Key points to note:

•        All citizens of the Federal Republic of Nigeria have the right to receive quality emergency medical care.

•         All accident and emergency patients are entitled to urgent medical intervention - for at least the first 48 hours; whether they can afford it or not.

•         The Accident & Emergency Department offers comprehensive emergency care 24 hours a day.

•          Ambulance services are available 24 hours daily for transfer/referral of patients to other facilities.

 

A.        A&E Procedure

1.        Patients come to the A&E through referrals from other centres, or from accident scenes

2.        If the patient is critically ill, he/she is moved on a trolley or wheelchair, by a designated Porter, to the reception.

3.        The triage doctor and/or nursing staff should immediately attend to the patient in order to assess the condition, and where needed; provide initial resuscitation/first aid. Then the patient is transferred to the medical officer on call representing the required specialty for the definitive management of that particular patient.

4.        Intravenous access should be established quickly, and appropriate specimen samples for investigation are collected within 10 minutes of presentation.

5.        After initial resuscitation, the Patient must then be properly registered.

6.        The nurse takes the vital signs; including temperature, blood pressure, weight, oxygen saturation (Sp02), and random blood sugar.

7.        The duty nurse initiates, and inputs, the nursing processes

8.        The medical officer on call, in the required specialty, then does a full assessment, makes a provisional diagnosis, and commences definitive treatment. Patients that need ward/lCU admission are identified

9.        The billing staff then begin to prepare the patient's treatment cost, including possible admission deposit.

10.      The patient that needs ward admission, and has paid, is then transferred to the ward/lCU

 

l. Triage

The triage officer of the emergency department shall initiate the triage activity when required; she/he shall carry out a quick examination (within 2 - 4 minutes) and assess the nature of intervention that may be required according to the condition of patient.

 

The type of service may be:

i.          Immediate - The patient shall be attended to within O to 1 minute. She/he is immediately taken to the resuscitation trolley, usually located at a point equipped with oxygen and other Cardiopulmonary resuscitation requirements. After stabilization the patient shall be transferred to the respective ward or ICU.

ii.         Very urgent - The patient shall be attended to within 1 5 minutes.

iii.        Urgent - The patient shall be attended to within 30 minutes.

iv.        Less urgent - The patient shall be attended to within 60 minutes

v.         Non-Urgent - The patient shall be attended to within 120 minutes.

 

*The above time frame is applicable when the patient load is high, and some kind of selection is required for initiation of treatment. Otherwise, all the patients shall be attended immediately

 

*Patients in categories iv & v should normally be attended to in the General out-patient clinic, unless there is a fresh laceration, or have been involved in a road traffic (or domestic) accident. *All cases with potential for litigation (victims of road traffic accidents, assault, stab wounds, gunshot) should be reported to the police as soon as possible, while maintaining proper medical ethics

 

*No patient shall remain in triage area for more than 2 hours!

 

ll. Methods of triage

Triage can be performed rapidly by assessing

•          Airway

•          Respiratory rate & breathing pattern

•          Alertness, Verbal response, Reaction to pain and Unresponsiveness                 (AVPU)

•          Blood pressure & Pulse

•          Temperature

•          Mobility

•          Trauma (bump, bruise, cut etc.)

 

Ill. Management of patients in Triage and Observation area:

*The Initial assessment will include ascertaining the level of consciousness (Glasgow Coma Score), Blood Pressure, Pulse, Temperature, Sp02, Random Blood Sugar.

a.         No patient needing ward admission should remain in the emergency room for more than 24 hours.

b.        The nurses shall manage the patients according to the prescription of the physician/ surgeon as listed on the treatment sheet

c.         The nurse on duty must check the status of life saving drugs, oxygen availability etc., before taking over the charge of the shift.

For any observed shortages, requisition must be made immediately and kept in stock.

d.        Privacy must be provided to patients while performing any wound dressings.

e.         Intravenous or intramuscular injections to the gluteal region must not be administered in the sitting position. Intramuscular injections in the upper limb can be administered while the patient is sitting with the back rested (e.g., using a chair, not a stool).

f.         Aseptic precaution must be taken when handling any patient, taking tissue samples, or giving any drugs parenterally.

g.         The dilution, and rate of administration of any injection must be done as specified by the doctor's prescription and nursing procedures. Before giving any injection the date of expiry, and route of administration must be verified on each vial or ampoule.

h.        Any medicine or injection dispensed to a patient must be recorded in the nursing chart.

I.          The drugs and consumables must be kept well arranged on the table or rack and the surrounding must be clean

j.          The rate of intravenous infusions, and oxygen administration must be based strictly on the prescription of the doctor

k.         Bio-medical wastes must be properly disposed in appropriate covered                 bins.

l.          Syringes and Needles must be disposed in the "sharps" container.

 

IV. A&E Admission Policy

1.        Only patients whose assessments, during triage, fall under immediate, very urgent and urgent shall be admitted to the A&E ward for further stabilization.

2.        The A&E is only for providing emergency care and not for keeping the patient for continued treatment.

3.        A patient shall not be kept in the A&E beyond 24 hours except under special consideration, and with the permission of the Head of Clinical Services or the Medical Director.

4.        Gravely ill patients presenting to the A&E MUST at least, be resuscitated and stabilized (even within their own vehicles, if necessary), before possible referral to another health facility on account of non-availability of bed spaces in the A&E, and on the wards.

5.        No patient once transferred from the A&E to the respective ward, or treated in respective departmental Operating Theatre shall again be brought back to the A&E.

6.        Blood transfusion, if required as a life saving measure, shall be made available to patients; subject to availability. Relatives of patients shall be compulsorily required to donate equal units of blood as provided by the hospital during the emergency.

7.        Patients' privacy is maintained during all hospital procedures including consultation, examination, counselling, and procedures like drug injection and wound dressing. Screens have been provided in the A&E.

 

V. Transfer of patient to the ward/operating theatre/lCU

1.        Transfers will be done 24 hours daily, and will always be based on the clinical needs of the patient.

2.        All relevant documentation must accompany the patient.

3.        The need for any equipment to accompany the patient must be assessed e.g., portable oxygen cylinders, monitors, ventilators etc.

4.         All necessary drugs, infusions/transfusion, consumables, and personal property must accompany the patient.

5.        There must be adequate, appropriate, and timely communication between transferring and receiving staff, and with the patient or relative/ caregiver.

6.        The receiving ward/theatre must confirm their preparedness before the patient is shifted to the ward/theatre.

7.        If a patient receiving blood transfusion is to be transferred to another ward/theatre, the transferring and receiving nurses must jointly review the documentation from the blood bank; including certificate of compatibility for that particular patient and the patient's record of clinical signs (fever, tachypnoea, skin rashes etc.) to exclude blood transfusion reaction.

8.        A patient requiring ward admission shall be moved to the designated ward after she/he has been resuscitated and stabilized.

9.        A patient being transferred to a designated ward, must be accompanied by at least 2 staff; either 2 Porters OR 1 Porter + 1 clinical assistant OR 1 Porter/clinical assistant + 1 Nurse.

A Nurse is only mandatorily required for very sick patients, e.g., patients with cardiopulmonary instability.

10.      A Trolley or wheel chair is required for the transfer of patients.

11.      An unstable patient being transferred to ICU/Operating Theatre should preferably be accompanied by a Doctor or Nurse.

12.      No patient once admitted to respective ward  or treated in respective department or operating theatre shall again be brought back to A&E ward.

13.      Porters are available to assist in the movement or transfer of patients from bed to chair or trolley etc. They should be informed of the patient's (in)abilities and basic requirements, and any additional needs/orders e.g., "nil-per-os" prior to moving. If assistance is required, the transfer must be led and coordinated by Nurse.

14.      Patients who are able to move into a wheelchair without any assistance may be independently transferred by a porter.

15.     It is the responsibility of all staff to ensure that equipment used e.g., wheelchairs, transfer chairs, trolleys and manual handling equipment etc., are serviceable, and suitable to carry out the transfer of patients without risk to the patient, themselves or any other staff, patients or visitors while in transit. The maintenance department must be called upon when necessary. All staff must be trained in patient handling techniques, prior to deployment to the clinical areas.

 

This will include appropriate verbal and non-verbal communication skills training and sensitivity to equality and diversity as an integral part of ensuring dignity and respect.

16.      All staff must ensure that:

a.         The patient identity is checked at all times; to avoid applying the treatment plan for one patient to another.

b.        The patient is not transferred from the A&E without informing the ward or theatre staff first.

c.         They know the intended destination for the patient. If in any doubt this should be checked with the appropriate Nurse or Doctor.

d.        Clothing/bed linen on the trolley/ wheelchair is tucked in to avoid the risk of it getting caught in the wheels.

e.         The patient is kept fully informed about the transfer process; what you are doing and where you are taking them.

f.         The patient is not rushed, if not ready

g.         The principles of safer pushing and pulling are applied

h.        The brakes are applied when bed/trolley/ transfer chair/wheelchair is not in motion

17. The patient should be moved with the minimum amount of disruption/discomfort and all aspects of privacy, dignity and patient comfort should be optimized during the transfer process.

18.      The condition of the patient must be monitored during the course of the transfer, and appropriate action instituted accordingly if the patient deteriorates during the transfer.

19.      On arrival at the receiving ward or theatre, the nurse/attendant should ensure that the nurses are made aware of the patient's arrival

20.      The nurse accepting the patient in the receiving ward must ensure that they have necessary information to care for the patient safely and correctly and ensure continuity of care.

21.      The receiving ward must be made aware of any possibly contagious diseases before a patient is transferred.

 

B. Communication

1.        There must be adequate and effective communication between the A&E department and the receiving ward/theatre

2.        The Nurse in charge of the patient's care in the A&E must provide a verbal telephone handover to the Nurse in charge of the receiving ward; if the former is not accompanying the patient.

3.        Patients must be informed, at the earliest opportunity, that they will be transferred out of the A&E. The Doctor or Nurse must explain, in clear terms, the reason for the transfer to either the ward or theatre; ensuring that the patient or next-of-kin/spouse/caregiver understands what was discussed. Adjustments must be made where communication may be difficult; e.g., in case of cognitive problems or learning difficulties.

 

C. Documentation

1.        The doctor must ensure that all necessary details concerning the patient management; including the in-patient treatment outline is properly documented.

2.        The Nurse in charge is responsible for ensuring that all appropriate documents including receipts etc. accompany the patient to the ward/ theatre.

3.       Nurse should ensure that all required information is recorded in the nursing  Process and transferred to the receiving ward.

4.        Where necessary, monitoring of vital sings should continue during the transfer process

 

D. Oxygen Therapy

1.        If the patient's respiratory or cardiovascular status is unstable a Nurse must always act as the escort for the patient.

2.        Prior to commencement of the transfer of a very sick patient requiring oxygen therapy, the Nurse must check and ensure there is sufficient oxygen available for the full duration of the transfer and that the oxygen delivery equipment is fully functional.

 

3.        The oxygen saturation (Sp02) of the patient must be monitored and documented prior to transfer, and at the receiving ICU/ward/theatre. In very sick patients, Sp02 should be monitored during transfer as well.

 

E.         Management of patients who are brought in dead to the A&E.

1.        The patient must be examined and properly certified clinically dead by the triage Doctor, or any other available Medical Officer.

2.        All cases "brought in dead", should be referred to the Lagos state coroner service for proper determination of the cause of death. The exception to this rule is when a Consultant who has been managing a terminally ill patient, feels (with certainty) that the illness may have led to the patient's death. Such a Consultant may be obliged to issue the Certificate of the cause of death.

3.        The name of such patients should be entered in the A&E attendance register along with all the possible details about the deceased obtained from the accompanying persons; whose name(s) and address (es) should also be noted and recorded in the register.

4.        In cases where death has occurred due to natural causes (like in [21 above) and there is no suspicion of any foul play, the corpse(s) may be handed over to the relatives on their request and this must be recorded with signatures of relatives or care givers.

5.        All other cases, [in which death has occurred due to accidents, assault (including rape), burns, suicide etc.] where it is suspected that death has not been due to natural causes, must be registered as medico-legal cases (MLC). The hospital legal officer should be consulted, and the case should be reported to the police.

 

6.        In all the above cases, the death reports must be duly completed and forwarded to the Head of Medical Records Section, and the Registrar of Births & Deaths.

 

F. Management of patients who die in A&E/Casualty ward.

1.        When patients die in the A&E, their relatives should be informed; after the patient must have been duly certified clinically dead.

2.        The corpse should be evacuated to the mortuary. The Medical Officer (or the resident doctor) of the managing clinical unit must issue a cover note for the evacuation of the corpse to the mortuary.

3.        The Supervisory Matron on duty should ensure that the corpse is promptly sent to the mortuary; with the appropriate care and consideration.

4.        In the event that the relatives are not available at the time a patient dies; when they eventually arrive in the casualty, the attending Medical Officer or Nurse should show due courtesy and sympathy to them, and help them in every possible way in making necessary arrangements.

* If any patient (either in the emergency room, or on the wards) dies within 24 hours of admission, the case should be referred to the Lagos State Coroner service for determination of cause of death and issuance of death certificate. This must be explained clearly to the family members, or next-of-kin of the deceased by the handling Doctor.

 

G. Discharge/Leave Against Medical Advice /Refusal of treatment:

1.        The Doctor, at the time of discharge of a patient, is responsible for providing the patient with verbal and legibly written instructions for follow up care at home and fills up the discharge summary.

2.        The discharge summary must contain the details of the patient, admission date, laboratory investigations done, diagnosis, treatment given and follow up advice. The full name of managing Doctor, unit, and the department, must be clearly mentioned.

3.        Any Patient refusing further hospital management should be properly counselled against taking such a decision; he/she must be educated on the possible deleterious effects of his/her intending action, he/she should also be informed that; should he/she go ahead with his/her decision and his/her clinical condition worsens, UCTH will not be obliged to continue rendering medical care to him/her upon presenting again at the A&E.

 

After due counselling, if the patient or his/ her next-of-kin still decides to go ahead with this decision, they should be requested to complete and sign the "Discharge Against Medical Advice (DAMA)" form and this should be attached to the patient's clinical notes.

4.        Refusal to sign the DAMA form should be documented in the patient's clinical records, with the DAMA form attached.

5.        A patient who leaves the unit prior to the start of treatment should have such information noted in the patient's clinical notes, and the reason (if known), for the patient leaving should be documented.

6.        The patient who leaves the hospital against medical advice and without the knowledge of the hospital staff should be marked as LAMA in the patient's clinical notes, and it should be reported to the police.

 

A register of all such LAMA cases shall be maintained.