women and Children Protection Units (WCPU) in all Government Hospitals.

Defines the levels of care delivered by a Level 1, 2, and Level 3 WCPU in terms of Personnel, Services, Training Capability and Research.
Republic Act No. 9745
Anti-Torture Act of 2009 and its Implementing Rules and Regulations Provides guidance on the detailed approach in the examination, documentation and certification of victims of torture as defined in the law.

9.3 Health Information Management for Medico-Legal Cases in the Emergency

Department

1. Medico-legal information shall generally be guided by the provisions in the latest Department of Health - Hospital Health Information Management Manual accessible through: http://bit.ly/DOHHFDBManuals.
2. More specifically in the ED, the following guidance is provided to ED Staff handling such information:
   a. All medico-legal information shall be treated with utmost confidentiality as provided by the Data Privacy Act.
   b. Documentation of medico-legal should be complete, accurate and legible. At the minimum, the following information should be provided in the record in accordance with Section 2 of Executive Order No. 212, series of 1987, amending Presidential Decree No. 169 on the reporting of the wounds by medical practitioners.
   i. The name, age, and address of the patient; ii. The name and address of the nearest of kin of the patient; iii. The name and address of the person who brought the patient for medical treatment; iv. The nature and probable cause of the patient’s injury;

v. The approximate time and date when the injury was sustained; vi. The place where the injury was sustained; vii. The time, date, and nature of the treatment; and viii. The diagnosis, the prognosis and/ or disposition of the patient.
c. All Medico-legal documentation shall be done in a timely manner as prescribed in Section 9.5.1.
3. Training and protocols should be cascaded to all ED staff with identified roles and responsibilities.

9.4 Consent for Examination

Consent shall be obtained from the patient or legal guardian for clinical assessment, medical procedures, procedures, and diagnostics to be done to the patient.

1. Informed consent should include the following information: a. The examination to be conducted would be a medico-legal one and would culminate in the preparation of a medico-legal injury or report b. All relevant investigations needed for the said purpose would be done c. The findings of the report may go against the patient if they do not tally with the history given.
2. Consent for medical examination may be deferred in cases where the medical examination is deemed necessary upon the Order of a competent court where the case is pending.

9.5 Medico-Legal Documentation and Reporting

9.5.1 Guidelines on Medico-Legal Documentation

All Medico-Legal cases should be managed and disposed of by the physician of the respective department concerned.

1. Complete medico-legal documentation shall comprise of the following: a. A Medico-Legal Report (See Annex C)
   b. Copy of the ED Treatment Record (See Annex D) c. Additional documentation as deemed necessary.
2. In cases of Dead on Arrival, a Post Mortem Examination Record shall be prepared in lieu of the ED Treatment Record.
3. In addition, the following logbooks shall be accomplished by the designated ED personnel: a. Medico-legal logbook
   b. Women and Children Protection Unit logbook (if appropriate)
4. All Medico-Legal documentation should be completed within 48 to 72 hours after the conduct of the examination and should be endorsed to the Hospital Health Information Management Department including collected evidence.
5. Cases treated as a Medico-Legal case shall be reported to the nearest Philippine National Police (PNP) Unit without delay. The physician in-charge may designate other hospital personnel (i.e., Guard-on-duty) to inform the aforementioned unit of the MLC.

9.5.2 Issuance of Medico-Legal Certificate and Access to Medico-Legal Records

Medico-Legal Certificates are legal documents to be presented in court, quasi-judicial bodies, investigation agencies, as documentary evidence to prove the truth of the physical injuries sustained by the victim. It must be executed by the hospital medico-legal officer/ consultant, immediately for police/ prosecutors investigation or inquest. The following guidelines are to be followed:

1. Issuance of Medico-Legal certificate and access to Medico-Legal Records should be coursed through the Hospital Health Information Management Department.
2. It shall follow the processes of requesting the certificate and access to records as provided in the latest HHIM Manual.

9.6 Medico-Legal Case Evidence Guidelines

9.6.1 Preservation of Medico-Legal Case Evidence

1. All relevant evidence shall be identified, sealed, and labeled properly.
2. In cases of physical injury, the following articles should be preserved in sealed envelopes: a. Clothing worn by the patient showing evidence of injury such as tears, bullet holes, cuts, blood stains, etc.
   b. Each piece of evidence will be encircled and numbered with matching description in the MLC report and case sheet c. Bullets recovered from a body should be identified by etching a mark on the bottom before preservation d. The chain of custody of the MLC evidence must be properly recorded
3. In cases of Burns and Carbon Monoxide poisoning, the following should be preserved in sealed containers: a. Articles soiled with inflammable substances like burnt pieces of clothing, scalp , hair, etc.
   b. Whole blood for carbon-monoxide levels
4. In cases of non-viable dismembered body parts, this shall be forwarded to the Surgical Pathology section of the laboratory for gross and microscopic examination and documentation. It shall follow the latest guidance on documenting dismembered body parts as reflected in the Medical Certification of Death, Handbook for Filipino Physicians, Guidelines and Procedures.
5. In cases of sexual offenses, the following articles should be preserved in a sealed container: a. Clothing worn by the patient and showing evidence of injury, blood and seminal fluid; b. Vaginal Swab preferably from posterior fornix/ anal swab.

9.6.2 Chain of Custody

The chain of custody is a systematic documentation of transfer of evidence collected from a patient to another person/ office. The ED staff/ personnel who removed physical evidence like bullets or shrapnel recovered from the patient, shall be responsible for documenting the detailed description of the object/s, its location where it was removed/ recovered, its position or direction, and the date and time when the physical evidence was recovered.
Sample documentation forms are provided in the Annex section that may be adopted for documenting the chain of custody, which will be used as proof of transfer and receipt of the physical evidence. The chain of custody shall also apply to the personal belongings/ effects of patients without companions. The hospital shall have a written policy on who shall be the custodian of such physical evidence and personal belongings or personal effects.

9.7 Medico-Legal Aspects of Poisoning

Poison may be defined as any substance which when absorbed into the body or by local action on the tissues injures health or destroys life. Administration of any substance with the intention of causing injury or death is punishable. In suspected poisoning, the following articles will be preserved and forwarded for forensic examination: • Gastric lavage/ gastric contents/ vomitus and soiled clothing, blood, urine • Other relevant body fluid depending on the poison ingested.

9.7.1 Care for Cases of Poisoning

1. When poisoning is suspected, every attempt must be made to save the patient’s life.
2. Case sheet shall be properly captioned, personal particulars noted, along with date and time of reporting.
3. A careful history is to be elicited including the relationship of food or medicine taken and the toxic manifestations. All signs and symptoms are to be noted.
4. The vomitus, urine, feces, stomach wash, sample of food or medicine, should be examined.
5. Any suspicious bottle or utensil seen near the victim, the clothes and bed clothes used by the victim are preserved for chemical analysis.
6. It is advisable to take a second opinion and advice of a senior colleague in all matters regarding diagnosis and treatment.
7. If there is any indication of danger to the general public, for example, food poisoning from a hotel, the local public health authorities must be notified at once so that suitable remedial measures are taken.

9.7.2 Special Precautions

Emergency medical treatment will be administered. 2. Poison Control Center shall be consulted. 3. Medical certificates of cause of death will be issued stating that cause of death to be ascertained after chemical analyses. 4. Samples of MLC will be preserved and handed over to the police for forensic examination. 5. A receipt shall be obtained from the police for all samples that are handed over for forensic examination.

9.8 Medical Negligence and Reckless Imprudence

9.8.1 Medical Negligence

This refers to the treatment of a patient causing damages or injuries to health, life, or limb due to the lack of care, skill, or training on the part of the doctor. The term “damage” means mental or functional injury to the patient, while “damages” are assessed in terms of money by the court on the basis of loss of concurrent and future earnings, costs, and reduction in quality of life.

The following are to be established to the satisfaction of the court: • The doctor owed him a duty to conform to a particular standard of professional conduct. • The doctor breached that duty. • The patient suffered actual damage. • The doctor’s conduct is the proximate cause of the damage.

9.8.2 Reckless Imprudence

The negligence is so great as to go beyond a matter of mere compensation; not only the doctor has made the wrong diagnosis and treatment, but has shown gross ignorance, gross carelessness or gross neglect for life and safety of the patient. The doctor may be prosecuted in a criminal court for having caused injury or death, under the following conditions: • Injecting anesthetic in fatal dosage or in wrong tissues, transfusing wrong blood or medicine. • Amputation of wrong finger, operation on wrong limb, removal of wrong organ etc. • Operation on the wrong patient or on the wrong side. • The principle of “res ipsa loquitur” or the doctrine stating that the occurrence of an accident implies negligence, shall apply to cases where instruments or sponges are left inside the part of the body operated. • Leaving the tourniquet too long resulting in gangrene. • Applying too tight plaster on splints, which may cause gangrene or paralysis. • Performing criminal abortion.

References

Administrative Order No. 2013-0011 Revised Policy on the Establishment of Women and Their Children Protection Units in All Government Hospitals. (2013, March 11). https://www.childprotectionnetwork.org/wp-content/uploads/2019/06/AO-WCPU-Gov.-Hosp..pdf Ayala, B. (2019, July 19). Medical Malpractice in the Philippines. Respicio & Co. Law Firm. Retrieved January 19, 2022, from https://www.respicio.ph/features/medical-malpractice2 Executive Order No. 212 July 10, 1987. (n.d.). LawPhil. https://lawphil.net/executive/execord/eo1987/eo_212_1987.html GR No. 171127. (2015, March 11). LawPhil. Retrieved January 19, 2022, from https://lawphil.net/judjuris/juri2015/mar2015/gr_171127_2015.html Presidential Decree No. 169 April 4, 1973. (n.d.). LawPhil. https://lawphil.net/statutes/presdecs/pd1973/pd_169_1973.html Republic Act No. 3815 The Revised Penal Code. (n.d.). LawPhil. https://lawphil.net/statutes/acts/act_3815_1930.html Republic Act No. 7610 Special Protection of Children Against Abuse, Exploitation, and Discrimination Act. (n.d.). LawPhil. https://www.lawphil.net/statutes/repacts/ra1992/ra_7610_1992.html Republic Act No. 8353 The Anti-Rape Law of 1997. (n.d.). LawPhil. https://lawphil.net/statutes/repacts/ra1997/ra_8353_1997.html Republic Act No. 8505 Rape Victim Assistance and Protection Act of 1998. (n.d.). LawPhil. https://lawphil.net/statutes/repacts/ra1998/ra_8505_1998.html

Republic Act No. 9262 Anti-Violence Against Women and Their Children Act of 2004. (n.d.). LawPhil. https://www.lawphil.net/statutes/repacts/ra2004/ra_9262_2004.html Republic Act No. 9745 Anti-Torture Act of 2009. (n.d.). LawPhil. https://lawphil.net/statutes/repacts/ra2009/ra_9745_2009.html

10. CONTINUOUS QUALITY IMPROVEMENT IN THE ED

10.1 General Principles of Continuous Quality Improvement

Continuous Quality Improvement is defined in the Administrative Order No. 2020-0034 or “Revised Guidelines on the Implementation of Continuous Quality Improvement (CQI) Program in Health Facilities in Support of Quality Access for Universal Health Care,” as process through which the level of quality is defined, pursued, achieved and continuously improved through the establishment of formal mechanisms or systems, and structure within the organization. It is a strategic approach to provide the best health care possible for all and a preventive strategy that uses constant innovation to improve work processes and systems by reducing time-consuming and low-value activities.”

Administrative Order No. 2020-0034 provides for the overall guide on the implementation of CQI in health facilities with focus on the following principles:

1. People-Centeredness - ensure that health facilities are responsive to the needs of its clients as provided in Administrative Order No. 2020-0003, “Strategic Framework on the Adoption of Integrated People-Centered Health Services in All Health Facilities”
2. Data-Driven Decision Making - clinical and administrative decision making are supported by data-driven models and data analytics
3. Safe - ensure that patients and staff suffer undue harm from the treatment itself and from the manner it was given as guided by Administrative Order No. 2020-0007, “National Policy on Patient Safety in Health Facilities”
4. Timely - ensure that the appropriate care is given at the appropriate time after a need is recognized.
5. Efficient - ensure that in the process of healthcare service delivery, resources are maximized to avoid waste and appropriately used to optimize patient benefit.
6. Equitable - ensure that the care provided is individualized based on the need.

10.1.1 Goals of CQI

The Emergency Department shall strive to achieve the following goals in the overall implementation of its CQI Program:

1. Develop greater leadership support

2. Train and involve more staff in monitoring and improvement activities

3. Set clear priorities for what to monitor and what to improve

4. Base decisions on indicator data, and

5. Make improvements based on benchmarks with other organizations, locally and possibly internationally.

10.1.2 Plan-Do-Study-Act Cycle

Administrative Order No. 2020-0034 likewise provides the overall framework for the implementation of CQI through the Plan-Do-Study-Act Cycle (PDSA Cycle). It is a systematic approach to gain valuable insights to drive the continuous improvement of services being provided. The table below provides the general process on how to implement the PDSA Cycle.

Table 37. Components of the PDSA Cycle. Administrative Order No. 2020-0034 Component Description Tools and Output Plan Define the Problem and Define the Root Cause • Identify Area for Improvement • Assemble a Team • Identify current processes • Identify potential change strategies • Identify improvement theory
Tools: Root Cause Analysis, Process flow analysis, Pareto Diagram/ Charts

Output: Quality Improvement Plan
Do Customer Protection and Countermeasure • Test/ Pilot the theory Tools: Project Management and Logical Framework

Output: Result of Pilot Study Study Study the result and confirm effectiveness.
Note: The shift from Check to Study was introduced to provide emphasis on understanding the result rather than for recording and compliance purposes.
Tools: N/A

Output: Monitoring Findings
Act Feedback/Feed forward • Scale up implementation
• Establish Future Plans Tools: Three A’s of Acting (Adapt, Adopt, and Abandon)

Output: Standardization of successful improvements, celebrate successes

10.2 Tools and Strategies for CQI in the ED

10.2.1 Compliance to Standards

A self-assessment checklist can be used to serve as an initial step for ED Managers and Administrators to plan the overall quality improvement of the Emergency Department.

10.2.2 Hospital Information System to support CQI

An important strategy to support the overall implementation of the CQI is the implementation of the Hospital Information System with a dedicated Emergency Department Information Systems (EDIS) component. EDIS are increasingly created and utilized as these systems have proved to be important

tools for accumulating and storing data specific to both patients and the ED. These data can be used in real time by clinical staff or administrative managers to identify and troubleshoot problems in flow (e.g. radiology or laboratory delays, overcrowding, or an influx of patients), and can also be used retrospectively for research and quality-improvement purposes (Leventhal, 2020).

For EDIS and EMR developers as well as ED administrators, the following are the recommendations in creating an information management system specific to the ED (Leventhal, 2020). Collection of the data should minimize interruptions and optimize patient safety as well as be useful in improving provider wellness through the following:

1. A dedicated EDIS from the main EMR optimized for ED workflow
2. Standardization within the EDIS for the entire care team
3. Standardized and structured data collection at triage
4. Reservation of modal or interruptive alerts for only the most severe or high-risk alarms
5. Elimination of low-yield Best Practice Advisories (BPA) and alerts, and development of alternative solutions for intervening on rare events
6. Order sets and orders specific to ED care
7. Event-based notification for key positive and negative results that affect disposition or destination
8. A streamlined handoff process for admissions
9. Standardized discharge instructions
10. Further research dedicated to EDIS-specific and ED-specific communication

10.2.3 Bed Management Strategies

1. Create Bed Management Policy
   a. Emergency Department must coordinate with admitting and discharge section, and specific wards
   b. Patient admission and discharge processes must be streamlined for better patient flow into and out of the Emergency Department
2. Create a dedicated Bed Management Team whose role is to look into the real time operational indicators and direct actions to address bottlenecks.

Table 38. Roles and Responsibilities of ED Management Team Relative to Bed Management ED Chair / Designated ED Physician for the Day Heads the bed management team in terms of planning and strategies to be implemented Ensures all patients with disposition at a timely manner Maintains ED flow and coordinates with other services Call for regular meeting with composite team Unit Manager / Nurse Supervisor / Senior Nurse Oversees the implementation of the bed management strategies Facilitates discharge and transfer of patient from ED to ward Medical Social Worker Identifies and assists patients with MSSD related concerns causing delays in admission (from ED) and discharge (from ward). Admitting Officer Updating of census / bed tracker for patients pending admission, pending discharge, and vacant beds.

Engineering Identifies and addresses facilities requiring repair, hindering admission and discharge. Utility Supervisor Facilitates timely cleaning and disinfection of patient beds discharged. Security Personnel Assists the composite team doing rounds for safety and security from combative or difficult patients and relatives.

10.2.4 Lean Management

Another strategy that ED Managers and Administrators can use to ensure the efficiency of ED process flow and address ED crowding is the principles of Lean Management in the overall operations of the ED. Lean Management is a process to determine the non-value added and time-wasting processes in a given process of procedure (Chan et. al 2014).

Figure 9 provides for the general process or principles in the conduct of Lean Management. In addition, References for the implementation of Lean Management in the Emergency Department which may be accessed through: bit.ly/EDLeanManagement.

Figure 9. Lean Management Principles. Reprinted from “Applying Lean Management Principles to Emergency Department,” by R.B. Smarta and T. Shinde, 2019, Interlink Insight, 18(2), Figure 3.5.

10.2.5 Performance Governance Systems and International Organization for Standardization

With the growing demands of the Filipino people, so has the expectation of government service with the Civil Service Commission (CSC). For a more efficient and effective governance, the CSC adopted

the so-called Performance Governance System (PGS) in which it aims to translate the organizational goals into results guided by a set of performance and metrics. This is based on the premise that “you cannot manage what you cannot measure.” The following are the different stages of certification: Stage 1: Initiation Stage 2: Compliance Stage 3: Proficiency
Stage 4: Institutionalization On the other hand, to better appreciate operations at par with the international standards, the Department of Health submits itself to the ISO standards. The ISO is an independent body which provides standards of the organization and it certifies to help for the overall efficiency of the services that we provide.
ISO 9001 clarifies and standardizes processes, exposes variation and non- conformance, and eliminates the need for constant inspection. Once certified, it helps in providing integrity and credibility for our organization.

10.2.6 Emergency Department Quality Improvement Framework

A quality framework for emergency departments based on the following five areas should be the basis of continuing quality improvement performance measures and activities: • Clinical • Research • Education and training • Administration • Professional profile of the ED

10.3 Implementation of CQI in the Emergency Department Setting

10.3.1 Implementation based on the Resource Stratified Framework (RSF)

Based on service and performance needs of the ED/EU the following elements of the CQI framework should be incorporated into the ED program by administrators to ensure culture of quality Level 1 Hospital Level 2 Hospital Level 3 and Specialty Hospitals Clinical or operations audits

Professional Staff Training

Administration QI activities All of L1 in addition to

Advocacies/public health
Education and Training All of L2 in addition to

Emergency Medicine Specialty Training

Nursing Certification Program, Emergency Nursing Care Training, or its equivalent

Research

10.3.2 Activities to support CQI Initiatives

A culture of quality and leadership of the ED managers and administrators as supported by hospital management are critical to have continuing improvement strategies and programs to sustain safe and effective care. The following activities should be integrated in the ED for continuous review and improvement of structures, processes and performance or outputs. Communication and integration to

prehospital and inpatient units should also be ensured. The following are recommended by the International Federation for Emergency Medicine (IFEM) as key aspects to maintain quality and safety in EDs (Hansen et al., 2020):

Audits – a structured process review of processes and cases in the Emergency Department to evaluate quality or services rendered. Information derived from audits allow management to benchmark and prioritize needs for continuous improvement.

Incident Monitoring – a system or processes of reporting of incidents or untoward events where the reporting employee will be without fear of reprimand. Reported incidents and other data collected in this process are analyzed and acted upon for prevention of future occurrences of the said event.

Guidelines - according to Hansen et al, guidelines which are complete (covers all ED scenarios and conditions), accessible (easy to use interface, guided by intuition, logically arranged), practical, and relevant to local patients must be developed to maintain quality and safety in EDs.

Morbidity and mortality - similar to an audit, morbidity and mortality reviews are to be conducted in a blame-free setting with multi-disciplinary participation to optimize learning from cases for review. Information obtained must be used towards continuous improvement.

Integration and communication - as emergency care functions in a continuum, so shall communication and service provision in the ED be in constant sync with its other components, particularly with ambulance, hospital specialties, and primary care providers. This includes standardizing practices related to safe handover of patients. In this endeavor, the WHO Medical Emergency Checklist (Annex H) and the WHO Trauma Care Checklist (Annex I) may be used as a systematic approach to review actions taken during the primary and secondary surveys, and prior to leaving the patient’s bedside. The aforementioned checklists may be used as is, or may be modified, as institutions see fit.

Table 39. Description of Quality Improvement elements and activities for Emergency Departments that should be part of the CQI Framework Element CQI Activities
Clinical Profile Participation in national clinical indicator collection based on national standards

1. Regular clinical audits (examples): a. high volume or high-risk clinical conditions b. documentation standards c. clinical guideline compliance/variance d. unplanned returns to emergency department
2. Audit of procedural complications
3. Audit of medical imaging (examples): a. Appropriateness b. Turnaround time c. Results checking
4. Audit of medical imaging (examples): a. Appropriateness b. Turnaround time c. Results checking
5. Audit of medication errors
6. Regular mortality and morbidity meetings
7. Guidelines for orientation to the emergency department
8. Involvement in hospital accreditation Administrative Profile The administrative function of an ED should include the following:
9. A designated Quality Team (including medical and nursing staff, may include clerical, allied health professionals and consumers; the team should also have administrative support)
10. Regular audits (examples): a. waiting times b. death audit c. trauma audit d. complaints/patient satisfaction/patient experience e. clinical practice guideline and protocol compliance/variance.
11. Risk management
12. Financial considerations
13. Equipment considerations
14. Workforce considerations such as turnover rates, sick leave rates, vacant positions, staff satisfaction, occupational safety including nosocomial infections, and violent incidents, performance appraisals and staff meetings to ensure continuity of communication Professional
15. Participation of staff in committees and faculties of EM and other clinical professional bodies
16. Representation of emergency medicine and nursing on appropriate national bodies
17. Participation in submissions on health policy
18. Health advocacy roles (examples): a. Participation in public health b. Liaison with quality and accreditation organization

Education and Training Emergency departments should be involved in education and training relevant to emergency medicine and, where relevant, a record should be kept of the following:

1. Departmental educational program including: a. regular meetings b. guaranteed staff access to program (protected teaching time) c. a record of attendance d. evidence of periodic evaluation of education program
2. Presence of specialist emergency medicine training program
3. Instructors for accredited training courses (examples): a. ACLS/PALS/NALS
   b. BEC
   c. ATLS d. Ultrasound
4. Staff who have completed accredited training courses (examples): a. ACLS/PALS/NALS
   b. BEC
   c. ATLS d. Ultrasound e. Customer focused staff training courses f. Cultural competency training
5. Departmental educational roles (examples): a. nursing educator b. administration staff educator c. Participation by staff in team-training d. Clinical student teaching and training e. Participation by staff in scientific meetings including hosting, attendance f. Collaboration with medical and nursing educational institutions e.g. with universities and colleges
   g. Participation by staff in continued professional development (CPD) h. Participation in multidisciplinary, interdepartmental, and pre- hospital & retrieval education Research Departments should be involved in research relevant to emergency medicine
6. Research projects (internal and external to the department)
7. Research presentations at scientific meetings Publications by emergency department staff

10.4 Emergency Department Quality Metrics/ Indicators

As earlier discussed, data-driven decision making is critical in the overall conduct of CQI. The table below provides indicators or parameters that are to be measured at the ED level to ensure quality and efficient services. ED Managers shall use these indicators to monitor the quality and efficiency of the services of the ED.

Table 40. Suggested indicators for EDs, grouped by the domains of structure, process and outcome to address the six Institute of Medicine domains of high-quality care (IFEM, 2019) Domain
Structure Process Outcomes Safe Staff with the right skill Adequate assessment spaces Adequate security

Reporting system for safety concerns (without fear of reprisal) Ability to share and learn from adverse incidents -
Administration acts on staff concerns in timely manner

Analysis of incident reports (Patient Safety Indicators) (there should be many non- serious incidents and a few serious incidents) Incidence of Needle Stick Injury Incidence of Splash Injury Incidence of Fall Incidence of Medication Error Effective Adequate assessment spaces Sufficient equipment
Adequate monitoring Disaster/major incident plan

Care standards or evidence- based guidelines for common and important presentations available Quality improvement activities being conducted Audit performance against international, national or local standards for common presentations, such as sepsis or multiple injuries Hospitalized Standard Mortality Ratio Morbidity / Mortality (general or specified conditions) Diagnostic and procedural errors Patient Centered Structural environment allows for privacy and dignity Dedicated areas for vulnerable groups (e.g. children, mentally ill, elderly) Patient complaint system (with follow-up actions) Left without being seen rate

Patient experience (Client Satisfaction Survey) Patients’ ability to participate in own care Collection and use of Patient-reported outcomes Time to analgesia audit

Timely Ambulance notification system Adequate clinicians to initially assess a patient promptly

Patients seen initially by a: Clinician trained in triage Time to consultation by doctor Time to be seen by decision maker Patients needing admission are moved swiftly out of the ED Total length of stay in the ED (from arrival to departure) Percentage of patients who leave the ED without being seen ED boarding Rate Measure of performance but also measure of patient surge/surge capacity Efficient Emergency doctors available who can assess and provide initial treatment for all emergency presentations, regardless of age or pathology

Patients investigated and treated according to evidence-based guidelines

Appropriate use of investigations

Appropriate and timely support from other specialities Number of admissions from the ED Avoidable patient re- presentations to the ED Good communication with other healthcare providers

Equitable ED available to all patients who need it, 24/7, regardless of age, disease or finances Patients seen in order of clinical priority

Comparable access and clinical outcomes despite: • Gender • Race • Religion • Other minorities • Ability to pay

The table above provided a menu of Emergency Department indicators to be measured that may aid ED Managers to determine the status of their ED operations. On the other hand, the table below provides a list of ED indicators, descriptions, reporting requirements, and ideal frequency of collection as recommended by the Technical Working Group for the development of this manual and determined as appropriate for the Philippine setting.

Table 41. Summary of the suggested minimum ED indicators that may be measured by individual facilities. Facilities are not limited to the indicators listed below. Indicators Description and Importance Reported Requirements Numerator/Denominator
Ideal Frequency of Collection
Input Indicators Human Resources Description: Measures the percentage of ED staff with training/credentials matched with requirements in Chapter 3

Importance: Ensures ED staff have the appropriate skill mix to perform their role in providing quality emergency care. Proportion expressed as percentage of ED staff with adequate ED relevant skills

e.g. BLS - 100% for ALL ED Staff

Bi-annual Evaluation
Monthly monitoring in case of expiring BLS/ACLS Description: Proportion of nursing staff and medical staff to the ED patient consults

Importance: Determine if the ratio of the ED staff available to the patient volume in the ED is sufficient to provide quality services.

Nursing Staff - all nurses actively handling patients during their shift

Nursing Attendant (NA) - all NAs actively handling patients during their shift

Medical Positions - all medical physicians managing patients during their shift

Patient Consults - all patients who presented in the ED who received treatment
Proportion expressed as ratio of available health human resource items particularly to patient volume

e.g. Total nursing staff : ED patient consult
Total nursing attendant : ED patient consult Total medical positions : ED patient consult

In 24 hours, there were 48 nurses who went on duty who accommodated 240 ED patient consults.

48 nurses : 240 ED patient consults

Daily collection Monthly monitoring Annual reporting Infrastructure

Description: Determines if facility has adequate space with necessary infrastructure for provision of quality services

Importance: Ensures patients are provided services with dignity and staff Consider the following factors on infrastructure: • Adequate space for patient assessment • Structural environment allows for privacy and

are safe from hazards arising from space concerns dignity of patients and staff Operational Indicators/ Process Indicators
ED Length of Stay or Turnaround time

Description: Measures the average Length of Stay from Triage until actual transport out of patient

Importance: Provide an overview on ED Crowding
Mean in minutes or hours

Daily collection (may be sampled for high volume institutions) Monthly monitoring Annual Report ED Disposition Time Description: Measures the average time from triage to disposition decision of treatment officer.

Importance: Provides insight to the efficiency of decision-making of the treatment officer and if further training is necessary. Mean in minutes or hours

Daily collection (may be sampled for high volume institutions) Monthly monitoring Annual Report Overstaying Description: Refers to patients with ED Disposition Time of more than 4 hours.

Importance: Provides insight to the efficiency of decision-making of the treatment officer and if further training is necessary. N: Number of overstaying patients D: Total number of patients seen in 24 hours

Daily collection Monthly monitoring Annual Report ED Boarding
Description: Indicator that refers to patients who have a disposition of admission, transfer, or discharge but still in the ED for any reason. This excludes patients admitted in the ED observation units, if applicable.

Importance: Provides an overview on the access blocks present in the ED which need to be addressed N: ED boarded patients
D: Total number of patients physically present at a specific reporting time

Daily collection Monthly monitoring Annual Report Outcome Indicators ED Population
Patient Demographics Case-Mix Distribution based on Triage Scale Description: Patient demographics, case-mix, and triage categorization as determined via patient records

Importance: Information on ED Populations allow for better preparation in terms of medications, supplies, and appropriate training needed to accommodate these patients Counts

Daily collection Monthly monitoring Annual Report

ED Dispositions: Admissions Transfer Discharge (sent home, DAMA, Abscond, ED Death) Description: ED Dispositions as determined via patient records

Importance: Information on Dispositions allow for better preparation in terms of medications, supplies, and appropriate training needed to accommodate these patients Counts Ratio

Daily collection Monthly monitoring Annual Report No. of Dead on Arrival Description: Number patients received at the ED who were brought in deceased

Importance: Determining the incidence and prevalence of DOA patients will allow for interventions on pre-hospital care and CPR use in home care Counts Ratio

Daily collection Monthly monitoring Annual Report Reattendance within 24 hours requiring admission Description: Number of patients who return to the ED after 24 hours from initial consultation, now requiring admission for the same complaint. May be referred to as discharge failure in other models.

Importance: Allows for facility to re- evaluate how disposition is decided upon as well as how follow-up instructions or home care instructions are provided. Counts Ratio

Daily Collection Monthly Monitoring Annual Report Responsiveness / Patient Experience / Patient Feedback System Description: Measure the overall Client/Patient Satisfaction Rate

Importance: This will allow the facility to determine how they perform in the eyes of the client/patient and ways to improve services. This also allows patients to play a role in how the services are delivered. Daily Collection Monthly Monitoring Annual Report Needle Stick Injury

Fall

Medication Error
Description: Measure the overall rate of patient safety events such as needle stick injuries, fall, medication errors in the ED

Importance: Allows the ED to evaluate if protective systems are in place to prevent such harm to both patients and the ED staff.

Daily Collection Quarterly Monitoring Annual Report Triage Response Time Description: Takes note of the number of patients whose time from arrival to triage to being seen by a

(Total number of patients seen within prescribed time based on

physician/nurse is within the appropriate time based on their triage category

e.g. If using CTAS Category 1 (Critical/Resuscitative) - seen immediately Category 2 (Emergent) - seen within 15 minutes Category 3 (Urgent) - seen within 30 minutes Category 4 (Less Urgent) - seen within 60 minutes Category 5 (Non-Urgent) - seen within 120 minutes

Importance: This allows the ED to determine if patients are seen in a timely manner and to use this indicator on
triage category / Total ED consults) x 100

Target:
92% Emergent (Category 1 and 2) 70% Urgent (Category 3, 4, and 5)

Daily Collection Monthly Monitoring Monthly Report Out of Hospital Cardiac Arrest (OHCA)

Return of Spontaneous Circulation (ROSC) Rate in OHCA

Description: Measures the number of cardiac arrest occurring outside the hospital and the number of OHCA events with return of spontaneous circulation

Importance: The ROSC rate of OHCA occurrences represent the outcome of pre-hospital response and interventions provided to the patient. N: total number of ROSC in OHCA
D: total number of OHCA

Daily Collection Monthly Monitoring Annual Report In-Hospital Cardiac Arrest (IHCA)

ROSC Rate in IHCA Description: Measures the number of cardiac arrest occurring inside the hospital and the number of IHCA events with return of spontaneous circulation

Importance: The ROSC rate of IHCA occurrences represent the outcome of in-hospital resuscitation efforts and interventions provided to the patient. N: total number of ROSC in IHCA D: total number of IHCA

Daily Collection Monthly Monitoring Annual Report

References

Chan, H., Lo, S., Lo, W., Yu, W., Ho, S., Yeung, R., & Chan, J. (2014). Lean techniques for the improvement of patients' flow in the emergency department. World Journal of Emergency Medicine, 5(1), 24-28. U.S. National Library of Medicine: National Institutes of Health. 10.5847/wjem.j.issn.1920-8642.2014.01.004

Department of Health (Philippines). (2020, July 28). Administrative Order No. 2020-0034 Revised Guidelines on the Implementation of Continuous Quality Improvement (CQI) Program in Health Facilities in Support of Quality Access for Universal Health Care. Hansen, K., Boyle, A., Holroyd, B., Phillips, G., Benger, J., Chartier, L. B., Lecky, F., Villancourt, S., Cameron, P., Waligora, G., Kurland, L., & Truesdale, M. (2020, July 2). Updated framework on quality and safety in emergency medicine. Emergency Medicine Journal, 37(7), 437-442. https://emj.bmj.com/content/37/7/437.info Leventhal, E. L., & Schreyer, K. E. (2020, August). Information Management in the Emergency Department. Emergency Medicine Clinics of North America, 38(3), 681-691. National Library of Medicine: National Center for Biotechnology Information. 10.1016/j.emc.2020.03.004 Rotter, T., Plishka, C., Lawal, A., Harrison, L., Sari, N., Goodridge, D., Flynn, R., Chan, J., Fiander, M., Poksinska, B., Willoughby, K., & Kinsman, L. (2019). What Is Lean Management in Health Care? Development of an Operational Definition for a Cochrane Systematic Review. Evaluation & the Health Professions, 42(3), 366-390. 10.1177/0163278718756992 Smarta, R. B., & Shinde, T. (2019, July). Special Feature: Applying Lean Management Principles to Emergency Department. Interlink Insight: Perspectives for Business Performance - Key Stakeholders Business Perspective, 18(2), 9-14. https://interlinkconsultancy.com/wp-content/uploads/2020/06/Interlink-Insight- Vol.18-Issue-2-2019-20.pdf Souza, D. L., Korzenowski, A. L., Alvarado, M. M., Sperafico, J. H., Ckermann, A. E. F., Mareth, T., & Scavarda, A. J. (2021, June 19). A Systematic Review on Lean Applications' in Emergency Departments. Healthcare, 9(763). https://doi.org/103390/healthcare906763 Tiso, A., Crema, M., & Verbano, C. (2021). A framework to guide the implementation of lean management in the emergency department. Journal of Health Organization and Management, 35(9), 315-337. 10.1108/JHOM-01-2021-0035

department head office p p e r a c k operation c e n t e r o f f i c e ( o p c e n ) counceling/ bereavement r o o a c u t e c a r e / general treatment a r e a n u r s e s ' s t a t i o n equipment & s u p p l y s t o r a g e O P E R A T I N G R O O s a t e l l i t e b i l i n g & c a s h i e r / registration s t a t i o n h o l d i n g r o o scrub-up /clean-up s u b

sterilizing r o o medication r o o c l e a n l i n e n s u p p l y r o o s t a f f b r e a k r o o r e c o r d s r o o doct or/ s t a f f c a l l r o o m u t i l i t y r o o m e l e c r o o m t o i l e t t o i l e t h e a t h e m e r g e n c y m a n a g e m e n t s u p p y r o o ( h e s ) m a l e t o i l e t f e m a l e t o i l e t p w t o i l e t s a t e l l i t e m e d i c a l s o c i a l w o r k e r o f f i c e a c u t e m e n t a l h e a l t h r o o w o m e n & c h i l d r e n protection u n t a c u t e c a r e / general treatment a r e a d i r t y u t i l i t y / l i n e n r o o janitor's c l o s e t a m b u l a t o r y t r e a t m e n t a r e a o b - g y n e t r e a t m e n t a r e a o b s e r v a t i o n u n t w a t n g a r e a p r o c e d u r e / e x a m i n a t i o n r o o r e s p i ra t o r y servi ce uni t resuscitation a r e a t r i a g e a r e a w h e e l e d stretcher b a y decontamination r o o i s o l a t i o n r o o t o i l e t t o i l e t toilet conference a r e a to hospital ancillary services o r r o r o r r o r E m e r g e n c y D e p a r t m e n t L e v e l 1 - 7 5 B e d H o s p i t a l a m b u l a n c e b a y O P T I O N A L O P T I O N A L .

ANNEX A

Sample Emergency Department Floor Plan for Level 1 - 75 Bed Hospital Sample floor plan is based on developmental standards and are considered ideal. For minimum requirements, please refer to licensing standards.

department head office p p e r a c k operation c e n t e r o f f i c e ( o p c e n ) counceling/ bereavement r o o a c u t e c a r e / general treatment a r e a n u r s e s ' s t a t i o n equipment & s u p p l y s t o r a g e p r o c e d u r e / e x a m i n a t i o n a r e a O P E R A T I N G R O O s a t e l l i t e b i l i n g & c a s h i e r / registration s t a t i o n h o l d i n g r o o scrub-up /clean-up s u b

sterilizing r o o medication r o o c l e a n l i n e n s u p p l y r o o s t a f f b r e a k r o o r e c o r d s r o o do ctor/ s t a f f c a l l r o o m u t i l i t y r o o m e l e c r o o m t o i l e t t o i l e t h e a t h e m e r g e n c y m a n a g e m e n t s u p p y r o o ( h e s ) m a l e t o i l e t f e m a l e t o i l e t p w t o i l e t s a t e l l i t e m e d i c a l s o c i a l w o r k e r o f f i c e a c u t e m e n t a l h e a l t h r o o w o m e n & c h i l d r e n protection u n t a c u t e c a r e / general treatment a r e a d i r t y u t i l i t y / l i n e n r o o janitor's c l o s e t a m b u l a t o r y t r e a t m e n t a r e a o b - g y n e t r e a t m e n t a r e a o b s e r v a t i o n u n t w a t n g a r e a r e s p i r a t o r y s e r e u n t resuscitation a r e a resuscitation a r e a t r i a g e a r e a w h e e l e d stretcher b a y decontamination r o o i s o l a t i o n r o o t o i l e t & b a t h a nt e- ro o m quarantine o f f i c e r r o o t o i l e t t o i l e t & b a t h d o c t o r ' s r o o n o r s u r g e r y r o o t o i l e t t o i l e t toilet conference a r e a f r e e t to hospital ancillary services o r r o r o r r o r o r r o r g e n s e t to hospital lobby a b e f g h j k E m e r g e n c y D e p a r t m e n t L e v e l 2 - 1 0 0 B e d H o s p i t a l a m b u l a n c e b a y a b u a n e p a r k n g

ANNEX B

Sample Emergency Department Floor Plan for Level 2 - 100 Bed Hospital Sample floor plan is based on developmental standards and are considered ideal. For minimum requirements, please refer to licensing standards.

MEDICO-LEGAL REPORT DATE:_________ TIME:_________ Patient Name: Address: Age Sex Civil Status: Date and Time of Incident: Place of Incident: Nature of Incident: Blotter Page Number (if applicable): Name & Address of Nearest Kin: Name and Address of Person who Brought the Patient Date and Time of Treatment: Nature of Treatment: Diagnosis: Prognosis: Disposition: Attending Physician:

ANNEX C

EMERGENCY DEPARTMENT TREATMENT RECORD I. TRIAGE RECORD (to be filled by Triage Officer) Infectious/Hazardous Non-infectious/ Non-Hazardous Mass Casualty Incident PATIENT INFORMATION Name (Last, Given, Middle) Date: MM/DD/YYYY Time of Arrival: Age Sex ⬜Female ⬜Male Height: Weight: Date of Birth: Referred by: OPD Private MD Hospital Other: ____________ Mode of Arrival Ambulance Walk-in Private vehicle Police escort Triage Category* Emergent Urgent Non-Urgent *May be modified to 5-tier triage scale Informant Patient: Family : ______________ Friend Referring MD EMS VITAL SIGNS: RR HR BP T O2 Sat GCS ___ (E___ V___ M ) PAIN SCALE: CHIEF COMPLAINT: Triage Officer Date Time PRIMARY SURVEY Airway Normal ⬜ Angioedema ⬜ Stridor ⬜ Voice changes ⬜ Oral/Airway burns Obstructed by: ⬜ Tongue ⬜Vomit ⬜Blood ⬜ Secretions ⬜ Foreign Body Airway: ⬜ Repositioning ⬜ Suction ⬜OPA ⬜ NPA ⬜ LMA ⬜ BVM ⬜ ETT Cervical Spine Stabilized: ⬜ Not needed ⬜ Done before arrival ⬜ Done in Emergency Department (not needed-not altered, no pain/TTP, no distracting injury, no focal neuro deficit) Breathing Normal Spontaneous Respiratory Rate: ___________ Chest Rise:⬜ Shallow ⬜Retractions ⬜ Paradoxical Trachea: ⬜ Midline ⬜Deviated to ⬜L ⬜R Breath Sounds: ⬜L ⬜R _______ Oxygen:L ⬜ NC ⬜Mask ⬜ NRB ⬜ BVM ⬜ CPAP/BIPAP ⬜ Ventilator Chest needle/tube (circle): ⬜ L - size: Depth:cm ⬜ R - size: Depth:cm ⬜3-sided dressing Circulation Normal Skin: ⬜Warm ⬜Dry ⬜ Pale ⬜Cyanotic ⬜ Moist ⬜ Cool Capillary refill: ⬜ <3 sec or ______ sec Pulses: ⬜ Weak ⬜ Asymmetric JVD: ⬜ Yes ⬜ No ⬜ Bleeding controlled (bandage, tourniquet, direct pressure) Access: ⬜ IV Loc: ___________ Size: _______ ⬜CVL: Loc:____ Size:_________ ⬜ IO: Loc:__________ Size:_________ ⬜ IVF: mLs ⬜ NS ⬜ LR ⬜ Other: ________________ ⬜Blood Ordered ⬜Pelvis stabilized Disability Normal Exposure Exposed Completely Blood Glucose:_____ ⬜ Glucose ⬜ Naloxone Responsiveness: ⬜ A ⬜ V ⬜ P ⬜ U GCS: ____ (E___V____M____) Moves Extremities: ⬜LUE ⬜RUE ⬜LLE ⬜ RLE Pupil: Size L________ R________ Reactivity: L________ R________ FAST Not indicated Not available Normal Peritoneum: ⬜ Negative ⬜ Indeterminate ⬜ Free Fluid:________________ Chest: ⬜ Negative ⬜ Indeterminate ⬜ Pneumothorax (R/L):___________ ⬜ Pleural Fluid (R/L):____________ ⬜ Pericardial effusion Primary Survey Assessment Primary Survey Interventions

ANNEX D

MEDICAL HISTORY Allergies:_______________________________ ⬜ Unknown Medications: ⬜ Anticoagulant: _____________ ⬜ Unknown Other: Past Medical: ⬜ HTN ⬜ DM ⬜ COPD ⬜Asthma ⬜PTB ⬜ Psych ⬜ Renal ⬜ Unknown Other: Past Surgeries (type & date): ⬜ Unknown Time of last meal: :_ ⬜ Unknown Last Menstrual Cycle: _____________ G___P___ ⬜Unknown Pregnant? (circle) Yes / No ⬜ Reported ⬜ Testing done Last Tetanus: ______________________________ ⬜ Unknown Substance Use: ⬜ Tobacco ⬜ Alcohol ⬜ Drugs ⬜ IV Drugs ⬜ Unknown Safe at home? _________________________________________ Substance use within 6 hours of injury: ⬜ Unknown ⬜ None ⬜ Reported ⬜ Evidence (positive test or clinical findings) ⬜ Alcohol ⬜ Other Substance (if known): ______________ Event/History of Present Illness for Trauma Date of Injury: MM/DD/YYYY Time of Injury: : Place of Injury: ⬜ Unknown Activity at time of Injury: ⬜ Unknown Mechanism of Injury (select one or multiple): ⬜ Road traffic incident ⬜Driver ⬜Passenger ⬜Pedestrian ⬜Airbag ⬜Seat belt ⬜Other vehicle restraint ⬜ Helmet ⬜Extricated Patient vehicle:__________________________ ⬜Ejected Hit by/crashed with:_______________________ ⬜Fall from:__________ ⬜Hit by falling object: ____________ ⬜Stab/Cut ⬜Gunshot ⬜Sexual Assault ⬜Other blunt force trauma (struck/hit):____________________ ⬜Suffocation, choking, hanging ⬜Drowning:_____________________________ Life vest: Y/N ⬜Burn caused by: ___________________________________ ⬜Poisoning/Toxic Exposure:___________________________ ⬜Unknown ⬜ Other: ____________________________ First care sought: Prehospital care ⬜None ⬜ Layperson first aid ⬜ Healthcare professional (EMT) Care given: Other Details of Incident ⬜ Loss of consciousness(circle): <5 mins / 5-29 min / 30min-24hr / >24hr ⬜Head trauma: Y / N ⬜Neck trauma: Y / N Other: Intent: ⬜ Unintentional or accidental ⬜ Intentional ⬜ Self harm ⬜ Assault ⬜ Legal process, political unrest or war ⬜ Unknown Assaulted by: _________________________________________ HISTORY OF PRESENT ILLNESS (Narrative for Non-Trauma) Treatment Officer Date Time Assessment DIAGNOSTICS ⬜ CBG ⬜CBC ⬜ RBS BUN Crea Na K Cl Ca Mg P ⬜ Uric Acid LDH Chol TG LDL HDL ⬜ ALT AST alk phos ⬜ Protime/PTT ⬜ CPK MB ⬜ CPK MM ⬜ CPK Total ⬜ Trop I ⬜ Trop T ⬜ Blood CS ⬜ Urinalysis ⬜ Pregnancy Test ⬜ Urine GS/CS ⬜ Fecalysis ⬜ Stool GS/CS ⬜12-Lead ECG ⬜X-RAY (Indicate Area and View): ⬜Ultrasound (Indicate Area): MRI: (Indicate Specific Request)

---

⬜Plain ⬜Contrast ⬜ CT SCAN: (Indicate Specific Request)

---

⬜Plain ⬜ Contrast

THERAPEUTICS Oxygen Supplementation: __ LPM via NPO Diet IVF: Medications: Dosage Time given Signature Monitor RESULTS CBC CHEMISTRY EKG RADIOGRAPHS REFERRALS Referred by Time Service Reason for Referral Time Received by NURSES NOTES DATE TIME BP HR RR TIME WT CBG Signature DISPOSITION OUTCOMES Date Time ⬜Discharge - Completed Treatment and Sent Home ⬜Discharge Against Medical Advice ⬜Left without being seen ⬜Absconded ⬜Admit ⬜Transfer to another health facility ⬜Self Conduction ⬜Ambulance ⬜Improved ⬜Dead on Arrival ⬜ED Death Discharge Diagnosis Discharge Plans Medications Special Instructions FOLLOW-UP WITH PRIMARY CARE PROVIDER ATTENDING PHYSICIAN

EMERGENCY DEPARTMENT TRAUMA SHEET

ANNEX E

POST MORTEM EXAMINATION RECORD Name of the Cadaver: Nationality: Address: Date & Time of Examination: Examining Physician: Head and Neck Thorax Abdomen Upper Extremities Lower Extremities Genitalia

ANNEX F

CHAIN OF CUSTODY Patient Name Date and Time of Collection Collected By: Description of Items: Turned Over By: Received By: Date Signature over Name and Designation

ANNEX G

Immediately after primary & secondary surveys:

IS FURTHER AIRWAY INTERVENTION NEEDED?
May be needed if: • Abnormal level of consciousness (AVPU scale) • Stridor • Respiratory Distress • Hypoxaemia or hypercarbia YES, DONE NO *if intervention is needed but unavailable, respond YES and note missing item, date & time on stockout log sheet. IS THERE A SEVERE ALLERGIC REACTION?
(ADRENALINE NEEDED) YES NO IS THERE A TENSION PNEUMOTHORAX? (NEEDLE/DRAIN NEEDED) YES NO DOES THE PATIENT NEED OXYGEN? YES
NO IS THE PULSE OXIMETER PLACED AND FUNCTIONING? YES NO DOES THE PATIENT NEED BRONCHODILATORS?
(e.g. salbutamol) YES NO DOES THE PATIENT NEED IV FLUIDS? YES NO ASSESSED FOR ONGOING BLEEDING (including gastrointestinal, vaginal, and other internal): BY EXAM NGT ULTRASOUND CT DIAGNOSTIC PERITONEAL LAVAGE IS TREATMENT FOR HYPOGLYCAEMIA NEEDED? YES NO IS TREATMENT FOR OPIOID OVERDOSE NEEDED? YES NO IS THE PATIENT HYPOTHERMIC/HYPERTHERMIC? YES NO When initial resuscitation is complete: HAVE VITAL SIGNS BEEN RECHECKED?
YES
HAS THE PATIENT BEEN GIVEN: ASPIRIN ANALGESIC TRANSFUSION ANTIBIOTICS NONE INDICATED
DOES THE PATIENT NEED AN ECG? YES NO PREGNANCY TEST DONE? YES NOT INDICATED HAVE ALL TESTS AND IMAGING BEEN REVIEWED?
YES NO, PLAN IN PLACE WHICH SERIAL EXAMS ARE NEEDED? NEUROLOGICAL ABDOMINAL
VASCULAR RESPIRATORY NONE PLAN OF CARE DISCUSSED WITH: PATIENT/FAMILY RECEIVING UNIT
PRIMARY TEAM OTHER SPECIALISTS
RELEVANT EMERGENCY UNIT CHART COMPLETED? YES
Medical Emergency Checklist WWW.WHO.INT/EMERGENCY CARE Version Feb 2019

Annex H

The WHO Trauma Care Checklist ! Injury kills more people every year than HIV, TB and malaria combined, and the overwhelming majority of these deaths occur in low- and middle-income countries. Timely emergency care saves lives: if fatality rates from severe injury were the same in low- and middle-income countries as in high-income countries, nearly 2 million lives could be saved every year. The WHO Trauma Care Checklist is a simple tool – designed for use in emergency units – that emphasizes the key life-saving elements of initial trauma care. A systematic approach to every injured person ensures that life-saving interventions are performed and that no life-threatening conditions are missed. The checklist reviews key actions at two critical points:

1. Immediately after the ‘primary’ & ‘secondary’ surveys

2. Before the team leaves the patient’s bedside Developed and validated by a large global collaboration, the WHO Trauma Care Checklist is appropriate for use in any emergency care setting and can be easily adapted to local context. Department for Management of NCDs, Disability, Violence and Injury Prevention World Health Organization |Avenue Appia 20 | 1211 Geneva, Switzerland emergencycare@who.int

Annex I

Trauma Care Checklist Immediately after primary & secondary surveys: Before team leaves patient: IÝ ¥çÙ㫛٠ƒ®Ùóƒù ®Äã›Ùò›Äã®ÊÄ Ä››—›—? May be needed if: • GCS 8 or below • Hypoxaemia or hypercarbia • Face, neck, chest or any severe trauma ù›Ý, —Êě ÄÊ IÝ ã«›Ù› ƒ ã›ÄÝ®ÊÄ ÖěçÃÊ-«ƒ›ÃÊã«Êكø? ù›Ý, ‘«›Ý㠗ك®Ä Ö½ƒ‘›— ÄÊ IÝ ã«› Öç½Ý› Êø®Ã›ã›Ù Ö½ƒ‘›— ƒÄ— ¥çđã®ÊĮĦ? ½ƒÙ¦›-Êٛ IV Ö½ƒ‘›— ƒÄ— ¥½ç®—Ý ÝãƒÙ㛗? ù›Ý ÄÊ㠃òƒ®½ƒ½› ù›Ý ÄÊ㠮ė®‘ƒã›— Fç½½ ÝçÙò›ù ¥ÊÙ (ƒÄ— ‘ÊÄãÙʽ Ê¥) ›øã›Ùă½ ½››—®Ä¦, ®Ä‘½ç—®Ä¦: ݑƒ½Ö ƒ‘» ֛ٮěçà AÝݛÝݛ— ¥Ê٠֛½ò®‘ ¥Ùƒ‘ãçٛ ù: ›øƒÃ ø-كù ‘ã AÝݛÝݛ— ¥ÊÙ ®Äã›Ùă½ ½››—®Ä¦ ù: ›øƒÃ ç½ãكÝÊçė ‘ã —®ƒ¦ÄÊÝ㮑 ֛ٮãÊěƒ½ ½ƒòƒ¦› IÝ Ý֮ă½ ®ÃÃʐ®½®þƒã®ÊÄ Ä››—›—? ù›Ý, —Êě ÄÊ㠮ė®‘ƒã›— ù›Ý IÝ ã«› փ㮛Äã «ùÖÊ㫛Ùî‘? ù›Ý, óƒÙîĦ ÄÊ DÊ›Ý ã«› փ㮛Äã 웗 (®¥ ÄÊ ‘ÊÄãك®Ä—®‘ƒã®ÊÄ): çٮăÙù ‘ƒã«›ã›Ù ăÝʦƒÝãÙ®‘ ã琛 ‘«›Ý㠗ك®Ä HƒÝ 㫛 փ㮛Ä㠐››Ä ¦®ò›Ä: ã›ãƒÄçÝ òƒ‘‘®Ä› ƒÄƒ½¦›Ý®‘Ý ƒÄ㮐®Êã®‘Ý ÄÊě ®Ä—®‘ƒã›— Hƒò› ƒ½½ ã›ÝãÝ ƒÄ— ®Ãƒ¦®Ä¦ ››Ä ٛò®›ó›—? ù›Ý ÄÊ, ¥Ê½½Êó-çÖ Ö½ƒÄ ®Ä Ö½ƒ‘› ÄÊě ®Ä—®‘ƒã›— W«®‘« ݛٮƒ½ ›øƒÃ®Äƒã®ÊÄÝ ƒÙ› 웗›—? ěçÙʽʦ®‘ƒ½ ƒ—Êîă½ òƒÝ‘罃٠ÄÊě P½ƒÄ Ê¥ ‘ƒÙ› —®Ý‘çÝݛ— ó®ã«: փ㮛Äã/¥ƒÃ®½ù ٛ‘›®ò®Ä¦ çÄ®ã ÖٮÃÙù 㛃à Ê㫛٠Ý֛‘®ƒ½®ÝãÝ Ù›½›òƒÄã ãكçà ‘«ƒÙã ÊÙ ¥ÊÙà ‘ÊÃÖ½›ã›—? ù›Ý ÄÊ㠃òƒ®½ƒ½› N›çÙÊòƒÝ‘罃٠ÝãƒãçÝ Ê¥ ƒ½½ 4 ½®ÃÝ ‘«›‘»›—? ÄÊ㠃òƒ®½ƒ½› óóó.ó«Ê.®Äã/›Ã›Ù¦›Ä‘ù‘ƒÙ›