Second part

- General Policies

- A brief overview of the policies

The policies that will be presented are just a model, and the hospital has the right to make the policy in accordance with its work system.

The policy is reviewed every three years unless there is any change in it during those three years.

At the beginning of each policy, fill out the table as follows:

At the end of each policy, fill out the table as follows:

Evaluation policies

Evaluation areas and content policy according to each department

Politics :

 The hospital is committed to clarifying the areas and contents of the evaluation according to each department.

The Purpose :

 Clarifying the areas and contents of the evaluation according to each section, which helps provide appropriate medical care to the patient, reach an accurate diagnosis, and develop a treatment plan.

Working procedures:

 First: The treating physician:

1- The initial patient evaluation must include identifying the personal history, the patient’s complaints, and the patient’s family history.

2- The initial patient evaluation must clarify the patient’s medical history and medical examination, which includes (vital signs - examination of body systems according to specialty and condition).

3- Review the results of any evaluation performed on the patient outside the hospital (medical report) before admitting the patient for treatment inside the hospital.

4- Identify the patient’s previous treatments and the extent of his response to them in order to:

·  Determine the initial diagnosis.

·  Determine the research required for the patient.

·  Develop an appropriate treatment plan.

·  Identify the patient’s medical care needs and choose the best care for him.

5- The doctor re-examines the patient clinically after reviewing the patient’s complete medical history, within 24 hours of the patient’s admission to the hospital, according to the medical history and medical examination form.

6- Each of the departments determines the content of the medical evaluation according to the specialty and clinical work guides (heart, women, dialysis, premature infants).

7- The doctor records the diagnosis, examination results, and medical history in the patient’s file and signs it with the date and time.

8- The doctor re-evaluates the patient based on the results of the tests and examinations and the progress of his health condition. He registers and signs, writing the date and time in the patient’s file.

Secondly, nursing:-

· The nurse evaluates the patient upon admission to the hospital using the nurse evaluation form.

· The initial information and data are recorded when the patient enters the department on the nurse’s patient evaluation form:

-   Vital signs (pressure - pulse - respiratory rate - temperature).

-   Weight and height.

-   Having an allergy.

-   Pain assessment

-   Evaluation of skin condition

-   Assess the patient regarding the possibility of a fall

-   Nutritional assessment.

-   Evaluation of motor activity.

-   The patient’s need for restraint or isolation.

-   Informing the patient of his rights, responsibilities, and hospital policy within 24 hours of admission.

Third, anesthesia:

The anesthesiologist evaluates the patient's condition:

1- Before administering anesthesia according to a pre anesthesia sheet form showing the type of anesthesia planned.

2- Observing and evaluating the patient during anesthesia according to the form prepared for this purpose.

3- Evaluate the patient before leaving the recovery room according to the recovery model.

Fourth: Physiotherapist (evaluation of motor, functional, and rehabilitative activity in case the patient needs it).

 Fifth: The treating physician evaluates the nutritional needs of patients, especially the cases that are sorted according to the nursing evaluation upon admission.

Sixth: The social worker, according to his job description (he verifies patients’ satisfaction, and conducts social research when the patient needs financial, material, educational, or social support).

Responsible: 

Doctor - Nurse - Social Worker.

Forms: 

(medical report - patient ticket - emergency form - nursing evaluation - anesthesia sheet - physical therapy form - patient satisfaction questionnaire).

References:

 Egyptian Accreditation Standards 2013.

Timeframe policy for completing the assessment

Minimum frequency policy and re-evaluation content

Policy: 

Re-evaluation of patients in critical and non-critical cases that require long-term (chronic) treatment.

Purpose: 

To ensure that patient care and assessment are properly monitored and continued

Working procedures :

First: In acute cases (critical units):

The treating physicians in the departments evaluate and determine the following

1-    Degree of awareness and awareness.

2-    Vital signs.

3-    The occurrence of complications.

4-    The results of the tests and treatment or (surgical interventions).

5-  The extent of response to treatment.

o       The nursing evaluation rate is continuous, and the alternate doctor is called when a critical result is issued (physiological - laboratory - x-ray) and when there is pain, and the doctor re-evaluates.

o     The re-evaluation of the patient is documented and a follow-up note is recorded at least once per shift (every 24 hours), and any procedures resulting from a call or emergency or important events for the patient are recorded with the date and hour.

Second: In non-acute cases:-

Treating doctors evaluate patients in non-acute cases and ensure...

·      Vital Signs .

·      Complications occur

·      The results of the tests and treatment

·      Patient compliance with treatment and medical instructions.

This is done every 12 hours for the internal department by the specialist or doctor on duty, unless the clinical evidence requires less than that and this is documented in the patient’s file.

Third: Conditions that require long-term treatment (chronic diseases)

The doctors treating the departments that care for patients who need long-term or (chronic) treatment ensure that:

·      Vital Signs .

·      Complications occur.

·      Results of  tests and treatment.

·      The extent of the disease.

The frequency of re-evaluation shall be once a day by the doctor on duty or as required by clinical evidence and documented in the patient’s file.

1.       The specialist doctor re-evaluates the patient from various specialties while the patient is in the hospital to determine the extent of the response to the treatment and its effectiveness.

2.    The on-duty nurse re-evaluates the patient each shift to determine the patient’s needs.

Fourth: Cases that need to be re-evaluated

·      The treatment plan developed for the patient         Individualized care plan

·      Change in patient  condition

·      Diagnosis                                               Patient diagnosis

·      Expected outcome of care, treatment or service

·      The extent of the patient’s response to previous treatment

3.    The re-evaluation is documented in the patient’s file

The patient should be re-evaluated immediately before anesthesia is administered

Fifth: Content of re-evaluation for nursing

1-    Vital signs: every 6 hours in inpatient departments, every 2 hours in care and premature care, after blood transfusion, before surgical operations, during recovery, and when the patient complains that requires re-measurement, or according to the doctor’s instructions.

2-    Pain:

3-    The possibility of the patient falling: every shift.

4-    Skin condition: all skin color during recovery.

5-    Nutritional evaluation: when the patient needs it according to the doctor’s orders.

6-    Measuring blood sugar: according to the doctor’s instructions.

7-    The patient’s need for restraint or isolation: according to the doctor’s orders.

Forms:    Medical follow-up form.

References: Egyptian Accreditation Standards 2013

Pain assessment, re-evaluation and management policy

Policy:  

The hospital is committed to a process of assessment, re-evaluation and pain management.

Purpose: 

To explain the process of assessing, re-evaluating, and treating pain.

Procedures :

1-    The responsible nurse assesses the pain (according to the following table), determines its severity, describes the pain and its frequency by asking the patient and looking at the patient’s facial expression (in the event that he is unable to speak or in the event that he is a child), and this is recorded in the pain assessment form and kept in the patient’s file when Admission of the patient to the hospital.

10	8	6	4	2	0	Class
Not possible	Intense	[Medium	Basic	Weak	X	The patient's feeling of pain
Perfect	Big	Medium	Basic	X	X	Pain hinders the patient's normal movement
						Term

2-    The treating physician develops a pain treatment plan and records this in the patient’s medical file.

3-    The responsible nurse implements the treatment and follow-up plan according to the pain model and the doctor’s instructions.

4-    The responsible nurse re-evaluates the pain and records it in the previous form and completes it with each nursing shift. It is possible to re-evaluate more than that depending on the patient’s condition:

1.    The charge nurse reassesses pain once before surgical operations, after surgical operations, once every hour for 3 hours, then every shift, or according to the doctor’s orders.

2.    The charge nurse reassesses pain if pain is present and one hour after pain medication is given.

Responsible: Nursing staff members - Doctor.

Forms  : Pain Assessment Form   .

References:-  Approved Egyptian Accreditation Standards 2013

Attachments : Clinical evidence for the indications for medications used to treat pain

- Nursing plan policy

- Medical files (anticipated events policies)

Policy for uniform and consistent content of the patient's medical file

Policy: 

Staff familiarity with the established composition of the patient’s medical record.

The Purpose :

·   Having a medical record for every patient examined and treated.

·   The fixed composition of the patient’s medical record contains sufficient information such as:

◾ Identify the patient by name - address - file number.

◾ Allows continuity of care.

◾ Confirm the diagnosis.

◾ Justifications for treatment.

◾ Documenting treatment steps and results.

·   The components of hospital patient medical records are standardized and have a specific format, and doctors and nurses are committed to using the forms optimally and containing:

 ◾ Writing treatment orders in a unified manner and in the same place.

·   Department nurses are obligated to familiarize the patient with all patient record forms, which contain:

  ◾ Patient’s name in quadruplicate - standard number

·    It is done with examination reports, rumors, the medical report, and a copy of the discharge summary in the patient’s file.

·   The medical team corrects or amends one of the data recorded in the medical record by placing parentheses around the inaccurate data, taking into account ensuring that it is still readable, signing in front of him, and recording the date and time of making the correction, as it is not permissible to erase or delete incorrect data.

·   Availability of data related to consultations as evidence that the consulting physician reviewed the patient’s medical record and the results he reached when conducting the medical examination on him, as well as the consulting physician’s opinion and recommendations.

·   Issuing verbal diagnostic and therapeutic orders to a qualified nurse. The orders must be signed within twenty-four (24) hours, and all orders must bear the date, time, signature, and procedures applied.

·   The clinical data recorded in the medical record and any other data and signatures are clear and legible.

·   Send a referral form with the patient when he is transferred to another hospital, while keeping a copy in the patient’s file.

·   Giving the patient a discharge summary with complete information.

Procedures:

Nurses ensure that the file contains the following data upon entry:

·   Patient’s full name - uniform number - age.

·   Name, address and telephone number of a relative of the patient or someone who can be contacted in case of emergency.

·   Nurses do the following:

·   Writing the patient’s name in full and his uniform number on all pages of the medical file.

·   Recording the vital signs and medical condition of the patient in the vital signs record and the nurse’s notes record

·   Modify the treatment implementation plan according to the doctor’s amendment on the doctor’s orders page.

·   Doctors do the following:

·   Complete the patient examination record and the record contains the following data:

·   The type of allergy the patient suffers from, if any.

·   Whether the patient suffers from any chronic infectious disease such as hepatitis.

·   Diagnosis when the patient enters the hospital.

·   The patient’s complete medical history: previous, current, and family medical history.

·   A detailed statement of the patient’s clinical examination, a statement of the results drawn, and the action plan.

·   Mention the results of laboratory tests and x-rays

·   Write the type of treatment applied clearly on the doctor’s orders page.

·   Request all required examinations or tests on the clinical progress page

·   Recording all types of follow-up, consultations, and routine and special treatments appropriately in the appropriate forms.

·   Take notes on the development of the condition at least daily for patients with serious conditions, as well as for patients whose conditions are difficult to diagnose or control their clinical problems. Notes of the development of the condition must also be recorded at the time of the observation to allow for continuity of care and the possibility of transferring the patient from one department to another. Also, as much as possible, it must be determined Each problem that the patient suffers from should be clearly stated in the case progress notes and linked to the orders issued regarding it, as well as the results of examinations and treatment. On the other hand, comprehensive notes about the development of the condition during the surgical procedure and immediately after the completion of the surgery must be recorded in the record. This is done for the purpose of providing correct information for use by any caregiver who subsequently assumes responsibility for caring for the patient

·   Writing all surgical reports immediately after the end of the surgical operation, provided that they include the patient’s full name, medical file number, date of the surgical operation, diagnosis before and after the surgical operation, the name of the surgeon and his assistant, the name of the surgical operation, and a detailed statement of the results and methods used during the operation and anesthesia. The samples taken, the amount of fluid secreted, complications, reasons for surgery, and the patient’s condition before the operation.

Writing a summary of discharge or death in all medical files of patients admitted to the hospital, which includes:

 ◾ Entry and exit dates.

 ◾ Initial diagnosis - final diagnosis.

 ◾ Analysis.

 ◾ Actions taken.

 ◾ Medical drugs and other treatments.

 ◾ The patient’s condition and the next stop upon discharge.

 ◾ Discharge instructions, including food, medication, and follow-up instructions.

 ◾ The name of the doctor who discharged the patient.

Complete the referral form as follows:

 ◾ Reason for referral

 ◾ The required means of transportation and follow-up

 ◾ Description of the case

 ◾ Next stop

The emergency patient's medical file contains:

 ◾ Patient arrival time and discharge time.

 ◾ Final results at the end of treatment.

 ◾ The patient’s condition upon discharge.

 ◾ The patient’s destination upon discharge.

 ◾ Medical care instructions for patient follow-up.

 ◾ Documentation of the discharge order from the treating physician.

Responsible: 

Nursing and medical staff members.

Forms: 

Patient records - content of the medical file for each department.

References: 

Ministry of Health Medical Records Guide.

The policy of who has the authority to write in the patient’s medical file

Policy: The medical team, including nurses and treating doctors, is authorized to write in the patient’s medical file their names, clear and legible, and their job titles, provided that the information is clear and in legible handwriting, with the date and hour written.

Purpose: Determine who has the authority to write in the medical file.

Procedures:

·   When recording their performance in patient files, nurses are obligated to write their names (first name) and record the date and hour.

·   When registering in patient files, doctors are obligated to write their names (first and last names), use clichés, and write the date and time.

·   All research, examinations, and treatments requested for the patient must be signed by the treating physician, with his name written in triple and his stamp.

·   The person performing the medical tests and x-rays signs the results of the tests and x-ray reports with his or her full name and the date and hour.

Administrator:

Nursing and medical staff members.

The policy of who has the right to view the patient’s medical file to ensure the confidentiality of the information

Politics:

·      The medical record is considered a legal document, and therefore its confidentiality must be maintained, and this confidentiality is the basis of the legal aspect of the medical record.

·      Establish controls to maintain the confidentiality of information and determine who has the right to view the medical record and what data they are permitted to view.

Purpose: 

To maintain and protect the confidentiality of patient information and data.

Procedures:

·      All hospital employees sign a declaration of confidentiality of patient information.

Circumstances in which access to information in the medical file is permitted:

·      If the file is requested from the medical team to view the patient’s examinations or information of clinical value, the doctor writes a request to extract the previous file in the current file, and the doctor signs it clearly and with the date, then submits the file to the medical records official to extract the medical file.

·      In the event that the sick applicant is himself, his legal representative, or external parties such as (the Administrative Prosecution - the Public Prosecution - Inspection Bodies - the Ministry of Health), the hospital director or medical director shall review the request and provide the information in one of the following ways:

◾        Orally.

◾         An exact copy of the file.

◾        Summary of the case.

◾         The original file. In this case, a representative from the hospital will refer the file and return it after the decision on it is completed.

·      If the patient is transferred to another hospital, the specialist doctor fills out the transfer form, which includes a summary of the case (diagnosis - reason for transfer).

·      In the event of requesting a medical report on a case, the patient or his legal representative submits an oral request to the official of the Medical Records Office to contact the treating physician to write the report on the case. This is done on the same day and delivered to the applicant.

·      The hospital has the right to withhold some medical information about the patient in the event that the information represents harm to the patient, such as (  the patient’s knowledge of the nature of the patient’s medical condition may affect his psychological state and lead to the deterioration of his condition).

·      List of persons authorized to view the hospital’s medical file:

◾         The doctor responsible for the case.

◾         Doctors from other departments who are consulted about the patient’s condition.

◾         The nurse in charge of the case.

◾         The patient or his legal representative with the authorization of the patient.

◾         Hospital Director.

◾         Medical Director  .

◾         Quality and performance improvement coordinator.

◾         Judicial and supervisory authorities and the Ministry of Health when needed.

◾         Medical statistics officer.

◾         Accounts Officer.

Responsible: All hospital staff.

Forms: Declaration of confidentiality of information

Policy for protecting medical records and information from loss, damage, tampering, and unauthorized use or access

Policy: Protect medical records and information from loss, damage, tampering and unauthorized use

Purpose: To ensure that the medical file is preserved from loss or damage and to ensure that the patient’s medical information is preserved so that it can be retrieved when needed.

Procedures:

The hospital’s medical records room meets the following specifications:

·      Ventilation is adequate.

·      Lighting is sufficient.

·      Protection against fires.

·      Intact storage shelves.

·      Offices for employees.

·      Entry to the file storage area is not permitted to anyone other than authorized persons (patient affairs employees only).

·      The medical records office administrator files the patient's medical records on a shelf in the order of the month for each department.

·      The Medical Records Office official shall repair all records with loose papers or torn covers immediately before important information recorded in them is exposed to further loss or damage.

·      The official in the medical records office keeps all reports related to diagnosis, examinations, etc., such as medical reports, laboratory results, etc., in the medical file, except for x-rays, which are kept in the radiology department.

·      There is a record of requests recorded in the place where files are kept, which includes the borrowed files and the person borrowing the file from the persons authorized to view the file.

·      The medical records clerks assigned to work in the filing area are responsible for maintaining the cleanliness of the area and the proper ordering of files on the shelves.

Responsible : Medical Records Office

Policy for disposing of medical files and the duration of keeping records and files

Purpose: 

To clarify the disposal of medical files by legal means and to clarify the legal period for keeping records and files.

Politics:

·      Dispose of records within the specified period in accordance with regulations and laws.

·      Dispose of records completely to prevent anyone from viewing them or extracting identical copies of them.

·      Records may not be disposed of except based on an administrative order issued by the hospital director general.

Procedures:

·      Inactive medical records may be disposed of after a certain period of time determined by the Ministry of Health guidelines.

·      Records scheduled for disposal should be registered according to the patient's name, medical file number, and last date of activity.

·      Records must be completely destroyed to prevent anyone from viewing them or extracting duplicate copies of them.

·      The medical records official and clerk shall, on the first of December of each year, review the medical records to extract what has expired and is worthy of being permanently disposed of, in accordance with the guiding policies of the Egyptian Ministry of Health website.

·      The medical records officer shall keep all records related to lawsuits or other investigations of a confidential or serious nature and shall not dispose of them until after the lawsuits are completed.

·      The Medical Records Officer, on the first of January of each year, examines the discarded documents and after verifying the authenticity of the discarding, they are packed into bags by the department’s workers to be delivered to the Directorate of Health Affairs  for disposal in accordance with the ‘archives list’.

·      The following is the schedule for maintaining medical files and records.

The Reviewer :

·      Accredited Egyptian Accreditation Standards 2013

Policy of information given to the patient and family upon admission to the hospital

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, n. 8, and achieves 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:

·   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/or smoking ban.

·   The receptionist/admission office employee informs the patient of the cost of accommodation and treatment and reviews the price list, in accordance with Ministerial Resolution No. 186 of 2001.

The treating physician acquaints the patient and his family with the necessary information that will help them make an informed decision, including:

·   Nature of the disease and diagnosis.

·   Expected result of treatment.

·   Planned date of discharge from the hospital.

·   Suggested treatment steps.

Responsible: treating physician - nursing staff members.

Forms: Conversion form. 

References: Approved Egyptian Accreditation Standards 213

Patient management policy in the event that there is no available space for the required medical service

Policy: The hospital is committed to finding an alternative solution for the patient in the event that there is no room 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:

·      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  first aid to the patient and writes a report on the case.

·      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.

·      After confirming the approval of the hospital to which the transfer will be made, the doctor responsible for completing the transfer procedures shall.

·      By providing an equipped means of transportation suitable for the patient’s condition.

·      The treating physician writes the private data in the referral form and keeps a copy of it and attaches it to the report on the patient’s condition while providing an appropriate companion for the patient.

·      The treating physician provides medical instructions to the patient and his companion during transportation.

Responsible:  Attending physician          -  Nursing staff members

Forms : Conversion form

The Reviewer :

·      Accredited Egyptian Accreditation Standards 2013

The policy of coordination and cooperation between all departments 

(including doctors and nursing staff) through the internal departments

Policy: The hospital is committed to providing means of coordination and cooperation between all departments.

Purpose: To know how to coordinate the provision of medical care to all patients.

Working procedures:

·      Coordination between doctors and nurses.

·      Implement nursing and physician orders in a timely manner.

·      Record delivery and receipt for each category and carry out follow-up and required orders.

·      Medical consultation.

·      Coordination between departments during transportation or requesting diagnostic services:

·      Use policies that determine the appropriateness of transporting the patient within the hospital:

·      Surgical and non-surgical treatment services after conducting a medical consultation and accepting the case.

·      Diagnostic services and therapeutic services.

·      Emergency services and internal department.

Responsible : Attending physician         -   Nursing staff members

The director, his deputy or the administrative representative

Forms : Conversion form.

References: Egyptian Accreditation Standards 2013

Patient entry and exit policy

Policy: The hospital is committed to providing means of coordination and cooperation between all departments.

Purpose: To know how to coordinate the provision of medical care to all patients.

Working procedures:

·   Coordination between doctors and nurses.

·   Implement nursing and physician orders in a timely manner.

·   Recording the delivery and receipt for each category and implementing the required follow-up and orders.

·   Medical consultation.

·   Coordination between departments during transportation or requesting diagnostic services:

·   Use policies that determine the appropriateness of transporting the patient within the hospital:

·   Surgical and non-surgical treatment services after medical consultation and acceptance of the case.

·   Diagnostic services and therapeutic services.

·   Emergency services and the internal department.

Responsible: treating physician - nursing staff members

The director, his deputy or the administrative representative

Forms: Conversion form.

References: Egyptian Accreditation Standards 2013

Patient entry and exit policy

Policy: The hospital is committed to providing means of entry and exit for patients.

Purpose: Unifying the standards for entry and exit of patients to ensure a distinguished level of service without wasting capabilities or differentiation in the provision of medical service.

Procedures:

First: Login procedures:

·   The specialist of other specialized units is responsible for the decision to admit and discharge the patient after reviewing the consultant, if necessary, while adhering to the specifications included in the clinical work manuals approved by the unit director and compiled in the policy attachments.

·   The qualified anesthesiologist has the right to request a reservation for a patient if he discovers the patient’s need during the patient’s evaluation before elective surgeries. The physician notifies the existing specialist of the need for an empty bed for the patient on the day before the surgical operation.

·   The qualified anesthesiologist has the right to request that a patient be detained in intensive care if it becomes clear to him that the patient’s need is during the patient’s evaluation before urgent surgical operations. The treating physician notifies the specialist doctor in intensive care of the need for an empty bed for the patient before the patient enters the operating room.

·   The qualified anesthesiologist has the right to request that a patient be detained in intensive care if he discovers the patient’s need during the surgical procedure if an emergency occurs. The specialist physician in the intensive care unit shall be notified immediately.

·   The treating physician/anesthesiologist makes the request by filling out the medical consultation form.

·   The treating physician in any department must provide a medical consultation with the care physician if the patient’s condition meets the specifications for admission to intensive care.

Second: Specifications of leaving care

·   Stability of the patient's vital signs.

·   Respiratory rate stabilized and blood gas levels improved well.

·   The patient does not need medications that are difficult to administer outside intensive care, such as cardiac stimulants and others that are given intravenously using devices such as a solution pump and a solution syringe.

·   Accompanying cardiac arrhythmia and no serious heart disorders.

·   Stable nervous condition and no convulsions.

·   Removal of circulatory catheters.

·   The patient does not need high-level nursing services, such as care for a throat tube or a laryngeal incision.

Responsible: the treating physician - intensive care doctors - anesthesiologist - head of the premature infants department - head of the dialysis department

Models:

· Specifications established on a physiological and diagnostic basis for admission to intensive care.

· Specifications established on a physiological and diagnostic basis for admission of premature infants.

· Specifications established on a physiological and diagnostic basis for admission to dialysis.

The Reviewer :

· Egyptian Quality Standards 2013

Policy for terminally ill patients

Policy: The hospital is committed to providing medical services of a special nature to a terminally ill patient.

Purpose: Providing 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 careful 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.

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 - employee of the Citizens Service Office.

The Reviewer :

· Egyptian Quality Standards 2013 - Joint Commission International Standards 2014.

Patient transfer, referral and discharge policy 

Policy: 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.

Purpose: Defining what is meant and the situations in which a 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.

·   A specialist doctor for another.

·   One institution to another.

Patient referral is sending a person 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.

The patient is discharged 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 physician develops a medical care plan for the patient upon his admission to the hospital, completes the medical examination and 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: Discussing 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 making a decision, at the beginning of developing a treatment plan, 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 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.

The method of transferring/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:

·   Inspect 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 hour and result of the call are documented in the nursing status book in the case of internal referral/transfer.

·   The responsible nurse notifies the admission and hospital accounts office to take the necessary measures for the transfer/transfer/discharge process.

·   The nurse reviews the patient’s complete data and ensures 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 of the non-availability of the necessary service for the patient in the hospital.

·   The treating physician ensures that there is a place suitable 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 nurse and ancillary services worker transport the patient in a safe manner, as mentioned previously.

·   The nurse makes sure to send a copy of the patient’s examination, procedures performed, research results, diagnoses, and treatment...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 date of follow-up in the outpatient clinic.

·   The doctor completes the discharge form for the patient and completes all the 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 the method of taking medications, the method of dealing with the medical condition, ways to obtain rehabilitative services, methods of proper therapeutic nutrition, and follow-up appointments in the outpatient clinic.

·   The nurse hands the patient his discharge form.

·   The department supervisor ensures that the financial settlement is completed.

·   The nurse removes the cannulas from the patient’s hand, if any, before leaving the department.

The nurse 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 trolley according to the patient’s need until the patient is discharged.

Responsible for implementation:

· Doctor - nursing staff - service worker.

Models:

· Exit form - Transfer form.

The Reviewer :

· Egyptian accreditation standards approved 2013.

· Regulations and governing laws.

Hospital medical emergency response policy

Policy: The hospital is committed to responding to medical emergencies.

Purpose: Preparing departments to deal with emergency situations that require emergency dealing, while developing a system to respond to calls for emergency cases.

Procedures:

·   The nursing supervisor for each floor 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.

A female supervisor in each role reviews these vehicles 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 holding training courses on cardiorespiratory resuscitation for all employees (doctors and nurses) in the hospital on a one-day basis every two years. Those who have completed the course are given a certificate stating this, and their direct supervisor is responsible for monitoring the workers’ access to the courses.

·   Any hospital employee who suspects a case of cardiac arrest calls the cardiorespiratory resuscitation team by telephone to the intensive care unit and the floor nurse or by the switch to make a call and mention the floor/department and the room number to which you want to move.

·   The floor nurse 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.

·   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 cardiorespiratory resuscitation team consists of an intensive care physician, a care nurse, in addition to a case doctor, a floor/department or room nurse, and a security personnel (according to the established schedule).

·   It is the responsibility of the nurse to bring the emergency vehicle for the role in which the cardiac arrest occurred.

·   The team leader is the intensive care physician who is responsible for administering electric shocks, obtaining a clear airway and breathing, and participating in 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 the work of 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.

·   The intensive care nurse is 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 floor/department nurse is responsible for recording the events of cardiac arrest, the dates for giving medications, the shape of the heartbeat, and the time the heart returns to beating on the form designated for that. She is 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.

·   We must work to provide care places on an ongoing basis in order to receive post-cardiac arrest cases that may occur in the 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 suddenly by the unit director/quality coordinator in the hospital to ensure that doctors and nurses respond to the call and the time between the call and the response is calculated as a form of performance evaluation within the unit, with the results being submitted to the quality coordinator in the hospital.

·   Cardiorespiratory 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 staff - CPR team.

Models:

Table of contents and arrangement of the emergency vehicle

Monthly CPR team schedule

Cardiorespiratory resuscitation protocol

The Reviewer:

Egyptian quality standards 2013.

Cardiorespiratory resuscitation protocol

Health education policy for patients and their families

Policy: 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 family regarding 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 necessity of staying away from active and passive smoking.

·   Exercise and health-related behaviors.

·   The relationship between the patient and society.

·   Exit and follow-up instructions.

Purpose: Improving health care outcomes by educating the patient and his family to aid in recovery and upholding 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 nurse use a special record/form to educate patients and their families.

·   The treating physician, the responsible nurse, and the patient’s medical service provider evaluate the patient’s educational level and determine the educational needs upon admission.

·   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 nurse ensure that the patients’ educational record includes 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 nurse ensure that the forms for the departments participating in the educational seminars are placed in the patients’ educational record.

·   The treating physician and the responsible nurse make sure that the patient’s questions are given the opportunity.

·   The treating physician and the responsible nurse 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 to receive educational seminars for patients in the internal departments and outpatient clinics.

·   The hospital is committed to developing a unified educational material for chronic diseases/dialysis patients.

Administrator:

·   The treating physician - nursing staff - medical service provider from any department involved in patient education

Models:

·   Patient and family education model

The Reviewer :

·   Professional Ethics Regulations - Egyptian Quality Standards 2013.

- Unexpected events policies

Incident reporting policy

Policy: A policy that explains the system for reporting near misses/incidents that enable employees to report them in order to help in continuous improvement of performance.

Purpose: To provide an organized mechanism in the hospital to identify problems that lead to negative outcomes for patients, visitors, or employees in order to detect them early and prevent them from occurring.

Definitions:

·   Near miss: An unplanned event with the potential to cause harm that was intercepted in time or by chance resulting in no harm to the person.

·   Incident/accident: Any incident that occurs in the hospital (that does not represent routine patient care) that negatively affects or has the potential to affect the health or lives of patients, visitors, or hospital workers.

Procedures

General procedures:

·   The report must be written and completed by the person who discovered the accident or the person involved in this accident.

·   The report must be written immediately after discovering the incident and submitted to the Quality Coordinator no later than 48 hours.

·   The quality coordinator presents the report to the head of the relevant department and the hospital director to take corrective measures.

·   Confidentiality must be observed in dealing with or maintaining these reports, while restricting access to them to persons with authority to do so.

·   Do not use the information in this report as a means of taking disciplinary action against anyone.

·   These reports should generally be discussed at Quality Committee and Medical Board meetings for educational purposes or to establish regulations limiting their occurrence.

Items that make up the report

·   Information about the infected person and the department he is in.

·   The type of incident/unexpected event that has significance.

·   Information about the near miss/accident/unexpected event that has significance.

·   Description of the incident, indicating any action taken immediately after the discovery and the factors that led to this incident.

·   Corrective actions taken.

·   Data of the person who discovered the incident/unexpected event that has significance. Filling out this part is not mandatory.

·   The department head verified the report.

·   Instructions from the hospital director.

People responsible for writing the report

·   All hospital employees, including doctors, nurses, pharmacists, chemists, radiology technicians, and non-medical service personnel.

Corrective action plan and assigned responsibilities in the event of unforeseen accidents:

·   After the report reaches the hospital’s quality coordinator (within 48 hours of the incident), he reviews it and returns to the head of the department in which the incident occurred and the person or persons who discovered the incident to find out the reasons that led to the incident. This is done within 48 hours of the report reaching the quality coordinator.

·   The quality coordinator (or his designee from the quality team) classifies this incident as (specific to environmental safety - specific to medications - specific to patient safety and security)

·   The Quality Coordinator (or his designee from the Quality Team) refers to (the Environmental Safety Officer - the Pharmacy Manager - the Patient Safety and Security Officer) according to the classification of the incident to make recommendations with the Quality Coordinator (or his designee from the Quality Team) so that this incident does not occur again. Other.

·   After making the necessary recommendations to avoid this incident from occurring, a corrective plan will be developed to implement these recommendations by the quality coordinator and the responsible person according to the classification of the incident and the head of the department in which the incident occurred.

·   The corrective plan includes recommendations, who is responsible for implementing each recommendation, the time frame for implementation, and the required resources.

·   The quality coordinator (or his designated member of the quality team) follows up on the implementation of the established corrective plan and submits a report on it for discussion at the quality committee meeting.

Responsibilities

The employee who discovered the accident:

·   Rapid intervention to protect or support the patient’s health condition.

·   Immediately inform the existing doctor

·   Writing the report before the end of the shift.

The doctor who was informed of the accident

·   Recording the results of the medical examination and the required medical care.

Hospital manager

·   Review the condition and ensure that corrective actions have been implemented and provide any assistance required.

Quality coordinator

·   Monitor all reports and ensure that all important steps to resolve the problem have been completed.

·   Writing a monthly summary of all reports.

·   Writing a quarterly report to the Quality Committee for discussion.

·   Maintain a file of all reports for three years.

Occupational safety and health officer

·   Examine all reports related to occupational safety and health to review safety-related incidents.

·   Forming a team from the Occupational Safety and Health Committee to review safety-related incidents.

·   Recording the results of the inspection and the corrective actions taken in the report.

·   Return the completed report to the Quality Coordinator.

·   Writing a monthly summary and presenting it to the Occupational Safety and Health Committee.

Responsible for implementation:

·   The employee who discovered the accident.

·   The doctor who was notified.

·   Head of Department .

·   Hospital manager .

·   Quality coordinator.

·   Occupational safety and health officer.

The Reviewer

·   Egyptian Accreditation Standards 2013- Regulating laws and regulations

Models

·   Incident report form

Attachments

·   Accidents and near misses that must be reported to the hospital.

A list of facts that can be reported

·    Patient escape

·   The patient’s suicide, suicide attempt, and violence.

·   Unexpected mortality and complications, including those resulting from institution-acquired infections.

·   Confirmed blood transfusion reactions (except for routine adverse reactions such as chills and fever).

·   Significant events in anesthesia and pain relief that caused harm to the patient.

·   Significant differences between preoperative diagnosis and postoperative diagnosis, including surgical pathology findings.

·   Significant adverse drug reactions that caused harm to the patient.

Significant medication errors that caused harm to the patient, such as:

 ◾ Giving the wrong medication.

 ◾ Giving the wrong dose.

 ◾ Giving the medicine incorrectly.

 ◾ Giving medication to an incorrect patient.

  Related to operations:

  ◾ Cancel the operation.

  ◾ Unexpected removal of any organ.

  ◾ Wrong patient.

  ◾ Incorrect counting of tools.

  ◾ Cases of error in the operation (patient - operating party - procedure).

  ◾ Leaving a foreign body in the patient.

Laboratory related:

   ◾ Incorrect data in the sample.

   ◾ His eye is wrong.

   ◾ Improper storage.

   ◾ Incorrect laboratory results.

Related to the hospital:

   ◾ A visitor was injured.

   ◾ Bed sores.

   ◾ Wrong needle injury.

Security neutrality:

    ◾ Theft or loss of personal property.

    ◾ A fight with a visitor or patient.

    ◾ Not following hospital policies.

    ◾ Suicide attempt.

Fire and safety:

    ◾ Fire.

    ◾ Spillage of a chemical.

    ◾ Blockage of one of the emergency exits.

    ◾ Expired fire extinguisher.

    ◾ Gas leak.

    ◾ Water leakage.

    ◾ Unsafe electrical wires.

·   Serious physical or psychological harm to a patient, employee, or visitor (nerve damage - loss of a limb or organ - death).

Significant Error/Accident/Unexpected Event Report Form

Policy: The existence of standards and processes for intensive analysis of significant and undesirable unexpected events.

Purpose : To increase public knowledge about events, their causes, and strategies to prevent them, focus the hospital's attention on understanding the reasons behind the event, and change hospital systems and processes in order to reduce the likelihood of such an event occurring in the future.

Definitions

◾         A significant unanticipated event  is any unexpected event in health care that results in death or serious physical or psychological injury to a patient.

Procedures:

◾         A report is written about the occurrence of the event as in the policy.

◾         The quality coordinator selects a team consisting of people close to this event and a member of the hospital’s quality team to analyze the reasons and determine the basic factors behind the occurrence of this event, provided that this is done within a month of the formation of the team.

◾         Analysis identifies changes that could be made in systems and processes (either through redesign or development of new systems or processes) that would reduce the risk of such events in the future.

The analysis must be accurate, documented, and comprehensive, including the following:

◾         Identify the human factors and other things that are directly related to the event and the processes and systems relevant to its occurrence.

◾         Analyze basic systems and processes through a series of questions.

◾         Identify risks and their potential contributions to this type of event.

◾         Identify potential improvement in processes or systems that would lead to a reduction in the likelihood of such events occurring in the future.

◾         After identifying the root causes, the team will develop a corrective plan to avoid these causes in the future, provided that the time frame for implementing this plan does not exceed three months.

Time frame :

◾         The root causes must be analyzed and a corrective plan must be developed within a month of the event occurring.

◾         The corrective plan must be implemented within a period not exceeding three months.

◾         The root cause analysis and the implementation of the corrective plan are reviewed by the hospital’s Quality Committee.

Responsible for implementation:

Quality Committee

work team

Persons responsible for implementing the plan

The Reviewer

Egyptian Accreditation Standards 2013.

Regulating laws and regulations.

Models

Incident report form

- Patient rights policy

- Patient security and safety policies

Correct patient identification policy

Policy: 

Identifying the patient using two means before giving him treatment: blood or one of its derivatives, taking samples from the patient, or any diagnostic or therapeutic procedure.

The Purpose:

Achieving patient safety and reducing the risks that the patient may be exposed to during any procedure within the hospital.

Working procedures:

1- Everyone from the health team who deals with the patient must include:

·  Doctors.

·  Nursing.

·  Pharmacists.

·  Lab. Technician.

·  Ray technician.

·  Physiotherapist.

Use at least two means of identification for the patient to verify his identity:

·   The name is fourfold.

·    File No.

·   The nurse ensures that the identification bracelet data is correct before placing it on the right arm by matching it with the patient’s data and ensuring that it is legible and clear. If it is not possible to place the bracelet on the right arm for any reason, such as the presence of a cast, it is placed on the left arm.

·   The charge nurse will place a new bracelet if the original is lost or becomes illegible.

·   The nurse makes sure the patient’s full name is as it is in the patient’s medical file and does not depend on another name (such as a nickname), and confirms the file number even if she is sure she knows the patient.

2- The patient’s identity is verified before every interaction with him, such as:

Ø Giving treatment.

Ø Transfusion of blood or one of its derivatives.

Ø Taking a blood sample or any other samples necessary for medical analysis and laboratory examination.

Ø Transfer of the patient.

Ø Conducting diagnostic tests.

Ø Or when taking any other actions.

Note: 

Do not apply an identification label before taking the sample or on the package when it is empty.

3- When taking any procedures, the nurse asks the patient about his name and introduces the patient herself and the procedure that will be performed, taking into account the presence of the patient’s bracelet and the two means of identification clearly written on it, which are the patient’s name and the file number.

4- The nurse then matches the patient’s data on the bracelet with that in the medical file to confirm the patient’s identity before any procedure is taken.

5- When taking a sample, the laboratory technician or nurse places a label identifying the sample that includes the patient’s name and file number immediately after taking the sample and before leaving the place.

Note: 

The laboratory technician performs the same patient identification procedures before withdrawing any sample.

6- In the case of premature infant patients, a bracelet is placed on the child’s right leg.

7- In the case of patients who have disturbed consciousness or are in a coma and for whom there is no way to prove their identity, their identity is proven by the following (anonymous/unknown - patient number - date and hour of admission)

· If it is an accident, a report is prepared to prove the accident.

8- For newborns, they are identified by a bracelet placed on the foot with the following recorded:

·      Mother's name

·      Male Female

·      File No

9- Dialysis patients: They are identified by an enclosed badge with the patient’s name on it

10- Patients in the emergency room or recovery room with the patient’s triple name and reception ticket number

11- Outpatient patients have their test tubes and x-rays identified by the patient’s full name and outpatient ticket number

12- The radiology technician marks the x-rays with the patient’s quadrant name, file number, date, and time

13- None of the hospital employees remove the bracelet of any deceased patient until he leaves the hospital

14- In the event of an error in the patient identification process, reference is made to the incident report requirements policy

Responsible: Medical team

References: - International standards for patient safety.

- Egyptian Accreditation Standards 2013.

Patient delivery and receipt policy

Policy: 

The hospital’s medical team is committed to the process of handing over and receiving patients’ conditions in the various departments, including:

• Identify the necessary duties that must be handled during the delivery and receipt process.

• Determine who is responsible for delivery and receipt.

• Determine how to document the delivery and receipt process.

The Purpose:

The delivery and receipt process is a vital process in order to maintain the safety and security of patients by codifying the exchange of patient information between the medical team while he is in the hospital for the continuity of providing medical care to patients.

Responsible for delivery and receipt:

• Between doctors of the same specialty by using the delivery and receipt model.

• Between doctors with different specialties for patients whose condition requires consultation with doctors from more than one specialty, using the medical consultation form.

• Emergency doctors when transporting the patient to and from hospital departments (patient transfer form).

• Between nursing staff members with each shift change (status book).

• Nursing staff members when transporting a patient to and from operations, care, or to another department (time out form)

Working procedures:

• When a new patient is admitted, the head nurse or her representative receives the patient from the paramedic and the admission or reception office worker, and records all the patient’s data and what the treating physician requested in the patient’s condition record.

• The nurse records the patient’s condition throughout the shift in the patient condition record.

• After the shift ends and the nurse attends the next shift, the nurse delivers to her the conditions of all patients in terms of the development of their medical condition, especially critical cases, surgical cases, treatment given to the patient, any change that has occurred, and any requests such as bringing test results or rumors related to the patient and preparing the patient for operations, if any.... ........etc., with the delivery and receipt documented with the signature of the two nurses in the notebook.

• In cases of operations, the nurse prepares the patient for the operation according to the doctor’s instructions. The nurse hands over the patient and the patient’s pillow to the operating nurse and the patient’s treatment if requested by the doctor in accordance with the patient preparation form for operations and the patient receiving portion of the time-out form.

• After completing the operation, the operating nurse calls the nursing home nurse to come to receive the patient and the patient’s pillow.

• When there is a need to transfer the patient, the nurse transfers the patient and hands over the patient’s file after updating it to the nurse of the department to which the patient is transferred within the hospital.

• Resident doctors receive and receive the patient at the start of the work shift according to the patient handover form, which includes: (patient name - file number - diagnosis - positive medical examination results - positive test results - follow-up and notes).

• When the patient needs to be referred for consultation, the consultation form is used and the required data is recorded according to the form.

Administrator:

• Nursing staff members.

• The doctors.

Models:

• Medical file.

• Record patients’ conditions.

• Consultation form.

• Delivery and receipt form for doctors.

• Operations time-out model.

The Reviewer:

• International standards for patient safety.

• Egyptian accreditation standards.

Policy to avoid incorrect connection of catheters and tubes

 Specifies the necessary data that must be placed on catheters as well as those responsible for handling them to avoid connection or incorrect use of catheters.

The Purpose:

·      Achieving patient safety by avoiding incorrect connections of catheters and tubes in all hospital departments.

Working procedures:

·      Patients, their families, or hospital employees do not have the right to disconnect, install, or reinstall any type of tube or catheter, except:

Ø    The doctor.

Ø    Nurse.

Ø    Supervisor.

Informing the patient of this is the responsibility of the nurse in charge of the patient's room.

·      The department creates a policy for each type of tubes and catheters in the department, explaining:

o     The person responsible for the installation.

o     Installation and installation method.

o     Ensure the integrity of the installation.

o     Follow up and take care of the connection.

·      The following information is required to be shown on each catheter: the name of the installer, date and hour.

·      Installation and verification of the correct installation of each type is carried out according to its policy.

·      The doctor must specify the name and type of tube through which the medication will be administered.

·      The nurse must check all connections before giving any medication and before and after performing any procedure in accordance with the policy for each type.

Administrator:

•       Nursing staff members.

•       the doctors.

The Reviewer:

•       International standards for patient safety.

•       Egyptian accreditation standards.

Policy to prevent patient falls and take the necessary measures to avoid falls                

Policy: 

Each patient's potential fall risk is assessed upon admission to the hospital  including the potential risk associated with the patient's treatment regimen on the form in the nursing assessment portion.

•       Necessary measures must be taken to prevent falls.

Purpose: 

Preventing patient falls by evaluating and re-evaluating cases regarding the possibility of falling and taking the necessary measures and precautions to prevent this.

The Definition:

Fall:

 Any change in the patient's position from one level to a lower level, which leads to the patient touching the ground or any surface at a lower level.

Precautions that must be taken to protect patients from being exposed to the risk of falling:

•       Environmental factors

•       Identify patients at risk of falling.

•       Educating patients at risk of falling and their families.

•       Environmental factors:

The hospital/department takes into account the various environmental factors and influences that provide security and safety for the patient and prevent the possibility of him falling. Therefore, the department nurse or her representative periodically ensures that:

•       The patient beds are safe and free from any breakage or malfunction.

•       The sides of patient beds are safe and there are no defects.

•       The patient bed brakes are safe and work efficiently.

•       Safety of the trolley used to transport patients between departments.

•       Do not move patients while department workers are performing the cleaning process to avoid patients falling during that time.

•       Ensure the safety and quality of lighting.

•       Ensure that there are no obstacles in the corridors.

•       Ensure that the bell in the bathrooms works well.

•       Ensure and keep the floors dry and clean so as not to increase the risk of slipping and falling.

1-    Identifying patients at risk of falling

The nurse assesses the patient for fall risk according to the items on the nursing assessment form upon admission.

If there is a patient who may be at risk of falling, the nurse should do the following:

•       Raise the sides of the bed

•       Place the symbol (F) on the patient’s identification bracelet.

•       Put the symbol (F) on the door of the patient’s room and/or bed if the room contains more than one patient.

•       Repeatedly asking if you want to go to the bathroom.

2-    Educating patients at risk of falling and their families through treating doctors and nurses

•       Alert the patient to notify the nurse if he feels dizzy, sluggish, unbalanced, etc

•       Warning the patient not to resort to sudden movements when changing position from sleeping to standing or sitting.

•       Warning the patient not to bend down to pick up anything from the ground.

•       Make sure to use comfortable shoes without heels that do not help with slipping.

•       Be sure to keep the bell near the patient’s bed.

•       The necessity of committing not to leave unwanted objects on the nightstand next to the bed or in the bathroom.

•       Alert the patient to request assistance while walking and moving around.

•       Do not place any sharp tools near the patient.

•       Ease of movement of the medical team, patients and their families in the hospital rooms and rooms by not occupying them with any tools or equipment.

•       Encourage the patient to use wall supports while walking to prevent falls, if any.

•       Recording health education for patients and their families in the patient’s medical record.

3-    If a patient suffers a fall, the following must be followed:

•       The nurse measures vital signs before moving or assisting the patient to move or stand.

•       When the patient may be injured or fractured, the patient should not be moved at all.

•       The nurse notifies the doctor to examine the patient and determine how to lift him.

•       The nurse helps the patient and places him in the wheelchair after ensuring that the brakes are lifted to prevent movement.

•       The nurse records the falling incident on an incident report form.

•       The responsible nurse re-evaluates the patient when there is any change in the condition of the patient who is at risk of falling, provided that she documents any change in condition as follows:

o     The full name of the assessing nurse.

o     Evaluation date.

o     Evaluation hour.

o     The new result of the assessment.

List of patients at risk of falling:

•       A patient with a disorder in the level of consciousness of all types and causes

•       A patient with all types and causes of convulsions.

•       A patient with limb fractures.

•       Diabetic coma patient.

•       A patient with high or low blood pressure.

•       Geriatric patient.

•       The mentally ill patient, especially if he has suicidal tendencies.

•       Patient with imbalance (stroke patient + hemiplegia).

•       Pediatric patients.

•       Patients treated with sedatives, diuretics and blood pressure lowerers.

Administrator:

•       Nursing staff members.

•       the doctors.

•       Maintenance.

•       Environmental safety officer.

References:   - International standards for patient safety. - Egyptian Accreditation Standards 2013.

Safe use of restraint and seclusion policy 

Politics :

The patient's safety and security are maintained and his right not to be restricted unless there is harm to the patient or those around him

The patient is restrained for the shortest possible time after evaluating the patient and ensuring the necessity of restraint using the least means

The patient is restricted based on the order of the qualified treating physician

Purpose: To preserve the patient’s rights and dignity and prevent him from harming himself or others.

Restraint: is a means that reduces or prevents the patient's movement. There are two types:

 Either physical: This is a method of restraining the patient by the hands, feet, and torso of the body.

 Or medicinal: It is a medication given with the aim of reducing the patient’s movement and calming his behavior.

Isolation: This is the restriction of the patient’s residence in a special room or area in cases of violence and aggressive behavior by the patient towards himself or those around him, including workers, patients, and others.

Reasons for restriction:

·   A patient who suffers from psychological disorders that make him capable of harming himself or those around him.

·   A neurological patient who suffers from a cerebral shock and in the event of agitation makes him unable to move unconsciously and capable of harming himself and others.

·   The post-operative patient is agitated, leading to harm to himself and others.

·   A liver patient who suffers from a state before hepatic coma and is agitated.

·   The patient is conscious but has a history of harming himself before or removing the devices installed on him, such as the monitor - the central vein - or injection and pumping devices.

Reasons for isolation: The patient with behavioral diseases is isolated in a room alone until he is transferred to another hospital and the patient’s family is informed.

Procedures :

 First: Patient evaluation:

The charge nurse determines the patient's need for restraint based on his behavior

The treating physician records the restriction order in the patient’s medical file, explaining the following:

     ⭕ The reason for the restriction

     ⭕ Type of registration required

     ⭕ The time of giving the restriction order/the specific period of restriction

Restriction started:

Registration is performed using the fastest available method, whether pharmaceutical or physical, except after consulting a consultant. However, in some cases it is prohibited to use the pharmaceutical method.

Restriction method:

The nurse uses a leather belt, gauze and cotton ties, or other means to restrain parts of the body. The four limbs are often used for restraint, except in cases such as meal times and personal hygiene.

Female: The charge nurse wraps the legs together and then ties them to the foot of the bed.

Male: The nurse in charge binds each patient's leg individually to the foot of the bed.

The treating physician shall sign the verbal registration order within 24 hours from the time he is notified of the case.

The nurse takes care not to harm the patient psychologically or physically during the restraint.

The nurse takes care to maintain the patient's privacy.

Patients whose freedom is legally restricted. The doctor is prohibited from participating in restricting them except when there is a strict medical necessity (Article 35 of Professional Ethics - Resolution 238 of 2003)

Second: Patient follow-up:

The nurse records the patient's follow-up using the relevant form and includes the following data:

⭕ Patient behaviors - Vital signs - Blood circulation - Skin condition

The responsible nurse follows up on the patient under restraint for medical and surgical reasons at least every two hours, and this is documented in the patient’s medical file.

The nurse follows up on the patient who is under restraint for psychological reasons at least every half hour, and the observations are recorded in the patient’s medical file on the patient restraint form .

Third: Renewal of the restriction order:

Restraining orders made for medical and surgical reasons must be renewed by the treating physician at least every 24 hours based on continued need.

Restraining orders made for psychological reasons must be renewed by the treating physician at least every 6 hours based on continued need.

Fourth: Ending the restriction:

Specifications for ending the restriction: It is either the patient’s state of consciousness completely improves or it deteriorates and a coma occurs.

The trained nurse ends the patient's restraint in accordance with the doctor's orders, according to the patient's condition and according to medical evidence, provided that the time and date of ending the restraint are recorded.

Fifth: Training:

The patient care policy officer in the hospital provides practical training to the doctors and nurses in the internal care department on how to implement the policy.

Sixth: Health education for the patient and his family: 

The doctor/responsible nurse introduces the patient and his family to the following:

⭕       The extent to which the patient needs to be restrained

⭕       Duration of restriction

⭕       Rating rate during restriction

Responsible: The treating physician

Forms: Restraint and Prosecution Order Form

References: Egyptian Quality Standards 2013 - Joint Commission International Standards 2014

Policy to prevent bed sores while the patient is in the hospital

Policy: Evaluate patients most at risk of developing bed sores and take measures to prevent them.

Purpose: To achieve patient safety in the hospital by preventing the occurrence of bed sores.

Working procedures:

•   The nurse evaluates the skin condition of each patient upon admission to the hospital on the relevant form in the nursing assessment part.

•   Patients who are confined to bed must be re-evaluated by the nurse in charge at the beginning of each shift. Only in the case of patients who are unable to move, the department nurse should do the following to prevent the occurrence of bed sores:

o   Make a plan to turn the patient every two hours on the patient turn over form and attach the form to the medical record.

o   The skin is massaged to stimulate the patient’s blood circulation, especially the areas with great prominence, to avoid bed sores, and this massage and its time are recorded in the medical record.

o   Observing the patient’s skin to discover any area of ​​the skin that shows redness and recording this in the medical record.

o   Furnishing patients’ beds in the correct way and avoiding any folds in the bed sheets to avoid the occurrence of bed sores.

o   Place an air mattress for the patient - if possible - to reduce and prevent the occurrence of bedsores.

o   Pay attention to the degree of softness and dryness of the skin and use creams and moisturizers to avoid dryness.

o   Taking care of the skin by giving the patient a full bath daily and when needed.

o   Therapeutic nutrition that suits the patient according to his health condition, based on the doctor’s orders, to stimulate the body’s tissues and prevent the occurrence of bed sores.

•   If the patient has bed sores, the following is done:

o   All of the above is done to avoid increasing the area of ​​bed sores.

o   The treating physician makes sure to move the patient according to his condition.

Administrator:

•   The doctors.

•   Nursing staff members.

Models:

•   Patient turning model.

•   Degrees of bedsores.

The Reviewer:

•   International standards for patient safety.

•   Egyptian accreditation standards 2013.