General Ward-staff work schedule

8AM

• TAKE OVER/HANDOVER OF ALL PATIENTS IN THE WARD COLLECTIVELY
• WARD ATTENDANTS SHOULD MOP THE FLOOR, CLEAN THE DOORS AND WINDOWS.
• JOB ALLOCATION IS PREPARED FOR STAFF, BY THE WARD MANAGER (OR DEPUTY), BASED ON NURSING PROCESS.
• BREAKFAST SERVED BY NURSES, THEN COLLECTION OF DIRTY DISHES BY THE ATENDANTS.
• CLEANING OF FOOD TROLLEY AND PLATES BY THE ATTENDANTS.

9 AM

• TAKE OVER/HANDOVER OF ALL PATIENTS IN THE WARD COLLECTIVELY
• WARD ATTENDANTS SHOULD MOP THE FLOOR, CLEAN THE DOORS AND WINDOWS.
• JOB ALLOCATION IS PREPARED FOR STAFF, BY THE WARD MANAGER (OR DEPUTY), BASED ON NURSING PROCESS.
• BREAKFAST SERVED BY NURSES, THEN COLLECTION OF DIRTY DISHES BY THE ATENDANTS.
• CLEANING OF FOOD TROLLEY AND PLATES BY THE ATTENDANTS.

9AM

• BED MAKING
• COLLECTION OF DRESSING PACKS FROM CSSD
• COLLECTION OF DIRTY LINEN BY LAUNDRY STAFF.

9.30 - 10AM

• ADMINISTRATION OF DRUGS
• WOUND DRESSING, CARE OF PRESSURE AREAS.
• DOCTORS' WARD ROUNDS

11.AM

• STAFF BREAKFAST ENDS.

12 NOON

• 6-HOURLY ADMINISTRATION OF DRUGS SERVED.
• 1PM
• PATIENTS' LUNCH SERVED BY NURSES/ ATTENDANTS.

2PM

• 8-HOURLY ADMINISTARTION OF DRUG SERVED
• PATIENTS' OBSERVATION DONE (TEMPERATURE, PULSE, RESPIRATION, BLOOD PRESSURE.
• UPDATE FLUID INPUT/OUTPUT CHARTS
• WRITING OF REPORTS BY THE SENIOR NURSE.

2:30PM

• TIDY UP THE WARD, AND HANDOVER TO THE AFTERNOON STAFF.

3PM

• WARD ATTENDANTS ON AFTERNOON DUTY TO SWEEP AND MOP THE FLOOR, TIDY UP THE WARD GENERALLY.

 

3:30PM

• ALL MORNING STAFF LEAVE THE WARD.

4-6PM

• VISITING HOURS FOR PATIENTS'
• RELATIVES, WRITING OF OFFICE REPORT, OBSERVATION DONE.

6PM

• ALL VISITORS TO LEAVE THE WARD
• SUPPER IS SERVED TO PATIENTS
• PREPARATION FOR SURGERY (SUCH
• AS SHAVING OF PATIENTS, ADEQUATE INSTRUCTIONS ON DO'S AND DON'T BEFORE SURGERY ETC).
• AFTERNOON ATTENDANTS TO COLLECT ALL DIRTY DISHES AND TIDY UP THE TROLLEY.
• TREATMENT OF PRESSURE AREAS, AND
• TURNING OF PATIENTS
• BOWEL PREPARATION (WHERE APPLICABLE)

8PM

• HAND OVER TO THE NIGHT STAFF
• 4-HOURLY OBSERVATION/TREATMENT DONE
• ADMINISTRATION OF NIGHT (NOCTE) DRUGS
• SETTLING PATIENTS CALMLY FOR THE NIGHT.

1OPM

• CARE OF PRESSURE AREAS
• TURNING OF PATIENTS
• DEPLOYMENT OF MOSQUITO NETS OVER
• THE PATIENTS
• CLEANING OF BOWLS BY THE ATTENDANTS
• WRITING OF THE NEXT DAY'S MEAL
• SHEETS ACCORDING TO PATIENT'S PRESCRIBED DIET
• WRITING OF BEDSTATEMENT.
• 12 MIDNIGHT
• 6 HOURLY TREATMENTS DONE
• PATIENT'S STATISTICS SENT TO THE SUPERVISORY MATRON
• INTAKE & OUTPUT RECORD DONE
• NURSES HAVE THEIR BREAK IN RELAY (12MN - 2AM).

2AM

• 4 HOURLY TREATMENTS IS DONE 4-5AM WRITE OFFICE REPORTS.

5.30AM

• BED BATHING OF ALL PATIENTS
• TREATMENT OF BED SORES/PRESSURE AREAS
• ORAL TOILETING
• OBSERVATION DONE

6AM

• SUBMIT THE WARD REPORT TO THE OFFICE.
• TIDY UP THE WARD.

9AM

• BREAKFAST SERVED
• GETTING PATIENT READY FOR SURGERY
• COLLECTION OF DIRTY/SOILED LINEN

 

Duties of Porters and Attendants

1.        Errands concerning patient care (e.g., to the lab, pharmacy, blood bank, and consultation requests from one team of doctors to another) are of utmost importance, and indeed the first order of business for any attendant or porter!

2.    All blood samples collected on the wards should be dropped on the designated receiving trolley in each ward, together with the lab request form and attached receipt of payment for the investigation. These tissue samples (blood, pus, swab etc) should then be sent to the lab by the respective attendant or porter.

3.    When a patient is to be transfused, a transfusion order is written by the attending doctor, then the receipt of payment for grouping/ cross-matching and screening should be handed over to the attendant or porter to proceed to be the blood bank to retrieve the issued blood for that particular patient. The blood bag should ideally be inspected by BOTH the Doctor and Nurse on duty to ensure that the details tally and the blood has been screened and cross-matched, and certified for the particular patient in question.

4.        If a patient is to undergo surgery, the blood for transfusion should be collected by one of the attendants or porters from the theatre

5.        When a team of doctors want the doctors from another team to review their patients, they have to produce a written request letter, which should be handed over the supervising nurse on the ward at that particular time. This is first, to make the nurse aware that a team is being invited, and secondly, for the nurse to direct the attendant or porter (who are directly supervised by the nurse) to deliver the consult to any of the doctors in the team of doctors being invited.

6.   Any Attendant or Porter who flouts these regulations will be severely punished, as the care of patients is our major priority!

 

GUIDELINES ON THE CARE OF PATIENTS

1.     Any Doctor attending to a patient must discuss his/her findings, planned investigations, treatment, and possible course of illness with the patient

2.       Proper appointments must be given if patient requires follow up

3.    Doctors and other health care workers must keep strict confidentiality concerning a patient's clinical presentation and diagnosis. THIS MUST NOT BE DISCUSSED WITH THIRD PARTIES, AND DEFINITELY NOT ALONG THE CORRIDORS!

4.     When patients are admitted onto the wards, they should know their diagnosis, reasons for admission, treatment options, the Doctors expectation from treatment (cure, reduction of symptoms etc.) and possible duration of hospital stay.

5.     All patients admitted onto the wards must get daily updates on their progress to either the patients themselves, or their recognised next-of-kin.

6.   All discussion must be properly documented, including the patients' responses.

7.     All patients refusing treatment advice, or other modalities of management must signify in their own handwriting with their signatures appended

8.   We advise that all managing Doctors should get the attention of the recognised next-of-kin whenever any patient is refusing treatment, or being difficult in any way. Except in cases where the patient is insisting on maintaining confidentiality concerning disclosure of his ailment.

9.     The Doctor responsible for any patient's well-being, and co-ordination of multi-specialty management is his/her primary Doctor. E.g., if a man who had appendectomy developed breathing difficulties for which he was admitted into the ICU, the primary responsibility for co-ordinating his overall treatment falls on the surgeon who he presented to initially! The primary doctor is responsible for regular updates to the patient.

10.    All Doctors should, as much as possible, try to make themselves accessible to their patients.

 

Short stay admission

Short stay admission is the entry of a patient into the wards for a duration that should not exceed 48 - 72 hours in the hospital. This is usually for clinical conditions that are not severe, and the patient is expected to recover quickly e.g., acute asthma, febrile convulsion, uncontrolled vomiting e.g., hyperemesis gravidarum, acute watery diarrhoea with dehydration. It is also for minor procedures like blood transfusion, IV chemotherapy, intravenous catheter insertion etc.

 

This measure has been put in place to encourage more ward admissions, in order to free up the emergency room spaces to handle incoming cases.

 

This will involve the following;

1.      Payment of the cost of 48 hours stay (for the particular ward) as deposit for transfer into the ward.

2.      It would be at the discretion of the managing Consultant only

3.      If the patient's stay exceeds the initial 48 hours, she/he is expected to pay             for a further 24 hours to continue with treatment; they are not allowed to             owe!

 

Use of side rooms in general wards

1.        Side rooms are not for isolation of infected/ contagious patients only

2.        While it is expedient to use these wards for   isolating cases of infectious diseases, e.g., Koch's Disease, they are not for this purpose only.

3.        The use of these wards for isolation is for the protection of other patients in the general ward.

4.        It is expected that when patients who are thought to be infected/contagious are discharged, the rooms will be disinfected like every other ward or bed used by any discharged patients; infectious or not.

5.        Therefore, when there is no patient on admission who will require isolation, these rooms should be made available to other patients.

6.        The practice of "infectious disease colonies" has long been abandoned.

7.        If we practice universal precaution, proper barrier nursing and routine effective disinfection, then we can't go wrong.

 

Care of Patients with Sickle Cell disease

1.      There shall be a rebate in the cost of providing certain services to people with sickle cell disease

2.      All patients accessing these services must be registered prior to accessing services, not at presentation for complaints of ill health

3.      There must be documented proof of genotype status from our lab (cost to be borne by the patient)

4.    Such people intending to continue to access these rebates must attend meetings and programmes of the sickle cell centre regularly to qualify for continued rebates

5.      Drugs will be made available to people living with sickle cell disorder at cost price, with no mark-up whatsoever.

6.      Laboratory tests are not subsidized for now

7.    We are presently processing further reductions in consultation fees, bed charges, normal delivery, surgical fees, and cost of other procedures in the hospital e.g., physiotherapy, ultrasound scans, x-rays (without printing of films).

 

WARD CHECKLIST FOR PATIENTS GOING FOR SURGERY OR OTHER PROCEDURES

 Name of Patient: .

 Age: .

Sex: .

Procedure:  

1.        Has the surgical site been prepared?

2.        Are the results of all requested investigations available?

3.        Have all adjuvant (Pre-Op) drugs been given?

4.        Have all special requests, e.g., 'bowel prep', been done?

5.        Does the patient have an IV canula sited in a good peripheral vein?

6.        Has the patient paid for the procedure?

7.        Has blood been donated?

8.        Has consent for the procedure been obtained from the patient?

 

Name of Nurse:

 Signature:

 Ward:

Date:

 

Cleaning of Hospital beds

A.        All hospital beds, bed-side tables and cupboards must be cleaned weekly, and when any patient is discharged or dies

B.        Not all deaths are from infectious causes that require deep cleaning.

C.        Even when the cause of death is from an infectious origin, there are simple measures for disinfecting beds, beddings and the immediate surroundings. D. It is expected that anyone carrying out this procedure should be gloved and masked

 

For routine cleaning of the beds, the following cleaning procedure is implemented;

1.      The linen is removed, and sent to the laundry

2.      The bed, bed-side table and cupboard are all wiped with soap and water

3.      The mattress covering (McIntosh) is washed with soap and clean water If the previous occupant of the bed is thought to have suffered from an infectious, and possibly contagious disease;

4.     After cleaning with soap and water; the bed, bed-side table and cupboard are wiped with dilute hypochlorite solution (bleach)

5.     After washing as in (3) above, hypochlorite solution (bleach) is applied on the mattress covering and left to stand for at least 5 minutes.

6.     Thereafter, the hypochlorite is rinsed off with water, and left to dry in the sun.

7.     As soon as the mattress covering is dry (usually about 30 minutes up to an hour), it can be returned to the bed.

8.     The environmental health unit should be invited to fumigate the ward (or bay) where the patient suspected of having a possibly contagious infection occupied.

 

Disposal of sharps and contaminated waste

Sharp objects and contaminated waste should be disposed of properly by nurses, and doctors who used or removed them to avoid infecting other hospital workers!

 

1. '     Sharps' containers have been provided at every service point. These are for all needles, scalpel blades etc.

2.      Covered pedal bins are available; these should be lined with waste bags of different colours;

a.         Black: for general waste like paper, plastic covering of foods etc

b.        Yellow: for possibly infectious waste like gauze for dressing, saliva, urine bags etc

c.         Red:  for highly infectious waste like; body tissue, blood-soaked drapes and gloves, used disposable vaginal speculum, used blood bags etc.

3.      Posters have been provided on notice boards all around the hospital, and on the bins themselves to guide all users on the segregation of waste

 

BLOOD TRANSFUSION

1.     All patients requiring blood transfusion should have a blood sample obtained, by his/her Doctor, for grouping & cross matching.

2.     The blood sample should be sent to the blood bank, along with a transfusion request

3.        In an emergency, the blood bank will issue at least one pint of blood to the patient; but afterwards this has to be replaced by a donor presented by the patient, or in the absence of a donor, send the patient's relative to any laboratory from a list of 3 shortlisted private blood banks vetted by both the Head of Pathology and the Director (MLS), and approved by the hospital.

4.     In non-emergency situations, the patient is expected to have arranged for his/her blood by either donation by a presented donor, or by purchasing blood from any of the 3 blood banks approved by the hospital.

5.      Any blood sourced from outside blood banks must be certified by the Lagos state blood transfusion service.

6.     All blood sourced from outside blood banks must be cross matched in our (UCTH) blood bank, and certified by the laboratory staff on duty before transfusion within UCTH.

 

GUIDELINES FOR THE USE OF HIGH DEPENDENCY UNITS (HDUs)

1.       HDUs are located in some wards

2.      These are for patients considered to be too sick for the normal hospital beds, but not sick enough to be cared for in the ICU

3.       Patients in the HDU will be billed NI 00,000 per week (i.e., NI 4,300 per day)

 

4.      In the absence of a patient requiring HDU care, the bed space can be used for other cases requiring ward admission at normal daily rates.

5.     The primary doctor initially managing such a patient admitted to the HDU, will continue to be responsible for the care of that patient in the HDU. However, as usual, the managing team can invite any other doctor considered necessary for the care of this patient in the HDU; e.g., anaesthetist, ENT surgeon, neurosurgeon, endocrinologist, cardiologist, nephrologist etc.

6.      It is recommended that all patients are initially observed in the HDU for not more than 48 hours, so as to give other patients requiring HDU care a chance. After 48 hours, if the patient currently being managed in the HDU is not sufficiently improved enough to go back to normal care, he/ she should be re-assessed and compared with whichever other patient is thought to require HDU care; whoever is worse (and would benefit from HDU care) should be moved to the HDU. This assessment is the responsibility of the managing team if both patients in question are being managed by them. But if the patients are being managed by 2 different teams, the anaesthetists should do the assessments to ensure objectivity at all times.

7.       Patients being discharged from the ICU may require an initial period of HDU care on the ward

8.       General indications for HDU care are patients that;

I. Require more frequent vital signs monitoring than 4-hourly

ii. Do not require invasive mechanical ventilatory support

iii. May require respiratory support including nasal oxygen, up to     possibly CPAP

iv. Require cardiac monitoring, usually by heart rate and ECG tracing

v. Require continuous SP02 monitoring

9.      Medical Indications for HDU admission include;

    I.          Post cardiac arrest, but breathing spontaneously

    ii.         Non-ST elevation myocardial infarction

    iii.        Unstable dysrhythmia resistant to reversion

   iv.      Patients with cardiac disease requiring low-dose intravenous inotropic     or vasodilator therapy

  v.      Patients on infusion for blood pressure control (e.g., Labetalol) requiring close monitoring

vi.        Cardiac arrhythmias

vii.       Acute severe asthma (not responsive to usual rescue ß2-adrenegic receptor agonist

vii.      Acute severe asthma (not responsive to usual rescue ß2-adrenegic receptor agonist therapy)

viii.      Cerebrovascular accidents (CVA)

ix.        Diabetic keto acidosis

x.         Thyroid dysfunction

xi.        Following prolonged uncontrolled seizures

xii.       Sickle cell disease, presenting with severe anaemia, renal I                           nsufficiency or CVA

10.      Surgical indications for HDU admission include;

I.          Acute trauma with massive blood loss

ii.         Head trauma or other causes of CNS depression sufficient to prejudice the airway and protective reflexes

iii.        Post neuro-surgery

iv.        Following major abdominal surgeries

v.         Stable post-operative patients with high risk of bleeding e.g., those on anticoagulant therapy

vi.        Elderly post-operative patients

vii.       Patients with eclampsia/pre-eclampsia

 viii.     Post amputation in poorly controlled diabetic patients

ix.        Severe sepsis with cardiorespiratory instability

x.         Severe burns affecting the face and chest

 

11.      Nursing care for HDU Patients:

i.     These patients must have a high-level review at least twice daily (minimum of SMO, who must discuss with the consultant)

ii.     Vital signs (BR Pulse Rate, Respiratory Rate, Temperature, SP02) must be documented at least hourly, or more frequently if required by the managing team.

iii.    The Nurse must create and implement effective care plans for individual patients

iv.    There must be vigilance for early detection of subtle or sudden changes in the patients' medical condition

v.      In the event of a sudden deterioration in a patient's condition, the nurse should start resuscitation (if necessary) while calling for a doctor (usually the member of the managing team who is on call)

vi.   Drugs, fluids, and other medicaments must be administered in the correct doses, on schedule, and via the prescribed routes at all times

vii.    It is desirable (but not mandatory) that all patients in the HDU should have central lines

viii.    Hourly urine output must be charted

ix.      Making the patients as comfortable as possible

x.      Patients' relatives must be carried along, and briefed regularly by the managing team

12.      In case of doubt, consult the anaesthetist or physician on call.

 

PROPER EVACUATION OF CORPSES AFTER A PATIENT PASSES ON

1.    All wards must anticipate the possible passing of a moribund patient; therefore, they must be prepared to handle the aftermath.

2.       The materials required for the 'last office' must be stocked by all wards

3.      As soon as the family has been informed of the death of their loved one and they have viewed the corpse, the last office must be performed.

4.      If the family members are not available at the time of death, they should be contacted by telephone, and given a maximum of 2 hours to come and view the corpse of their loved ones before the last office is performed

5.      The family should be given the option of arranging for the evacuation of the corpse of their loved one within 30 minutes to 1 hour; thereafter, the hospital reserves the right to evacuate the corpse to the St Paul's mortuary on the family's behalf.

6.     Should the corpse be deposited in St Paul's mortuary, the family shall be responsible for all mortuary fees.

7.    While the arrangement for evacuation is going on, the corpse will be temporarily kept away from public view by storing within the sluice room of the respective ward. THIS STORAGE SHOULDN'T EXCEED 1 HOUR!

8.    Evacuation of corpses should be through the rear exits of the wards, or through the back entrance by maternity ward; thereby avoiding the main hospital entrance in the process.