Evidence Based Ayurveda Treatment

PATIENT CARE

a) The planning and provision of care are based on individual patient assessment and focused on the patient's response to actual or potential alterations to health.
b) All patients are treated alike irrespective of their religion, caste, social status, financial ability etc. The safety of all patients seeking health care at this hospital is the prime responsibility of this hospital. A uniform patient care system is laid down in all areas so as to provide excellent service.
c) Similar care is given in different settings which are guided by applicable laws and regulations; care delivery is uniform in emergency and ambulance services, Cardio Pulmonary Resuscitation, while using blood and blood products and other high dependency areas, Post-surgical recovery rooms, etc.
d) D.Y.PATIL AYURVEDIC HOSPITAL upholds the policy of delivering uniform care to all patients irrespective of the case,right from the admission to discharge for IPD cases, in OPD services and emergency services.
e) Laboratory facility, OT facility, Diagnostics, Nursing Care and Dietary Services are uniformly provided to all patients irrespective of category of patients.
f) All protocols are uniformly followed in the same manner with all patients irrespective of the category status.
g) Uniform care is followed adhering to all laws & regulations.
h) It is further ensured that the care and treatment orders are legibly signed, named, timed and dated by the concerned doctors and nurses, the main idea being that the authorities of these orders are identifiable by all and the chronology of care process is maintained.

policy on emergency services
Policy For Emergency
In Case of in house emergencies RMO/CMO examine the patient & provide basic medical help to stabilize the vital parameters of the patient.
RMO/CMO inform the treating consultant (egAtiyog of panchkarma). The Patient coming to casualty are examined and given first aid. If the disease presented is within the scope of ayurvedic treatment,the patient undergoes treatment at the HCO, after the patient is admitted through proper admission procedure. Otherwise,the patient is referred to D Y Patil Hospital. A Memorandum of Understanding (MOU) is signed with the above Hospital.

a) Screening and diagnostic tests are recommended and carried out as and when required in the Triage, keeping in mind the patient’s immediate medical needs; for example, in the case of a head injury, the CMO shall have to make a quick appraisal of the criticality of the case and recommend an X-Ray if he so decides. Tests are also carried out in concurrence with the consultant for arriving at the clinical diagnosis.

b) Patients are not transferred or admitted or discharged without the CMO reading the reports of all tests recommended by him or the consultant in the Emergency, unless the critical nature of a patient’s condition warrants immediate transfer to the operating theater or a critical care unit.

Reception of patient
1. Emergency staff ensures availability of wheelchairs and stretcher trolleys at the Emergency room (ER) main door.
2. In cases where the patient is unaccompanied / unconscious, he/she are immediately referred to higher center.
3. After examining the patient first aid treatment is given by casualty medical officer. Further , he contacts the Consultant on-call in the relevant specialty by means of the telephone. Registrars/CMO shall apprise the Consultant of the patient’s condition and take instructions regarding investigations, treatment & further management.
4. CMO/Consultant fills out the Admission Request Form if the patient requires admission. A patient is to be admitted only when the Consultant advises admission.
5. When a patient is discharged to go home or transferred to another organization, it is duly documented.
6. If the patient’s disease/condition is beyond the scope of service of HCO, the said patient is given first aid treatment & transferred to D Y Patil Hospital.

Handling Medico legal Cases
a) All cases of accidents, burns, assaults, alleged suicide or homicide, poisoning, road traffic accident, rape, drowning, etc. are registered as medico legal cases (MLC).
b) All cases registered as medico legal in hospitals where he/she reported first, registered as Medico legal ,the outside MLC number is duly recorded on the case file.
c) Any case of a cognizable offense as mentioned above even if brought at a later date, by the police, the police and the hospital are duly informed and the case registered as medico legal.
d) When a case identified as medico legal is brought to Emergency Dept. CMO provides medical care as required.
e) The emergency staff informs the police by calling 100. The time of call and the police personnel spoken to shall also be documented in the MLC register. They also call the Security Supervisor. Police intimation report is made in duplicate, one copy for security office and one for police.
f) MLC Form are filled by CMO in duplicate (one copy for Medical Records Dept. and one for the police) MLC report are completed and signed as soon as possible after the patient arrives in Emergency and in all cases before the CMO goes off duty. CMO shall not be relieved until MLC reports for patients managed in the tenure of duty are completed.
g) An entry must be made in MLC intimation report in case the patient is already registered as Medico legal in another hospital.
h) Custody of Medico legal case records are under the CMO on duty. If more than one CMO is on duty the senior CMO is responsible for the custody of the records. MLC records after completion are kept under lock and key in the custody of the Medical Record Officer.

Triaging

a) Through regular modules, held for both Doctors and nursing staff, the staff are trained in the technique of Triaging
b) The policy of prioritizing patients is based on the urgency of their individual need for medical care.
c) Under normal working conditions, patients are triaged and allotted beds in the ER as per the urgency of their medical needs, using the ESI scores.
d) During external disasters (Code Red) patients are triaged as Red, Yellow, Green and Black according to the following criteria:
1) Red
First Priority, Most urgent, Life-threatening shock or hypoxia is present or imminent, but patient can be stabilized and, if given immediate care, probably survive.

Examples Red:
• Respiratory arrest or severe respiratory distress or SpO2 < 90
• Cardiac arrest
• Hypotension (BP < 90 mm Hg)
• Trauma patient who is unresponsive or requires immediate fluid resuscitation
• Overdose with a respiratory rate of 6.
• Severe bradycardia or tachycardia with signs of hypo-perfusion.
• Chest pain, pale, diaphoretic, blood pressure 70/ mm Hg
• Anaphylactic reaction.
• Baby that is flaccid.
• Unresponsive with strong odor of ETOH.
• Hypoglycemia with a change in mental status

Yellow
Second Priority, Urgent, Injuries have systemic implications or effects, but patient is not yet in life threatening shock or hypoxia; although systemic decline shall ensue and given appropriate care, patient seems able to withstand a 45 to 60 minute wait without immediate risk.

Examples of Yellow
Following diagnosis with stable blood pressure. Tachycardia / dyspnea may or may not be present
• Acute abdominal pain
• Gastro-intestinal bleeding
• Acute arterial occlusion
• Fever in immune-compromised patients
• Testicular torsion
• Acute renal failure
• Ectopic pregnancy
• Spontaneous abortion
• Rule out meningitis
• Acute Cerebro-vascular accident
• Vomiting / diarrhea in children
• Acute asthmatic attack
• Pleural effusion
• Spontaneous pneumothorax
• Road traffic accident with transient loss of consciousness

Green
Third Priority, Non-urgent, Injuries are localized and without immediate systemic implications; with a minimum of care, patient’s condition generally does not deteriorate for up to several hours.

Black
Dead, No distinction can be made between clinical and biological death in a mass casualty incident, and any unresponsive patient who has no spontaneous ventilation or circulation is classified as dead.

Transfer of patients for Diagnostic tests / other hospitals

1) To aid clinical diagnosis, samples are collected and sent to various labs for analysis and reporting. Reports are sent back to the emergency on a priority basis.
2) Screening and diagnostic tests are recommended and carried out as and when required in the Triage, keeping in mind the patient’s immediate medical needs, for example, in the case of a head injury, the CMO makes a quick appraisal of the criticality of the case and recommends an X-Ray or a CT Scan if he so decides. Tests are also carried out in concurrence with the consultant for arriving at the clinical diagnosis.
3) Patients are not transferred or admitted or discharged without the CMO reading the reports of all tests recommended by him or the consultant in the Triage, unless the critical nature of a patient’s condition warrants immediate transfer to the operating theater or a critical care unit.
4) Patient information is transferred between CMOs, nurses and other staff – whether concerning transfer, transport or medical condition- from one shift to the next through detailed handovers, which includes written or verbal communication.
5) The information includes medical status of the patient, the treating doctor’s comments, the CMO’s notes, and special information like transport and transfer information, discharge information, etc.
6) When a transfer within the hospital is done, the patient’s condition is communicated to the consultant/ treating doctor / registrar / duty doctor / floor doctor of the area where the patient is being transferred to. The medical condition of the patient, his medical care requirements and the reason for his transfer is communicated to the concerned person by the CMO and documented in the case file.
7) Transfer to another facility on patient and family request or non-availability of resources like beds etc., follows policies on transfer of stable and unstable patients.
8) Admission or discharge to home or transfer to another organization is also documented.
9) In case of discharge to home or transfer to another organization a discharge note is given to the patient.

CARE OF VULNERABLE PATIENTS (ELDERLY, PHYSICALLY CHALLENGED AND CHILDREN).

1. PURPOSE: Policies and procedures to guide the Care of vulnerable patients which includes the elderly, physically/mentally challenge and children.

2. SCOPE To provide comprehensive treatment and care for all children including neonates. The facilities provided consists of a pediatric ward & Neonatal units like Nursery, NICU etc. & also specially trained staff are available round the clock in these units. Scope of pediatric services are displayed in the front office area.

3. RESPONSIBILTY: Consultant
Nurse
RMO
Security
Attendant
Aaya
Ward boy.

4. POLICY
a) The hospital policy is in consonance with the national and international guidelines for the care of vulnerable patients. It also maintains the prevailing laws that are being followed during the care of the vulnerable patients. (Pregnant ladies, pediatric patients, physically and mentally challenged, elderly patients are treated as vulnerable ).
b) The hospital identifies the vulnerable patients in a responsible process where accountability is fixed for those who are delegated with this task of identifying these patients, risk management in these patients and monitoring of these patients (at least twice a day). All these patients are assessed for risk of falls and the same is documented.

A. Purpose: To provide guidelines, instructions in order to ensure a safe environment for vulnerable patients (Infants, Children, disabled, mentally Retarded and elderly patients).

B. Scope: Hospital wide.

C. Policy:
1. Safeguarding is a crucial element of providing care for all patients.
2. It is essential that all staff understand their role and responsibility in the identification of a vulnerable patient and how to respond and act in accordance with Hospital Policies
3. Wheelchair accessibility is available within the hospital.
4. We have separate registration counters for vulnerable patients.
5. Lift is available for vulnerable patients.
6. Handrails are provided on staircases.
7. Clear pathway and assistance is provided for the disabled and senior citizens to move around at their own pace.
8. Washrooms with grab bars are designed mainly for the disabled and aged people.
9. Call bells are present in the washroom in case of any emergency.
In our Hospital all the beds in Balrog (Pediatric) ward are with railings to ensure safety.
10. In our hospital 59 beds are dedicated for vulnerable patients.

d) The informed consent for this group of people is obtained from their family representative, by explaining the patient’s status.

e) The nursing staff that provide care to all the patients in vulnerable category are experienced, skilled, possess knowledge & are efficient. These nurses, attendant, ward boy, Aaya are trained & competent in that area of care. The nursing staff continuously supervises the patients & they are sensitized about the importance of maintaining vigilance and taking care with due diligence.

1. POLICY:

a. Gynaecologists, trained medical officers and staff nurses take care of obstetric cases & and these are duly documented.

b. High risk obstetric cases include emergencies like Shock, PIH (pregnancy induced hypertension), Foetal distress, PET (pre eclamptic toxemia), APH (ante partum hemorrhage), PPH (post-partum hemorrhage), Meconium aspiration, Ectopic pregnancy, Eclampsia, Inevitable abortion, Amniotic embolism etc. High risk obstetric cases are assessed and in case of emergency are referred to DY PATIL General Hospital.

c. There are documented procedures to guide the provision of ante-natal services. This includes assessment, diet counseling and frequency of visits.
i. The assessment of obstetric cases includes maternal nutrition, immunizations and education. High risk obstetrical care is provided to required cases by the gynecologist and Trained Medical Officers and nurses.
ii. SOP for the obstetric care includes assessment of these patients including nutrition and education. It could include Ante-natal & Post-natal care. The organization has defined the types of obstetric care provided. It is displayed in a prominent location i.e. registration counter.

d. Assessment for Maternal nutrition
i. Initial Assessment of patient: All patients attending the obstetrics and gynaecology OPD after obtaining a detailed History undergoes routine obstetric gynaecology examination which includes: General examination for pallor icterus; Thyroid swelling; Pedaloedema followed by examination of breasts, abdomen. This is followed by speculum examination and pervaginal examination.

e. Post-natal monitoring is performed and documented.

1.0 POLICY:

a) The policies and procedures for Panchakarma are well documented in (DYPATIL/AYUR/SOP/PK/01). Also the procedure for the Surgical /parasurgical processes is as per the standards and are well documented .Please refer SOP Of Shalya ,Shalakya&streerog department .

b) Physician/surgeon takes an informed consent from the patient prior to the Panchakarmaor any parasurgical/surgicalprocedure. This includes the list of and parasurgical procedures, Panchakarma therapies and treatment procedure as well as competency level for performing these procedures. Examples for Parasurgical procedures include ksarasutra, raktamokshana, Agni karma, kshara karma, etc. Examples for Treatment procedures include Abhyanga, Pinda sweda etc.; Shalakya procedures like Kriya kalpas, Prasooti & Streeroga procedures like Uttara basti, Pichu, Prakshalana, etc.
Please refer SOP Of Shalya ,Shalakya&streerog department .

c) Patients have a preoperative (parasurgical), pre-procedure (Panchakarma) assessment and a provisional diagnosis documented prior to surgery/procedures.

d) Documented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgery/procedures. All patients undergoing Para surgical Procedure are assessed pre- operatively which is documented by a surgeon/physician. Similarly all Panchakarma procedures are assessed before the procedure by the physician and should include yogya-ayogya for the particular therapy, and a provisional diagnosis is made which is documented. This shall be applicable for both routine and emergency cases. The organization able to demonstrates methods to prevent these events e.g. check list for panchkarma/identification tags/markings/cross-checking as per WHO “Safe surgery save lives” initiative. Check list for all operative procedure

e) Persons qualified by law are permitted to perform the procedures that they are entitled to perform. The organization identifies the individuals who have the required qualification(s), training and experience to perform, Para surgical/Panchakarma procedures in consonance with the law.

f) A brief operative note / note regarding the procedure is documented on IPD case sheet prior to transfer of patient from recovery area OT. This note provides information about the procedure performed and the status of the patient before shifting and documented by the surgeon or Physician/member of the surgical team.

g) It includes the Parasurgical procedure performed, name of the surgeon(s)/physician, salient steps of the procedure and the key findings. It includes monitoring of samyak and asamyaklakshanas of the procedure. If it is documented by a person other than the physician, the same is countersigned by the Physician. The operating surgeon/physician document the post-operative/post-procedure care plan. Post-operative plan includes advice on IV fluids, medication, care of wound, nursing care, observing for any complications, etc. For post- procedures, the plan includes advice on Samsarjana Krama for Vamana/virechana, pathya-apathya for other procedures, nursing care, observing for any vyapaths, etc.

h) Adequate area, appropriate facilities and equipment/instruments are available in the OT /Panchakarma therapy and Treatment procedure room. For Surgical/para surgical procedures, the organization ensures that the OT has facilities for pre-op holding, hand-washing area, operating rooms, storage area, recovery room, collection area for waste and linen etc. Panchakarma therapy and treatment procedure room may be combined or separate.

i) Patient, personnel and material flow conforms to infection control practices. The layout of the theatre is such that the mix of sterile and unsterile material does not happen.

j) Guidelines for various Parasurgical procedures / Panchakarma therapy and other Treatment procedures are prepared separately and adhered. For Parasurgical procedures e.g. the methodology of Ksharasutra, agnikarma etc. followed in the HCO is documented. For Parasurgical procedures the methodology is based on classical texts like Susrutasamhita, Astangahridaya etc. e.g. “Parasurgical procedure protocol”.

k) For Panchakarma therapy and other Treatment procedures like Vamana karma protocol, Abhyanga protocol, Netra tarpana protocol, pichu protocol, etc. followed in the HCO is documented. For Panchakarma therapy and other Treatment procedures, SOP for the documented procedures are prepared based on classical texts like Charaka Samhita, Susrutasamhita, Astangahridaya, etc. Standard precautions and asepsis is adhered to during the conduct of therapies. In case the organization has a policy of re-using devices it ensures that they are properly sterilized where appropriate. Further, the integrity of the devices is checked.

l) A quality assurance program is followed for the Parasurgical / Panchakarma therapy and other treatment services. This is an integral part of the organization’s overall quality assurance programme. It focuses on post-operative complications e.g. bleeding, non-healing wound etc. For Panchakarma therapy &other treatment procedures, it also focuses on yogya-ayogyalakshanas, samyak-asamyaklakshanas, vyapaths, etc.

m) The quality assurance program includes surveillance of the OT / Panchakarma or treatment procedure room. Surveillance activities include the monitoring of efficacy of OT / Panchakarma, treatment procedure room cleaning, disinfection processes etc.

1. POLICY:

a) Documented procedures guide the administration of moderate sedation which includes identification of procedures where this is required, the mechanism for writing orders, the pre-procedure assessment, monitoring during and after the procedure and the discharge/transfer out criteria after the procedure.

b) Informed consent for administration of moderate sedation is obtained. This is taken by the person performing the procedure/administering sedation/RMO/Nurses.

c) Competent and trained persons perform sedation. This includes identification of procedures where this is required, the mechanism for writing orders, the pre-procedure assessment, monitoring during and after the procedure and the discharge/transfer out criteria after the procedure.

d) The person administering and monitoring sedation is different from the person performing the procedure.

e) Intra-procedure monitoring includes at a minimum the heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, and level of sedation. The same is documented. In addition, certain other parameters monitored on a case-to-case basis. The cardiac rhythm monitored on a monitor during the procedure and the same is documented. However, in case of rhythm abnormalities also, the same is documented.

f) Patients are monitored after sedation and the same documented. The patient’s vitals monitored at regular intervals till he/she recovers completely from the sedation. At a minimum, the heart rate, respiratory rate, blood pressure, oxygen saturation and level of sedation are monitored. The level of sedation is monitored by using a checklist which incorporates the various components of levels of sedation (minimal, moderate and deep).

g) Vital criteria are used to determine appropriateness of discharge from the recovery area. These are developed and documented by the organization in consonance with physiologic parameters and best clinical practices. The criteria are applied by a qualified individual and the same documented.

h) Equipment and qualified manpower are available to rescue patients from a deeper level of sedation than that intended. The equipment includes emergency resuscitation equipment. A person trained in airway management/anesthesiologists is available in the hospital.