SOP – Federal Medical Centre, Keffi

STANDARD OPERATING PROCEDURE

FEDERAL MEDICAL CENTRE, KEFFI

STANDARD OPERATING PROCEDURES

AND

GUIDELINES FOR CLINICAL SERVICES

THE INSTITUTION.

Federal Medical Centre, Keffi is located in Nasarawa State, North Central Nigeria. This hospital was established in the year 2000 using the facilities of the then General Hospital, Keffi.

It is a tertiary healthcare institution which provides both basic and specialist services.

The hospital consists of three (3) major divisions;

Clinical services
Administration and
Finance
VISION STATEMENT.

To emerge as a centre of excellence in Health care delivery, sustained by dedication to duty, unity of purpose and respect to humanity

C. MISSION STATEMENT.

To utilize available resources most judiciously and efficiently towards achieving remarkable optimum results characteristics of high professionalism.

To be known for hospitality and high level of professional practice commensurable with the technological age in delivery of health services

To establish a commendable workforce guided by selfless service in an inter- disciplinary approach with the sole aim of promoting health for the social and physical needs of the society.

To install hope in the community towards encourage stakeholders’ participation and patronage for the growth and well being of the centre and the community.

D. OUR CLIENTS

Our main clients are our patients to whom we owe unalloyed loyalty in our medico-legal responsibilities. By extension, our clients include the patients’ relations and other members of the public that require either our services or information. Others include governmental and non-governmental organizations.

INTRODUCTION

WHAT IS A STANDARD OPERATING PROCEDURE (SOP).

A Standard Operating Procedure (SOP) specifies in writing what should be done, when, where and by whom.

THE BENEFITS OF STANDARD OPERATING PROCEDURE (SOPs).
SOPs provide an opportunity to fully utilize the expertise of all members of the team.
SOPs help to assure the quality and consistency of the service.
SOPs help to ensure that good practice is achieved at all times.
SOPs enable delegation and may free up time for other activities.
SOPs help to avoid confusion over who does what (role clarification).
SOPs provide advice and guidance to locums and part-time staff.
SOPs are useful tools for training new members of staff.
SOPs provide a contribution to the clinical audit processes.

1.3. SERVICE STANDARD.

– Provide a workable maximum waiting time of 30minutes for out-patient cases by appointment system while ensuring prompt attention at various points.

Every out-patient seeking treatment at the hospital will be registered on the Electronic Medical Record (EMR) System for recording various details of systems, diagnosis and treatment being provided.
The patients’ right to privacy, dignity, religious and cultural beliefs, and also their right to be informed, right to consultation and choice will be respected.
No patient shall be treated or examined without his or her consent or the consent of the guardian in the case of a minor, or the consent of an acceptable next of kin in the case of a patient who is unconscious or otherwise unable to express him or herself. If the next of kin is not available in case of emergency, the doctor shall be obliged to carry out necessary treatment or operation without such consent.
No patient may be used for any research or experiment without a written consent or without being informed of potential hazards or discomforts involved. The care provider shall be obliged to carry out the necessary treatment or procedure having informed the office of the Head of Clinical Services (HCS), through the appropriate channel after clearance from the hospitals research and ethics committee.
All patients and visitors to the hospital will receive courteous and prompt attention from staff and officials of the hospital in the use of its various services.
Only trained and qualified staff and professionals shall attend to patients in every department of the hospital.
Routine laboratory and radiological reports will be made available within 24hours and within shorter periods for emergencies.
Admission process from point of referral to the wards shall be completed within 2hours, subject to availability of bed space.
Wheel chairs and trolleys are provided at strategic locations to move very sick and emergency cases.

2.0 OPERATIONAL STRUCTURE/ DEPARTMENTS/ UNITS

2.1. Department of Clinical Services

The Department is headed by the Head of Clinical Services (HCS) who coordinate the affairs of the department and reports to the Medical Director /Chief Executive (MD/CE). The Department consists of the following unit:

Accident &Emergency(A&E)
Anti Retroviral Therapy (ART)
Chemical Pathology and Metabolic Medicine
Clinical Micro-biology
Dental
Ear Nose and Throat (ENT)
Family Medicine
Haematology and Blood Transfusion
Health Information Management (HIM)
Internal medicine
Medical Laboratory Services
Nursing Services
Nutrition and Dietetics
Obstertrics and Gynaecology, (Obs & Gynae)
Ophthalmology
Orthopaedics
Paediatrics
Pathology and Forensic Medicine
Pharmacy
Physiotherapy
Radiology
Surgery

Activities of the department is aided by several committees, these are;

Drug Revolving Fund (DRF)
Services Revolving Fund (SRF Committee)
Theater Users Committee
Continuing Education Committee
Anti Retroviral Therapy (ART)
Injection Safety/Infection Control Committee
Post Exposure Prophylaxis (PEP) Committee
Research Ethics Committee
Clinical Services Advisory committee
Standard Operating Procedures(SOP) Committee
Health Information Management (HIM) Data Entry Tools Committee
Radiation Safety Committee, Blood Transfusion Safety (BTS) Committee
Emergency Squad Committee
Drug Therapeutic Committee
Health Information Management Committee
Hospice Committee
Infection, prevention and Control Committee
COVID 19 Committee
Clinical Audit and Clinical Governance Committee

It is advised that services revolving fund committee be split to allow for the few of the operational units some autonomy- in quantifying their requirements, procurements and along with accounts, manage their accounts as a means of improving efficiency. The suggested operational units are Laboratory, Radiology and few of the clinical areas rendering essential and/or sensitive services. This would be one of the ways of making these units to be more efficient and effective in service delivery.

2.2 OPERATIONAL UNITS

For efficient and coordinated service delivery, the core clinical area shall operationally exist as service units. These units shall

consist of all staff that function in the related service outlets i.e doctors, nurses and others
operate as a team that shall meet regularly for the purpose of the development of service improvement strategies, clinical/service audit, educational/ CME activities and other reasons that might be found necessary, these units and the related outlets are;
Accident and Emergency
Family Medicine Department- the family medicine clinic and primary care clinic for NHIS
Medical Department- MOPD, Medical Wards, Side Lab in the ward, the ECG/ECHO rooms
Surgical Department- the surgical wards, the theaters, SOPD, Orthopaedic and ENT clinics
Paediatric Department-EPU, Paediatric wards, SCBU, POPD, Paediatric ART
Obstetrics and Gynaecology Department- Labour ward, Gynae emergency, Gynae and Antenatal clinics, Gynae Ward
Dental Department

viii Opthalmology Department- eye clinic

Antiretroviral Therapy Unit- Adult and Paediatric ART, PMTCT, Home Care

3.0 STANDARD OPERATING PROCEDURES (SOPs) FOR CLINICAL ACTIVITIES AT SERVICE OUTLETS

3.1. General Guidelines

This should be applicable to all staff providing clinical and related services within all the outlets of the hospital

Compliance with the civil service regulations and minimum service standards of the hospital and the Servicom Charter
Punctuality at duty posts- arriving and closing at stipulated times
Treatment of Patients/ clients with care, courtesy, compassion and respect
Appropriate and neat dressing
Wear name tag/ Identification card while on duty
Maintain good team spirit, working together towards a common goal
For core clinical departments, in-patients are to be review (with documentation) twice daily including weekends by appropriate staff
Strict adherence to good clinical practices- prescribing, dispensing etc
Following professional protocols in the management of patients
Strict compliance to standard nursing procedures- for both in and out patients
Compliance with National Standards and in accordance with international best practices.
All prescriptions, request for laboratory and radiological investigation must be on Electronic Medical Record (EMR) platform. Prescriptions on EMR platform should be in generic name.
Prescription and comprehensive management plan for those going on admission should be outlined on the EMR before patient is moved to the ward
It is mandatory for all officers who are first and second on-call to be at duty post and to sleep in during call hours. This could also apply to more senior officers (Senior registrars and Consultants) as may be required by their department
Close User Group (CUG) must be provided for the team on call across departments and must be held by the second on call. This line must be accessible throughout the call period.
Sleeping –in facilities including meals to be available from 6:00pm (dinner) on week days , then 1:00pm (lunch) and 6:00pm (dinner) on weekends and public holidays

3.2 FAMILY MEDICINE/GENERAL OUTPATIENT CLINICS

This comprises of both the Family Medicine. Below is an overview of the SOPs for the outpatient Clinics

Figure 1 [FAMILY MEDICINE]

TRIAGE UNIT CONSULTING UNIT ANCILLARY UNIT

NURSES DOCTORS ATTENDANTS

* Vital signs * Clerk and examine pt. * Clean department

* Arrange Cards/Folders * Order investigations * Movement of patient’s

* Sort critically ill patients * Treat patients * Documentation

* Enlightenment * Review patients * Movement of critically ill-patient

*Process admissions (SPCs) * Referrals * Enlightenment

* Enlightenment

3.2.1 FAMILY MEDICINE DEPARTMENT

The Family medicine department is an entry point for patients desiring health-care services in Federal Medical Centre, Keffi except for those brought in as emergencies or those referred directly to the specialist clinics. It is the first point of call for a patient who has obtained a treatment card via Electronic Medical Record (EMR). The patient data is transferred from the Records (Health Information Management) Department to the triage unit and the patient sits in the lounge (waiting area) to be attended to by the health-care providers.

a. General SOP for the Family Medicine Department

The family medicine department realizing its strategic position and role in the hospital has continually strived to be good ambassadors for the Federal Medical Centre, Keffi. The Department embraced the gospel of SERVICOM (Service Compact with all Nigerians) an initiative of the Federal Government insisting the Citizen have the Right to Be Served Right.

The Department has shown excellence in this regard hence SERVICOM rules and practices are firmly rooted in the SOP of the Hospital and Departments in particular.

The primary aim and targeted result is to ensure that patients are treated with respect, courtesy and with satisfaction and that patients are seen within 10 minutes from triage to consultation.

b. Other activities of the Department

* The department engages in monthly Quality Circle Meetings to review and map out new strategies for improving service delivery embracing all the units of the family medicine department.

* Weekly health talks (Mondays and Tuesdays to educate the patients on the workings of the Department)

* Service Improvement Committee (SIC) charged with the responsibility of coming up with new ideas, innovations that will improve service delivery/efficiency in the department.

* Monthly Health Audit (to review disease patterns, management strategies for better results).

c. The Triage Unit

Triage is a process of prioritizing patients based on the severity of their condition. In other countries triage is most commonly used in accident and Emergency. Here we use an adaptation of the process, suitable for Out-patient Services in Nigeria.

The triage unit of the family medicine is manned by Nurses assisted by ancillary staff (attendants). The Unit is headed by a Matron with other cadres of Nursing Staff.

The triage unit opens by 7:00am and closes by 4:00pm daily (except on public holidays and weekends 8:00am – 12 noon).

d. SOP for Triage Unit

The Nursing/Staff in Triage Unit

Receive patient’s data from Records Departments after documentation
Observe and record Vital signs (BP, Temp, Pulse, Resp) and other relevant bio-data (height, weight etc)
Identify trigger points in the triage process according to state of the patient using trigger point indicators (such as very high temp., convulsion, very low BP, very high BP, bleeding abnormal behaviors, signs of shock or severe sepsis).
Sort patients according to above parameters for;
Early consultation
Referral to specialist clinics such as Casualty, Dental, ANC, Maternity, O & G clinics (to reduce time spent to access medical services)

* Direct patients already triaged to Consulting rooms to see doctor.

* Direct patients who have missed their way to family medicine department to appropriate Departments.

* Book patients who want advanced booking to see the Doctor at a later date and time

* Give Health Education/talks to patient on relevant health information.

* Liaise with SERVICOM Unit to enlighten patients on the rights, roles and obligation for better health-care delivery in the Centre.

* Ensure that the spirit of team work, mutual respect, proper ethical conduct and practices are upheld in the Centre.

e. Consulting Unit

The Consulting Unit comprises the Doctors. It is headed by a Consultant Physician and has other Cadres of Medical Officers.

The doctors are assisted by Clinical Attendants. Consultation starts by 8.20am and ends 4:00pm. (Weekends and public holidays 9:00am – 12 noon).

f. SOP for Consulting Unit

The functions of the Consulting Units are

To see patients
Obtain health history (clerking)
Examine patients thoroughly and commensurately
Request for relevant investigations
Prescribe medications based on diagnosis
Document and sign with date all relevant forms
Review patients and subsequently discharge patients from treatment
Make appropriate referral (within and outside) for patients in need of specialized management.
Ensure that patients are satisfied with services rendered
Ensure confidentiality in patients information management
Ensure regular update via seminars, clinical presentation and discussions, workshops, update courses to improve standards and quality of services rendered to the patients.
Enlighten the patient about his/her medical condition (while maintaining Confidentiality and instilling hope).
Ensure that the spirit of team work, mutual respect, proper ethical conduct and practices are upheld in the Department.

g. The Ancillary Unit

This unit comprises the clinical assistants (Attendants). This unit starts work by 7:00am and ends 4:00pm. (Weekends/public holidays 7:00am – 12 noon).

h. SOP for Attendants

The duties of this unit are;

Ensure cleanliness of the Department (offices, surroundings and conveniences)
Direct patient from triage rooms to consulting rooms.
Record patients personal data (including Name, Age, Sex, diagnosis, referral units etc)
Move patients of critically ill patients to referral units or departments.
Arrange and ensure orderliness in patient’s flow between the triage unit and Consulting Unit.
Ensure that patients complaints are listened to and solved or brought to the notice of other units/personnel in the Department
Ensure that the spirit of team work, mutual respect, proper ethical conduct and practices are upheld in the Department.
Carry out other duties that may be assigned to them to ensure effectiveness in the Department.

3.2.2 SPECIALIST CLINICS (SPCs)

This consists of the outpatient clinics of the core clinical departments and presently provides the largest collection of specialist services in Nasarawa State. They include:

Pediatric Outpatient Clinics (POPD)-(Pediatrics Department)
Medical Outpatient Clinics ( MOPD), Medicine Department
Surgical Outpatient Clinic (SOPD), general surgery
Antenatal Clinic (O &G department)
Postnatal Clinic (O&G department)
Gynecology Clinic (O&G department)
Orthopaedics Clinic (O&G department)
Eye Clinic (Ophthalmology department)
Ear, Nose & Throat, (ENT department)

The various departments have separate schedules for their outpatient clinics (Refer to the schedules by various departments).

a. General SOP for the SPCs

All patients to be seen in the SPCs must be referred from the Family Medicine Department, the Accident and Emergency, another clinical department or from another health facility aside from FMC, Keffi.
Such Patients must have been given appointment for that particular day. On no account shall a patient without appointment be seen in a particular clinic day.
Each clinic is expected to develop its own clinic triage content and standard procedures for both new and follow up cases
All new cases must be reviewed by either a consultant or the most senior medical officer in the unit
The number of new and old cases to be seen on each clinic day shall be predetermined and efforts put in place to ensure adherence. The list of all patients to be seen on a particular day shall be made available by the records department through EMR before the commencement of the clinic.
Cases seen in every clinic shall be appropriately documented
Follow up appointment messages shall be sent to the patient with respect to the next appointment. Slip shall be issued to the patient to take to the medical records for booking towards the next appointment
Appropriate health talks and request for feedback will be given before the commencement of the clinics
A system of clinical audit and service improvement plans shall be in place to periodically evaluate and appropriately review and update services

b. The Triage Unit for SPCs

The SPCs shall have their own set of Triage unit- manned by Nurses assisted by ancillary staff for the purpose of triaging for the various clinics.
The triage unit opens by 7:00am. and closes by 4:00pm. daily (except on public holidays and weekends).
The Unit shall also be responsible for the processing of patients for admission (i.e appropriate documentation and arranging for the transfer of patients to the appropriate ward.

The Nursing/Staff in Triage Unit

Review list of patients booked for the clinic for that day from EMR
Observe and record Vital signs (BP, Temp, Pulse, Resp) and other relevant bio-data (height, weight etc) on the EMR.
Identify trigger points in the triage process according to state of the patient using trigger point indicators (such as very high temp convulsion, very low BP, very high BP, bleeding abnormal behaviors, signs of shock or severe sepsis etc).
Sort patients accordingly based on appropriate parameters for consultation
SERVICOM will give talks on hospital processes and patient’s rights and privileges and appropriate channels of laying complaints to patient on relevant health information.

4.0 CASUALTY/EMERGENCIES

Because of the sensitive location- along a major highway and near suburban communities of the Federal Capital Territory and being the health facility with the largest complement of specialists in Nasarawa State, the hospital often receives a large number of emergency cases. The Accident and emergency unit of the hospital is thus the most sensitive unit in the hospital. This has necessitated the setting up of an emergency response squad in the hospital.

Emergency services are provided in the Accident and Emergency (A/E) (medical and surgical emergencies), the EPU (for Pediatric emergencies) and the Gynecological and Obstetric emergency units (for related emergencies).

4.1. ACCIDENT AND EMERGENCY UNIT

The Accident and Emergency (A/E) Unit .Comprises of the following;

1. Triage Unit headed by a Consultant Family Physician

2. Surgical emergency Unit headed by a Consultant trauma Surgeon

3. Medical emergency Unit headed by a Consultant internist.

A. The administrative headship of the Aand E department shall be rotated among the three heads above.

The administrative head shall be responsible for the following:

The day to day running of the main A/E unit and ensuring that facilities are available
Co-ordination of the activities of all units within the A/E and administrative management of the main unit and chair the A/E management committee
Shall take responsibility for patients in the Department
Daily casualty ward round for all patients in the A/E
Preparing the roster for the casualty doctors
Manages the casualty theater, in conjunction with trauma Surgeon and the theater users committee
In conjunction with other departments, shall ensure a smooth, continuous coverage of the casualty, management of the patients and their prompt movement to the ward or discharge (as applicable)
Have the responsibility, in conjunction with the HCS, for the mobilization of doctors and other health workers in the hospital in the event of a mass casualty

B. Casualty officers/ Residents from family Medicine on Casualty Posting

Shall (along with the Registrars from both Medical and Surgical emergencies ) ensure a continuous 24 hour coverage of the unit, on a roster basis
Shall be responsible for the initial review of patients presenting to the casualty, this shall also apply to medical and surgical teams on call particularly for referrals coming from outside the hospital.
Shall take responsibility- including periodic evaluation- of all patients in the casualty, even after referral to the team on call
Shall be responsible (along with the Registrars from both medical and surgical emergencies) for the immediate stabilization and/or resuscitation of patients brought in to the A/E unit.
Shall be responsible for the sorting out of patients to determine the order they would be seen
Shall be responsible for the referral of patients to the appropriate unit and shall take responsibility of the patient until reviewed by the team

C. Residents in Medical and Surgical Emergencies

Are expected at their duty post from 8:00am -4:00pm on every working day.
Shall attend to appropriate emergency referred to them immediately and physically hand over to the Unit on Call for that day (where necessary).
Patients Management should be along with appropriate supervising Consultant.
Shall regularly review their patient in the casualty until moved to the wards. They should ensure movement of their patient to the ward within 48 hours of review

D. Team on-Call

Shall be available to review and possibly take over patients referred to them on their call day.
They shall be physically present and manage the surgical / medical emergency patients as appropriate from 4:00pm on a working day and 8am on weekends /public holidays till the following day.
They shall be responsible for admission of Patients for in- hospital Care.

E. Nursing staff

In-charge shall not be less than the rank of Chief nursing officer (CNO)
Shall coordinate nursing services and along with the head of accident and emergency unit, ensure continuous availability of adequate personnel and equipments and consumables, handles requisitions, see to the day to day running of the A and E, and rosters nurses for duty
Nursing staff in A and E unit to have post basic training in emergency nursing and to be proficient in Basic Life Support Skills
To receive patient, triage based on severity of illness, check vital signs and direct to the Casualty Officer
Assist the Casualty officer in attending to the patients especially when there is need for immediate intervention
Inform the team on call about referrals
Process admissions and transfer of patients into the ward
Medication administration
Use clinical assistants to collect medications from A/E pharmacy

F. Hospital Attendants/ Clinical Assistants

Ensure cleanliness of the A /E complex (offices, surroundings and conveniences)
Shall constitute the evacuation squad
Move patients critically ill patients to wards
Carry out directives from accident and emergency committee.

G. A/E Pharmacy

There shall be a pharmacy outlet in A/E to be headed by not lower than Chief Pharmacist.
The outlet shall operate 24 hour service, to handle all emergencies and patients in the A/E complex.

H. A/E Laboratory

There shall be a Laboratory in the Accident and Emergency Complex to be headed by not less than Principal Medical Laboratory Scientist (PMLS).
The Laboratory shall ensure prompt sample collection, processing and release of Completed results.
The Laboratory shall operate 24 hour service, to handle all emergencies and patients in the A/E complex.

I. Accident and Emergency Committee

This shall consist of the Administrative head of A/E, heads of triage, Surgical and Medical, Pharmacist, Medical Laboratory Scientist and Nurse in-charge at the A and E complex.
They shall ensure smooth operations of the accident and emergency Complex.

5.0 IN HOSPITAL CARE

5.1 ADMISSION PROCESS

I. Patient Source

All admissions shall be from

The emergency points.
Casualty (for surgical-including surgical specialties and medical emergencies.
Emergencies pediatric unit
Gynecology and Obstetrics emergency unit.

The Specialist Clinics.

These include the six (6) medical and surgical outpatient clinics (MOPD and SOPD); the Ophthalmology Clinic, the Ear, Nose, Throat clinic etc.

The General Outpatient.
Mainly for observation or day cases

ii. General Admission Process

Patients shall be admitted under a managing consultant whose name must be indicated on the EMR.
Prescriptions must be dully filled by the admitting Doctor for all patients before they are moved to the ward.
The admitting process shall be handled by a Nurse at the admission point. He or she shall be responsible for
Completing the EMR processes
Transfer of the patient to the appropriate ward or unit.
Ensure the patient is appropriately received by a Nurse – the admitting Nurse on the ward.
The admitting Nurse must ensure that:
Patients’ details are entered into the admission or discharge register.
The admitting unit’s house or Medical Officer is informed of the admission.
Allocation of bed space to the patient.
Open a vital sign and drug administration chart for the patient.
Send the inpatient prescription to the pharmacy for drug collection.
Document the patients’ vitals including ward urinalysis.
Document the admission in the nurse’s report for that shift.
Institution of the nursing process.
All patients must be fully clerked by the unit House Officer within 24hours of admission.
Routine investigations for all admitted patients shall include;
Ward urinalysis for at least glucose and protein.
Full blood count and erythrocyte sedimentation rate.
A random blood sugar or fasting blood sugar.
Serum Electrolyte and urea estimation.
C X R-PA.

iii. Admission from the Art Clinic

Patients considered for in-hospital care (as inpatients) from the ART clinic should be referred for review by the medical team on call-through the casualty. The admission process would then follow the steps out-listed above.

5.2 IN-HOSPITAL CARE FOR IN-PATIENTS

Patients admitted to the ward as in-patients are expected to benefit from nursing care-offered by Nurses posted to the ward and regular review by the managing team of doctors. It shall be the responsibility of the entire clinical team- the Doctors, Nurses, laboratory staff and Pharmacist to manage the patients.

The Doctors shall
Clerk and examine patients
Periodical assess/review patients condition
Order laboratory investigations
Prescribe and review medications
Lead ward rounds and make documentations in the patients case note
Referrals
Discharge
Certification of death
Carry out minor procedures include setting up of intravenous lines
Collection of blood samples.

Nurses
Patient admission, – receive and admit patient
Nursing care
Take vital signs and document /chart
Admission of medications and document on treatment chart
Participation in ward rounds
Organization of the ward and patients
Co-ordinate activities related to patient care such as collating, prescriptions drug collections, samples for investigations and sending to the laboratory etc.
Handling discharges, transfers, movements for investigations and corpses to the mortuary.
Pharmacist
Supply of medication to in-patients
Provision of drug information
Examination of inpatient prescriptions and chart and communication/ feedback of observations to the nurses and / or doctors

d . Medical Laboratory Scientist

Shall ensure the appropriate sample is collected for investigation
Ensures prompt processing and transmission of completed results

. e. Clinical Assistants and Hospital Attendants

Shall be answerable to the Nurses on the ward
Shall be responsible for movement of patients(under supervision), case specimens and medications
They shall also be responsible for the cleaning of the wards
Documentation

5.3 PROCEDURE FOR REFERRALS

There shall be Provision for both electronic and paper (written) referrals.
Referral letters shall be written in duplicate with a copy kept in the electronic case note of the patient
Referral letters shall be on the directive of the unit consultant
Referral can be delivered to the unit on call or desired unit (only within working hours (8:00am-4:00pm)

5.4 PROCEDURE FOR DISCHARGE

Patients shall have their outstanding bill settled and cleared by the accountant in the unit before being discharged by the Doctors and allowed to leave the ward except appropriate waiver is granted.

On discharge demise, discharge summaries (exit Summary) shall be written for all patients using the prescribed discharge summary sheets/EMR. This shall be done by one of the Doctors involved in the management of the patient
Appropriate documentation shall be entered into the admission and discharge summary book within the EMR by the nursing staff
To-Take-Home (TTH) drugs shall be written out by the Doctor on the in-patient treatment sheet in the EMR. This is to be collected by the nursing staff and handed over to the patient/ relatives with appropriate instructions on use and safety instructions.
All discharged patients shall have their booking for their next follow up clinic effected before leaving the hospital
Cases of self Discharge-Against-Medical-Advise shall be made to sign on the folder before they are allowed to leave the ward. Discharge summary shall also be filled for such and they should also have their TTH drugs collected and clinic booking effected. Effort shall be made to discourage such cases. This should also be documented in the EMR.

5.5 DEATH CERTIFICATION

All cases of death shall be certified as such by a Medical Doctor before the corpse is appropriately packaged and moved to the mortuary.
All cases of death within 24 hours shall be regarded as coroners’ case and reported to the police except the existing law states otherwise.

5.6 ISSUANCE OF DEATH CERTIFICATES

The following procedure shall be followed in the issuance of death certificates to relatives of patients who died under the care of the hospital

The relations shall make a request, in writing, to the office of the Medical Director who on approval shall forward same to the Head of Clinical Services
The HCS then forwards the approved request to the department of Health Information Management where the records of the deceased patient and the team that managed is retrieved
The approval and retrieved record is then forwarded along with the Death Certificate Record/ Book is the forwarded to the appropriate team
The team, usually with the knowledge of the Head of the units then fills the appropriate portion of the death certificate. Doctor’s (who shall not be less than a Medical Officer/Registrar in rank) details shall include full names, rank and qualifications and usual signature with the name of the Doctor fully written.
The filled Death Certificate and the patients record is returned to the office of the HCS where the Certificate is issued to the next of kin of the patient who dully acknowledges the receipt of same
Deceased patients record is returned and the book is returned to the HIM department

6.0 SURGERIES

6.1 Guidelines for Elective Surgery

Admission should be via the clinics and Emergency in some cases.
Admission should be at least 24 hours before surgery
Head of Anaesthesia and Nurse in-charge should ensure all elective Cases in the theatre start by 8:00am
Operation list should be made with the Knowledge of Unit consultant and should be compiled by the managing team.
Operation Lists should reach the following offices at least 24hours before surgery.
Theatre Manager (Medical Doctor)
Main theatre Periop Nurses
Anaesthesia Department
Theatre Pharmacys
Head of Clinical Services
Head of department office
Blood bank
Surgical ward/ Emergency
the Booking for Surgery from appropriate surgical or Gynecological Clinic
Admission for Surgery and pre-visit review including anesthetics, cross check of vital and essential baseline laboratory results e.g. EIU, PCV, ECG etc.
Ensuring availability of grouped and cross matched blood in the blood bank
Pre operative preparations of patient, material and Theater
Intra operative care and surgical procedure
Immediate post op care

6.2 Documentation of Surgical Procedure and Treatment Orders

Recovery room Nurse to accompany patients and appropriately hand over (including patient’s records to the Nurse on the Ward)

6.3.1 Anaesthesia Department

Allocation to anesthetics should be made a day before surgery and Anaesthetics to take Patient does the review a day to the surgery
Patients should be allotted to Anaesthetist latest the night before surgery
All special requirements and recommendations should be made to relevant units the day before Surgery.

6.3.2 Perioperative Nurses

Allocation of cases should be done the day before each elective surgery.
The nurses on night duty should set up the operating suits the night before surgery
Nurses with interest in a specific specialty should be given opportunity to take interested cases; however, they could also be recognised where necessary.

6.3.3 Ward Nurses

Preoperative shower should be taken the morning of surgery
Ensure informed Consent is given by the surgeon and witnessed by the Nurse a day before the surgery.
Operation site should be shaved where necessary except otherwise stated
Patient should be tallen to the main theatre in company of a nurse.
The patient should reach the theatre within 15minutes of request from the theatre
Vital signs should be taken/ recorded and Patient Prepared for theatre by 8:00am on every elective theatre day.

6.3.4 Receptionist / Recovery Room Staff

The recovery room staff /receptionist should be a Nurse
They should send for the first Patient on elect is list latest by 7:30am and Subsequent Patient is requested.
They should be the one to receive each Patient brought from the wards
They should verify the patient’s name, diagnosis, Surgery, and readiness as stipulated on the operation list.
They should inform the Perioperative nurse about the Patient’s arrival
Ensures Patient is moved to the designated .operation Suit.
Receive the Patient after surgery.
Monitors Vital signs of the patient in the recovery room.
The recovery room must inform the wards of the patients readiness

6.3.5 Head of Theatre

Head of theatre shall be an Officer not lower than the rank of Assistant Director Nursing Services (ADNS)
Shall be in theatre outfit and supervises the receptionist, Periop and assistants
All Complaints in the theatre should be verified by the Head of Theatre during surgery.
Shall ensure the incident form is appropriately filled.

6.3.6 Day Cases

All day cases should arrive the hospital latest by 7:00am
All day cases should be seen at the male /female surgical ward and their vital sign taken by the nurses on duty.
All day cases Should be sent back to the ward after surgery
All day cases should be reviewed by a doctor before discharge (Allowed home).

7.0 EMERGENCIES

Emergency Surgeries should be attended to promptly
As with all surgeries, payment is encouraged. However, inability to pay should not be an impediment to emergency surgery
Emergency surgery should take place within one hour (1hr) from the time the Patient is reviewed and stabilized.
All service Providers must be notified ie. Anaesthetists
All cases of emergency surgery must be reviewed by the Managing team before surgery.
Theatre must be booked immediately while Periop nurses and anaesthetist should be informed for appropriate review
In line with existing blood banking policy, blood is loaned out to be replaced before the Patient is discharged
All pharmaceutical Packs Composition must be given immediately while payment is made later.

8.0 LABORATORY SERVICES

8.1 MEDICAL LABORATORY DEPARTMENT

Headed by a Director Medical Laboratory Services who coordinate the activities of the various sectors/units of the department
The medical laboratory department consist of the following units
Chemical pathology
Medical microbiology
Parasitology
Hematology
Blood group serology(BGS)/Transfusion services
Cytology/histology
Immunology

Each having its own sectional head

Main function of the department includes

Specimen Analysis
Counseling of Donors and Patients
Training (Student and Intern MLS)
Research

8.2 SERVICE AND OPERATIONS

Operate 24 hr service daily

Routine service- 8:00am-4:00pm

Call service-4:00pm-8:00am week day 24hr during weekends

8.3 PROCEDURE

Activity 1: Patients’ Laboratory Request(s)

Patients Come from clinics, wards as in -Patients or private patients who are registered as Walk-in patients or register with the hospital to obtain PID.
All patients’ laboratory test requests are sent to the laboratory through Electronic Medical Record (EMR) except patients from private Establishments, referrals and when there is network failure.

Activity 2: Verification of Laboratory Request(s)

All general and NHIS patients’ laboratory requests are verified at the laboratory reception according to first come first serve (except emergency cases).

Person Responsible: Authorized Medical Laboratory personnel only.

Activity 3: Payment of Laboratory bills

Payments for all laboratory investigations are made and evidence of payment obtained.

Where: Electronic banking only within the hospital payment outlets.

Activity 4:Registration of Laboratory Request(s)

All laboratory requests are registered at the laboratory reception after presentation of evidence of payment or NHIS card.

Person Responsible: Authorized Medical Laboratory personnel only.

Activity 5: Collection of Specimen(s)

(A) Blood collection

Collection of blood specimens from patients/clients

Person Responsible: Medical Laboratory Scientists, Medical Laboratory Technicians, Medical Laboratory Assistants, Clinicians, Nurses.

(B) Collection of body fluids and tissues

Collection of CSF, Pleural fluid and synovial fluid, Ascetic Fluid, Tissues and Cytology specimen from patients.

Person Responsible: Clinicians and any other authorized personnel only.

(C) Collection of Semen, sputum and Urine

Person Responsible: Patients only

(D) Collection of other clinical specimen(s)

Collection of HVS/ECS, Aspirate, Wound swab and throat swab etc.

Person Responsible: Medical Laboratory Scientists, Clinicians, Nurses and any other authorized personnel only.

Activity 6: Labelling Of Specimen(s)

All specimen containers collected are labelled appropriately at the point of collection.

Person Responsible: Medical Laboratory Scientists, Medical Laboratory Technicians, Medical Laboratory Assistants, Clinicians and Nurses and any other authorized personnel only.

Activity 7: Transportation of Specimen(s)

Patient specimens collected in the wards and clinics are transported safely and efficiently to the laboratory.

(a) Blood

Person Responsible: Medical Laboratory Technicians, Medical Laboratory Assistants, Health attendants only.

(b) Other Specimen(s)

Person Responsible: Health attendants

Activity 8: Receipt of Specimens at the Laboratory

All specimens are received at the Laboratory Reception.

Person Responsible: Authorized Medical Laboratory personnel only.

Activity 9: Acceptance/Rejection of Specimens

(a) All appropriately collected and labelled specimens are received at the laboratory reception.

(b) Specimen is rejected when:

i. The time of specimen collection does not meet requirements of the assay to be performed;

ii. Documentation is incomplete or the information documented on the specimen and the chrome /form does not correspond;

iii. The specimen or specimen volume is inappropriate or insufficient for the test required;

iv. The specimen’s condition (integrity) is unacceptable according to the SOP of the test required;

v. If specimen is clotted (for certain Haematological analysis);

vi. If blood specimen from several clients are mixed up;

vii. There is delay between collection of specimen and arrival in the Laboratory e.g. semen, ECS etc.

Activity 10: Analysis

All specimens are processed and analysed in the laboratory.

Person Responsible: Medical Laboratory Scientists, Medical Laboratory Technicians, Medical Laboratory Assistants and Pathologists.

Activity 11: Dispatch of Results

All laboratory results are dispatched after reporting and documentation through:

(i) EMR

(ii) Hand to hand for private patients or referrals.

Person Responsible: Authorized Medical Laboratory personnel only.

E) BLOOD TRANSFUSION

(1) Request: Request come from the Clinicians to the blood bank

(2) Sources of blood

Patients get blood through two sources:

(A) National Blood Transfusion Services (NBTS)

(a) NBTS (Screened blood):

(b) Cross matching only

(B) Family replacement:

(a) Patients present donors for necessary screening and other investigations.

(b) All prospective blood donors are screened for the four transfusion transmissible infections (TTIs). They are: HIV screening test, Hepatitis B and C screening test and VDRL test.

(d) All qualified donors are bled into a blood bag.

Person Responsible: Authorized Medical Laboratory personnel only.

(3) Blood collection from the blood bank

(i) Routine blood collection from the bank

All routine pints of blood are signed and collected from the blood bank by Clinicians, Nurses and Health Attendants.

(ii) Emergency blood collection from the bank

All emergency blood requests/ collection from the bank are made, signed and collected by Clinicians only.

(4) Time frame of blood collection from the bank

Any pint of blood collected and kept outside the Blood bank without use after one hour (1hr) is not accepted back into the blood bank.

(5) Punctured pint of blood

All punctured pints of blood are not accepted back into the blood bank.

9.0 RADIOLOGICAL SERVICES

The radiology department as presently constituted and equipped carries out routine radiographic procedures, special radiological investigation and Ultrasonography.

Staff includes Medical doctors (consultant radiologists and medical officers), radiographers and radiography technicians and clinical assistants.

Source of patients

Patients come from clinics, wards as in -Patients or private patients who are registered as Walk-in patients or register with the hospital to obtain PID.
The Patients Proceed to the radiology department where there are billed and payment made accordingly.

Services provided include

Routine and specialist radiographic examinations (24 hours daily)
Special radiological examinations e.g. contrast studies
Ultrasonography, elective an emergencies

Procedures involved for the various services provided in the units includes the following

Assessment by the Radiographer
Booking of the patient for special procedure and Ultrasonography or immediate payment if it is a routine procedure
Registration- after payment
Carrying out the procedure

Collection of Result

Emergency cases are taken Cause of within 24hours
The result should be made available on EMR
The results are to be reposted by consultant Radiologist

Strict attendance to safety concerns and radiation exposure is very vital in the radiological department.

10.0 PHARMACEUTICAL SERVICES

Guidelines and procedure for most of the operation of the pharmacy department and activities related to the use of medicines are in the Hospital Drug Policy.

The Pharmacy department shall be headed by Director Pharmaceutical Services
The Pharmacy department shall, among other function, be the central coordinating point for all activities related to drugs/medications in the hospital. It shall be responsible for:

1. Procurement of drugs and consumables

2. Storage of procured drugs and consumables.

3. Distribution of procured drugs and consumables.

4. Dispensing of medications (for both out and in patients)

5. Provision of appropriate drug information

6. Participation in ward rounds.

7. Organisation of drug related research

Dispensing shall be from one of the dispensing outlets which shall include the Family Medicine (GOPD) pharmacy (8:00am-9:00pm) while other outlets offer 24 hour services example Inpatient Pharmacy and the A&E pharmacy, Theater pharmacy, O &G pharmacy, Paediatric pharmacy and ICU pharmacy.

The pharmacy shall entertain prescriptions made on EMR
Dispensing shall follow standard dispensing practices
Every prescription shall be professionally assessed to determine suitability – i.e assessment for validity, safety and clinical appropriateness
Dispensing shall follow standard dispensing practice as stated in the hospitals drug policy and drugs and quantity dispensed shall be documented

11.0 GUIDELINES AS IN THE HOSPITAL DRUG POLICY

Drug selection
A Hospital formulary shall be produced and made available to prescribers, dispensers and service outlets within the Hospital. The formulary shall be managed by the formulary subcommittee of the hospitals Drug Therapeutic Committee (DTC).
Drugs included in the formulary shall be listed using generic or international non-proprietary names (INN) and should be based on the health needs of the majority of the population. They should have substantial safety and risk/benefits ratio with sufficient accumulated scientific data.
As much as possible , formulations containing more than one active ingredients shall be avoided, unless one or more of the following criteria are met:

a. The clinical condition justifies the use of more than one drug in a fixed combination

b. Two or more pharmacologically active ingredients are synergistically active in a product, or

c. Patient compliance is enhanced by the combination

2. Drug Procurement

Procurement of drugs shall be restricted to drugs registered in Nigeria and on the National essential drug list and /or the Hospital formulary
Procurement shall be by the international non-proprietary Names (INN) or generic Names only. Brand or company /suppliers preference to be determined by price /cost , pharmaceutical and pharmacokinetic/bioavailability consideration
Procurement shall be by open, competitive or restricted tender of prequalified suppliers and shall be conducted in a transparent manner with the advice of the
Pharmacy Department. Emergency procurement can sometimes be allowed but this shall not be more than once within a three month period.

3. Prescriptions

The objective is to ensure that drugs are prescribed rationally. Consequently;

Electronic Prescription System/ EMR shall be adopted and Perfected in all units of the Hospital.
Up-to- date standard Treatment Guideline and the Hospital Formulary shall be made available to all prescribers in the hospital
Prescribing shall be by International Non-proprietary Names (INN) or generic names.
Drug prescriptions shall be made by only duly qualified and licensed medical practitioners. Inter professional collaborations where professional interventions by pharmacists on drug therapy problems (actual or potential) is encouraged and such activities should be documented.
Minimum items on the prescription to include patients and prescriber details. Generic name of drugs, formulation, route of administration strength, dose and duration of use.
Discharge (for inpatients) To-Take-Home(TTH) drugs should be prescribed, dispensed and handed over to the patient/relations, with appropriate drug information, before patient leaves for home
Effort shall be made to provide appropriate drug information at prescription point
Feedback on effect (both benefit and adverse) of drug shall be encouraged
In-patients prescription shall not be for more than 72hours (3-days) at the first instance then subsequently 5-days interval. This is to allow for review of medications and avoid continuous unintended administration of medicines. This policy shall not apply to medicines with defined duration of therapy (e.g. anti-tuberculous and antiretroviral drugs)

4. Drug Administration

The objective of medication administration shall be to ensure complete compliance, avoidance of medication error, appropriate review of inpatient prescription and monitoring the effect (both beneficial and harmful) of prescription medications. To ensure the above

Drug administration shall adhere to the principles of unit dose dispensing system
Physical administration of medications shall generally be the responsibility of the nursing staff. In some cases, clinicians may administer drugs as intravenous, intrathecal, anaesthetic drugs.
Medications administered shall be chartered /recorded appropriately on prescribed Medication Administration Recording (MAR) on EMR.
The MAR shall among other things contain details of prescriber , medication, prescribed right ,dosage and duration , timing of administration and the detail(Name and Signature) of the person and time of medicine administration
Monitoring the effect of the drugs on the patient shall be the responsibility of the members of health care team (Clinicians, Nurses, Pharmacist, Med. Lab Scientist) who are directly in contact with the patient. Ordering appropriate changes in therapy shall primarily be the responsibility of the clinician and this should be done in collaboration with the members of the health care team .

12.0 NURSING SERVICES

The head of nursing services shall be an officer not lower than Director Nursing Services
Provides services in most services outlets in the Hospital e.g. Theater and appendage, Clinics, Family Medicine (GOPD) and Specialist, Wards, Compound station and special units e.g. NPI
Provides SOPs and guidelines for operations of nursing services as a profession and those governing the service outlets.
Of special importance, however is the Compound unit and the Theater

Compound Unit
Shall be headed by a Nurse not lower than the rank of Assistant Director Nursing Services assisted by lower Cadre Nurses and Clinical Assistants.
Time of operation shall be 24 hours
The duties are
To coordinate nursing related services within the Hospital during regular work hours, shifts/calls periods.
Receives complaints and channels same to appropriate quarters towards effecting solution
Receives mails(including referral and emergency calls) and delivers same to appropriate departments
Handles all call related issues within the hospital.
Co-ordinates and takes responsibility for the movement of the call van.
Write compound reports
Supervise all shifting staff under Nursing Services during that period
Handles special requisitions for equipments/materials for use within the Hospital during shifting and call service.
Liaise with other units and departments in case of any challenges with patient management.

B. Theater

Operational areas include: Main Theatre ,CSSD and recovery room
To be headed by an officer not lowers than a Chief Nursing Officer.
He or She ensures availability of sterile surgical/medical materials to the team
Makes requisitions and collection of supplies
Documentation and keep same
Ensures adequate preparation of patients for surgery
Assists intra-operatively and following to full recovery before transferring to the ward.

13.0 HEALTH INFORMATION MANAGEMENT (HIM) DEPARTMENT

This department/ unit shall be responsible

for the documentation of cases
patient identification by the assignment of a unique number, PID
establishment of procedure for control, storage and retrieval of records
coding and indexing
design of documentation tools
notification of Infectious diseases
release of health information for purposes of research and training

Activities/Operations of the Unit

General
The unit shall operate 24 hours daily service- in 3 shifts of 7:00am-2:00pm,2:00pm-9:00pm and 9:00pm-7:00am
A medical record desk shall also be in operation in the various service outlets, especially the GOPD, A&E, specialist clinics to handle admissions and discharges.
A central library shall be in place to keep records of both outpatient and inpatients. These records can electronic or hard copies.
Records of patients for a particular clinic should be available at least 24 hours before the clinic.

Procedures

Family Medicine/GOPD – shall be handled from the main records unit and operate from 7am till 6pm daily.
For New Patients
Presentation of patients at the MR desk
Payment of prescribed fee to the cashier/ bank
Documentation/ registration and issuance of patients’ identification (PID) card
Patients directed to triage units
Follow ups
Presentation of PID card/Number
Documentation on the EMR
Patients directed to triage units
A&E- MR Desk officer shall exist as a unit within the premises of the A&E and shall operate a 24-hour service. It shall handle all emergency cases.
Presentation, documentation and payment of prescribed fee
Issuance of PID cards
Appointment unit- here the unit acts as an intermediary between the clinician and the patient by arranging the place, date and time of the appointment
All bookings shall be at the medical records/health information unit
Preparation of list of patients for clinic to be completed 24 hrs before clinic
After clinic, appointment by doctors is retrieved from the EMR and patient booked appropriately.
The unit also handles the booking of newly referred and discharged cases for the specialist clinics.
Admission and Discharge unit
Monitors records of patients from date of admission till discharge from the ward electronically.
Handles documentation of social data and clinical details of patient, date of discharge, name of consultant and outcome
Statistics unit
Involved in the collection, compilation, organization, summarizing, interpretation as well of patients health records which can be expressed in numerical or graphical forms
Data used are those obtained from all the other subunits/desks within the hospital
Activity involves daily visit to the service outlets to retrieve appropriate

Information and produce/present returns – monthly, quarterly, biannually or annually

14. 0 NATIONAL HEALTH INSURANCE SCHEME (NHIS)/ CREDIT SERVICES UNIT

The unit serves as a focal point between the centre, NHIS HQ, and the HMOs
The unit shall also coordinate and supervise services provided to beneficiaries and other people enjoying credit services from the hospital as NHIS enrollees.
Relate with HMOs/ Corporate bodies enjoying credit services with respect to capitation payment, payment for services
The NHIS management team shall include the following
A senior clinician – nominated by the HCS
A senior administrative officer- who shall be the administrative officer
A Quality Assurance Officer – preferably an health care provider and member of SERVICOM
An account staff
A Focal persons from Pharmacy
A Focal Person from the Laboratory

Other complement of staff shall include

A desk officer
A client relationship officer/marketer
The team shall meet regularly to, among other things, develop and implement service improvement strategies and ensure quality service delivery to beneficiaries.

Services and Procedure

Services (clinical consultation, laboratory, surgery and pharmaceutical services shall be provided based on NHIS and company’s guidelines
Care is usually classified as either Primary (General Practitioner) or Basic Care and Secondary care(Specialist) which shall be subject to approval by the HMO
While charges for Primary care shall be as dictated in the HHIS guideline, Secondary care shall be fee for service- based on existing charges
All beneficiaries shall be registered, Principal and Dependants according to the prescribed guidelines
First point of call for care shall be the GOPD, from where enrollee shall be referred appropriately. This might not be applicable to obstetric cases.

15.0 MANAGED CARE/ RETAINERSHIP;

A special unit should be created to work out the guidelines for the management of patients that come in under this arrangement.

16.0 STRIKE/ INDUSTRIAL ACTION

Upon receiving an ultimatum of industrial action, at least three (3) working days from the date of commencement of the strike action. The Head of Clinical Services (HCS) should convene a meeting of the Clinical Services Advisory Committee (CSAC) to work out modalities of maintaining some level of service delivery during the strike.

Depending on the union going on strike, the cadre of staff who by definition according to Civil Service Rule (CSR) are not to proceed on strike should be redistributed to manned the emergency points by the Head of Clinical Services (including; Accident and emergency, gynaecological ward, labour ward, medical laboratory, Radiology, pharmacy and nursing services. Such points should be made to provide skeletal emergency services at least between the hours of 8:00am to 4:00pm.

The public relation unit should at the commencement of any industrial action should sensitize members of the public on the limitations that such strike action may bring to patient care.