Part Two
- Expected Events Policy
Screening process policy to determine patients' needs for medical and nursing care
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Politics :
The hospital is committed to conducting a priority assessment of patients' needs for therapeutic and nursing services when admitting the patient to the hospital and the appropriate department for the patient's condition
The purpose :
Providing medical care to the patient appropriate to his condition and in accordance with priorities and clinical work guides (therapeutic, diagnostic, palliative) when the patient is admitted to the inpatient department of the hospital.
Working procedures:
The department's nursing staff members are responsible for conducting the initial nursing assessment of the patient's condition, using the nursing staff evaluation form.
The responsible department nursing staff performs the pain assessment according to the pain assessment form
The nursing staff responsible for the case develops a nursing care plan according to the nursing assessment and documents it in the nursing plan form.
The responsible nursing staff members in the department contact the specialist doctor and inform him of the patient’s condition
The specialist doctor reviews the medical history, completes the medical examination, and determines the patient’s needs for medical care
The specialist doctor develops a treatment plan for the patient according to the priorities and treatment protocol for the case, which includes:
Necessary tests - Required tests
Treatment is according to the treatment description form
Required follow-up and observation - Any other instructions
The responsible nursing staff implements the treatment plan in the examination and research form, specifying the timing of the request and the hour of implementation.
Administrator :
· The treating physician - members of the nursing staff in the department
Models:
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The Reviewer :
Approved Egyptian accreditation standards.
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Policy: The hospital is committed to informing and informing the patient and his family upon admission of the necessary information to make the appropriate decision to treat the patient
Purpose: To determine the information that is given to the patient and his family upon admission to the hospital, which helps in making the appropriate decision to treat the patient, ensures the preservation of patients’ rights, facilitates the period of stay and obtaining the required medical care, and informs patients of their responsibilities towards the hospital, which achieves the satisfaction of patients and their families.
Working procedures:
1. When the patient enters the hospital, the receptionist or admission office employee introduces the patient and his family:
· Patients’ Bill of Rights - Patients’ Duties and Responsibilities Document
· Hospital instructions regarding visits, food and/and no smoking
2. The receptionist/admission office informs the patient of the cost of accommodation and treatment and reviews the price list, in accordance with Ministerial Resolution No. 186 of 2001.
3. The treating physician acquaints the patient/his family with the necessary information that will help them make an informed decision, which includes:
· Nature of the disease and diagnosis - Suggested treatment steps
· Expected outcome of treatment - Planned date of discharge from hospital
Responsible: The attending physician - members of the nursing staff in the department
References: Approved Egyptian accreditation standards.
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Policy for dealing with patients in the event that there is no available place for the required medical service
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Policy: The hospital is committed to finding an alternative solution for the patient in the event that there is no place for the required service in the hospital
Purpose: To know how to act in the event that there is no room for the required service in the hospital
Working procedures:
1. When a case is discovered for which there is no available place to provide the required medical service in the hospital, the treating physician provides
Provides first aid to the patient and writes a report on the condition
2. The hospital helps the patient and his family to find an alternative place, through the emergency department and the directorate, and provides a report to the patient’s family about the situation.
3. After confirming the approval of the hospital to which the transfer will be made, the doctor responsible for completing the transfer procedures
Providing an equipped means of transportation suitable for the patient’s condition
4. The treating physician writes the specific data in the referral form and keeps a copy of it and attaches it to the report
The patient’s condition and providing an appropriate companion for the patient
5. The treating physician provides medical instructions to the patient and those accompanying him during transportation
Administrator :
· The attending physician - Nursing staff members
Models:
Conversion form
The reviewer :
· Approved Egyptian accreditation standards.
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Coordination and cooperation policy between all departments (including doctors and nurses)
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Politics :
The hospital is committed to providing means of coordination and cooperation between all departments
The purpose:
Know how to coordinate the provision of medical care to all patients
Working procedures:
1-Coordination between doctors and nurses
Nursing staff implement doctor's orders in a timely manner
Recording the delivery and receipt for each category and implementing the required follow-up and orders
Medical consultation
2-Coordination between departments during transportation or requesting diagnostic services:
Use policies that determine the appropriateness of transferring a patient within a hospital between:
Surgical and non-surgical treatment services after medical consultation and acceptance of the case
Diagnostic services and therapeutic services S1-DS18
Emergency services and internal department.
Administrator :
The attending physician - the department’s nursing staff members
The director, his deputy or the administrative representative
Models:
Conversion form
The reviewer :
Approved Egyptian accreditation standards.
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Policy for terminally ill patients
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Purpose: To provide medical services of a special nature to a terminally ill and near-death patient that keeps him free from pain while providing psychological, social and spiritual support to the patient and his family.
Procedures:
· The treating physician signs a thorough medical examination and carefully reviews the patient’s file, including analyses, x-rays, and examinations, to determine the patient’s final condition.
· The treating physician presents the results of the clinical examinations and analyzes to the consultants in the appropriate specialties to determine the patient’s health condition and ensure the futility of any progressive treatment provided to him.
· After the consultants decide that this condition is incurable, a list of the symptoms accompanying the patient and how to treat them is written so that the patient is in a healthy state free of pain, even if this requires general anesthesia for the patient (see AP.15)
· The patient’s family is interviewed and the case is explained in detail by the consultants and the director of the unit caring for them, and moral support is provided to them conduct health education for them on how to deal with the condition
· The hospital is committed to providing and facilitating social support by consulting the citizen service office employee and providing the opportunity for the patient, if he requests, to have a clergyman attend for religious and spiritual support for the patient or his family.
Administrator :
· The treating physician and the treating consultant
· Citizen Service Office employee
The Reviewer :
· Egyptian quality standards
· Joint Commission International standards
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Patient transfer, referral and discharge policy
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The Purpose :
Definition of what is meant and the cases in which the patient is transferred/transferred/discharged.
Establishing the foundations that ensure maintaining the patient’s security and safety and identifying those responsible for transferring, referring and discharging the patient inside and outside the hospital.
The Definition :
Patient transfer is the formal transfer of responsibility for patient care from:
One care unit to another.
One medical service to another
One specialist doctor for another
One institution to another
· Patient transfer
The person is sent from:
One doctor to another or one specialist
One department or service to another or different resources either for advice or care that is not provided by the referring entity or because it is not qualified to provide this service.
· Patient discharge
The hospital is committed to maintaining the patient’s security and safety and identifying those responsible during the process of his transfer, referral, or discharge from the hospital.
The patient is discharged to home
Working procedures:
First: Planning for transfer or transfer of the patient and discharge when developing a treatment and care plan for the patient
The treating doctor develops a medical care plan for the patient upon his admission to the hospital, completes the medical examination and the required tests, diagnoses the condition, and provides first aid to the patient.
The patient's need for transfer or referral is determined when developing a medical care plan for the patient according to his condition and to ensure continuity and continuity of medical care.
The patient's medical care plan must include the patient's planned discharge date
Second: Discuss the reason for the referral/transfer/discharge of the patient with the patient and his family
The treating physician explains the reasons for making the transfer/referral/discharge decision to the patient and his family
This is done when a decision is made, when a treatment plan begins to be developed, or when clinical and diagnostic results appear that are not available in the hospital
The doctor records the reason for transferring or transferring the patient inside or outside the hospital in the medical file
Third: Follow the correct and safe methods when transporting or referring a patient
The doctor records the required procedure within the patient’s medical file and ensures that all file data is completed, mentioning the reason for referral/transfer/or the patient’s condition upon discharge.
In the case of referral, the referral form is completed explaining the patient’s condition/reason for referral/required procedure
In the case of consultation, the consultation form is completed in accordance with the Medical Consultation Policy PA 6
The method of transporting/referring the patient is determined according to his health condition
When transporting/transferring a patient using a wheelchair or bed, the following measures must be taken:
Check the bed/chair and ensure its safety
Make sure the sides of the bed are in place
The department supervisor contacts the referral/transfer location to ensure the availability of the required service for the patient, and the time and result of the call are documented in the nursing status book in the case of internal referral/transfer.
The responsible nursing staff notifies the admission office and hospital accounts to take the necessary measures for the transfer/transfer/discharge process
Nursing staff members review the patient's complete data and ensure that the recorded data is correct.
Fourth: Transferring a patient to another facility, cases of referring a patient to another facility:
In the event that the service is not available in the hospital.
Patient's request for transfer to another facility
The specialist doctor provides first aid to stabilize the patient's condition, if necessary.
The specialist doctor determines the patient's condition.
The specialist doctor notifies the patient or his companions that the necessary service is not available for the patient in the hospital.
The treating physician ensures that there is a suitable place for the patient’s condition before transferring him by contacting the place receiving the patient and explaining the patient’s condition.
The treating physician notifies an ambulance to transport the patient, accompanied by the ambulance doctor and ambulance nurse, or transport the patient according to his desire after writing an acknowledgment from him or his family.
The treating physician completes the patient referral form
The nursing staff and the ancillary services worker transport the patient in a safe manner as mentioned previously.
The nursing staff ensures that a copy of the patient’s examination, procedures performed, research results, diagnoses, and treatment are sent with him to the place he is transferred to.
Fifth: Discharge of a patient:
When the patient's medical condition improves and stabilizes, the consultant/specialist determines the patient's discharge date, the treatment plan at home, the type of nutrition, and the follow-up date in the outpatient clinic.
The doctor completes the discharge form for the patient and completes all data in clear writing, and the patient is given the original discharge form and keeps a copy in the file.
The specialist doctor explains the instructions that will be implemented during the recovery period to the patient and his family, including how to take medications, how to deal with the medical condition, ways to obtain rehabilitative services, methods of proper therapeutic nutrition, and follow-up appointments in the outpatient clinic.
The nursing staff gives the patient his discharge form
The department supervisor ensures that the financial settlement is completed.
The nursing staff removes the cannulae from the patient's hand, if any, before leaving the department.
The nursing staff reviews the patient's discharge plan to determine his method of discharge
The assistive services worker transports the patient from the department using a wheelchair or a trolley according to the patient’s need until the patient is discharged.
Responsible for implementation:
the doctor
Nursing staff members in the department
Service worker
Models:
Checkout form
Conversion form
The Reviewer :
· Approved Egyptian accreditation standards
· Regulations and laws
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Hospital medical emergency response policy
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The Purpose:
Preparing departments to deal with emergency situations that require emergency dealing, and developing a system to respond to emergency calls.
procedures:
The nursing supervisor of each department prepares an emergency vehicle with life-saving medications and tools according to the attached list that specifies the components and arrangement of the emergency vehicle, provided that the vehicle is close and available for use 24 hours a day.
The supervisor of each department reviews these carts daily
The hospital's pharmacists' department assigns a pharmacist to visit the emergency vehicle and verify its contents and suitability on a daily basis.
The medications used from the emergency vehicle are replaced immediately after they are used from the emergency cabinet of the department that used them. If these medications are not available in the emergency cabinet of any department, they are replaced from the intensive care emergency cabinet until they are dispensed from the hospital pharmacy.
The hospital (training officer) is committed to providing training sessions on cardiorespiratory resuscitation for all employees (doctors and nurses) in the hospital on a one-day basis every two years. Those who have obtained the training certificate are given a certificate stating this, and their direct supervisor is responsible for monitoring the workers’ obtaining the training courses.
Any hospital employee who suspects a case of cardiac arrest calls the cardiorespiratory resuscitation team by telephone to the intensive care unit and members of the nursing staff in the department or by using the switch to make a call and mention the department/department and the number of the room to which you want to move.
The department's nursing staff calls the rest of the team if the switch is not available.
In cases of cardiac arrest that occur in intensive care, the care physician is called and the cardiorespiratory resuscitation team is not requested unless the care physician requests it, and his responsibility is to supervise the patient’s resuscitation.
In cases of cardiac arrest that occur in operating rooms and units where the patient is supervised by an anesthesiologist, the cardiorespiratory resuscitation team is not called unless the anesthesiologist requests it, and he is responsible for supervising the patient’s resuscitation.
The first person to reach the patient performs cardiac resuscitation.
The case doctor is responsible for explaining the medical condition, reviewing the patient’s files, and informing the team leader of any information he needs. He also participates in performing cardiac resuscitation. He is responsible for communicating with the patient’s family, informing them of developments in the patient’s condition, and involving them in any medical decision that requires their participation.
Intensive care nursing staff members are responsible for giving medications and taking samples requested by the team leader and assisting the rest of the team members according to the team leader’s instructions.
The department's nursing staff members are responsible for recording the events of cardiac arrest, the dates for administering medications, the shape of the heartbeat, and the time the heart returns to beating on the form designated for that purpose. They are also responsible for giving breathing to the patient in the manner determined by the team leader.
The security personnel provides the appropriate atmosphere for the team's work and is present when informing the patient's family of any developments in his condition.
Work must be done to provide care facilities on an ongoing basis to receive post-cardiac arrest cases that may occur in hospital floors, after first aid has been provided in the internal department and his condition has been stabilized.
The medical team in the care is trained to respond quickly and immediately when called upon, and all members of the medical team must be present in the room where the emergency is and deal with the case in accordance with the cardiorespiratory resuscitation policy.
The call system is tested unexpectedly by the unit manager/hospital quality coordinator to ensure that doctors and nurses respond to the call, and the time between call and response is calculated as a form of performance evaluation within the unit, with the results reported to the hospital quality coordinator.
Cardiopulmonary resuscitation is performed according to the attached protocol.
All hospital employees are trained to deal with cardiac arrest cases (basic level), while care and anesthesia doctors are trained at the advanced level.
Administrator:
· All hospital employees
· CPR team
Models:
· Table of contents and arrangement of the emergency vehicle
· Monthly CPR team schedule
· Cardiorespiratory resuscitation protocol
The Reviewer:
· Egyptian quality standards.
· Cardiorespiratory resuscitation protocol
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Health education policy for patients and their families
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Politics:
Providing health education to patients visiting the hospital and their families ensures that patients are provided with important information that will help them recover and protect them from diseases when they enter the hospital, during their stay in the hospital, and after discharge. This is evident in the hospital’s commitment to educating the patient and his or her family related to the following:
Pathological diagnosis of the patient
Tests, diagnostic examinations and treatment
Use of medications and possible side effects
nutrition
Interactions between food and medicine
Physical therapy and rehabilitation
Special information on how to reduce the risk of diseases through nutrition
The harms of smoking and the need to avoid active and passive smoking
Exercise and health-related behaviors
The relationship between the patient and society
Exit and follow-up instructions
The Purpose:
Improving health care outcomes by educating the patient and his family to assist in recovery and raising the value of healthy behavior by providing health information about the various medical specialties necessary for the patient.
Procedures:
· According to Professional Ethics Regulation No. 238 of 2003, health education for patients and their families is considered one of the duties and responsibilities of the doctor and the medical team.
· The treating physician and the responsible nursing staff use a special record/form to educate patients and their families.
· The treating physician and the nursing staff responsible for the patient’s medical service evaluate the patient’s educational level and determine the educational needs upon admission of the patient.
· Any department participating in the educational seminars records its own seminar with its signature and date in the patient educational record
· If abbreviations are used, an explanation is provided for each abbreviation to clarify the information.
· The treating physician and the responsible nursing staff ensure that the patients’ educational record contains the type of information provided to the patient, to whom the information was provided, the extent of the response of the patient or his family, and a summary of the educational session that was conducted for the patient.
· The treating physician and the responsible nursing staff ensure that the forms for the departments participating in the educational seminars are placed in the patients’ educational record.
· The treating physician and responsible nursing staff ensure that the patient’s questions are given the opportunity.
· The treating physician and the responsible nursing staff ensure that the patient understands the discharge instructions and follow-up steps, and this is recorded in the patient’s file.
· The hospital provides a special place for patients in the internal departments and outpatient clinics to receive educational seminars.
· The hospital is committed to developing a unified educational material for chronic diseases/dialysis patients.
Administrator:
· Physician
· Members of the department’s nursing staff
· Medical provider from any department involved in patient education
Models:
· Patient and family education model
The Reviewer :
· Regulations of professional ethics
· Egyptian quality standards.
Preparation Review The Trust