Internship at Sagar Hospital Final Report 2008 09 by Rijo Ste 1382

PESIT - HOSMAC PGDHHM - JUNIOR INTERNSHIP

1

Junior Internship At

Sagar Hospitals Jayanagar, Bangalore

Guides: Dr Mohan Reddy Medical Director, Sagar Hospitals

Dr. Major Madhu Regional Head – South, Hosmac India Pvt. Ltd.

Dr. Jithendra Kumar Senior Consultant, Hosmac India Pvt. Ltd.

Presented by Rijo Stephen Cletus. B.E.

PGDHHM course by HOSMAC-PESIT


2

ACKNOWLEDGEMENT

I wish to express my sincere gratitude to Dr. Mohan Reddy, Medical Director,

administration, Sagar Hospitals, Jayanagar, Bangalore for giving me the opportunity to do my

Junior Internship at his highly esteemed Organization.

I am grateful to Dr. Madhu Malathi and Dr. Jithendra Kumar for their valuable

guidance, advice, suggestion and encouragement rendered to me at every stage.

I am also extremely thankful to Mr. Sundar (Dialysis Department), Mr. Pradeep

(Pharmacy), Mr. Raja (Biomedical Engineering), Mr. Imdad Ali (Ambulance Department)

for giving me information and valuable guidance during the period of internship1. Without

their encouragement and guidance this project would not have materialized.

The guidance and support received from all the members who contributed to this study was

vital for the completion of this study. I am grateful to all of them for their constant support

and guidance either directly or indirectly towards completion of my study.

Rijo Stephen Cletus


3

Table of Contents

INTRODUCTION TO THE HOSPITAL ....................... ..............................................................6

SAGAR GROUP .............................................................................................................................. 7

ABOUT SAGAR HOSPITALS, JAYANAGAR.................................................................................... 8

LOCATION....................................................................................................................................... 8

VISION AND MISSION.............................................................................................................9

FACILITIES.................................................................................................................................... 10

DIAGNOSTICS & TREATMENT SERVICES.................................................................................. 10

CENTRES OF EXCELLENCE ....................................................................................................... 12

QUALITY POLICY..................................... .............................................................................13

ACCREDITATIONS........................................................................................................................ 13

CARE FOR INTERNATIONAL PATIENTS...................................................................................... 14

STUDY OF DIALYSIS DEPARTMENT....................... ............................................................15

DIALYSIS....................................................................................................................................... 16

PRINCIPLE OF DIALYSIS ............................................................................................................. 16

TYPES OF DIALYSIS .................................................................................................................... 17

THE PHYSICAL STRUCTURE OF THE DIALYSIS DEPARTMENT ............................................... 19

DIALYSIS MACHINES ................................................................................................................... 19

ORGANIZATIONAL STRUCTURE................................................................................................. 20

SHIFTS.......................................................................................................................................... 21

DISTRIBUTION OF RESOURCES ................................................................................................ 21

ACTIVITIES UNDERTAKEN TO SUPERVISE................................................................................ 21

EXTERNAL CLEANING OF THE MACHINES AFTER EVERY DIALYSIS...................................... 21

REVERSE OSMOSIS (RO) PLANT ............................................................................................... 22

PREPARING THE MACHINE FOR DIALYSIS................................................................................ 24

STARTING AND CLOSING OF DIALYSIS ..................................................................................... 24

STARTING OF DIALYSIS............................................................................................................... 25

CLOSING OF DIALYSIS ................................................................................................................ 26

FIGURE – ARTERIO-VENOUS FISTULA ...................................................................................... 27

FIGURE – REPRESENTATION OF THE FLOW OF DIALYSATE AND BLOOD ............................. 28

FIGURE: VENOUS BLOOD AIR TRAP .......................................................................................... 29

MEDICAL EMERGENCY DURING DIALYSIS................................................................................ 30

STUDY OF PHARMACY DEPARTMENT....................... ........................................................34

INTRODUCTION TO PHARMACY DEPARTMENT........................................................................ 35

NEED FOR THE DEPARTMENT ................................................................................................... 36

FUNCTIONS.................................................................................................................................. 36

PHYSICAL STRUCTURE .............................................................................................................. 38

THE ORGANIZATIONAL STRUCTURE OF THE DEPARTMENT .................................................. 39

THE HUMAN RESOURCE MANAGEMENT .................................................................................. 39

ACADEMIC QUALIFICATIONS AND DESIGNATIONS .................................................................. 40

JOB RESPONSIBILITIES .............................................................................................................. 40

REGULATORY COMPLIANCE ...................................................................................................... 41

FORMULARY ................................................................................................................................ 41

STORAGE ..................................................................................................................................... 41

SALES ........................................................................................................................................... 42


4

OUTPATIENT PRESCRIPTIONS................................................................................................... 43

INPATIENT PRESCRIPTIONS....................................................................................................... 43

SALES RETURNS ......................................................................................................................... 44

EXPIRY DRUGS RETURN ............................................................................................................ 44

STOCK CHECKING....................................................................................................................... 45

BREAKAGE ................................................................................................................................... 45

STUDY OF BIOMEDICAL ENGINEERING DEPARTMENT......... ..........................................46

BIOMEDICAL ENGINEERING DEPARTMENT .............................................................................. 47

TECHNICIANS............................................................................................................................... 48

WORKING HOURS........................................................................................................................ 48

PHYSICAL STRUCTURE .............................................................................................................. 48

TECHNOLOGY.............................................................................................................................. 48

PROCUREMENT........................................................................................................................... 48

PREVENTIVE MAINTENANCE...................................................................................................... 49

BREAKDOWN MAINTENANCE..................................................................................................... 49

STUDY OF AMBULANCE SERVICES DEPARTMENT ............. ............................................50

AMBULANCE SERVICES DEPARTMENT..................................................................................... 51

HOW THE SERVICE REQUEST PROCESSED ............................................................................ 52

WHEN IS A SERVICE REQUEST DECLINED ............................................................................... 52

PRESENT DEMAND FOR THE AMBULANCE SERVICE .............................................................. 53

THE VEHICLES AND THEIR TYPES............................................................................................. 53

MAINTENANCE OF THE VEHICLES............................................................................................. 54

THE HUMAN RESOOURCE.......................................................................................................... 55

AMBULANCE DRIVERS................................................................................................................ 55

SOME IMPORTANT GUIDELINES ................................................................................................ 55

DRIVERS SHIFTS ......................................................................................................................... 56

RECOMMENDATIONS...........................................................................................................57

INDEX.....................................................................................................................................58


5

PPPaaagggeee LLLeeefffttt BBBlllaaannnkkk

IIInnnttteeennntttiiiooonnnaaallllllyyy


6

INTRODUCTION TO THE HOSPITAL


7

SAGAR GROUP

Sagar Group is a forerunner in path-breaking ventures that have been touching the chords of

the populace in the city of Bangalore. Founded by Barrister Shri R. Dayananda Sagar, the

group pioneered in Education more than five decades back. In memory of the Father of the

Nation, Sri R. Dayananda Sagar founded the Mahatma Gandhi Vidya Peetha Trust, which

today runs 22 institutions ranging from primary education to doctoral levels offering

100+courses spread over Science, Arts, Commerce, Management, IT, Engineering, Dentistry,

Pharmacy, Nursing and Physiotherapy.

It ventured into healthcare services in 1960 under the qualified leadership of Dr. Chandramma

Sagar. The healthcare and educational activities have attained a global brand status bringing

pride to Bangalore. These services together employ close to 5,000 professionals and an

equal number of support staff, impacting the lives of large sections of society.

The vision of this philanthropic couple is being realized through the efforts of Dr. D.

Hemachandra Sagar, Chairman – Sagar Group and Dr. D. Premachandra Sagar, Vice-

Chairman – Sagar Group, both qualified doctors themselves. Their dynamic leadership is

carrying the legacy of the founders of the group forward with a mission to add value to life and

make healthcare affordable to everyone.


8

ABOUT SAGAR HOSPITALS, JAYANAGAR

Sagar Hospitals is a comprehensive healthcare provider in Bangalore with two multi-specialty

hospitals, four clinics and a chain of pharmacies. The 665 beds facility spread across two

locations in South of Bangalore is equipped with the latest medical technology offering

affordable medical treatment with personalized care.

Apart from the world’s latest 128 slice cardiac CT, the hospital has some of the path breaking

diagnostics and surgical equipments. This combined with highly skilled medical, nursing,

administration and paramedical staff makes Sagar Hospitals one of the most trusted

healthcare providers in Bangalore. Following international management practices, the hospital

caters to patients from India and overseas. Luxurious patient rooms range from presidential

suites to general ward categories. Attractive health insurance plan makes it possible for

people to avail complete medical benefits. Various health check-up packages for different age

groups are available at the preventive health check department of Sagar Hospitals.

LOCATION

It is located in the South of Bangalore in the city’s largest residential locality – Jayanagar.

The hospital started functioning in July 2002.


9

VISION AND MISSION

VISION STATEMENT

To create an enduring legacy in medical care and well-being using state-of-the art technology and processes that stand for the ultimate in care.

MISSION STATEMENT

To offer best of the class healthcare service to primary, secondary and tertiary needs at affordable prices.


10

FACILITIES

250 beds

40 specialties

Private deluxe rooms

Luxurious presidential suites

Spacious single rooms

Comfortable semi private beds

Economical General ward beds (male & female)

Cost effective Daycare

DIAGNOSTICS & TREATMENT SERVICES 60 Intensive Care Beds

7 Operating Theatres

12 bed Day Care Unit

16 bed Neonatal Unit

State-of-the-art Cathlab

Drug De-addiction center

Birthing Suite

Yoga & Physiotherapy

CT / MRI

24 hour pharmacy, laboratory, ambulance and blood bank..

OPD consultation rooms

Well-equipped OPD consulting rooms to avoid long waiting time and a spacious patient

waiting lounge with comfortable seating and pleasant ambiance.

Laboratory


11

Hi-tech laboratory with pneumatic systems to transfer samples and medicines; complete

range of investigations in the areas of Haematology, Clinical Pathology, Biochemistry,

Histopathology, Cytopathology, Microbiology and Immunology.

Open 24 hours with a dedicated team.

Radio Diagnostics

The latest 128 slice cardiac CT and 1.5 Tesla MRI with Total Imaging Matrix.

Casualty and Emergency

A team of skilled and experienced paramedics, headed by an experienced doctor specializing

in emergency and trauma care. A dedicated operating theatre is attached to the emergency

unit with a spacious triage and recovery room functioning 24 hours.

Preventive Health Check

Various health check packages for different age group ranging from a newborn to 90 year

olds.

Patient Rooms

Spacious and Comfortable rooms with television, internet and video conferencing facility.

Spacious and comfortable Presidential Suites.

Isolation wards for patients with infectious diseases.

Yoga and Physiotherapy

The Physiotherapy Department provides post-operative care for patients and the Department

of Yoga offers a therapeutic yoga certificate course.

Book Shop, Coffee Shop

Dedicated admission and billing counters and a team of insurance advisors.

24 hour Blood Bank

Dialysis Centre

Dedicated labor rooms with birthing suites

Cubicle ICUs


12

Minimally Invasive Operating Theatre with L.E.D. lights

Green Light Laser procedures for treating enlarged prostate

Robotic Enabled OT

Roof-top food court

CENTRES OF EXCELLENCE

• Sagar centre for cardiac care

• Sagar center for diabetes and endocrinology

• Sagar centre for pediatrics

• Department of neuroscience

• Department of nephrology and urology

• Department of orthopedics


13

QUALITY POLICY

We will offer the most competitive cost advantage with the world's most advanced medical

and technological infrastructure while practicing best in class medicine.

ACCREDITATIONS

Sagar Hospitals is NABH accredited and ISO 9001 certified.

National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent of

Quality Council of India, set up to establish and operate accreditation programs for healthcare

organizations. The board is structured to cater to much desired needs of the consumers and

to set benchmarks for progress of health industry.

NABH accreditation for Sagar hospitals, Jayanagar was in December 2007

Globally, ISO 9001 has been established as the most fundamental quality management

system. ISO 9001 emphasizes customer satisfaction and continual improvement for sustained

growth of the business.

ISO accreditation for Sagar hospitals, Jayanagar was in September 2004.


14

CARE FOR INTERNATIONAL PATIENTS

The team at Sagar Hospital's International Patient Care Center extends to a full range of

personalized services to international patients and their accompanying family members. A

dedicated team of professional patient care coordinators ensure that every patient's visit is

comfortable, pleasant and hassle free. The International Patient Care team at Sagar Hospitals

takes care of every minute details of overseas patients, offering world-class medical treatment

at approximately one-third of the cost compared to the West.

Interpreters are available to help you understand your medical condition and treatment

procedures. Interpretation services are provided in the following languages:

English, Bengali, Arabic, Urdu, Japanese, German, French and Hindi.

Language assistance by qualified sign language interpreters are provided for those

challenged with impaired hearing


15

STUDY OF DIALYSIS DEPARTMENT


16

DIALYSIS In medicine, dialysis (from Greek "dialusis", meaning dissolution, "dia", meaning through,

and "lusis", meaning loosening) is primarily used to provide an artificial replacement for

lost kidney function (renal replacement therapy) due to renal failure. Dialysis may be used for

very sick patients who have suddenly but temporarily, lost their kidney function (acute renal

failure) or for quite stable patients who have permanently lost their kidney function (stage 5

chronic kidney disease). When healthy, the kidneys maintain the body's internal equilibrium of

water and minerals (sodium, potassium, chloride, calcium, phosphorus, magnesium, sulfate)

and the kidneys remove from the blood the daily metabolic load of fixed hydrogen ions. The

kidneys also function as a part of the endocrine system producing erythropoietin and 1,25-

dihydroxycholecalciferol (calcitriol). Dialysis is an imperfect treatment to replace kidney

function because it does not correct the endocrine functions of the kidney. Dialysis treatments

replace some of these functions through diffusion (waste removal) and ultrafiltration (fluid

removal)

PRINCIPLE OF DIALYSIS

Dialysis works on the principles of the diffusion of solutes and ultrafiltration of fluid across

a semi-permeable membrane. Blood flows by one side of a semi-permeable membrane, and a

dialysate or fluid flows by the opposite side. Smaller solutes and fluid pass through the

membrane. The blood flows in one direction and the dialysate flows in the opposite. The

counter-current flow of the blood and dialysate maximizes the concentration gradient of

solutes between the blood and dialysate, which helps to remove more urea and creatinine

from the blood. The concentrations of solutes (for example potassium, phosphorus, and urea)

are undesirably high in the blood, but low or absent in the dialysis solution and constant

replacement of the dialysate ensures that the concentration of undesired solutes is kept low

on this side of the membrane. The dialysis solution has levels of minerals like potassium and

calcium that are similar to their natural concentration in healthy blood. For another


17

solute, bicarbonate, dialysis solution level is set at a slightly higher level than in normal blood,

to encourage diffusion ofbicarbonate into the blood, to act as a pH buffer to neutralise

the metabolic acidosis that is often present in these patients. The levels of the components of

dialysate are typically prescribed by a nephrologist according to the needs of the individual

patient.

TYPES OF DIALYSIS

There are two primary types of dialysis, hemodialysis and peritoneal dialysis, and a third

investigational type, intestinal dialysis.

Hemodialysis

In hemodialysis, the patient's blood is pumped through the blood compartment of a dialyzer,

exposing it to a semipermeable membrane. The cleansed blood is then returned via the circuit

back to the body. Ultrafiltration occurs by increasing the hydrostatic pressure across the

dialyzer membrane. This usually is done by applying a negative pressure to the dialysate

compartment of the dialyzer. This pressure gradient causes water and dissolved solutes to

move from blood to dialysate, and allows the removal of several litres of excess fluid during a

typical 3 to 5 hour treatment. In the US, hemodialysis treatments are typically given in a

dialysis center three times per week (due in the US to Medicare reimbursement rules),

however, as of 2007 over 2,000 people in the US are dialyzing at home more frequently for

various treatment lengths.[2] Studies have demonstrated the clinical benefits of dialyzing 5 to

7 times a week, for 6 to 8 hours. These frequent long treatments are often done at home,

while sleeping but home dialysis is a flexible modality and schedules can be changed day to

day, week to week. In general, studies have shown that both increased treatment length and

frequency are clinically beneficial.

Peritoneal dialysis

In peritoneal dialysis, a sterile solution containing minerals and glucose is run through a tube

into the peritoneal cavity, the abdominal body cavity around the intestine, where the peritoneal


18

membrane acts as a semipermeable membrane. The dialysate is left there for a period of time

to remove waste products and water, and then it is drained out through the tube and

discarded. This cycle or "exchange" is normally repeated 4-5 times during the day,

(sometimes more often overnight with an automated system). Ultrafiltration occurs

via osmosis; the dialysis solution used contains a high concentration of glucose, and the

resulting osmotic pressure causes fluid to move from the blood into the dialysate. As a result,

more fluid is drained than was instilled. Peritoneal dialysis is less efficient than hemodialysis,

but because it is carried out for a longer period of time the net effect in terms of removal of

waste products and of salt and water are similar to hemodialysis. Peritoneal dialysis is carried

out at home by the patient and it requires motivation. Although support is helpful, it is not

essential. It does free patients from the routine of having to go to a dialysis clinic on a fixed

schedule multiple times per week, and it can be done while travelling with a minimum of

specialized equipment. Because survival and quality of life are similar with both peritoneal

and hemodialysis, the selection of modality by the patient should be dictated by the life style

that each therapy offers.

Hemofiltration

Hemofiltration is a similar treatment to hemodialysis, but it makes use of a different principle.

The blood is pumped through a dialyzer or "hemofilter" as in dialysis, but no dialysate is used.

A pressure gradient is applied; as a result, water moves across the very permeable

membrane rapidly, "dragging" along with it many dissolved substances, importantly ones with

large molecular weights, which are cleared less well by hemodialysis. Salts and water lost

from the blood during this process are replaced with a "substitution fluid" that is infused into

theextracorporeal circuit during the treatment. Hemodiafiltration is a term used to describe

several methods of combining hemodialysis and hemofiltration in one process.


19

THE PHYSICAL STRUCTURE OF THE DIALYSIS DEPARTMENT It is located in the first floor. Total area is roughly about 1500 sft

Present Bed Capacity - 7 bedded, with sufficient place for the beds with the equipment and

place for personnel to freely move round

Equipments – Total 10 machines including 3 machines used as standby which are normally

used in ICU.

DIALYSIS MACHINES

The machine Company - Model Number and Quantity

Nikkiso – DBB26 : 2 nos

Worked Hours : M- 1 :- 34068 hrs.

M- 2 :- 33612 hrs.

Nipro – Surdial : 2 nos


M- 4 :- 32970 hrs.

B.Braun – Dialog : 2 nos


M- 6 :- 24806 hrs.

Gambro – AK 95 S : 4 nos


M- 8 :- 10264 hrs.

M- 9 :- 09722 hrs.

M- 10:- 03959 hrs.


20

ORGANIZATIONAL STRUCTURE

HOD - Dr. Sanjeev Hiremath

Consultant Nephrologist.

Reports to: MD

Senior Technician

Mr Sundar Singh

Academic profile: Grad in B.Sc. 6 Months training in Dialysis at Apollo Hospital, Chennai.

Experience: 22 Years

Repoorts to: HOD

Technicians

No. of technicians - 6

Academic Qualification required: Diploma in Dialysis Technology or Trained in Dialysis

technology post graduation

Experience: 3 to 10 years

Reports to: Sr. Technician

Nurses

Total number of nurses – 8

Nursing in charge – 1

The nursing incharge reports to the Nursing Superintendent

All other nurses report to the Nursing In charge

Academic profile of nurses: Diploma in Nursing or B.Sc. Nursing

Experience: 3 to 10


21

SHIFTS

General shift 9 am to 5 pm

First Shift 8.00 am to 2.00 pm

Second Shift 2.00 pm to 8.00 pm

Night Shift 8.00 pm to 8.00 pm

DISTRIBUTION OF RESOURCES

Sr. Technician : General shift

Technician : First (Morning) shift - 3 technicians,

Second (Afternoon) shift - 2 technicians,

Night shift - 1 technician.

ACTIVITIES UNDERTAKEN TO SUPERVISE

1. Preparing the machines for dialysis before the patient comes.

2. Receiving and preparing the patient for dialysis, initiation and termination of dialysis.

3. Ensuring that all the parameters are set in the machine.

4. Continuous monitoring of all the relevant parameters throughout the procedure.

5. Ensuring that all the necessary materials are available at all times.

6. Taking instructions from the consultant and implementing the same.

EXTERNAL CLEANING OF THE MACHINES AFTER EVERY DIALY SIS

Acid / Bleach wash for the internal hydraulic tubing at end of the day.

M-1, M-2, M-3, M-4 : Manual Setting – 30 minutes

M-5, M-6 : Auto Program – 38 minutes

M-7, M-8, M-9, M-10 : Auto Program – 48 minutes

Check Biochemistry values once a week.


22

REVERSE OSMOSIS (RO) PLANT

This is the water purifying system for dialysis machines.

Sand Filter - filters undissolved suspended particles from the feed water.

Activated Carbon Filter - removes bacteria and odor by adsorption.

Water Softener - Softens the feed water by nullifying the hardness of the feed water thus

increasing the RO output.

Micro filters

20” 10 micron filter is used which filters particles up to the size of 10 microns if the particles

have escaped from sand and carbon filters. It needs to be changed once in three months.

20” 5 micron filter which filters particles up to the size of 5 microns if particles have escaped

from sand and carbon filters and the 10 micron filter. It needs to be changed once in three

months.

RO unit - It is a 3 membrane unit and the approximate output is 650 – 700 lts per hr. Life

span of the membrane is approximately 3 years.

Collection Tanks - Permeate water is collected in 2 tanks of 2000 lts each. From the tank

water is passed through UV lamp which kills micro-organisms if present.

Back wash procedure for Sand and Carbon filters

1. Switch off the feed water pump.

2. Turn the handle in the multiport valve mounted on top of the filter vessel to back wash

position from filter position.

3. Switch on the feed water pump and allow the water to flow through the filter.

4. Water moves in opposite direction and pushes all dust particles through the drain. Wait

till the presence of the dust in the drain to clear.


23

5. Switch off the fed water pump.

6. Turn the handle in the multiport valve to Rinse position.

7. Switch on the feed water pump. Filter is rinsed.

8. Repeat the above till get satisfied and allow the water to other side.

Time taken for this procedure mentioned above is approximately 30 to 45 minutes.

Repeat frequency - Once in 3 days.

Softener – regeneration

1. Take 18 Kg of common salt in the regeneration tank.

2. Add filtered water dissolve the salt and make it to 50 lts.

3. Turn the multiport valve handle to slow rinse (regeneration) position.

4. Place the injection tube in the regeneration tank.

5. Switch on the feed water pump.

6. Slowly open the injection valve and allow the salt solution to get sucked in.

7. Once over close the injection valve. Switch off the pump.

8. Turn the multiport valve handle to fast rinse position.

9. Switch on the feed water pump and rinse the softener.

10. Check the hardness of the water using hardness testing kit.

11. Once the desired level (<40 ppm) attained switch off the pump.

12. Turn the multiport valve handle to service position.

Time taken for this procedure, mentioned above is approximately 2 hrs 30 minutes.

Repeat frequency: Once in a week.


24

PREPARING THE MACHINE FOR DIALYSIS

1. Connect the water input line to the RO water line and open it.

2. Place the drain line in the drain hole.

3. Plug in the electrical connection and switch on the machine.

4. Set the machine for rinse mode for 10 minutes.

5. After rinse set preparation mode and connect acid and bi-carbonate concentrate

solution.

6. Machine goes in to self checking mode and come final conductivity..

7. Once machine ready start the dialysis…

8. Connect the dialyser and blood tubing to the machine and prime with normal saline.

Tap on the head of the dialyser and remove all the air from the blood compartment. Fill

the tubing also with saline. Connect the recirculation connecter in the tip and set for

recirculation.

Time taken for preparation is 30 minutes.

STARTING AND CLOSING OF DIALYSIS

Before starting the dialysis the hands of the technicians and associated staff should be

thoroughly washed with soap solution and dried with a clean towel.

The following things should be kept ready before starting the dialysis procedure.

1. AV fistula needles 2nos

2. Disposable syringe 20ml 1

3. Syringe 1ml 1

4. Xylocaine injection

5. Sterile glove 1pair

6. HD set 1

7. Surgical spirit

8. Four Pieces of 3 inch plaster

9. Normal saline


25

STARTING OF DIALYSIS

Patient

1. Check patient weight and BP make the patient lie down on the bed.

2. Inform the consultant and take necessary instructions for the dialysis.

3. Open the HD set and place all the things mentioned above in the set.

4. Wear the hand gloves and clean the fistula hand top and bottom with spirit and put

sterile towel under the hand.

5. Load Xylocaine 2% in 1ml syringe.

6. Select a convenient place for cannulation.

7. Inject local injection and insert the fistula needle in to the vein. One needle should be

inserted towards the fistula (artery) and another one towards the heart (vein).

Machine

1. Switch off the blood pump and disconnect the recirculation connector from arterial line.

2. Clean the tip of the arterial line with spirit swab and connect to the arterial needle.

3. Set the pump speed of 100ml per minute on the blood pump and let the blood flow

through the line.

4. Once the saline in drained and the line filled with blood clamp the venous line of the

tube and immediately switch off the blood pump.

5. Clean the tips of the venous line connect to the venous needle.

6. Release the clamp of the venous line and needle.

7. Connect the venous monitor line and release the clamp.

8. Switch on the blood pump.

9. Set the time and weight loss, confirm and press UF/ Dialyze mode.

10. The dialysis starts.

11. Load 5000 IU of injection heparin in 20ml syringe make it to 10ml and fix in the syringe

pump in machine and set the flow rate.

12. Enter the time of starting, blood flow, venous pressure, TMP in the dialysis chart.

13. Check BP of the patient every half an hour and enter in the dialysis chart.


26

CLOSING OF DIALYSIS

Material needed: Gloves 1 pair, sterile gauze 1pack

Machine

1. Wear the gloves, switch off the blood pump and clamp the artery line and the artery

fistula needle.

2. Disconnect the artery line from the fistula needle.

3. Connect recirculation connector to the blood line and connect saline to it.

4. Switch on the blood pump and let 100 – 150 ml of saline to clean the blood line and the

dialyser off blood.

5. Once the saline in returned to the patient body switch off the blood pump and clamp

the venous line thus to prevent any air entering the blood stream.

Patient

1. Remove plaster from the artery needle.

2. Tightly fold gauze piece, pull half of the needle out pour little Neosporin Powder, put

the folded gauze piece there and remove the needle hold till bleeding stops and secure

with tourniquet.

3. Repeat the same procedure to the venous line also.

4. Check patient BP and Post dialysis weight and record it into the patient file.


27

FIGURE – ARTERIO-VENOUS FISTULA


28

FIGURE – REPRESENTATION OF THE FLOW OF DIALYSATE AN D BLOOD


29

FIGURE: VENOUS BLOOD AIR TRAP


30

MEDICAL EMERGENCY DURING DIALYSIS

Hypotension

A decrease in blood pressure is the most frequent complication reported during hemodialysis.

When fluid is removed during hemodialysis, the osmotic pressure is increased and this

prompts refilling from the interstitial space. The interstitial space is then refilled by fluid from

the intracellular space. Excessive ultra filtration with inadequate vascular refilling plays a

major role in dialysis induced hypotension. The immediate treatment to hypotension is to

discontinue dialysis and place the patient in a trendelenburg position. This will increase

cardiac filling and may increase the blood pressure promptly.

Cramps

In the majority of hemodialysis patients, cramps occur toward the end of the dialysis

procedure after a significant volume of fluid has been removed by ultra filtration. The

immediate treatment for cramps is directed at restoring intravascular volume through the use

of small boluses of isotonic saline. Prevention of cramps has been attempted with the

prophylactic use of quinine sulfate at least 2 hours prior to dialysis.

Cardiopulmonary Resuscitation on Dialysis

Check for breathing - Look, Listen and Feel.

Check for Carotid Pulse.

Open Airway

Open the patient's airway by head-tilt, chin-lift.

Blind finger sweep (open the mouth and remove any major obstructions.)

Give patient O2 connected ambu mask keeping head-tilt, chin-lift.


31

Commence CPR

1. Place two fingers above sternum then Place the heel of one hand 2-3 inches above the

xyphoid process (tip of the sternum).

2. Place your other hand on top of the first and interlace your fingers.

3. Lock your elbows and move your body directly above the patient. This allows you to

use the weight of your body, instead of your muscles, to perform compressions. You'll

tire less easily.

4. Start the compression by counting

5. 1 and 2 and 3 and 4 and 5



8. After one set of compression give two breaths. Between each breath count as :

9. One A thousand

10. Two A thousand

11. then give breath using an ambu bag.

12. In any resistance felt assess airway for breathing by Look, Listen and Feel.

13. If no breath continue CPR

Note

Compress the chest wall about 1.5-2 inches down (1/3 to 1/2 the total chest depth).

One of the biggest problems with CPR is ineffective compressions. Keep this in mind and

don't be afraid to actually compress the chest wall-you're trying to pump the heart by

squeezing the rib cage.

Push hard and fast.

Perform 15 compressions to every 2 breaths.

After every cycle of this (2 minutes), stop CPR and check for a pulse.

If no pulse, continue CPR until help arrives, periodically check for a pulse.

If a pulse or resistance is felt, reassess airway and circulation. Then tilt patient to recovery

position and connect O2 mask. Continue to check the pulse once a minute to ensure that you

don't lose it.


32

ROLE OF FIRST PERSON

1. Mr. Mr. are you okay, no response, no pulse.

2. Ask for help - HELP

3. Stop pump, lower the head end of the patient.

4. Disconnect blood lines, and give Ns.

5. Check for breath by Look, Listen and Feel.

6. Check for carotid pulse

7. No breath, commence CPR

8. Place two fingers above sternum. Place the heel of other hand and then Place your

other hand on top of the first and interlace your fingers. Start giving compressions

by counting.

1 and 2 and 3 and 4 and 5


1 and 2 and 3 and 4 and 15.

After one set of compression wait for two breaths.

If no resistance is felt continue CPR.

When changing to another person for compression then count as;



Switch and 2 and 3 and 4 and 15.

If resistance is felt stop CPR.


33

ROLE OF SECOND PERSON

Arrive to the patient along with the Ambu bag and O2 cylinder.

Connect ambu to the oxygen

Head-tilt, chin-lift

Do Blind finger sweep

Keep suction ON during compression

Connect ambu with O2 to the patient.

After 15 compressions, give two breath using ambu

After one breath count

ONE A thousand

TWO A thousand

Then give second breath

If no resistance is felt

Look, Listen and Feel for breath.

No breath continue CPR

If patient becomes concious or any resistance is felt.

Check for breath by Look, Listen and Feel. Then turn patient to recovery position i.e., to

the left side of the patient and connect Oxygen.

ROLE OF THIRD PERSON

Call the Doctor.

Bring the Emergency trolley to the spot.

Load the necessary Inj. As and when required.

Then document the medical data.


34

STUDY OF PHARMACY DEPARTMENT


35

INTRODUCTION TO PHARMACY DEPARTMENT

Pharmacy (from the Greek φάρµακον 'pharmakon' = drug) is the health profession that links

the health sciences with the chemical sciences, and it is charged with ensuring the safe and

effective use of medication. The scope of pharmacy practice includes more traditional roles

such as compounding and dispensing medications, and it also includes more modern

services related to patient care, including clinical services, reviewing medications for safety

and efficacy, and providing drug information. Pharmacists, therefore, are the experts on

drug therapy and are the primary health professionals who optimize medication use to

provide patients with positive health outcomes. The term is also applied to an

establishment used for such purposes. The first pharmacy in Europe (still working) was

opened in 1241 in Trier, Germany.[citation needed]

The word pharmacy is derived from its root word pharma which was a term used since the

1400–1600's. In addition to pharma responsibilities, the pharma offered general medical

advice and a range of services that are now performed solely by other specialist

practitioners, such as surgery and midwifery. The pharma (as it was referred to) often

operated through a retail shop which, in addition to ingredients for medicines, sold tobacco

and patent medicines. The pharmas also used many other herbs not listed.

In its investigation of herbal and chemical ingredients, the work of the pharma may be

regarded as a precursor of the modern sciences of chemistry and pharmacology, prior to

the formulation of the scientific method.

The pharmacy is one of the most extensively used therapeutic facilities of the hospital; it is

one of the few areas of hospital where large amounts of money are spent of purchases on

a recurring basis. It is also one of the highest revenue generating centers. A fairly high

percentage of the total expenditure of the hospital goes for pharmacy services. It caters to

out patients, inpatients, other areas like OT, Clinical laboratory.


36

NEED FOR THE DEPARTMENT

Make available all the drugs and pharmaceuticals needed for patient care according to the

hospital formulary: the right drug in the right formulary and dosage. An efficient dept

should determine in advance and stock adequate quantities of drugs, at the same time

avoiding idle inventory.

Disseminate information regarding drugs among the users, functioning as Drug

information centre.

Prepare certain medicines (usually intravenous fluids, mixtures and ointment) depending

on the policy of the hospital.

Observe high studies of professional skill in dispensing medicines according to the

prescriptions.

FUNCTIONS

The features of the hospital pharmacy are as follows

Procuring pharmaceutical items

(a) Requisition

(b) Purchase

(c) Receiving

(d) Checking

(e) Storing.

Dispensing items

(a) Preparing

(b) Packaging

(c) Labeling

(d) Dispensing.


37

Distribution of items to different departments as per their requirements

Quality control of drugs received by the hospital

(a) Check on arrival

(b) Periodic check

(c) Random check

(d) Dispensing.

• Maintaining information regarding quality, cost and sources of supply of all drugs,

chemical, and other items for information of medical, nursing, and other staff.

• Ensuring adherence to the laws, acts, rules, and statutory, regulations applicable to

pharmacies and dispensing.

• Establishing and maintaining adequate accounting procedures for pharmacy

charges, supplies, concessions and free services.

• Furnishing reports of the activities, periodically and a comprehensive report

annually.

• Serve as a member of the drug and therapeutics committee be actively involved in

its function and activities, and implement its decisions.

• Carry out research and participate in the evaluation of new drugs.

• Participate in performing therapeutic assessment of drugs and in the preparation of

a hospital formulary so that equally effective but less of expensive drugs may be put

on the formulary A formulary is a list of drugs approved by the medical staff and the

pharmacy committee for hospital use and kept in the inventory.

• Keep a note of essential list of drugs prepared by WHO.

• Have up to date information of drugs and have been banned in India or other

countries.

• Investigate problems of complaints related the drug therapy i.e (a) evaluation of

potency and active ingredient (b) Detection of harmful agent resulting due to

adulteration, improper preservation or expiry of drugs.


38

PHYSICAL STRUCTURE

The Pharmacy department at Sagar Hospitals is having three internal departments. They

are the Central Pharmacy, In-patient Pharmacy and Out-Patient Pharmacy. The Central

Pharmacy supplies the necessary drugs to the In-Patient and the Out-Patient Pharmacies.

The out patient pharmacy is located in the ground flood in an area which is adjacent to the

outpatient department. It is roughly about 500 sft in area. The drugs are stored in racks

along the walls and there are refrigerators to store medicine that need to be maintained at

cold temperatures. There is easy accessibility for people/ patients as it is along the main

common walkway and easy to locate.

The inpatient pharmacy is located in the 4th Floor very close to the lifts. It is roughly about

400 sft in area and has two sections partitioned by a wall. The drugs are stored in racks

along the walls and there are refrigerators to store medicine that need to be maintained at

cold temperatures. The Central Pharmacy is located in an area where there is minimal

public movement. Entry to the pharmacy store is restricted to authorized personnel.

The Central Pharmacy is located in the 5th Floor of the building. It is sufficiently large and

roughly about 1500 sft in area. The drugs are stored in racks along the walls and there

are refrigerators to store medicine that need to be maintained at cold temperatures. The

Central Pharmacy is located in an area where there is minimal public movement. Entry to

the pharmacy store is restricted to authorized personnel only.


39

THE ORGANIZATIONAL STRUCTURE OF THE DEPARTMENT

THE HUMAN RESOURCE MANAGEMENT

HOD – Mr. Pradeep

Job Designation: Manager Pharmacist

Central Pharmacy – It is a team of a mix of Pharmacists, Assistant Pharmacist and Pharmacy

trainees, five to six in all. Of these there are three pharmacists, additionally there are two

helpers.

In Patient Pharmacy – It has a total team size of seven resources. The resources are a mix of

Pharmacists, Assistant Pharmacist and Pharmacy trainees. Additionally they have 6

resources for helping them. They help in transportation of drugs from central stores to the

inpatient pharmacy and from there to the wards.

Chairman/ Vice Chairman/ CEO

Vice President

Manager Pharmacy

Central Pharmacy Sr.Pharmacist

In Patient Pharmacy Sr.Pharmacist

Out Patient Pharmacy Sr.Pharmacist

Graduate Pharmacist/ Pharmacist

Trainee Graduate Pharmacist Trainee Pharmacist

Delivery Boys



Delivery Boys



Delivery Boys


40

Out Patient Pharmacy – It also has a team size of seven resources, a good mix of

Pharmacists, Assistant Pharmacist and Pharmacy trainees. They have two cashiers and two

helper boys.

ACADEMIC QUALIFICATIONS AND DESIGNATIONS

• D Pharma with Experience - Pharmacist,

• D Pharma Fresher – till first 3 months – Trainee Pharmacists.

• B Pharma with Experience – Graduate Pharmacists,

• B Pharma Fresher – till first 3 months – Trainee Graduate Pharmacists.

JOB RESPONSIBILITIES

Manager Pharmacy

1. Seeking quotations, comparing and deciding on which drug to be purchased from

which distributor.

2. Placing orders for drugs required.

3. Solving issues relating to customer problems.

4. Stock checking along with pharmacists.

5. Preparing duty roster.

6. Handling sales in case of more number of patients.

7. Reporting to the accounts department and higher management.

Pharmacist/ graduate pharmacist

1. Issuing of medicines or drugs to the customers.

2. Making Purchase entry-Goods received note

3. Pharmacist working in the night shift will have to take care of billing, receiving cash and

return of medicines also.

4. Makes a note of drugs which are over or are less in number.


41

Cashier

1. Collects cash from the customers for the sales.

2. Hands over the cash to the accounts department after tallying the day’s collection at

the end of the shift.

3. Keeps the bills of the sales during the shift at the end of the shift in the storage

carton.

Computer operator

• Generate bills for the sales transactions in the pharmacy.

REGULATORY COMPLIANCE

Atleast one Pharmacist should be registered with Karnataka state Pharmacy council. The

licenses have to be displayed at a prominent position. The Drug License, Narcotics License,

AERB License etc have been secured.

FORMULARY

There is a Pharmacy Advisory Committee comprising of the director, medical director, the

manager of pharmacy etc., This committee has prepared a list of approved drugs that can be

prescribed by their hospital doctors. This list of hospital approved drugs is circulated among

all the departments. This list is reviewed on a regular basis at a frequency of atleast 3

months. Mr Pradeep is also the secretary of this board.

STORAGE

There are plastic trays in the cabinets. In cabinets no 1, 2, 3, 5 tablets, capsules, are stored in

the trays and below the trays syrups, tonic bottles are kept.


42

All the medicines, tablets and capsules are arranged in the alphabetical order from row 1, 2,

5, 6.

In the cabinet 3 ointment, lotions, drops, ampoules, are stored.

In cabinet no 4 IV fluids, respiratory solutions crepe Bandages, injections are stored.

In each tray in the cabinets there are 3 compartments where 3 company’s drugs are stored.

Each tray is labeled with the drugs in it.

At the beginning of the cabinet no 1 there is a separate storage area for only syringes.

Just below the dispensing counter the fast moving ampoules, syringes, IV fluids, IV set and

lozenges like strepsils and few tables like digene are placed in trays. This provides for easy

and fast access to frequently asked medicines.

There are closed cabinets below each shelf. The drugs are not replaced or placed in the

cabinets until the medicine is over or almost over in the tray. Only when it is very less in

number new drugs are placed in the tray. Until then the drugs are stocked in the closed

cabinet below. This ensures the first in first out principle of drug delivery that is it ensures the

drugs which were bought earlier are sold before the new stock being sold.

There is also a closed attic area for providing more storage area for drugs.

There is a separate store area for specific OT requirements. Here the items required for OT

like, gloves, masks, orthopedic surgical requirements are stored. This area is called as

surgical stores.

There are two cupboards where costly items for surgical need are stored like tracheotomy

tubes mesh etc is kept.

In the same area there is a separate rack where expired drugs are kept until the particular

distributor takes it back. This separate rack ensures that it does not get mixed with other

drugs.

SALES

The pharmacy caters to Outpatient, Inpatients, patients undergoing surgery and walk-in

patients also.


43

OUTPATIENT PRESCRIPTIONS

Doctors give the prescriptions to the patient which he/she brings it to the pharmacy. The

pharmacist receives the prescription. He/she then places all the medicines and items required

one by one at the space below the dispensing counter. She then gives the prescription to the

computer operator for entering the particulars taken, amount taken and issue a bill for the

same (annexure 2). In the mean while the pharmacist packs the medicines well and puts it in

a hand cover. After the bill is generated the computer operator hands it over to the

pharmacist. Once the pharmacist receives the bill she gives it along with the packed

medicines to the cashier. As the pass box through the cashiers counter is not too big, large

amount of medicines cannot be given to the customer through the box. At such times the

pharmacist gives only the bill to the cashier. After payment is done by the customer the

pharmacist hands over the medicines.

The cashier receives the cash from the customer puts a seal saying cash received and gives

a copy to the customer and keeps the copy with himself.

In case of payment being done by card, the customer has to inform earlier so that the mode of

payment is entered in the bill. In case of card payment the customer will swipe the card and

the customer copy of the bill generated is given to him and another copy signed by the

customer will be kept by the cashier.

INPATIENT PRESCRIPTIONS

The doctor prescribes the medicines required. The prescription is brought by the patient’s

attenders to the pharmacy. The drugs are dispensed in the same way as for outpatients and

it’s the same principle cash and carry.

If the patient is insured then the prescription for the patient is brought to the pharmacy by the

nurse in-charge of that ward. There is a provision in the software where once the hospital

number of the patient insured is entered, the address and the details of the patient are

displayed. The total sales of drugs for the patient are fed in and the bill is given to the nurse to

hand it to the patient or the patient’s attender.


44

As the computers are network connected the accounts department can access the billing

details of the patient and include them in their final bill.

In case a drug prescribed by a doctor, is not present in the pharmacy the pharmacist gives a

substitute only after the confirmation over phone or writes and sends it back with the patient

to the doctor who prescribed that medicine. Only after receiving a confirmation by the doctor

alternative or substitute drug is dispensed by the pharmacists.

There is a strict no to credit sales being followed at Sagar Pharmacy. If in case a patient is

critical and the patients attender does not have money a maximum of 2 hours of credit time is

given and only emergency life saving drugs are issued. If in case there is no attender with the

patient then, only on the request from the doctor to issue an important emergency or life

saving drug, the drugs are issued. Only the chief pharmacist or the in-charge pharmacist of

that shift has the authority to take decisions in such cases.

SALES RETURNS

The pharmacy takes back unused medicines everything from IV fluids, syringes, ampoules

and medicines if full strip dispensed is returned.

There is a separate counter for purchase return. There is one person for this purpose at the

counter. The return of medicines is taken only between 10.00 am to 6.00 pm from Monday to

Saturday only. But it is flexible enough i.e. medicines are taken back even after 6.00 pm and

on Sundays in case of the patient is getting discharged or any death case or so.

The medicines returned are checked for proper packaging, number and so on.

Then the bill number, medicines returned, date is entered. The total amount for the drugs

returned is displayed on the computer. A bill is generated and handed to the customer.

Cash is returned to the patient immediately at the cash counter.

The stock returned is placed in the rack adjacent to the counter. The medicines are placed

back into their respective places in the racks later in the day by the pharmacists.

EXPIRY DRUGS RETURN

Drugs before 1 month of expiry date are noted and the distributor is informed to take back the


45

drugs.

The expired drugs are entered in the system and purchase is returned to the distributor.

Expired drugs are stored in a separate rack until the supplier takes it back.

For the return taken, the supplier gives either a credit note which will be reduced from the

next bill or items worth the same amount will be immediately given.

STOCK CHECKING

Stock checking is done every half yearly. That is once in 6 months. The management

decides upon a date for the stock checking and informs the chief pharmacist.

The stock checking is done by all the pharmacy staff except 2 of them who will handle the

sales during that period. Stock checking is completed within 24 hrs.

A list of all the drugs in the pharmacy is taken from the software. A print out is taken the

particular drug is checked and entry is made against the drug name the quantity present.

The list at the end of the stock check is submitted to the management.

As and when sales of medicines occur during the stock checking so much of the quantity is

deducted from the list.

BREAKAGE

Breakage if occurs in the pharmacy, the broken number of pieces are informed to the supplier

for replacement.


46

STUDY OF BIOMEDICAL ENGINEERING DEPARTMENT


47

BIOMEDICAL ENGINEERING DEPARTMENT

Modern patient care revolves around not just the skill of the doctor, but technology as well.

When the equipment is running correctly, it allows the docs to do their job to the best of their

ability. With the most accurate diagnostic equipment at the docs' disposal, the patients have a

better chance at survival and recovery.

When things are running smoothly around the facility and nothing is broken, the biomedical

maintenance flight technicians use the time to perform routine preventative maintenance on

all the equipment.

They also provide the medics with training on how to properly use new equipment to prevent

user error.

Biomedical equipment models and makes also changes almost every day, It's not realistic to

think you can learn everything about every piece of equipment.

The technical school helps prepare the engineers by giving the foundation and framework --

the basics. The junior engineers fill in the gaps as they sort of teach themselves by using the

literature and skills picked up along the way from co-workers."

Plumbers work on pipes, carpenters work with wood, but we can work on everything in the

hospital. We're not limited to one field, when you work on medical equipment, you have to

know how to fix everything, and we do because there's no telling what you're going to see.

HOD - Mr Raju

Academic profile: BE in Electronics and Communication. Post Graduate in Medical

Electronics

Experience: 10 years.

Reports to: Asst. MD Dr.Lohit.


48

TECHNICIANS No. of technicians – 1 assistant

Academic: BE in Medical Electronics.

Experience: No prior experience.

Reports to: HOD

WORKING HOURS General Shift 9.00 am to 5.00 pm

In addition to it - on call support 24/7.

PHYSICAL STRUCTURE It is located at the second floor.

The area allotted is (7` x 10`) = 70 SFT.

TECHNOLOGY The department is provided with a helpline and a computer which is part of the hospital

network. Within the 70 SFT area provided to the department, there is a small office space, a

work station and 2 big sized shelfs, one for documents and the other for tools and

equipments.

PROCUREMENT The department participates in the decision making process of the procurement of Biomedical

Equipment (Hospital Assets) in the hospital. It receives copies of purchase orders placed for

procurement of biomedical assets. On arrival of the ordered equipment, the opening of the

pack is done in presence of a biomedical engineer who inspects the equipment for physical

fitness and technical compatibility. Then if the consignment meets the hospital requirements,

the items are approved and in-warded. Then the goods receipt number - GRN is prepared

and forwarded by the stores to the Accounts department.

The installation and operating of the equipment should be demonstrated to the biomedical


49

engineer as well. Also the biomedical engineer needs to be demonstrated and trained to

handle some basic breakdowns. Most important thing is that the engineers should be trained

on what should not be done during the course of maintenance. What activities would lead to

the lapse of warranty etc.,

PREVENTIVE MAINTENANCE The biomedical engineer has to perform daily routine visit to all departments to take stock of

the condition of the biomedical equipments. The visits are registered in a routine visit register.

This register contain all the details of any new breakdowns, breakdowns pending repair,

equipment wear and tear etc.,

BREAKDOWN MAINTENANCE When there is a breakdown call from any department, the Engineers visit the site and attend

to it. There are many aspects to be taken care before opening an equipment for

service/maintenance. The things to be checked before starting the maintenance procedure

are as follows:

1. Check whether the power chords and plugs of the equipment are not damaged.

2. The power supply sockets are not damaged

3. The equipment warranty should be checked. If it is still under warranty, the equipment

should not be opened and the service ticket has to be raised with the technical support

of the vendor.

4. If the equipment is on a major breakdown, and the equipment is high value equipment

and has been insured, then appropriate procedures to make the claim should be

followed.

5. If equipment broken down can be repaired by the department engineers, only then it

has to be opened.

6. If the equipment cannot be maintained by the departmental engineers, the respective

vendors should be informed and followed up to ensure the equipments are restored

with minimal breakdown time.

7. High Value equipment which are out of warranty period should be periodically checked

for the validity of AMC and insurance so that


50

STUDY OF AMBULANCE SERVICES DEPARTMENT


51

AMBULANCE SERVICES DEPARTMENT

An ambulance is a vehicle for transporting sick or injured people, to, from or between places

of treatment for an illness or injury. The term ambulance is used to describe a vehicle used to

bring medical care to patients outside of the hospital or to transport the patient to hospital for

follow-up care and further testing. The word is most commonly associated with the land-

based, emergency motor vehicles that administer emergency care to those with acute

illnesses or injuries, hereafter known as emergency ambulances. These are usually fitted with

flashing warning lights and sirens to facilitate their movement through traffic. It is

these emergency ambulances that are most likely to display the Star of Life, which represents

the six stages of prehospital medical care. Other vehicles used as ambulances include trucks,

vans, station wagons, buses, helicopters, fixed-wing aircraft, boats, and even hospital ships.

The term ambulance comes from the Latin word ambulare, meaning to walk or move

about which is a reference to early medical care where patients were moved by lifting or

wheeling. The word originally meant a moving hospital which follows an army in its

movements. During the American Civil War vehicles for conveying the wounded off the field of

battle were called ambulance wagons.[5] Field hospitals were still called ambulances during

the Franco-Prussian War[6] of 1870 and in the Serbo-Turkish war of 1876[7] even though the

wagons were first referred to as ambulances about 1854 during the Crimean War.

There are other types of ambulance, with the most common being the patient transport

ambulance. These vehicles are not usually (although there are exceptions) equipped with life-

support equipment, and are usually crewed by staff with fewer qualifications than the crew

of emergency ambulances. Their purpose is simply to transport patients to, from or between

places of treatment. In most countries, these are not equipped with flashing lights or sirens. In

some jurisdictions there is a modified form of the ambulance used, that only carries one

member of ambulance crew to the scene to provide care, but is not used to transport the

patient. In these cases a patient who requires transportation to hospital will require a patient-

carrying ambulance to attend in addition to the fast responder.


52

HOD: Mr Imdad Ali

Experience: total 13 years in transport related industry and coordination

Reports to: Dr Rajeev Matthew – HOD Emergency Department

HOW THE SERVICE REQUEST PROCESSED

When there is an incoming request call for an ambulance service, it is redirected to the CMO.

The CMO on a call determines the need and accordingly writes a requisition slip for ALS or

BLS and the required medical equipment and medicines to be carried along. The nurse

based on the instructions of the CMO takes along with her the required equipment and

medication. The CMO accompanies in the ambulance only is the patient condition requires

that level of attention or if the patient needs to be stabilized before getting into the ambulance.

Generally the entire process is completed in 5 minutes and the ambulance is moved to the

location to bring in the patient. In the mean time, the necessary gadgets required for

treatment are kept ready and the treatment starts immediately after the patient has reached

the hospital ER.

In case of patient dies mid way, normally all attenders of the patients insist on reaching the

hospital if the doctor is not accompanying. However it is not mandated by Law to take to the

hospital.

There is a separate vehicle to transport dead body. It is carried free of cost to home. This

service is provided only for non MLC cases.

Metador 307 is used for this purpose

WHEN IS A SERVICE REQUEST DECLINED If ambulances are not available (which has not happened till date)

The ambulance is not provided for cases of DAMA – discharge against medical advice


53

PRESENT DEMAND FOR THE AMBULANCE SERVICE

Daily average number calls for BLS service– 7 to 8 calls

Daily average number calls for ALS service - 3 to 4 calls

Daily routine calls for Discharge and others - 4 to 5 calls

Dead body carrying ambulance (non-MLC cases only) -- 2 to 4 cases per month

THE VEHICLES AND THEIR TYPES

No. of vehicles – 5

• ALS – Advanced life support ventilator – 2 nos.

• Imported Chevrolet Ambulance (LH Drive) - ALS – 1 no.

• BLS – Basic life support ventilator – 2 nos.

• OPD patients and discharge - versa ambulance – 1 no.

• Dead body Transportation van – 1 no.

Features

• ALS ambulance has all the features, equipment and properties of an ICU and can be

considered as a mini ICU

• BLS ambulance has Oxygen, Monitor, First aid and other medicines, facility for drips

etc.,

• In both ambulances there is a shelf with all essential ER drugs, Drips, and other

medical consumables.

• In ALS there is a defibrillator mounted permanently but in BLS there is provision to

mount portable defibrillator and other monitors.

• The vehicles are basic Tempo Traveler - ambulance model taken and the body

reconstructed by a professional Ambulance Body Building company.

• Veeresh Auto Builders, Bommasandra Industrial Area, Bangalore-560099 are the

people who do most of the ambulance body building in Bangalore and there is one or

two others in Bangalore.


54

Registration

• Vehicle classified as ambulance is registered with RTO under the ambulance3

category with seating capacity 1+1

Permit

• No permit required for ambulances to travel anywhere in India. So effectively it is

having all India permit though no fees is required to be paid.

Taxes

• Sales tax at the time of purchase is not exempt and normal vehicle tax rates apply.

• Road tax is exempted, but it is not 100%

• Service offered by ambulance is not taxable

MAINTENANCE OF THE VEHICLES

• Engine Oil is changed after every 10,000 kms

• All Vehicles are washed daily

• The important parameters like the air pressure, battery charge, tyre wear, etc., are

checked on a daily basis.

• The inventory of the medical supplies recorded and consumption is recorded regularly.

• Reorder the medical supplies if the stock has gone down below the reorder levels or

have expired.

• The ALS vehicles are to be charged daily and then the readings checked and

recorded.

• Regular inspection by the biomedical engineers for the proper functioning of the

internal biomedical gadgets.

• Annual calibration of the defibrillator and other biomedical equipments.

• Other aspects like diesel levels, and physical damages etc.,


55

THE HUMAN RESOOURCE

Number of drivers – 12

Academic qualifications: minimum 1st PUC,

Experience: 4 yrs and over

Reports to:HOD

On all ambulance trips, 1 nurse from ER and 1 helper boy are accompanied.

Doctor from ER accompanies if the need arises.

AMBULANCE DRIVERS

Ambulance department drivers are trained at St Johns and issued a certificate of training. (St.

Johns Ambulance Association certification)

At the St.John’s Certification course, the drivers are trained about about the basic rules and

regulations of ambulance transport, they are imparted knowledge in doing basic first aid, CPR

etc.,

SOME IMPORTANT GUIDELINES

• The Ambulance has to be moved slowly while moving pregnant women.

• Cardiac patients should be moved to the hospital as quickly as possible.

• Siren Rules – The ambulance can use Siren while going to pick up patients and

returning back to hospital. At Sagar Hospital, siren is fitted only on ALS and BLS

vehicles.

• The Versa Ambulance here only has beacon light and no siren is fitted and is used to

transport discharged patients.


56

• Driver can call 100 and request clearance in the route that they take to reach the

patient as well as return to the hospital.

• Trip sheet signed by the ER doctor should be carried by the ambulance driver at all

times when the ambulance is engaged and moving.

DRIVERS SHIFTS First Shift 8.00 am to 2.00 pm - 2 drivers+1

Second Shift 2.00 pm to 8.00 pm – 2

Night Shift 8.00 pm to 8.00 pm - 2


57

RECOMMENDATIONS

Dialysis department – Primarily the operations in the department is going fine. There are

some machines which have worked over 40,000 hrs. These machines should reconditioned

or condemned and replaced by new ones and is possible the software updated to latest

versions.

Pharmacy department – Space constraints were visible in the department. Presently the

procurement of stents, implants is being handled by the materials department. It is more

suitable if this can be handled by the Pharma department itself.

Biomedical Engineering department – the space allocated for this department is very less and

going forward more and more biomedical equipment are expected to come into the hospital

with the changing technology. So it is recommended that a ESD safe workstation in a clean

room area be allocated to the biomedical engineering department. Atleast 250 to 300 SFT of

area is required under the present work load with adequate space for storage of equipment

and paperwork.

Ambulance Department – Presently there has been not a single reported case of breakdown

while transporting patients including a puncture. Thus the maintenance of the vehicles is

adequate.


58

INDEX

A

Academic, 20, 21, 51, 59

active, 40

acts, 18, 39

acute, 15, 55

adulteration, 40

affordable, 6, 8

age, 7, 10

ambiance, 9

ambu, 33, 35

ambulance, 9, 54, 55, 56, 57, 58, 59, 60

ambulances, 55, 56, 57, 58

amounts, 38

ampoules, 45, 47

Arabic, 14

area, 19, 40, 41, 45, 51, 52, 61

artery, 26, 27

assistance, 14

B

B Pharma, 43

B.Braun, 19

bacteria, 22

Bangalore, 1, 2, 5, 6, 7, 58

beds, 6, 8, 9, 19

benefits, 7, 17

Bengali, 14

bicarbonate, 16

bi-carbonate, 24

billing, 11, 43, 47

bills, 44

Biochemistry, 10, 22

Biomedical, 2, 3, 49, 50, 52, 60

blood, 9, 16, 17, 18, 25, 26, 27, 32, 34

Blood Bank, 11

brand, 5

breakdown, 52, 53, 61

breakdowns, 52

breathing, 32, 33

C

calcium, 16

carbon, 22, 23

card, 46

cardiac, 6, 10, 11, 32

Cardiopulmonary, 32

care, 6, 8, 10, 11, 13, 37, 38, 43, 50, 52, 54, 55

carotid, 34

Carotid, 32

carton, 44

cash, 43, 44, 46, 48

Casualty, 10

categories, 7

caters, 7, 38, 46

Cathlab, 9

Central, 40, 41, 42

challenged, 14

Checking, 39

check-up, 7

chemical, 37, 39

chloride, 16

Clinical, 10, 38

clinics, 6

cold, 40, 41

comfortable, 9, 10, 13

Comfortable, 9, 10

commence, 34

comprehensive, 6, 39

computer, 46, 48, 52

concentrate, 24

concentration, 16, 18

conductivity, 25

connection, 24

consultation, 9

coordinators, 13

cost, 12, 13, 39, 56

counters, 11

counting, 33, 34

CPR, 33, 34, 35, 59

cramps, 32

crew, 55

Cubicle, 11

customer, 13, 43, 46, 48

Cytopathology, 10

D

D Pharma, 43

Day Care, 9

De-addiction, 9

diabetes, 11

diagnostic, 50

diagnostics, 6

Diagnostics, 10

dialysate, 16, 17, 18

Dialysis, 2, 3, 11, 15, 16, 20, 32, 60

dialyzer, 17, 18


59

diffusion, 16

disconnect, 26

Disconnect, 27, 34

diseases, 10

dispensing, 37, 38, 39, 45, 46

Dispensing, 39

Disposable, 25

disposal, 50

dissolution, 15

doctors, 6, 44

Drug, 9, 38, 44

drugs, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 57

E

electrical, 24

Emergency, 10, 36, 56

endocrinology, 11

Engine, 58

Engineering, 2, 3, 5, 49, 60

enlarged, 11

equilibrium, 15

equipment, 18, 19, 50, 51, 52, 53, 55, 56, 57, 61

equipments, 7, 52, 53, 59

equipped, 6, 9, 55

erythropoietin, 16

Europe, 37

Experience, 20, 21, 43, 51, 56, 59

experienced, 10

expired, 45, 48, 58

F

facility, 6, 10, 50, 57

filters, 22, 23

fistula, 25, 26, 27

fluid, 16, 17, 18, 32

fluids, 38, 45, 47

formulary, 38, 40

foundation, 51

framework, 51

French, 14

function, 15, 39

functioning, 7, 10, 38, 59

G

Gambro, 20

gauze, 27

general, 7, 17, 37

German, 14

glove, 25

gradient, 16, 17, 18

Graduate, 43, 51

Greek, 15

H

Haematology, 10

hardness, 22, 24

healthcare, 5, 6, 8, 12

hearing, 14

Hemodialysis, 17

Hemofiltration, 18

Hindi, 14

Histopathology, 10

hospital, 6, 7, 38, 39, 40, 44, 47, 51, 52, 55, 56, 60, 61

Hospitals, 1, 2, 6, 12, 13, 40

hour, 9, 11, 17, 27

hydrogen, 16

I

Imaging, 10

Immunology, 10

impaired, 14

improper, 40

In Patient, 42

India, 2, 7, 12, 40, 58

infectious, 10

initiation, 21

injection, 24, 25, 26

insurance, 7, 11, 53

Intensive, 9

international, 7, 13

interpreters, 14

Interpreters, 13

intestinal dialysis, 17

intravascular, 32

inventory, 38, 40, 58

investigations, 10

ions, 16

ISO, 12, 13

J

Japanese, 14

Jayanagar, 1, 2, 7, 12, 13

Johns, 59

K

kidneys, 15

L

Labeling, 39

labor, 11

laboratory, 9, 10, 38

language, 14

Laser, 11

laws, 39

leadership, 5, 6

locations, 6


60

lozenges, 45

lusis, 15

Luxurious, 7, 9

M

machine, 19, 22, 24, 25, 26

Machine, 25, 26, 27

machines, 19, 21, 22, 60

magnesium, 16

management, 7, 13, 43, 48

materials, 22, 60

Matrix, 10

medical, 6, 8, 12, 13, 36, 37, 39, 40, 44, 51, 54, 55, 56, 57, 58

medicine, 12, 15, 40, 41, 45, 47

medicines, 10, 37, 38, 43, 44, 45, 46, 47, 48, 49, 56, 57

membrane, 16, 17, 18, 23

metabolic, 16

Microbiology, 10

microns, 22, 23

minerals, 15, 16, 17

money, 38, 47

multiport, 23, 24

multi-specialty, 6

N

NABH, 12

Neonatal, 9

Neosporin, 27

Nephrologist, 20

nephrology, 11

neuroscience, 11

neutralise, 16

Nikkiso, 19

Nipro, 19

nurse, 47, 56, 59

nursing, 7, 21, 39

Nursing, 5, 20, 21

O

Operating, 9, 11

orthopedics, 11

osmosis, 18

overseas, 7, 13

oxygen, 35

P

Packaging, 39

paramedics, 10

parameters, 22, 58

Pathology, 10

patients, 7, 10, 11, 13, 15, 16, 18, 32, 37, 38, 40, 43, 46, 47, 50,

55, 56, 57, 60, 61

payment, 46

pediatrics, 11

peritoneal, 17

peritoneal dialysis, 17

personalized, 6, 13

pharmacology, 37

Pharmacy, 2, 3, 5, 37, 40, 41, 42, 43, 44, 60

philanthropic, 6

phosphorus, 16

Physiotherapy, 5, 9, 11

plaster, 25, 27

pneumatic, 10

potassium, 16

Powder, 27

Preparing, 21, 39, 43

preservation, 40

presidential, 7, 9

pressure, 17, 18, 26, 32, 58

prophylactic, 32

prostate, 11

pulse, 33, 34

Pulse, 32

purchase, 47, 48, 52, 58

Purchase, 39, 43

Q

qualified, 5, 6, 14

quality, 13, 18, 39

quinine, 32

R

Radio, 10

Receiving, 21, 39

recirculation, 25, 26, 27

recurring, 38

regeneration, 23, 24

renal, 15

renal failure, 15

replacement, 15, 16, 49

Requisition, 38

respiratory, 45

restoring, 32

Resuscitation, 32

revenue, 38

RO unit, 23

Robotic, 11

rooms, 7, 9, 10, 11

rules, 17, 39, 59

S

Sagar, 1, 2, 3, 5, 6, 11, 12, 13, 40, 60

saline, 25, 26, 27, 32

Sand Filter, 22

Science, 5

semipermeable, 17, 18

services, 5, 13, 37, 38, 39

sirens, 55

skilled, 7, 10


61

sodium, 16

software, 47, 48, 60

solutes, 16, 17

solution, 16, 17, 24, 25

Spacious, 9, 10

specialist, 37

specializing, 10

stabilized, 56

statutory, 39

Sterile, 25

storage, 44, 45, 61

Storing, 39

stream, 27

strepsils, 45

suites, 7, 9, 11

sulfate, 16, 32

Superintendent, 21

surgery, 37, 46

surgical, 6, 45

Surgical, 25

suspended, 22

swab, 26

syringe, 25, 26

Syringe, 25

syringes, 45, 47

T

tank, 23, 24

technicians, 20, 21, 25, 50, 51

technology, 6, 8, 20, 50, 61

temperatures, 40, 41

Theatres, 9

therapeutic, 11, 38, 40

therapeutics, 39

therapy, 15, 18, 37, 40

tobacco, 37

trauma, 10

treatment, 6, 13, 16, 17, 18, 32, 54, 55, 56

triage, 10

tube, 17, 24, 26

U

ultrafiltration, 16

Ultrafiltration, 17, 18

undissolved, 22

Unit, 9

Urdu, 14

urology, 11

V

ventilator, 57

video conferencing, 10

volume, 32

W

waiting, 9

ward, 7, 9, 47

washed, 25, 58

waste, 16, 18

water, 15, 17, 18, 22, 23, 24

X

xyphoid, 33

Y

Yoga, 9, 11

Documents

Internship at Sagar Hospital Final Report 2008 09 by Rijo Ste 1382