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Designed b y
Emergency and Injury Care
at Secondary and Tertiary
Level Centres in India
A Report of Current Status on
Country Level Assessment
Emergency and Injury Care at Secondary and Tertiary Level Centres in India
A Report of Current Status on Country Level Assessment This study was carried out with the financial support of
NITI Aayog, Government of India,
and conducted by
Department of Emergency Medicine ,
JPNATC, AIIMS.
PROJECT REPORT SUBMITTED TO
NITI Aayog, New Delhi
Emergency and Injury
Care at Secondary
and Tertiary Level
Centres in India
A REPORT OF CURRENT STATUS ON
COUNTRY LEVEL ASSESSMENT DISCLAIMER
Department of Emergency Medicine, JPNATC, AIIMS has received the
financial assistance under the Research Scheme of NITI Aayog (RSNA 2018)
to prepare this report. While due care has been exercised to prepare the
report using the data from various sources, NITI Aayog does not confirm
the authenticity of data and accuracy of the methodology to prepare the
report. NITI Aayog shall not be held responsible for findings or opinions
expressed in the document. This responsibility completely rests with the
Department of Emergency Medicine, JPNATC, AIIMS.
Copyright: © 2020 Department of Emergency Medicine, JPNATC, AIIMS,
New Delhi
All rights reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording or any information storage and retrieval system,
without permission in writing from the publisher.
This book and the individual contributions contained in it are protected
under copyright by the Department of Emergency Medicine, JPNATC,
AIIMS, New Delhi. iii
LIST OF
INVESTIGATORS AND
CONTRIBUTORS
S. No.Name Designation Organization
PRINCIPAL INVESTIGATOR
1Dr Sanjeev Kumar BhoiProfessor
Department of Emergency
Medicine, JPNATC,
AIIMS, New Delhi
CO-INVESTIGATORS
2Dr Praveen Aggrawal
Professor &
HOD
Department of Emergency
Medicine, AIIMS, New
Delhi
3Dr Tej Prakash Sinha
Associate
Professor
Department of Emergency
Medicine, JPNATC,
AIIMS, New Delhi
CONTRIBUTORS
4Dr Tanu Jain
Deputy Director
General
Directorate General of
Health Services, Nirman
Bhawan, New Delhi Emergency and Injury Care at Secondary
and Tertiary Level Centres in India iv
5Dr S Rajesh
IFS, Chief
Conservator of
Forests
Former Director
(Health)
Govt. of Arunachal
Pradesh
NITI Aayog, Govt. Of
India, New Delhi
6Dr K Venkatnarayan
Officer on
Special Duty
National Institute of
Transforming India (NITI)
Aayog
RESEARCH OFFICERS
7Ms Dolly Sharma Research Officer
Department of Emergency
Medicine, JPNATC,
AIIMS, New Delhi
8Dr Monica Sindhu Research Officer Foreword
Care of emergency and accident patients is of paramount importance in saving
lives, preventing disability and for achieving the intended health goals of the Nation.
However, accident and emergency services in India has witnessed uneven progress.
Given its extraordinary importance, it is time that India embarks on creating a world-
class, efficient, professional and integrated system, enabled by technology, for the care
any victim of accident, emergency or trauma in any part of the country.
To understand the imperatives in realizing this goal, NITI Aayog, jointly with
Ministry of Health & Family Welfare (MoHFW) conducted field visits and held multi-
stake holder meetings. It emerged from these deliberations that a pan-lndia study to
assess gaps in optimal delivery of emergency care services was a crucial starting point.
Accordingly, NITI Aayog commissioned Emergency Medicine Department, AllMS, New
Delhi to conduct a Nation-wide assessment of prevailing emergency care system in
India.
I am happy to note this study, which involved 100 Secondary and Tertiary level
health facility sites of government and private hospitals of all zones of the Nation,
has been completed. Besides highlighting the spectrum and load of emergency cases,
it brings out the prevailing gaps in ambulance services, health infrastructure, human
resources and equipment in the provision of optimal care. I complement the team for
conducting live observations of various processes involving efficiency of time-bound
procedures, patient satisfaction reports. Medico-legal burden, adherence to protocols
and data-entry operations.
My congratulations to the AllMS team for successful completion of the project and
the teams from NITI Aayog and Ministry of Health & Family Welfare for their useful
contribution In bringing out this timely report. The learnings from this study would be
useful for developing vision and plans toward creating world-class emergency care in
the country. Emergency conditions such as Acute coronary syndrome, stroke, respiratory diseases,
maternal and pediatric emergencies and injuries are the leading causes of death and
disabilities in India. Trauma is the leading cause of death among young, who often are
the sole bread earner of the family.
The landscape of emergency care includes timely access and acute care delivery to
critically ill and injured patients. Premature death and Disability Adjusted Life Years
(DALYs) can be prevented by establishing robust integrated emergency care system with
definitive care.
In this study, 100 healthcare facilities were randomly selected from 28 states and 2 union
territories of our Country and were assessed by team of assessors.
This study aims to find the available gaps in the emergency and injury care system in the
healthcare facilities, both in government and private sector. It also studied the linkages
between pre-hospital care and hospital care in India.
I strongly believe that the outcomes of this study will provide the policy inputs to improve
and strengthen the emergency care services at all tiers of the healthcare facilities in India.
I congratulate the researchers for conducting this very important study.
MESSAGE ix
ACKNOWLEDGEMENT
ACKNOWLEDGEMENT
We wish to express our sincere gratitude to all who helped us to complete this project in an
efficient time-bound manner. This study was carried out by Department of Emergency Medicine,
JPNATC, AIIMS, with the financial support of NITI Aayog, Government of India.
At the outset, we like to thank Dr V K Paul, Member, National Institution for Transforming India
who provided useful insights in conceiving this study and guiding throughout various processes.
We would like to thank to Dr Madan Gopal, Sr. Consultant, NITI Aayog for his kind support and
co-operation both during this study and submission of its report.
This study would not have been possible without the continued support. dedication and constant
engagement of all our research staff and team of national assessors, especially given the limited
time frame.
We would also thank all the nodal officials and all the staff of various hospital sites, who were
immensely cooperative in providing the needful inputs for the study, whenever our team reached
out to them.
Our special thanks to the teams representing our key stakeholders from the Ministry of Health
and Family Welfare and NITI Aayog, for their valuable contribution and time.
Finally, we thank the God almighty for giving this opportunity to successfully conduct this study;
which we hope, would bear an important imprint for making key policy decisions to deliver
optimal emergency care for the Nation.
Team of Investigators
JPNATC
AIIMS, New Delhi xi
TABLE OF CONTENTS
List of Investigators and Contributors iii
Foreword v
Message vii
Acknowledgement ix
Abbreviations xv
1. EXECUTIVE SUMMARY 1
1. Salient Findings of the Study 4
2. Key Recommendations 8
2. INTRODUCTION 11
3. REVIEW OF LITERATURE 15
1. Burden of Emergency Conditions in the South-East Asian Region 16
2. Burden in India 18
3. Current Status of Emergency Care in the India 19
4. WHO Emergency Care System Framework 20
5. Hospital Based Emergency Care in the Government Sector in India 22
6. Training 22
7. Academic Emergency Medicine 23
8. Gaps 23
8.1 Research and Development for Emergency Services 23
8.2 Organization and financing 24
4. AIMS AND OBJECTIVES 27
5. METHODOLOGY 31
6. OBSERVATIONS AND RESULTS WITH SUGGESTIONS 39
I. FIELD VISIT: ADMINISTRATIVE INTERVIEW/ONE YEAR DATA COLLECTION 39
1. Background Information of the Hospitals 39
2. Available Beds at Assessed Facilities 39 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India xii
3. Burden of Patients (OPD and Emergency) 41
4. Huge Mismatch between Emergency Beds & Burden of Emergency and Injury Cases: 44
5. Burden of Medico-legal Cases 46
6. Burden of Admissions through Emergency 48
7. Burden of Death of Trauma Patients 49
8. Burden of Patient’s Death due to Road traffic Injury 50
9. Burden of Brought Dead Patients 50
10. Blood Bank Services 51
11. Definitive Care Services 57
12. Ambulance Services 62
12.1 Available ambulances in hospitals 62
12.2 Hospital Ambulance Services 65
12.3 Use of Ambulances by Hospitals 67
12.4 Patient transfer in absence of hospital ambulance: 67
13. ED Protocol / SOP / Guidelines 68
14. Emergency care protocols 72
15. Measures ensuring Safety & Security in Hospitals 75
16. Disaster Management 78
17. Continuous Quality Improvement 82
18. Computerized Data Management System 87
19. Financing 92
20. Physical Infrastructure 96
21. Manpower in Emergency Department 98
22. Equipment and Supplies in ED 101
22.1 Biomedical Equipment 101
22.2 Compliance of critical available equipments 102
23. Point of Care Lab 107
24. Essential Medicines for Emergency 111
II. LIVE OBSERVATION 114
1. Disposition Time 114
2. Chest Pain 116
3. Stroke 120
4. Trauma 125
5. Incidence of Violence 128
5.1 Reason of Violence 128
5.2 Mitigation measures 129
6. Communication Skills in Emergency Department 130
7. Patient Satisfaction 131
8. Referral of the Patient 133
III. LIVE OBSERVATION (ONE DAY DATA OF EMERGENCY) 136
1. Burden of Patients (OPD and Emergency) 136
2. Disposition Summary 137 xiii
Table of Contents
3. Spectrum of Diseases 138
3.1 Adult Patients 138
3.2 Pediatric Patients 140
IV. COMPARISON OF EMERGENCY CARE IN VARIOUS SYSTEMS 142
1. Hospitals with Academic Emergency Medicine (n=5) 142
2. Govt. Secondary care v/s Tertiary care Hospitals 146
3. Private Hospitals vs Government Hospitals 151
4. NABH accredited vs non-NABH accredited Hospitals 151
V. COMPLIANCE OF INDIVIDUAL HOSPITALS TO THE CHECKLIST 152
7. DISCUSSION 155
8. CONCLUSIONS 159
9. SUMMARY OF KEY SUGGESTIONS EMERGING FROM THE STUDY 163
10. SUGGESTED KEY POLICY RECOMMENDATIONS 169
11. REFERENCES 175
12. ANNEXURE 179
Annexure-I: List of Hospitals 181
Annexure-II: Study Tool 185
Annexure-III: List of Scientific Advisory Committee Members 224
Annexure-IV: Patient Information Sheet 226
Annexure-V: Confidentiality / Conflict of Interest Agreement Form for National Assessor 228
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital 230
Annexure-VII: List of National Assessors 242
Annexure-VIII: Contact Details of Hospitals 249
Annexure-IX: Comparative compliance of Hospitals among categories 256 ABBREVIATIONS
xv
ACLSAdvanced Cardiac Life Support
AIIMSAll India Institute of Medical Sciences
ALSAdvanced Life Support
AMBUArtificial Manual Breathing Unit
APTTActivated Partial Thromboplastin Time
ATLSAdvanced Trauma Life Support
BLS Basic Life Support
CaCalcium
CABGCoronary Artery Bypass Grafting
CCUCritical Care Unit
CDCommunicable Disease
ClChlorine
CMOChief medical officer
CTComputerized Tomography
DALYsDisability-Adjusted Life Years
DLCDifferential Leucocyte Count
DNBDiplomat of National Board
DSADigital Subtraction Angiography
ECGElectrocardiogram
ECSEmergency Care System
EDEmergency Department
EHRElectronic Health Record
EMEmergency Medicine Emergency and Injury Care at Secondary
and Tertiary Level Centres in India xvi
EMSEmergency Medical Services
EMTEmergency Medical Technician
EREmergency Room
ETATEmergency Triage Assessment and Treatment
FFPFresh Frozen Plasma
GDAGeneral Duty Attendant
GDPGross Domestic Product
GHEGlobal Health Estimates
HAHospital Attendant
HbHemoglobin
HctHematocrit
HDUHigh Dependency Unit
HMRIHai Medicare and Research Institute
ICUIntensive Care Unit
INDUSEMINDO-US Emergency Medicine
INRInternational Normalized ratio
IPDIn-Patient Department
IPGMERInstitute of Post-Graduate Medical Education and Research
ITUIntensive Treatment Unit
IVIntra-venous
JPNATCJai Prakash Narayan AIIMS Trauma Centre
JRJunior Residents
KPotassium
LAMALeft Against medical Advice
LMALaryngeal Mask Airway
LMICsLower Middle Income Countries
MCIMedical Council of India
MLCMedico legal Cases
MOMedical Officer
NaSodium
NABHNational Accreditation Board for Hospitals & healthcare Providers
NCDNon-Communicable Disease
NITI Aayog National Institution for Transforming India
OPDOut Patient Department
OTOperation Theatre xvii
Abbreviations
PALSPediatric Advanced life Support
PCIPercutaneous Coronary Intervention
PEFPeak Expiratory Flowmeter
Pro-BNPN-terminal B-type Natriuretic Peptide
PTPlatelet Transfusion
RBCRed blood Corpuscles
RTIRoad Traffic Injury
SASanitary Attendant
SACScientific Advisory Committee
SDStandard Deviation
SEARSouth East Asian Regions
SOPStandard Operating Procedures
SPSSStatistical Package for the Social Sciences
SRSenior Residents
SSGSir Sayaji General
SSKMSeth SukhlalKarnani Memorial
STNMSir ThutobNamgyal Memorial
TEGThromboelastogram
TLCTotal Leucocyte Count
Trop-ITroponin I
Trop-TTroponin T
U.S.United States
USGUltrasound/Sonography
WHOWorld Health Organization EXECUTIVE SUMMARY
Non- Trauma Trauma
Symptoms/ History/ Exam finding based Injuries identified Mechanism of injury
R
E
D
1. Breathlessness / Pallor with Edema
2. Active Bleeding (Hematemesis, Hemoptysis, Epistaxis,
Hematuria, etc)
3. Active seizures
4. H/o Fainting / Syncope
5. Fever with Delirium
6. Poisoning with unstable vital sign
7. Snake / Scorpion bite
8. Burn >20% BSA (Burn of special areas)
9. Hanging /Drowning / Electrocution / Heat Stroke
R
E
D
1. Gun-shot wound
2. Major Vascular injury
3. Stab wounds
(Head/Neck/Chest/Abdomen/Groin)
4. Multiple injuries
5. Open fractures excluding fractures of
hand and feet
6. Two or more long bone fracture
7. Pelvic fracture
8. Visible neck swelling
9. Suspected sexual assault
10. Flail chest with paradoxical respiration
11. Chest trauma with
• Surgical Emphysema
• Seat Belt Mark
• CCT Positive
12. Traumatic Amputation
1. Fall from
• >3 times height of patient
• >5 stairs
2. Roll over vehicle
3. Co-passenger death
4. Ejection from vehicle
5. Railway track injuries
6. Steering wheel injury
7. Prolonged extrication time from
vehicle
8. Roll over vehicle
9. Stuck between 2 heavy vehicles
Y
E
L
L
O
W
1. Post-seizure stage
2. Pain abdomen / Loose motions (>3episodes)
3. Painful Bleeding P/R
4. H/o Bleeding
5. Pallor/ Known Anaemia for Transfusion
6. Fever with Headache/ chest Pain / Jaundice
7. Fever in patient on chemotherapy / HIV Patients /
Diabetic patients
8. Drug overdose, Poisoning with stable vital signs
9. Painful swelling / wound
10. Headache, dizziness
11. Unable to pass stool
12.Unable to pass urine
Y
E
L
L
O
W
1. Minor Head Injury
2. Open or closed fractures of hand & feet
3. Isolated long bone fracture
4. GCS-15 with -
• Alcohol
• Anticoagulant
• LOC and vomiting
• Nasal & ENT bleed
• Limb Weakness
1. Suspected abuse
(Child/Women/Elderly)
2. Significant assault
G
R
E
E
N
1. Minor symptoms of existing illness
2. Fitness urticaria / Skin rash
3. Fever
4. For medico-legal examination
5. Minor conditions and low risk conditions (cough, cold,
etc.)
G
R
E
E
N
1. Abrasions
2. Lacerations
3. Isolated fracture of small bones of hand and foot
4. Contusions and Bruises
NO DELAY!!
A
Noisy Breathing/Stridor;
Angioedema
Active seizures C
Radial Pulse - Present / Absent;
Pulse<50 or >120/min;
SBP <90 mm Hg or >220mm Hg;
Capillary refill >2 sec
Shock index > 1
B
Talking incomplete sentence;
RR<10 or >22/min;
SPO2 <90%
D
Altered sensorium,
Responding only to pain on AVPU-Scale of GCS < 12
C-Spine Injury with Single Breath count < 15
RED Physiology
Criteria >>
(If any one of these mentioned
vital criteria is present on the
assessment) >>
TTRRIIAAGGEE
EXECUTIVE SUMMARY01 EXECUTIVE SUMMARY01
3
Medical emergencies including Road Traffic Injuries are one of the major leading causes of deaths
in India. RTIs alone contribute to 1.5 Lakh deaths annually. Approximately 2 persons died of
heart attack every hour in 2015-16. Currently, Non Communicable Diseases alone account for
~62% of deaths in India and Communicable infections, Maternal, New born account for ~27%
of deaths. Most of these deaths present as emergency conditions. In fact, as per one estimate
more than 50% of deaths and 40% of total burden of disease in Low Middle Income Countries
could be averted with pre-hospital and emergency care. The global total addressable deaths and
DALYs that can be averted amount to 24.3 million and 1023 million lives respectively. In fact,
in South-East Asia alone, 90% of deaths and 84% of disability-adjusted life years (DALYs) are due
to emergency and trauma conditions.
Emergency care system in our country has seen uneven progress. Some states have done well,
while others are still in the budding stages. Overall, it suffers from fragmentation of services from
pre-hospital care to facility-based care in government as well as in the private sector. The system
also suffers from lack of trained human resource, finances, legislation and regulations governing
the system.
Absence of standalone academic department since its inception is another factor for the current
ails in the system.
In the light of the above, the present study was conducted. The study aimed to assess the prevailing
status of emergency and trauma care at government and private hospital settings of India to bring
out the existing gaps and provide a framework for further improvement and the needed policy
directions. Towards achieving this goal, a country-wide study of emergency and trauma care
services of 100 tertiary and secondary level hospitals in 29 States and 2 Union Territories from
5 regions of India was conducted.
The selected health facilities consisted of 20 hospitals each under the following categories: Govt.
Medical Colleges, Private hospitals>300 bed strength, Private hospitals<300 bed strength,
Government hospitals >300 bed strength and Government hospitals <300 bed strength. The
assessments were conducted by trained assessors, selected from all over country who followed
by the investigators and research team. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 4
SALIENT FINDINGS OF THE STUDY
Case load
Emergency and injury cases annually accounted for 9-13% of all patients presenting to
a health facility and 19-24% of admissions in Govt Hospitals and 31-39% admissions
in Private Hospitals.
Live observations revealed that emergency cases accounted for 11-30% of all OPD
patients on a given day.
Spectrum of major medical conditions presenting at Emergency
Departments
During live observations conducted for 24 hours at the study centres, the following
were the most common spectrum of cases encountered at the EDs:
Adult patients (n=4677): Trauma and road-traffic injuries (24%), Fever (20%), Pain
Abdomen (16%), Respiratory Distress (11%), Chest Pain (9%), Pregnancy-related
(6%), altered mental status (5%), Poisoning (4%), Stroke (3%) and Snake bite (2%)
Pediatric patients (n=1403): Fever (31%), Diarrhoea (21%), Respiratory distress
(17%), Pain abdomen (14%), Trauma and road traffic injuries (9%), Seizures (4%),
altered mental status (2%), poisoning (1%) and Snake bite (1%).
Ambulance Services
Even though 91% of hospitals had in-house ambulances, trained paramedics needed to
assist ambulance services were present only in 34%.
Provision of specialized care during ambulance transport were largely poor: only 19%
hospitals had mobile Stroke/ STEMI (for heart attack) program, with only 4% having a
mobile Stroke unit.
Most of the hospitals lacked Pre-hospital arrival notification system, with larger
representation of Government over Private Hospitals.
Physical Infrastructure
Despite high patient load reporting to the EDs, the number of beds available at Emergency
Departments accounted for only 3-5% of total hospital beds.
Amongst the critical infra-related quality parameters assessed in the EDs, the following
were important deficiencies: absence of point of care lab (73%), demarcated triage area
(65%), police control room (56%), separate access for ambulance (55%) and adequate
spacing for emergency department (52%).
Overall, on a standard matrix of assessment, Private Hospitals ranked better than
Government Hospitals. 5
Executive Summary
Human Resource
Most of the hospitals lacked presence of general doctors, specialists and nursing staff
dedicated for Emergency Departments vis-à-vis the average footfall of patients, even
though, the hospitals as such, had sufficient overall numbers of required human resource.
Besides, when present, most of the EDs were manned by junior doctors rather than
specialists.
Equipment status
Compliance with availability of overall recommended biomedical equipment and critical
equipment were largely found satisfactory at all private hospitals (86-93%) and Govt
medical college hospitals (68%), with deficiencies found largely in smaller government
hospitals (45-60%).
Specifically, equipment deficiencies pertained largely to the category of Pediatric-care
(75%). Equipments pertaining to Airway, Breathing, Circulation and General categories
had deficiencies pertaining to a few sets of specific equipments (10-72%).
Essential Medicines
Since it is essential to have the complete list of all recommended emergency medicines
24*7 in the emergency departments, assessment done for this aspect revealed that only
9% of all hospitals, fulfilled this criterion.
Overall, Private colleges fared better in maintaining the recommended inventory of
recommended medicines (86-89%) compared to Govt Hospitals (52-72%).
Definitive Emergency Specialized Care
Amongst study of definitive care services, availability of emergency operative care
services (for trauma, non-trauma, orthopedic, neurosurgical, obstetric care) varied
between 47-60% depending on the type of services and hospital facility.
Similarly, critical care services (involving intensive care services such as ICU, HDU,
PICU, NICU, CCU, Neuro ICU) varied across hospital facilities, but were typically
largely deficient at smaller Govt Hospitals.
Many Govt Medical Colleges lacked common HDU (55%), Cardiac ICU (55%) and
Neuro ICU (55%). In addition, they also lacked facilities for Coronary Artery By-pass
Graft (55%), Cardiac Cath Labs (30%) and interventional radiology (40%).
Blood Bank services
An in-house 24*7 functional Blood Banks were available in 90% of Govt Medical
Colleges, 70% of Govt Hospitals with >300 beds and 35% of Govt Hospitals with <
300 beds. While in Private there were present in 85% of Hospitals with > 300 beds
and 65% of Hospitals <300 beds.
Most of the Hospitals did not have a dedicated Blood Bank in the Emergency Department
nor an existing standard protocol for massive blood transfusion. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 6
Patient disposition time (Live observation)
The patient disposition time for the sickest group (Red zone) was high at Government
Medical Colleges (90 Minutes) vis-à-vis Private Hospital (15 minutes). The reasons for
this delay amongst others were due to: high patient load, lack of in-house specialists
in the ED, need for multiple cross referrals, with an overarching lack of a dedicated
department for emergency services.
On study of efficiency of various time-bound procedures that need to be conducted for
optimal management of Chest Pain, Stroke and Trauma; generally Private Hospitals fared
better than Government Hospitals. And amongst the latter, smaller hospitals fared worse.
Violence between relatives of the care-seekers and health care providers were noticed
22-47% of hospitals, with higher representations from Government Hospitals. The
reasons were largely due to delay in providing care in Government Hospitals and
failure of appropriate communication in the Private set-ups.
Most of the Private Hospitals and smaller Government Hospitals lacked facilities such
as presence of Police/ private security guards, to mitigate such violence episodes.
Patient Satisfaction (Live observation)
Patients availing emergency care at Private Hospitals were largely satisfied with the
services provided (65-82%) in contrast to Government Hospitals (31% to 65%)
MLC Burden
The burden of Medico-legal cases (MLC) was 2-9% of all admissions.
They were disproportionately more MLCs at Government Medical College Hospitals
than others (9% Vs 3%), probably due to higher selective transfer of such cases form
other hospitals to avoid procedural issues.
ED protocols, Quality measures and Disaster planning
Most of the Government Hospitals lacked SOPs/standard manuals for emergency care,
patient transfer-in/out and handling of death. Further, policies for triaging and disaster
management were found only in ~50% of Government Hospitals and were largely
present in Private Hospitals.
Specific protocols for definitive care for chest pain, suspected sepsis, stroke, trauma and
cardiac arrest were found lacking across the spectrum of hospitals, with a higher share
of Government Hospitals. Similar patterns were seen for Disaster management planning
and systems to enforce continuous quality improvements.
Computerized data entry systems
Though computerized electronic health records, patient registration system were present
at most of the hospitals; specific computerized systems for patient clinical examination
notes, lab investigation reports and for data retrieval for research were largely deficient
in the Government Hospitals. 7
Executive Summary
Most of the hospitals across the spectrum lacked trauma registry and systems for
surveillance of trauma and Emergency Care.
Financing
None of the Hospitals had funds dedicated for emergency care services. A few of the
Hospitals received funds as part for delivery of trauma-care. Of the zones, the Eastern
Zone was the worst afflicted in terms of receipt of funds from Central/ State Government.
On assessing funding for overall hospital services, Ayushman Bharat as the major funding
Scheme (53%) followed by NHM (15%), Other State, Central Government and PSU
Schemes (11% each)
Comparison of various Hospital set-ups
NABH accredited vs non-accredited Hospitals
Overall, NABH accredited Hospitals fared better on all counts that required maintenance
of rigour of quality and services to deliver optimal patient care and functioning of
systems.
Presence of ongoing academic program in Emergency Medicine
Hospitals conducting structured academic programs in the subject of Emergency
Medicine have comprehensive robust systems in place for efficient patient care services
including critical care and definitive care, tackling imminent disasters and continuous
quality improvement.
These systems also ensure effective communication skills amongst care givers and timely
delivery of care, translating into higher patient satisfaction levels.
Secondary Vs Tertiary level Government Hospitals
Secondary level Government Hospitals (District Hospitals) fared better than tertiary level
hospitals (Medical Colleges) in terms of having standard SOPs for management of cases,
mock-drills, regular audits, referral policies and better patient satisfaction responses.
However, most of them needed further strengthening of following services: Blood Bank
facilities and definitive care such as operative procedures and critical care.
Private Vs Government Hospitals
Private Hospitals fared better than the Government Hospitals in terms of having
emergency operative services, mock drills, training programmes, regular audits and
referral policies.
Private Hospitals also ensure effective communication skills amongst care givers and
timely delivery of care, translating into higher patient satisfaction levels. REVIEW OF LITERATUREEmergency and Injury Care at Secondary
and Tertiary Level Centres in India
8
KEY RECOMMENDATIONS
1. Develop a robust integrated emergency care service system which can comprehensively
address all medical. Surgical emergencies inclusive of trauma-related care.
2. Standardize protocols, SOPs for emergency care, inclusive of triage to have a common
optimal nation-wide policy.
3. Strengthen the prevailing pre-hospital services such that a world-class ambulance services
are made available 24*7, encompassing on-going definitive care through effective
paramedics, for all citizens of the country and, these should be optimally integrated
with hospital care with an efficient pre-hospital arrival system using latest Information
Technologies.
4. Create adequate space for emergency care systems at the prevailing health facilities
such that standardized emergency departments with recommended proportion of beds,
infrastructure, equipment, drugs and human resources become a norm.
5. Systems to ensure efficient handling of medical care during disasters need to be ensured
at all hospitals.
6. Expand Blood Bank related services such that even smaller Government Hospitals are
ensured timely availability of on-demand blood and its related products.
7. Upgrade all the prevailing emergency care services to meet the standardized norms,
with efforts made to accredit all the existing emergency departments. All medical
colleges should attain self-sufficiency in providing definitive care for all emergency-
related conditions.
8. Establish Academic Emergency Medicine departments to ensure continuous ongoing
medical education and development of skills for doctors, nurses and paramedics.
9. Create standalone Central/ State level efficient funding mechanisms to ensure continuous
upgradation of emergency related issues at all hospitals, with built-in mechanisms for
periodic assessments to check optimal delivery of services.
10. Develop mechanisms to ensure free treatment for emergency care services for all citizens
covering the minimal required period for early stabilization. SCENETRANSPORTFACILITY
EMERGENCY CARE
SYSTEM FRAMEWORK
All around the world, acutely ill and injured people seek care every day.
Frontline providers manage children and adults with injuries and infec-
tions, heart attacks and strokes, asthma and acute complications of
pregnancy. An integrated approach to early recognition and manage-
ment saves lives. This visual summary illustrates the essential functions
of a responsive emergency care system, and the key human resources,
equipment, and information technologies needed to execute them. The
reverse side adresses elements of governance and oversight.
? BYSTANDER RESPONSE
? DISPATCH
? PROVIDER RESPONSE
? RECEPTION
? EMERGENCY UNIT CARE
? DISPOSITION
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D REVIEW OF LITERATURE02 The emergency care system and facility-based care in India are in its infancy. It suffers from the
fragmentation of services from pre-hospital care to facility-based care both in government as well
as in private sectors. The system also suffers from the lack of trained human resources, finances,
legislation, and regulations governing the system.
The facility-based care in tertiary care lacks trained human resources due to the stunted growth of
academic emergency medicine since its inception. The other allied disciplines such as emergency
nursing and emergency medical technician are yet to take shape. Hence it is important to assess
the existing gaps in facility-based emergency care and the linkages to the emergency care system
in a representative stratified multi-stage random sample of 100 healthcare facilities across India.
The study was a cross-sectional survey across the five regions of the country.
In the survey, a total of 100 healthcare facilities were assessed with the help of a Consensus-based
tool (predesigned pretested data collection tool) for the data collection.
The project aims at country-level assessment of the gaps and linkages in emergency and injury
care at government medical colleges, private hospitals and district hospitals of India. This study
proposes:
1. To describe the burden of emergencies and injuries in the country
2. To identify and describe current gaps and suggest interventions to strengthen the
emergency/injury care (Pre-hospital care, definitive care, referral and rehabilitation
services)
3. Suggesting strategies to strengthen the emergency/injury care at the tertiary center level
4. Identification of prospects on strengthening/ establishing academic Emergency Medicine
at Medical Colleges
The purpose of the report is to identify the gaps in emergency and injury care systems in healthcare
facilities as well as to find out the linkages between the pre-hospital care and facility-based care
system in our country. Based on the findings and outcomes from the study, suitable policies will
be made to strengthen the emergency and injury care at the national level.
INTRODUCTION02
11 REVIEW OF LITERATURE03 03 REVIEW OF
LITERATURE
Emergency care can be defined as the delivery of time-sensitive interventions needed to avert
death and disability and for which delays of hours can worsen prognosis or render care less
effective.
All around the world, acutely ill and injured people seek care every day. Goal of an effective
emergency medical system should be to provide universal emergency care — that is, timely quality
emergency care should be available to all who need it.
However, there are many unfounded myths about emergency medical care, and these are often
used as a rationale for giving it a low priority in the health sector, especially in low- and middle-
income countries. These myths include equating emergency care to ambulances and focusing on
transport alone while neglecting the role of care that can be provided in the community and at
a health-care facility. Perhaps most common is the perception that emergency care is inherently
expensive; this myth focuses attention on the high-technology end of clinical care as opposed to
the strategies that are simple and effective. Efforts to improve emergency care, however, need not
lead to increased costs for many people around the world, emergency care is the primary point
of access to the health system, and is thus, essential to universal health coverage.
As per a study, injuries alone accounted for 14% of the burden of disease among adult in 2002.
It is thus challenging to define the burden of disease addressed by emergency medical systems.
Emergency medical system is a set of diseases encompasses of communicable infections, non-
communicable conditions, obstetrics and injuries. Patients with all these conditions may present
to the emergency medical system either in the acute stages (such as diabetic hypoglycaemia,
septicaemia, premature labour or asthma) or may present with conditions that are acute in their
natural presentation (such as myocardial infarction, acute haemorrhage or injuries)
(1)
.
A recent study showed that all 15 leading causes of death and disability-adjusted life years (DALYs)
globally were the conditions with potential emergent manifestations.
(2)
By ensuring early recognition of acute conditions and timely access to needed care, organized
emergency care systems save lives and amplify the impact of many other parts of the health
system. The World Bank Disease Control Priorities Project estimates that Emergency care system
(ECS) with sound organization, have the potential to address over half of deaths and a third of Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 16
disability in low- and middle-income countries.
(3)
Simple, low-cost interventions to strengthen timely emergency care delivery can have dramatic
impact on clinical outcomes, and well-integrated emergency care has enormous potential to save
lives even with limited input of new material resources.
BURDEN OF EMERGENCY CONDITIONS IN THE SOUTH-EAST
ASIAN REGION
Despite tremendous improvement in health care delivery in the SEAR over recent decades, high
rates of injuries and cardiovascular emergencies, now among the leading causes of death, co-exist
with persistent high rates of infectious disease and maternal and infant mortality in some areas.
Timely, quality emergency care prevents death and disability from all of these conditions, but
ECS are still under-developed in many SEAR countries. 90% of deaths and 84% of DALYs were
attributable to emergency conditions with South-East Asia having the second highest burden of
emergency conditions (Figure1).
Figure 1: DALYs per 100,000 population attributable to emergency conditions, by etiology: separated by income
level (A) and region (B). Distribution of deaths was similar. NCDs, non-communicable diseases; CDs, communicable
diseases; DALYs, disability-adjusted life years
(2)
**Source: Reference (2)
WHO has projected the rise in the burden of various diseases causing death in SEAR in 2015
and 2030 (Table 1).This projection shows a significant decrease in mortality from communicable,
maternal, perinatal and nutritional causes from 25.2% to 16.1%. However, there is a projected
rise in deaths due to non-communicable diseases (NCD) from 63.5% in 2015 to 72.5% in 2030,
which is a cause for concern.
(4) 17
Review of Literature
Table 1: Projections of mortality by cause for 2015 and 2030
(4)
Deaths (thousands) by cause projected to 2015 and 2030 in SEAR
Year20152030
Population (thousands)19207612205146
GHE 2012 cause category Deaths % Total Deaths % Total
All Causes14851 100 18595 100
I.Communicable, maternal, perinatal
and nutritional conditions
3748 25.2 2998 16.1
II.Non-communicable diseases9428 63.5 13472 72.5
A.Cardiovascular diseases 4159 28.0 5872 31.6
B.Respiratory diseases1712 11.5 2561 13.8
C.Malignant neoplasms1412 9.5 2310 12.4
D.Diabetes mellitus434 2.9 690 3.7
III.Injuries1676 11.3 2125 11.4
(Based on the GHE 2012 estimates of causes of death for 2011, the regional projections
of mortality by cause for years 2015 and 2030 were carried out in 2012.
(4)
**Source: Reference (4)
Injuries came at 6
th
in the list of common causes of death and are responsible for 11.3% of all
deaths in SEAR (Table 1). Road injuries are the commonest cause of death in SEAR increasing
from 24.7% to 28.9% from 2015 to 2030, respectively.
(4)
With 90% of deaths occurring in LMICs
which only account for 54% of the world’s vehicles, these deaths and injuries are unevenly
distributed.
(5)
Figure 2 illustrates country-specific road traffic fatality rates. Amongst people 15
to 29 years of age, road traffic injuries are the leading cause of death, and cost governments
approximately 5% of GDP in LMICs. Other notable areas of injuries are falls (18.5%) and self-
harm (19.4%) leading to deaths in SEAR (Table 2)
(4)
.
Figure 2: Road traffic fatalities per 100,000 populations in SEAR
(5)
**Source: Reference (5) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 18
BURDEN IN INDIA
The top five individual causes of disease burden in India were Communicable, maternal, perinatal
and nutritional conditions in 1990, whereas in 2016, three of the top five causes were Non-
communicable diseases(NCDs), showing a shift toward NCDs (Table 2). From 1990 to 2016 the
number of DALYs due to most NCDs increased. The increase in all-age DALYs rate between
1990 and 2016 was highest for diabetes (80·0% [95% UI 71·6–88·5]), ischaemic heart disease
(33·9% [24·7–43·6]), and sense organ diseases (mainly vision and hearing loss disorders; 21·7%
[20·1–23·3]). Of the individual NCDs that are in the top 30 leading causes of DALYs in 2016.
(6)
Table 2: Percentage contribution of disease categories to total deaths
by age groups for all of India, 2016
(6)
Year2016
Population (thousands)1324200
GHE 2012 cause categoryTotal (%)
All Causes100
I.Communicable, maternal, perinatal and nutritional conditions 27.5
II.Non-communicable diseases61.8
A.Cardiovascular diseases28.1
B.Respiratory diseases10.9
C.Malignant neoplasms8.3
D.Diabetes mellitus6.5
III.Injuries10.7
Data are % (95% uncertainty interval).
**Source: Reference (6)
Figure 3: Percent of total DALYs by age groups in India, 2016(6)
**Source: Reference (6)
The higher proportion of the total DALY burden relative to their proportion of the population 19
Review of Literature
was observed in the age groups of younger than 5 years and 45 years or older. The age group
of younger than 5 years group constituted 8.5% of the population and had 17.6% of the DALYs.
The highest proportion of DALYs were in children younger than 5 years (83·4%) attributed to
Communicable, maternal, perinatal and nutritional conditions%), and the lowest was in the
50–54 years age group (14·7%).The proportion of DALYs due to Non-communicable diseases
was highest at 78·8% in the 65–69 years group and exceeded 50% in the 30–34 years group
(Figure 3).The proportion of total DALYs due to injuries was highest in the age groups from 15
years to 39 years(range 18·3–28·1%).
(6)
CURRENT STATUS OF EMERGENCY CARE IN THE INDIA
Emergencies and accidents are common place in all parts of India. Though India is a developing
country, due to rapid economic growth and urbanization, it faces the ills of both an under-
developed as well as developed economy. Every day, India faces the dual challenges posed
by emergencies related to infections and communicable diseases and those related to chronic
diseases and trauma.
Pre-hospital care is being provided by the state government regulated ambulances in many states
by Emergency Management and Research Institute with a common toll-free number 108. The
command centre is however not situated or run by the government or the Emergency Departments.
108 do not provide any pre-hospital notification to the Emergency Departments.
Thus it is a rudimentary form of pre-hospital EMS that exists in India and needs modernization
and integration with the hospitals at state and national level. India also lacks a universal toll
free number and there are more than one numbers that lead to ambulance services for different
emergency conditions.
With more than 150,000 road traffic related deaths, 98.5% ‘ambulance runs’ transporting dead
bodies, 90% of ambulances without any equipment/oxygen, 95% of ambulances having untrained
personnel, most ED doctors having no formal training in EMS, misuse of government ambulances
and 30% mortality due to delay in emergency care, India portrays a mirror image of the U.S. of
the 1960s.
EMS has changed since the time it was commonly stated that, “EMS systems in India are best
described as fragmented.”
(7)
India has two different yet overlapping publicly funded ambulance
systems, with both popularly known by their helpline numbers, 108 and 102. Between them,
they have more than 17,000 ambulances across the union of 31 states and union territories. The
allocated federal fund for the ambulance services in 2013-2014 was $59 million.
(8)
The provision of emergency services is enshrined in India’s Constitution. As per the Article 21 of
India’s Constitution “right to life”, if any hospital fails to provide timely medical treatment to a
person result’s in the violation of person’s “right to life”.
(8)
India always had a disproportionately
small health budget because of its ambitious growth aspiration and fastest growing population,
with one doctor for every 1,700 people and 21% of the world’s burden of disease.
(9)
In India
almost 23% of all trauma is transportation-related, with 13,74 accidents and 400 deaths every day
on roads.
(10)
The rest of the 77.2% of trauma is related to other events such as falls, drowning,
agriculture related, burns, etc.
(11)
According to World Health Organization, India has the highest
snakebite mortality in the world estimates it at 30,000 every year.
(12) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 20
WHO EMERGENCY CARE SYSTEM FRAMEWORK
The WHO info graphics below (Figure 4 a & b) are visual representations of the WHO Emergency
Care System Framework, designed to support policy-makers wishing to assess or strengthen
national emergency care systems. It is the result of global consultations with policy-makers and
emergency care providers across all regions, and provides a reference framework to characterize
system capacity, set planning and funding priorities, and establishes monitoring and evaluation
strategies.
Figure 4a illustrates the essential functions of an effective emergency care system, and the key
human resources, equipment, and information technologies needed to execute them (organized
by health systems building blocks).
Figure 4b info graphic complements this by locating critical governance and oversight elements—
including system protocols, certification and accreditation mechanisms, and key process metrics—
within the Framework. Also identified in the figure are essential overarching laws and regulations
that govern access to emergency care, ensure coordination of system components, and regulate
relationships between patients and providers.
(a) 21
Review of Literature
(b)
Figure 4: WHO Emergency Care System Framework
(13)
**Source: WHO info-graphics
Figure 5: Integrated Model: The roots feeding the Emergency Care System
Patients may
access any level
of care directly Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 22
HOSPITAL BASED EMERGENCY CARE IN THE GOVERNMENT
SECTOR IN INDIA
Definitive care for victims with emergencies is offered by government hospitals, corporate hospitals
and a large number of small clinics. Government hospitals generally offer free care, but the quality
of that care differs between centres. Most university hospitals provide a reasonable level of
emergency care. District hospitals often lack trained staff, adequate infrastructure, and supply of
consumables.
(14)
Triage is rarely practiced. As a result, impressive but non-life-threatening extremity
trauma may take precedence over bacterial meningitis or myocardial infarction.
There are no dedicated trauma surgeons and very few designated trauma centres in India.
Orthopedic surgeons lead the trauma response in 50% of facilities.
(15)
In the remainder; the
responsibility is not clearly defined. In the absence of defined roles amongst specialists, clinical
decisions are often delayed. Multi-system injury patients are at the greatest risk.
Typically, most of the “emergency care” in the hospitals in India is provided in areas known
as Casualty or Accident rooms. Formal education and specialty training in emergency care are
neither available nor mandatory for personnel involved in emergency care. These Causality/
Accident room physicians lack any specific training in emergency medicine.
(14)
Proceedings have
only recently been initiated to recognize Emergency medicine as a distinct medical discipline.
Residents posted in these ‘rooms’ often rotate from various specialties such as surgery, orthopedics,
and medicine and have little commitment towards patient management. These physicians are
often waiting to retake the All India Entrance Examination in the hope of securing postgraduate
position in established fields recognized by the MCI.
(16)
In some hospitals, emergency rooms
(ERs) are traditionally divided into separately run medical and surgical teams. With this division
it becomes very difficult to deliver quality, cost-effective care. In many hospitals, physicians
staffing the emergency rooms lack the resources and knowledge to manage the wide variety of
emergencies. They therefore function as ‘postal carriers’ who ‘deliver ‘victims to the respective
specialties. The most junior and inexperienced staff frequently treat the most seriously injured
patients.
TRAINING
Husum et al. have demonstrated that laypeople trained in first aid can effectively respond to
emergencies in a community within a high trauma burden
(17, 18)
. In hospitals, most in-service
training for emergency care professionals is designed to address particular problems, such as
severe injuries, pediatric emergencies or obstetric emergencies. Yet because of the resource
constraints of low-income countries, the same personnel will be confronted with all of these
conditions. Unfortunately, few courses in emergency care have been rigorously evaluated
(19, 20)
.
The Advanced Trauma Life Support course, a meticulously controlled training course in clinical
skills for doctors that was devised by the American College of Surgeons, has improved patients’
outcomes in some settings, although it may be too expensive for most low- and middle-income
countries, and it is clearly inappropriate for settings where most patients are not seen by doctors.
In a tertiary hospital in Trinidad and Tobago, mortality from injury fell by 50% after doctors
attended this course
(21)
.Training in life-saving obstetric skills was found to contribute towards
reducing maternal deaths in Kebbistate, Nigeria, and in other sites where the intervention was
implemented
(22,23)
. 23
Review of Literature
Emergency Triage Assessment and Treatment (ETAT) training, part of WHO’s Integrated Management
of Childhood Illnesses strategy, has been used in many countries to improve pediatric emergency
care
(24)
. Other examples of training courses are Primary Trauma Care
(25)
, devised by the World
Federation of Societies of Anaesthesiologists, and Advanced Life Support in Obstetrics, devised
by the American Academy of Family Physicians
(26)
.The above courses are used to standardize
protocol-based emergency care but evaluations of their outcomes are still awaited. The National
Trauma Management Course in India
(27)
costs US $50.00 per trainee and is taught by local
trainers. This course has now become a national training standard for immediate trauma care in
India. The courses described above are all examples used to show that even in the absence of
ambulances it is possible to improve emergency medical systems. Low-income countries need to
identify training models that are appropriate for their emergency care personnel, who may need
to take on a variety of roles, especially those working at middle-level facilities, who respond to
different types of emergencies.
ACADEMIC EMERGENCY MEDICINE
Academic emergency medicine is a recognized post-graduate program since 2009. Presently,
more than 28 medical colleges are offering a total of 60 seats, a diplomat of national board (DNB)
offering more than 120 residency seats in Emergency Medicine in a year. This number is highly
inadequate and not enough to cater the needs of even one state of India. Indo-US collaborative
INDUSEM played a major role in shaping the academic emergency medicine in India and now
in SEAR and rest of the world too.
Emergency Medicine (EM) is a new academic discipline in its infancy in India. Dedicated
emergency medicine faculty will be the keys for developing a national skilled emergency care
workforce. A strategy for integrated, coordinated trauma care and injury prevention activities must
be developed in India. Gujarat has become the first state to pass legislation addressing emergency
medical services.
Emergency Medicine (EM) Departments are the front line for the community during a disaster.
A disaster is defined as that time, when the need for staff, supplies and space exceed resources
due to an extraordinary stress on a community, e.g. earthquake, biological outbreak or terrorist
attack. As a result, Disaster Medicine has been, and continues to be, an important focus for
Emergency Medicine. The Emergency Department (ED) is the place to train, set standards for
response, and create a culture of preparedness not only for the Hospital but the community as
well. As the Emergency Department heads the Hospital’s Committee on Disaster Preparedness
by establishing protocols, conducting training, and facilitating exercises, they also create the
opportunity for a good relationship between the hospital administration and the community. This
proactive involvement validates the EM program and creates added value for those involved:
physicians, residents, and students, thus improving better patient care.
(28)
GAPS
Research and Development for Emergency Services
As a neglected topic, emergency medical systems are part of the 10/90 gap in health research
whereby less than 10% of global research investment is spent on problems affecting 90% of the AIMS AND OBJECTIVESEmergency and Injury Care at Secondary
and Tertiary Level Centres in India
24
world’s population
(29)
. A review of the evidence on emergency medical systems as applicable to
low- and middle- income countries reveals many gaps in global knowledge. There is a need to
better understand the epidemiology of conditions that may be addressed by emergency systems
in these countries and to better understand which interventions may address them adequately.
Intervention trials in low- and middle-income countries are research priority in the field of
emergency medical systems. Well-designed, locally appropriate studies that establish effectiveness
are urgently needed, and they should include both those interventions that may be available in
high-income countries and newer interventions. Economic analysis is another area where research
is needed, especially in places where cost and cost–effectiveness information from low- and
middle-income countries is scant
(30)
. These gaps reflect the need for a more systematic analysis
of the areas towards which research investments should be directed in order that systems can be
based on credible evidence.
Organization and financing
An emergency medical system must be sensitive to and meet the needs of the poor. Issues of
access to the system become critical because a lack of money often deters people from using
emergency services. Different means of achieving this financial protection need to be explored,
including community financing
(31, 32)
.As a result, emergencies often lead to financial ruin for poor
families, and the implementation of some sort of financial protection for emergency health care
has not received adequate attention. Such protection would ensure that those with limited finances
are not deterred from using emergency services and that they do not get tipped into extreme
poverty by having to meet costs entirely out of their own pocket Community loan funds to cover
transportation and other requirements for emergencies, especially for obstetrics, have been used
in various setting, especially in Africa.
(33, 34) AIMS AND OBJECTIVES04 2704
AIMS AND OBJECTIVESAIMS AND OBJECTIVES
PRIMARY OBJECTIVE
1. To assess current status of facility based Emergency and Injury care in government
medical colleges & large private hospitals
SECONDARY OBJECTIVE
To assess the following:
1. Burden of emergency conditions including injuries
2. Assess the current status of Emergency and Injury care system linkages
a. Pre-hospital care (including intra-specific referral to ambulance services)
b. Hospital Care (Definitive care)
c. Measures of Academic Emergency medicine departments METHODOLOGY METHODOLOGY05 31
Methodology 05
METHODOLOGYMETHODOLOGY
The study was initially proposed and approved for the assessment of 50 tertiary care centres
(government medical colleges and large private hospitals) and 50 secondary care centres (district
hospitals) of India.
In consultation with NITI Aayog, it was decided that the health facilities to be assessed be
categorized in 5 categories for the study purpose: Medical College more than 500-bed strength
(20), Government hospitals more than 300-bed strength (20), Government hospitals less than
300-bed strength (20), Private hospitals more than 300-bed strength (20) and Private hospitals
less than 300-bed strength (20).
Figure 6: Map showing hospitals (tagged red) selected for this study from different states and different zones Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 32
Selection ofHealthcareFacilities
Finalization ofHealthcareFacilities
Teamformation ofNationalAssessors
Development ofStudyTool
Finalization ofStudyToolthrough
ScientificAdvisoryCommittee
TrainingofAssessors bytele/
video-conference
Field visitacross countryfor
DATACOLLECTION
• Oneyeardatacollection
• Basedonadministrativeinterview
• Basedonfacilityvisit
•Livedatacollectionfor24hours
•Basedonlive observation
•Data collectionofSpecific
Diseases
Categorization**:
A)Hospital-wise
B)Zone-wise
C)NABHAccreditation-wise
DataAnalysis
DraftReport
Figure 7: (a) Flow chart of Methodology
**where applicable
The study was carried out in five regions of India (North, South, East, West, and North-East)
including 29 States and 2 Union Territories, from which a total of 100 private and government
healthcare facilities were randomly selected from each zone.
This cross-section study was undertaken in two phases: 33
Methodology
1. Scientific Advisory Committee (SAC) meeting for the finalization of the tool by the
experts of various health departments
2. Quantitative and qualitative data collection as a pilot testing from two hospitals
Pilot testing was followed by collecting of data from the 100 randomly selected healthcare facilities
by a team of 3 assessors. The assessment was done by conducting administrative interview, facility
visit and live observation of the healthcare facility.
1. Identification of potential healthcare facilities: While selecting the institutions for
assessment, we had discussed with the experts’ group. After a series of meetings and
discussions with the experts’ team, it was decided that there should be no overlapping
of healthcare facilities.
We identified 100 healthcare facilities from five regions of the country and contacted
the respective state health dignitaries to nominate a suitable nodal person for obtaining
information about the healthcare facilities to assess suitability. These healthcare facilities
were visited by the assessors’ team for assessment.
2. Finalization of the sites: We started the formal process of site selection from 20th May
2019. The process of selection took 2 weeks and by 3rd June 2019, the sites were
finalized.
3. Development of study tools, standard operating procedures:
Study tools: The study tool was developed and finalized after SAC meeting and
beta testing. The beta testing was done in two healthcare facilities (AIIMS, New
Delhi and Sri Sayaji General [SSG] Hospital, Gujarat) before the assessment being
conducted at the proposed healthcare facilities. The study tool was divided into
three major categories: lead assessor tool, live observation tool, and emergency
burden tool. These categories were further subdivided into sections: background
information of hospital, hospital services, ED protocol/SOP and guidelines, safety
and security, disaster management, quality improvement, data management system,
financing, physical infrastructure, manpower, equipments and supplies, point of
care lab in ED and hospital, and essential medicines.
Standard operating procedures /manual: The study operational manual for data
collection was developed and acted as a guide.
4. Establishment of governance structure and a project implementation: Scientific
Advisory Committee (SAC) members were identified, which included 22 national
experts from emergency and trauma, public health, research, and epidemiology. They
provided technical guidance in study tool development, protocol development, and
quality assurance.
5. Training of assessors: A tele/video-conference was organized every week to train the
assessors. Based on the received data from sites, the assessors were trained subsequently
for the challenges and the problems/issues faced by the other assessors’ team during
the assessment.
6. Data Collection: Healthcare facilities data were collected by a team of assessors (one
lead assessor and two co-assessors) at each site visit. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 34
a. One Lead assessor (overall in-charge) was responsible for the conduct of survey and
major observations/assessment mainly through local administrator interview, data
source (hospital records) and site/facility visit, etc. He/she acted as a nodal person
for communication with the central project team at JPNATC, AIIMS, New Delhi.
b. Two other Co-Assessors were responsible for emergency department data collection
by live observation (mainly assessing the emergency department processes &
infrastructure [manpower, equipment, supplies, etc.]).
These assessors were trained for this study and were not blinded regarding the purpose
of the study. The assessors were trained with the study tool and assessors training manual
for the assessment of healthcare facilities. Data for the assessment of healthcare facilities
were obtained from face-to-face interviews with key staff at each facility.
The presence of supplies including medications and equipment was assessed through
direct observations. Assessors also checked the inventory of supplies in facilities which
allowed them to do so.
7. Definition and process of Live Data Recording: The assessment done by two Co-
assessors included continuous observation for 24 hours in healthcare facility without
any direct contact with patients admitted in the same premises. The live data recording
done by the Co-assessors was observation of the treatment process and procedures of
patients especially having three conditions: chest pain, stroke and trauma.
The process involved for live data collection (as per the data collection tool) was as
follows:
Arrival of the
patient at
healthcare facility
Final Disposal (Discharge/
referral/ admission to general
ward/ to ICU/to OT/ to Cathlab)
Triage Resuscitation
Relevant
Investigation
Relevant
Consultation
Disposal
Decis ion
8. Data analysis: Data collected from the health-facilities was entered using a Microsoft
Excel-based database. The analysis was done by using SPSS (Statistical Package for the
Social Sciences). The level of analysis for the assessment is the facility, and for overall
analysis it is category of the hospital.
Frequencies were computed for different sections of the study tool such as emergency
equipment, essential medicines and written protocols for the management whereas
median with IQR and minimum, maximum were computed to present the distribution
of continuous variables, for example, doctors per facility.
We had calculated the percentages of all essential equipment and medicines. We
assessed availability of equipments and essential medicines on three different scales:
50% or less (Score-0), 50% to 99% (Score-1), and 100% (Score-2). 35
Methodology
Figure 7b: Overall representation of strategy and procedures of Data Collection 37
Methodology
OBSERVATIONS AND
RESULTS WITH
SUGGESTIONS
06 39
Observations and Results with Suggestions 06
OBSERVATIONS
AND RESULTS WITH
SUGGESTIONS
I. FIELD VISIT: ADMINISTRATIVE INTERVIEW/ONE YEAR DATA
COLLECTION
We are presenting the observations based on the findings from both qualitative and quantitative
components of the assessment research.
1. BACKGROUND INFORMATION OF THE HOSPITALS
Out of 100 hospitals studied, 20 hospitals were medical colleges (more than 500 bedded), 20
hospitals were government hospitals (more than 300 bedded), 20 hospitals were government
hospitals (less than 300 bedded), 20 hospitals were private hospitals (more than 300 bedded) and
20 hospitals were private hospitals (less than 300 bedded).
Out of the 100 hospitals, NABH accredited hospitals were 28. There were only 5 hospitals that had
academic emergency medicine out of all 100 hospitals. Among all the assessed hospitals, 25 were
tertiary care government hospitals, 34 were secondary care (district) hospitals, 1 was secondary
care (trust) hospital and 40 were private hospitals (20 tertiary and 20 secondary care hospitals).
2. AVAILABLE BEDS AT ASSESSED FACILITIES:
The data of hospital bed strength was collected from each hospital such as hospital in-patient
beds and emergency beds separately. Out of 100 hospitals, 32 hospitals had triage beds and
follows triage policy.
The median [IQR] min-max of in-patient beds and emergency beds (the beds assigned for emergency
/ emergency department) for all categories of hospitals is shown in table 3 and represented in
figure 8. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 40
Table 3: Overall Summary of available Beds in Hospitals: Emergency Department
Beds and Inpatient Beds
Categories of
Healthcare Facilities
n
Emergency Department
beds in Hospital
Median [IQR] Min-Max
Total Inpatient beds
in Hospital
Median [IQR] Min-
Max
% of Emergency
Beds out of all
Beds at ED
Medical Colleges
(>500 bed strength)
20
46 [28]
10-210
1233[1147]
252-3500
3%
Govt. Hosp.
(>300 bed strength)
20
17 [25]
2-183
418 [306]
200-1079
4%
Govt. Hosp.
(<300 bed strength)
20
5 [6]
1-22
145 [182]
47-380
4%
Pvt. Hosp.
(>300 bed strength)
19
15 [14]
5-44
467 [196]
150-1000
4%
Pvt. Hosp.
(<300 bed strength)
19
10 [4]
3-15
200 [54]
48-400
5%
*n: number of hospitals which shared data with assessor’s team, IQR: Interquartile range
As mentioned in table 3, the percentage of beds in the emergency department accounted for 3%
of all hospital beds in medical colleges, 4% in government hospitals (>300 beds strength), 4%
in government hospitals (<300 beds strength), 4% in private hospitals (>300 beds strength) and
5% in private hospitals (<300 beds strength).
In medical colleges, maximum number of emergency beds was observed at JIPMER, Pondicherry
(210 beds out of 2137 in-patient beds), while minimum number of emergency beds was observed
at Tomo Riba Institute of Health & Medical Sciences, Papumpare (10 beds out of 252 in-patient
beds).
In government hospitals (>300 beds), maximum number of emergency beds was observed at
Indira Gandhi Government General Hospital, Pondicherry (183 beds out of 626 in-patient beds),
while minimum was observed at District Hospital, Dhamtari (2 beds out of 200 in-patients beds).
In government hospitals (<300 beds), maximum number of emergency beds was observed at
District Hospital, Ganderal (22 beds out of 200 in-patient beds), while minimum was observed at
District Hospital, Bishnupur & District Hospital, Peren both had 1 bed out of 50 in-patients beds). 41
Observations and Results with Suggestions
Figure 8: Overall representation of beds distribution in different categories of hospitals
The majority of hospitals did not have system for triage in their emergency department. Only 32
hospitals of all 100 hospitals had triage systems.
Systems for triage were present at 5 medical colleges (Government General Hospital, Guntur;
AIIMS, Bhopal; Rajiv Gandhi Government General Hospital, Madras Medical College; JIPMER,
Pondicherry and IPGMER & SSKM Hospital), 4 government hospitals more than 300 beds,
14 private hospitals more than 300 beds, 9 private hospitals less than 300 beds and
government hospitals less than 300 beds did not have any system for triage in their
hospital emergency or emergency department.
3. BURDEN OF PATIENTS (OPD AND EMERGENCY)
The annual census of the year 2018 (from 1
st
January 2018 to 31
st
December 2018) was collected
from all the hospitals, which includes number of patients visited in OPD, emergency, number
of medico-legal cases attended in emergency, number of admissions through emergency, etc.
In table 4, summary of patients visited in OPD and emergency at hospitals is reported with median
[IQR] and min-max (figure 9). The annual burden of patients visited in emergency department of
hospitals was calculated by dividing the total number of patients visiting in emergency with the
total number of patients visiting in the hospital (OPD + Emergency) and the median value of
percentage is reported in table. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 42
Table 4: Summary of Patients visited in Emergency and OPD in different Categories
of Hospitals (1
st
Jan 2018 to 31
st
Dec 2018)
Categories of
Healthcare Facilities
Emergency and Injury Care
Patients
OPD Patients
% of ED Patients
out of all
patients visited
in hospital
n
Median [IQR]
Min-Max
n
Median [IQR]
Min-Max
Medical Colleges
(>500 bed strength)
15
119461 [140435]
3560-477845
18
794860 [499481]
146000-3382591
13%
Govt. Hosp.
(>300 bed strength)
17
43001 [118984]
4876-308883
17
435229 [447465]
22000-1463635
14%
Govt. Hosp.
(<300 bed strength)
16
18738
[35140]1560-
227364
18
224897 [145985]
44400-743278
15%
Pvt. Hosp.
(>300 bed strength)
17
20861 [22118]
3676-103524
17
255000 [308000]
28278-749145
9%
Pvt. Hosp.
(<300 bed strength)
11
13800 [4908]
3699-43304
12
94292 [53143]
7188-170938
12%
*n: number of hospitals which shared data with assessor’s team, IQR: Interquartile range
In medical college, the burden of patients in emergency as well as in OPD were maximum at
SMS Medical College & Hospital and minimum at AIIMS, Bhopal (for emergency) and Regional
Institute of Medical Sciences, Imphal (for OPD).
In government hospitals >300 beds, the burden of patients in emergency as well as in OPD
were maximum at Indira Gandhi Government General Hospital, Puducherry and minimum at
District Hospital, Dhamtari (for emergency) and Southern Railways Hospital, Chennai (for OPD).
In government hospitals <300 beds, the burden of patients in emergency were maximum at Puri
District Headquarter Hospital and minimum at Sadar Hospital, Gaya; the burden of patients in
OPD was maximum at Government BDM Hospital, Kotputli and minimum at District Hospital,
Bishnupur, Manipur.
In private hospitals >300 beds, the burden of patients in emergency as well as in OPD were
maximum at Dr Ram Manohar Lohia Hospital, Lucknow and minimum at GNRC, Guwahati,
Assam. In private hospitals <300 beds, the burden of patients in emergency as well as in OPD
were maximum at Ramakrishna Mission Hospital, Arunachal Pradesh and minimum at Medeor
Hospital, Manesar.
The annual burden of patients who presented as emergency case, out of all patients visited the
hospital for the year 2018 were: 13% in medical colleges, 14% in government hospitals with more
than 300 beds, 15% in government hospitals with less than 300 beds, 9% in private hospitals
with more than 300 beds and 12% in private hospitals with less than 300 beds. 43
Observations and Results with Suggestions
Figure 9: Comparison of Patients visited in OPD and Emergency in different Categories of Hospitals
(1
st
Jan 2018 to 31
st
Dec 2018)
*M. C.- Medical College, G. H.- Government Hospital, P. H.- Private Hospital, OPD- Out-patient Department
Data maintained regarding adult/pediatric patients were heterogenous across the studied hospitals.
Only 43 hospitals maintained OPD data of adult patients and 37 hospitals maintained data of
pediatric patients. Similarly, 36 hospitals maintained ED data of adult patients and 28 hospitals
maintained data of pediatric patients respectively.
In table 5, separate adult and pediatric patient’s data for OPD and emergency is reported with
median [IQR] and min-max. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 44
Table 5: Summary of Patients visited in OPD and Emergency (Adult and Pediatric)
in different Categories of Hospitals (1st Jan 2018 to 31st Dec 2018)
Categories of
Healthcare
Facilities
Emergency and Injury care PatientsOPD Patients
Adult Pediatric AdultPediatric
n
Median [IQR]
Min-Max
n
Median [IQR]
Min-Max
n
Median [IQR]
Min-Max
n
Median [IQR]
Min-Max
Medical
Colleges
(>500 bed
strength)
9
80418
[141265]
11961-
347264
6
21849
[18019]
6429-130581
11
737333
[694550]
220097-
2937193
10
61418
[37814]
8900-445398
Govt. Hosp.
(>300 bed
strength)
10
23671
[12983]
7495-281011
9
3650 [25872]
461-30204
10
384335
[194085]
21000-1388295
9
46812
[41308]
1000-127688
Govt. Hosp.
(<300 bed
strength)
6
11809
[41883]
836-150007
5
687 [550]
311-22688
7
149737
[129722]
5889-586632
6
23035
[19350]
1479-96725
Pvt. Hosp.
(>300 bed
strength)
7
14326
[18854]
3667-32304
6
2201 [3899]
225-13378
9
220631
[331418]
28278-872227
7
33106
[27192]
9293-52612
Pvt. Hosp.
(<300 bed
strength)
4
7555 [2234]
4800-8778
2
763 [248]
515-1011
6
67096 [19035]
30000-150534
5
10908
[11471]
3285-30431
*n: number of hospitals which shared data with assessor’s team, IQR: Interquartile range
In addition, the definition for pediatric age group also varied among the assessed hospitals. Out of
100 hospitals, 28 hospitals were following 0-12 years age for pediatric patients, 20 hospitals were
following 0-14 years age, 10 hospitals were following 0-15 years age, 1 was following 0-16 years
age, 11 were following 0-18 years age, and 30 hospitals did not have the details for the same.
4. HUGE MISMATCH BETWEEN EMERGENCY BEDS & BURDEN OF
EMERGENCY AND INJURY CASES:
Table 6 depicts the gap between the emergency beds and burden of patients in emergency, it is
clear that there is a huge mismatch between emergency beds and burden of emergency cases. 45
Observations and Results with Suggestions
Table 6: Huge Mismatch between Emergency Beds & Burden of Emergency and
Injury Cases
Hospital Categories
% of Emergency and
injury cases
(One Year)
% of Emergency and
injury cases
(One Day)
% of Available
Emergency Beds
Medical Colleges13%17%3%
Govt. Hosp.
(>300 bed strength)
14%11%4%
Govt. Hosp.
(<300 bed strength)
15%11%4%
Pvt. Hosp.
(>300 bed strength)
9%10%4%
Pvt. Hosp.
(<300 bed strength)
12%30%5%
Different categories of hospitals have only 3-5% available emergency beds while the yearly burden
of patients’ ranges from 9 to 15%, which is much more than the available beds. It may be because
the resources available in the healthcare facilities are either underutilized or over-utilized. By the
above observation, it is clear that the optimum utilization of resources is missing in the hospitals.
The burden of emergency cases at medical college was high compared to both district hospitals
and private hospitals. It may be because people are not utilizing secondary care hospitals due to
lack of quality of care (lack of facilities present in district hospitals when compared to medical
colleges).
About 65.9% populations belongs to rural areas (according to the World Bank collection of
development indicators in 2018), most of the rural population cannot afford private hospitals
due to high expenses.
As per current MCI guidelines, 35 emergency beds should be available in 500 bedded medical
college i.e., 7% emergency beds. Table 8 A depicts the recommended number of beds per
category of healthcare facility
1. For MBBS & PG Programme: To start PG programme, 7% emergency beds (below table) are
sufficient, but to provide the quality emergency services this bed strength is less.
Table 7: Beds per centre as per MCI
No. Of UG
student
intake
Minimum
Total beds
ICU
beds
“Red”
category
beds/
Trolleys
“Yellow”
category Beds/
Trolleys
“Green”
category
beds/Trolleys
Triage beds/
Trolleys (other
than total beds/
trolley)
50 30 6 4 1553
100 35 7 5 1673
150 40 8 6 1884
200 45 9 7 2094
>200
50 or
above
10 8 22 10 5 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 46
2. For optimal care/services: To provide optimal emergency care services, we need to increase
the number of emergency beds to 12% of all beds with addition of 10% as buffer beds
based on footfall. Secondly, needs to be developed cashless for emergency care and thirdly,
to provide quality of care as per the existing and expected footfall we need to strengthen
district hospitals by-
Upgrading them to medical college
Developing residency programme in DNB: where in PG residents rotate regularly at
district hospitals
Initiate programme based in centivization of government hospitals
3. Upgradation of medical colleges and district hospitals to cater the existing and expected
footfall to provide quality service.
DNB (Diplomate of National Board) Emergency Medicine Criteria: The hospital should be
200 bedded with 50 patients per day in emergency (Assumption- By developing residency
programme, the footfall of patients will increase).
*Note: Emergency Beds: The beds assigned for emergency department.
Buffer Beds: The beds under department of emergency for addressing surge capacity including ICU facility and it should
have separate beds for disaster.
5. BURDEN OF MEDICO-LEGAL CASES
Table 8 summarizes the annual number of medico-legal cases attended in emergency of different
categories of hospitals with median [IQR] and min-max. The annual burden of medico-legal cases
attended at hospitals emergency was calculated by dividing the total number of medico-legal
cases attended at emergency with the total number of patients visiting in the emergency and the
median value of percentage is depicted. 47
Observations and Results with Suggestions
Table 8: Summary of Medico-legal cases attended at Emergency of different
Categories of Hospitals
Hospital Categories
Medico-legal Cases
% of MLC = Total MLC/
Total Emergency Pts.
n
Median [IQR]
Min-Max
Medical Colleges 13
15473 [16719]
216-91354
8.7%
Govt. Hosp.
(>300 bed strength)
18
2108 [4975]
87-23728
3%
Govt. Hosp.
(<300 bed strength)
15
1230 [1598]
236-10049
6.4%
Pvt. Hosp.
(>300 bed strength)
14
794 [1449]
257-2986
3.6%
Pvt. Hosp.
(<300 bed strength)
13
498 [927]
71-1500
2.5%
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range, MLC: Medico-legal cases
In medical colleges, maximum medico-legal cases in emergency were at Patna Medical College
& Hospital and minimum at New STNM Hospital, Sikkim.
In government hospital >300 beds, maximum medico-legal cases in emergency were at District
Hospital, Karim Nagar, Telangana and minimum at AIIMS, Patna.
In government hospital <300 beds, maximum medico-legal cases in emergency were at North
Goa District Hospital, Goa and minimum at District Hospital, Ganderbal.
In private hospital >300 beds, maximum medico-legal cases in emergency were at Dr Ram
Manohar Lohia Hospital, Lucknow and minimum at Cosmopolitan Hospitals Private Limited,
Kerala.
In private hospital <300 beds, maximum medico-legal cases in emergency were at Ruby General
Hospital, West Bengal and minimum at G G Hospital, Kerala.
Majority of district hospitals make more MLC’s when compared to medical college and private
hospitals. In district hospitals a dedicated CMO (Chief Medical Officer) is present, who makes
MLC cases. Preparation of MLC reports adds to the existing mandate of providing quality acute
care service by the emergency care provider.
Burden of Medico-legal cases on Emergency Department ranging between 2%-9%.
Suggestions for MLC:
These findings suggest higher burden of MLC’s at government hospitals. Amongst government
hospitals, the load is highest at medical colleges. Private hospital seems to have a disproportionally
lean load of MLC. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 48
Suggestions to improve MLC related services; the following are suggested:
1. Ensure equitable distribution for MLC related services among both government and
private sector.
2. Dedicated EMO (Emergency Medical Officer) / Senior Resident (Forensic Medicine) to
deal with MLC documentation and representation to court.
3. Develop cadre of Forensic Nursing and post them in the emergency for round the clock
frontline medico-legal service.
4. Station an in-house police post for mitigating plausible violence and protection of
emergency care provider. This would aid in better co-ordination of MLC documentation
and legal service.
6. BURDEN OF ADMISSIONS THROUGH EMERGENCY
In addition, table 9 summarizes the annual number of admissions through emergency at different
categories of hospitals.
The annual burden of admissions through hospital emergency department was calculated by
dividing the total number of admissions through ED with the total number of patients visiting in
emergency department.
Table 9: Summary of Admissions through Emergency Department at different
Categories of Hospitals
Hospital Categories
Admissions through Emergency
% of patients
admitted of those
visiting EDn
Median [IQR]
Min-Max
Medical Colleges14
31487 [23267]
552-80315
22.2%
Govt. Hosp.
(>300 bed strength)
15
6591 [13936]
373-55293
19.4%
Govt. Hosp.
(<300 bed strength)
12
1269 [4969]
147-227364
23.8%
Pvt. Hosp.
(>300 bed strength)
16
9877 [6749]
195-31899
31%
Pvt. Hosp.
(<300 bed strength)
14
4020 [4721]
1236-9834
39%
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range, ED: Emergency department
In medical college, maximum number of admissions through emergency was at Government
Medical College, Thiruvananthapuram and minimum at AIIMS, Bhopal.
In government hospital >300 beds, maximum admissions through emergency was at District
Hospital, Karim Nagar, Telangana and minimum at Deen Dayal Upadhyay Hospital, Himachal
Pradesh. 49
Observations and Results with Suggestions
In government hospital <300 beds, maximum admissions through emergency was at Puri District
Headquarter Hospital, Orissa and minimum at Morigaon Civil Hospital, Assam.
In private hospital >300 beds, maximum admissions through emergency was at Dr Ram Manohar
Lohia Hospital, Lucknow and minimum at Central referral Hospital, Sikkim.
In private hospital <300 beds, maximum admissions through emergency was at Jaipur Golden
Hospital, Delhi and minimum at Ruban Memorial Hospital, Bihar.
Admissions through emergency
Government Hospitals - 19% to 24%
Private Hospitals - 31% to 39%
Suggestions:
The number of admissions through emergency was high in district hospitals>300 beds than
medical colleges but they have less number of emergency beds to cater the existing footfall.
1. NABH Accreditation
2. District hospitals admits more patients in emergency than medical college, so
Upgrade them into medical college
Develop residency programme for emergency medicine
7. BURDEN OF DEATH OF TRAUMA PATIENTS
Table 10 depicts the annual number of death of trauma patients in emergency of different
categories of hospitals. It was compared with the total number of trauma patients (one day)
visited in emergency of all hospitals.
Table 10: Summary of Death of Trauma Cases in Emergency by Categories of Hospitals
Categories of Healthcare
Facilities
Death of Trauma Patients
(ONE YEAR)
Number of Trauma Patients visited in
Emergency (ONE DAY)
n
Median [IQR]
Min-Max
n
Total Pts
in one day
Median [IQR]
Min-Max
Medical Colleges
(>500 bed strength)
11 266 [1172]
40-8067
15 599 18 [25]
1-210
Govt. Hosp.
(>300 bed strength)
8 12 [35]
1-234
18 175 5 [11]
1-45
Govt. Hosp.
(<300 bed strength)
9 8 [23]
1-66
19 130 5 [6]
1-40
Pvt. Hosp.
(>300 bed strength)
9 14 [26]
2-206
18 143 3 [10]
1-35
Pvt. Hosp.
(<300 bed strength)
7 3 [37]
2-797
17 60 3 [4]
1-20
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 50
Death of trauma patients was high in medical college when compared to other categories of
hospitals. It may be assumed that the death of trauma patients was due to delay in definitive care
(beyond Golden Hour) and due to lack of trained human resources in emergency department.
Suggestion:
Develop a robust integrated emergency care system which includes injuries
8. BURDEN OF PATIENT’S DEATH DUE TO ROAD TRAFFIC INJURY
Table 11 depicts the annual number of patient’s death due to road traffic injury in emergency of
different hospital categories.
Table 11: Summary of Patient’s Death due to Road Traffic Injury by Categories of
Hospitals
Categories of Healthcare
Facilities
Patient’s Death due to Road Traffic Injury
n
Median [IQR]
Min-Max
Medical Colleges
(>500 bed strength)
8
171 [527]
1-1013
Govt. Hosp.
(>300 bed strength)
10
21 [81]
1-1042
Govt. Hosp.
(<300 bed strength)
5
11 [26]
11-37
Pvt. Hosp.
(>300 bed strength)
10
6 [19]
1-703
Pvt. Hosp.
(<300 bed strength)
7
6 [63]
2-324
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range
It may be assumed that the patients of road traffic injury died due to lack of pre-hospital care,
lack of injury prevention and may be they are non-salvageable.
9. BURDEN OF BROUGHT DEAD PATIENTS
Table 12 summarizes the annual number of brought dead patients in emergency of different
hospital categories with median [IQR] and min-max. 51
Observations and Results with Suggestions
Table 12: Summary of Brought Dead Patients in Emergency by
Different Category of Hospitals
Categories of Healthcare
Facilities
Brought Dead Patients
n
Median [IQR]
Min-Max
Medical Colleges
(>500 bed strength)
7
204 [137]
3-618
Govt. Hosp.
(>300 bed strength)
11
129 [170]
23-708
Govt. Hosp.
(<300 bed strength)
8
23 [24]
3-159
Pvt. Hosp.
(>300 bed strength)
11
70 [105]
5-733
Pvt. Hosp.
(<300 bed strength)
8
25 [91]
1-165
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range
It may be assumed that brought dead patients came to hospitals due to:
1. Failure to recognize, resuscitate and refer of sick patients either by bystander or
paramedic.
2. Probable non-salvageable patients.
Suggestions:
1. Develop and strengthen preventive emergency healthcare strategy such as National
Injury Prevention Programme
2. Develop a robust pre-hospital emergency care system including community
participation.
3. There should be installation of AED (Automated external Defibrillator) as a public access
device especially in mass gathering areas such as schools, shopping mall, railway station,
airport, religious gathering areas etc.
4. Implement good Samaritan law for all emergency conditions including injuries across
the country
10. BLOOD BANK SERVICES
Table 13 summarizes the hospital blood bank services for all categories of hospitals. As per the Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 52
assessment, 69 hospitals out of 100 had licensed in-house blood bank, out of which 66 hospitals
ran 24 X 7 services.
It was observed that 34 hospitals had a tie-up with an external blood bank facility, 57 hospitals
had separate component facility for packed cell (RBC), FFP, Platelet Cryoprecipitate, 57 hospitals
had availability of O- (Negative) blood in their hospitals (figure 10).
A. Hospital-wise comparison
It was observed that out of 20 medical colleges 18 had 24*7 blood bank service available in
hospital but one medical college (Tomo Riba Institute of Health & Medical Sciences, Papumpare)
did not have 24*7 blood bank facility while one medical college (B J Medical College & Sassoon
General Hospital, Pune) did not have in-house blood bank available but it had tie-up with other
blood bank.
Table 13: Summary of Hospital Blood Bank Services by Categories of Hospitals
Hospital Blood
Bank Services
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
FCPCNCFCPCNCFCPCNCFCPCNCFCPCNC
Licensed in-house
Blood Bank
181 1143 3 7 5 8170 2131 6
24*7 Blood Bank 181 1143 2 7 1 5170 2131 6
Tie up with
external blood
bank
7 1 2 6 4 1 6 3 4 6 0 5 9 3 3
Separate
Component
Facilities
161 2 6 6 6 6 2 8161 3131 6
O Negative Blood
Availability
172 1115 3 7 6 4153 2 7 4 9
ED Blood Storage4 1141 2175 3 9 4 1156 014
ED Blood
Transfusion
Protocol
6 0133 1153 213102 8101 9
Massive Blood
Transfusion
Protocol
7 0132 1164 1139 0118 012
**FC: Full Compliance, PC: Partial Compliance, NC: Non-Compliance, ED: Emergency department
Out of 100 hospitals, 11 hospitals (Christian Institute of Health Sciences & Research, Dimapur;
District Hospital, Ganderbal; District Hospital Bishnupur; Shija Hospital & Research Institute,
Imphal; Birla CK Hospital, Jaipur; Fortis Hospital, Jaipur; Civil Hospital, Sec-22, Chandigarh; Bhopal
Fracture Hospital, Bhopal; Sadar Hospital, Gaya; Paras HMRI Hospital, Bihar and Coronation
Hospital, Dehradun)were found which neither has in-house licensed blood bank nor has any
tie-up with external blood bank facility. 53
Observations and Results with Suggestions
Figure 10: Comparison of Hospital Blood Bank Services in Hospital Categories
The blood bank is under construction in Christian Institute of Health Sciences & Research,
Dimapur and District Hospital Bishnupur, while District Hospital, Ganderbal has only blood
storage. District Hospital, Dhamtari reported shortage of staff for blood bank.
**Blood Bank in the ED
It was observed that the majority of hospitals did not have facilities for storage of blood at ED.
Only 20 hospitals {10 government hospitals [6 district hospitals and 4 medical colleges], 10
private hospitals} had separate blood storage for ED.
Most of the hospitals did not have protocols for massive blood transfusion and ED blood transfusion
(Figure 10). Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 54
Best Practices for Blood Bank Services:
!In the 300-500 bedded government hospital category–District Hospital Baramulla,
Jammu & Kashmir had 24x7 blood bank availability and also had separate ED blood
storage with separate component facility.
!In the 100-300 bedded private hospital category- North Goa District Hospital had 24x7
blood bank availability and also had separate ED blood storage with separate component
facility.
6 district hospitals had separate blood storage
for ED:
District Hospital, Baramulla, J &K
District Hospital, Virajpet, Karnataka
Singtam District Hospital, Sikkim
District Hospital, King koti, Telangana
BDM District Hospital, Kotputli, Rajasthan
North Goa District Hospital, Goa
Only 4 medical colleges had separate blood
storage for ED:
B J Medical College, Pune
SMS Medical College & Hospital, Rajasthan
Patna Medical College & Hospital, Bihar
IPGMER & SSKM Hospital
Suggestions:
1. Blood bank services for 24*7 at all hospitals.
2. Blood storage facilities in the ED should be made mandatory for those medical college
and district hospitals (>300 beds) which deals with high volume major trauma cases,
emergency conditions requiring lifesaving blood transfusion services (e.g Massive upper/
lower gastrointestinal bleed, Massive hemoptysis, severe anaemia). 55
Observations and Results with Suggestions
B. Zone-wise comparison:
Table 14 and figure 11 summarizes the blood bank services for hospitals in different zones of India.
Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 56
Figure 11: Zone-wise Comparison of Hospital Blood Bank Services
It was observed that 5 hospitals in north zone neither had blood bank facility in hospital nor had
any tie-up with other blood bank. Similarly, 2 hospitals in east zone and 4 hospitals in north
east neither had blood bank facility in hospital nor had any tie-up with other blood bank. The
assessed hospitals of south zone and west zone had 24*7 available blood bank facilities either
in their hospital or had some tie-up with another blood bank facility.
Table 14: Zone-wise Summary of Hospital Blood Bank Services
Hospital Blood Bank
Services
North (n=30)South (n=21)East (n=11)West (n= 16)
North East
(n=22)
NCPCFCNCPCFCNCPCFCNCPCFCNCPCFC
Licensed in-house
Blood Bank
4323401642541114413
24*7 Blood Bank 3026311521622106313
Tie up with external
blood bank
6312416114033438
Separate Component
Facilities
831732153244298210
O-ve Blood
Availability
661822161534297410
ED Blood Storage 221713244239332002
ED Blood
Transfusion Protocol
1811010184247261813
Massive Blood
Transfusion Protocol
191911187038161903
**FC: Full Compliance, PC: Partial Compliance, NC: Non-Compliance, ED: Emergency Department 57
Observations and Results with Suggestions
11. DEFINITIVE CARE SERVICES
Definitive care is the care that is rendered conclusively to manage patient’s condition, encompassing
the full range of preventive, curative acute, convalescent, restorative, and rehabilitative medical
care.
In this study the following categories were assessed: emergency operative services, intensive care
unit services and specialized care services.
i. Emergency Operative Services:
It was observed that 53% hospitals had emergency operative services for trauma patients, 58%
hospitals had emergency operative services for non-trauma patients, 57% hospitals had emergency
operative services for obstetrics patients, 61% hospitals had emergency operative services for
orthopedic patients, and 47% hospitals had emergency operative services for neurosurgical
patients (table 15 and figure 12).
In addition, only 14 medical colleges had emergency operative services for trauma patients, 5
medical colleges showed partial compliance while one medical college (New STNM Hospital,
Sikkim) did not had emergency operative services for trauma patients. Also, 4 medical colleges
(Guru Nanak Dev Hospital, GMC, TRIHMS, New STNM Hospital and Patna Medical College)
did not have emergency operative services for neurosurgical patients.
Table 15: Overall Summary of Emergency Operative Services by Hospital Category
Emergency
Operative
Services
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt.hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
For Trauma
pts
14 5 17 9 31 8 1114 6 017 3 0
For Non-
Trauma pts
14 6 010 7 22 8 1014 6 018 2 0
For Obstetrics
pts
14 2 010 6 37 10 312 6 114 3 1
For
Orthopedic
pts
15 4 09 6 44 7 815 5 018 1 1
For
Neurosurgical
pts
13 2 44 3 100 3 1614 3 216 2 1
*n: total number of assessed hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 58
Figure 12: Comparison of Hospital Emergency Operative Services in Hospital Categories
ii. Critical Care Services
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit
(ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that
provides intensive treatment medicine.
Table 16: Overall Summary of Critical Care Services by Hospital Category
Definitive
Care Services
Medical
Colleges
(n=20)
Govt. Hospitals
(>300 bed
strength)
(n=20)
Govt. Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Common ICU 13 4 311 4 41 5 1416 3 117 3 0
Common
HDU
5 4 115 4 80 2 1814 3 214 2 3
Pediatric ICU14 1 34 5 90 2 1811 3 48 2 6
Neonatal ICU13 2 36 5 74 5 1112 3 312 3 2
Neurosurgical
ICU
8 3 74 1 110 0 1912 3 48 5 5
Cardiac ICU10 1 74 3 90 0 1915 2 215 1 2
*n: total number of hospitals, ICU: Intensive Care Unit, HDU: High Dependency Unit 59
Observations and Results with Suggestions
In this study, different types of ICUs were assessed. It was observed that majority of hospitals did
not had any common ICU as well as specialized types of ICU in their hospitals. A total of 58%
hospitals had common ICU, 38% had common HDU (High Dependency Unit), 37% hospitals
had pediatric ICU, 47% hospitals had neonatal ICU, only 32% hospitals had neurosurgery ICU,
and 44% hospitals had cardiac ICU were observed (table 16 and figure 13).
Figure 13: Comparison of Hospital Critical Care Services by Category of Hospital
It was observed that 20 out of 3 medical colleges (TRIHMS, Sher-i-kashmir Institute of medical
Sciences and Patna medical College) did not have common ICU. 3 medical colleges (Guru
Nanak Dev Hospital, GMC, TRIHMS, and New STNM Hospital) did not have pediatric ICU and
3 medical colleges (Sher-i-kashmir Institute of medical Sciences, New STNM Hospital and IGMC,
Shimla) did not have neonatal ICU.
iii. Specialized Care Services
Other than ICU, hospitals have some specialized care services, which were also assessed. It was
observed that 43% hospitals had cardiac cath lab, 28% hospitals had intervention radiology,
only 17% hospitals had intervention neuroradiology service with DSA, 26% hospitals had facility
for emergency CABG services, and only 18% hospitals had facility for radiofrequency ablation
services (table 17 and figure 14). Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 60
Figure 14: Comparison of Hospital Specialized Care Services by Category of Hospitals
Table 17: Overall Summary of Specialized Care Services by Hospital Category
Specialized Care
Services
Medical
Colleges
(n=20)
Govt.
Hospitals
(>300 bed
strength)
(n=20)
Govt.
Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Cardiac Cath Lab11 1 64 3 90 01914 3 214 22
Intervention
Radiology
9 2 71 4100 2178 4 610 44
Intervention
Neuro Radiology
with DSA
4 6 81 3110 0187 4 85 67
Facility for
Emergency
CABG Service
4 3112 3100 0189 5 511 43
Facility for
Radiofrequency
Ablation Service
5 0120 2120 0187 4 86 4 7
*n: total number of assessed hospitals 61
Observations and Results with Suggestions
Best Practices for Specialized Care Services at Hospitals
Cardiac Cath Lab:
1. Dr Shyam Prasad Mukharji Civil Hospital, Lucknow
2. Indira Gandhi General Hospital, Puducherry
3. Southern Railway Hospital, Chennai
4. District Hospital, Tenali*
Intervention Radiology*:
1. District Hospital, Baramulla
2. Puri District Hospital, Odisha
3. Indira Gandhi General Hospital, Puducherry
Intervention Neuroradiology service with DSA:
1. Indira Gandhi General Hospital, Puducherry*
Facility for Emergency CABG services:
1. District Hospital, Tenali
2. Southern Railway Hospital, Chennai
3. Indira Gandhi General Hospital, Puducherry*
*Facilities were present but not available for 24 hours due to lack of staff and equipments
Best Practices for Overall Definitive Care Services:
Overall the following hospitals had all compliance for defined definitive care
services, best practices were observed in Grant Medical Foundation Ruby Hall
Clinic, Shija Hospital & Research Institute, Manipal Hospital, Max Super Speciality
hospital, Ramakrishna Care Hospital and Primus Super Speciality hospital.
These hospitals had all types of emergency operative services, all types of ICU and
every specialized care services were observed in the above mentioned hospitals.
Suggestions:
1. Medical colleges should have all types of emergency operative, critical care and
specialized care services for 24*7.
2. District hospitals >300 beds should have trauma, non-trauma operative services, general
ICU (Intensive Care Unit), HDU (High Dependency Unit), NICU (Neonatal ICU) and
PICU (Pediatric ICU).
3. District hospitals <300 beds should have general operative services, general ICU
(Intensive Care Unit) / HDU (High Dependency Unit) and NICU (Neonatal ICU).
District hospitals may be upgraded into multi-speciality hospitals to improve the quality
of care. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 62
12. AMBULANCE SERVICES
12.1 Available ambulances in hospitals
A. Hospital-wise comparison:
A total of 378 ambulances were recorded in 100 hospitals, out of which 315 were functional,
31 were non-functional and the data of 32 ambulances were not known.
Out of the 315 functional ambulances, 148 ambulances were ALS (Advanced Life Support), 97
ambulances were BLS (Basic life Support), and 70 ambulances were neither ALS nor BLS (other
transport vehicles).
Table 18: Summary of available Ambulances by Hospital Category
Ambulance
Services
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
Total Ambulances 119 56 54 91 58
Functional 86 (72%) 37 (66%) 47 (87%) 91 (100%) 54 (93%)
ALS38 (44%) 21 (57%) 17 (36%) 40 (44%) 32 (59%)
BLS24 (28%) 6 (16%) 6 (13%) 45 (49%) 16 (30%)
Other Transport
Vehicles
24 (28%) 10 (27%) 24 (51%) 6 (7%) 6 (11%)
Non-Functional 16 (13%) 5 (9%) 7 (13%) 0 (0%) 3 (5%)
Data Not Known 17 (14%) 14 (25%) 0 (0%) 0 (0%) 1 (2%)
*n: number of assessed hospitals, ALS: Advanced Life Support, BLS: Basic Life Support
Figure 15: Representation of available Ambulances Status by Category of Hospitals 63
Observations and Results with Suggestions
Figure 16: Representation of types of Ambulances by Category of Hospitals
It was observed that ~48% of the ambulances were ALS of all the functional ambulances in
every category of hospital, and only 10% patients (red triaged patients) require ALS ambulances.
B. Zone-wise comparison
A total of 136 ambulances were found in north zone (n= 30), 82 ambulances were found in
south zone (n=21), 31 ambulances were found in east zone (n=11), 64 ambulances were found
in west zone (n=16), and 65 ambulances were found in north-east zone (n=22) of India (table
19 and figure 17, 18).
Table 19: Zone-wise Summary of available Ambulances in Hospitals
Hospital Ambulance
Services
North
(n=30)
South
(n=21)
East
(n=11)
West
(n=16)
North East
(n=22)
Total Ambulances 136 82 31 64 65
Functional103 (76%) 69 (84%) 29 (94%) 55 (86%) 59 (91%)
ALS33 (24%) 39 (48%) 17 (55%) 34 (53%) 25 (38%)
BLS35 (26%) 25 (30%) 8 (26%) 18 (28%) 11 (17%)
Other Transport
Vehicles
68 (50%) 18 (22%) 6 (19%) 12 (19%) 29 (45%)
Non-Functional6 (4%) 9 (13%) 2(7%) 9 (16%) 5 (8%)
Data Not Known27 (20%) 4 (5%) 0 (0%) 0 (0%) 1 (2%)
Good Practice by using Bike Ambulance
It was found that Max Super Speciality Hospital, Chandigarh has 2 functional bike ambulances
which were used for patient transport. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 64
Figure 17: Zone-wise Comparison of available Ambulances in Hospitals
Figure 18: Zone-wise Comparison of types of Ambulances in Hospitals
C. NABH Accreditation-wise comparison:
Table 20 and figure 19summarizes the number of ambulances on the basis of hospitals with
NABH accreditation and hospitals without NABH accreditation.
Figure 19: Comparison of available Ambulances with their types in NABH Accredited Hospitals and Non-NABH
Accredited Hospitals 65
Observations and Results with Suggestions
Table 20: Summary of available Ambulances in NABH accredited and non-NABH
Accredited Hospitals
Hospital Ambulance Services
NABH Accredited Hospitals
(n=28)
Non-NABH Accredited Hospitals
(n=72)
Total Ambulances121 32% 257 68%
Functional118 98% 197 77%
ALS59 49% 89 35%
BLS54 45% 43 17%
Other Transport Vehicles 87% 125 49%
Non-Functional32%28 11%
Data Not Known00%32 12%
*n: number of hospitals
Suggestions:
!As per MCI, number of in-hospital ambulances according to bed strength:
1. For > 300 beds, 1 ambulance should be present
2. For > 500 beds, 2 ambulances should be present
!The in-hospital ambulances should be optimally utilized in the common resource pool of
EMS (Emergency medical Service) of the region as per requirement.
!Regular maintenance of ambulances should be done.
!The ALS ambulances can be used for mobile stroke unit as well as for STEMI programme.
12.2 Hospital Ambulance Services
It was observed that out of 100 hospitals, 91 had in-house ambulances. Only 18% hospitals get
a pre-hospital notification of ambulance arrival at the hospital. Trained paramedics were available
in 34% hospitals.
Mobile stroke unit was available in only 4% hospitals and Tele stroke/STEMI (ST-segment elevation
myocardial infarction) was available in 19% hospitals. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 66
Figure 20: Comparison of Ambulance Services by Category of Hospitals
Table 21: Summary of Hospital Ambulance Services by Category of Hospitals
Ambulance
Services
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Ambulances in
Hospital
170 3170 1190 119 0 019 0 1
Pre Hospital
Notification
1 5130 3162 5139 4 66 6 8
Trained
Paramedics for
Ambulances
6 4100 7132 51312 4 314 2 4
Mobile Stroke
Unit
1 0190 1180 0201 0 182 1 16
Tele Medicine
Facility
7 1113 2152 1163 2 134 015
*n=number of hospitals 67
Observations and Results with Suggestions
12.3 Use of Ambulances by Hospitals
It was observed that mostly hospitals used the ambulances for inter-transfer of patients to other
hospitals,while a few number of ambulances used the ambulances to drop the patient (figure 21).
Figure 21: Overall representation of use of Ambulances by Hospitals
12.4 Patient transfer in absence of hospital ambulance:
It was found that in absence of hospital ambulance patient transfer takes place by private
ambulances in most hospitals, sometimes patient have to go by their own vehicles and sometimes
it takes place by 108 or 102 ambulances (figure 22).
Figure 22: Overall representation of Patient transfer in case hospital does not have ambulance services
It was observed that 6 hospitals (Christian Institute of Health Sciences & Research, Dimapur;
District Hospital, Baramulla, Jammu & Kashmir; Gauhati Medical College & Hospital; Government
General Hospital, Guntur; North Goa District Hospitaland IGMC, Shimla) does not have any
ambulances while 3 hospitals (Government Multispeciality Hospital, Sector 16, Chandigarh;
Apollo Hospitals, Chennaiand Deen Dayal Upadhyay Hospital, Shimla) did not share their
ambulance data with our assessor’s team. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 68
Best Practices for Hospital Ambulance Services:
!Primus Super Speciality Hospital is a private 138 bedded hospital and it have best hospital
ambulance services out of all 100 hospitals. It has mobile stroke unit as well as tele-
medicine facility.
!Hospitals have GVK centre which is a Centralized ambulance services in Goa.
!Mobile Stroke Unit was observed in Gauhati Medical College, Medeor Hospital, Sri
Ganga Ram Hospital, and Primus Super Speciality Hospital.
Note: It was found that some government hospitals did not have sufficient staff for ambulances
not even drivers. Jallianwala Bagh Matyr Memorial Hospital, Punjab and District Hospital,
Peroorkada, Kerala did not have manpower for ambulance.
North Goa District Hospital, Goa is running STEMI Programme by using tele-radiology. 6 hospitals
(Christian Institute of Health Sciences & Research, Dimapur; Synod Hospital, Aizawl, Mizoram;
Ramakrishna Mission Hospital, Arunachal Pradesh; District Hospital, Pasighat; Shija Hospital &
Research Institute, Imphal and Morigaon Civil Hospital, Assam) were found using tele-radiology
for various purpose such as for X-ray and CT scan.
Suggestions:
1. Create National Pre-hospital care guidelines.
2. Capacity building of existing paramedics by structured training program.
3. Creation of EMT (Emergency Medical Technician) course as a residency programme.
4. Dedicated job creation for EMT with performance based promotional ladder.
5. Establish Paramedic Council of India as regulatory body
13. ED PROTOCOL / SOP / GUIDELINES
A. Hospital-wise comparison:
In a healthcare facility, a protocol, also called a medical guideline, is a set of instructions which
describe a process to be followed to investigate a particular set of findings in a patient, or the
method which should be followed to control a certain disease.
It was observed that 41% hospitals had documented emergency manual, 30% hospitals had
documented policies and procedures for patient transfer in, 30% hospitals had documented
policies and procedures for patient transfer out, 57% hospitals gave discharge summary to patients,
58% hospitals had policy on handling cases of death, 44% hospitals had documented disaster
management plan, and only 41% hospitals had triage policy in ED. 69
Observations and Results with Suggestions
Table 22: Summary of ED Protocol / SOP / Guidelines by Category of Hospitals
ED Protocol
/ SOP /
Guidelines
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Emergency
Manual
1 3 154 7 93 3 1414 3 319 1 0
Policies and
procedures
for patient
transfer in
1 4 152 7 113 3 1413 0 711 6 3
Policies and
procedures
for patient
transfer out
1 5 141 9 102 6 1213 2 513 6 1
Discharge
Summary to
patients
7 7 58 5 76 6 816 4 020 0 0
Policy on
handling death
cases
9 6 510 5 58 7 414 3 317 3 0
Disaster
Management
Plan
6 2 125 5 105 3 1014 1 514 2 3
Triage Policy
in ED
5 0 143 2 155 0 1512 0 816 0 3
FIn medical college, only one hospital (IPGMER & SSKM Hospital) had emergency manual,
1 hospital (IPGMER & SSKM Hospital) had documented policies and procedures for patient
transfer in, 1 hospital (IPGMER & SSKM Hospital) had documented policies and procedures
for patient transfer out, 7 hospitals (Civil Hospital, Ahemdabad; Agartala Government Medical
College & G B Pant Hospital; Sher–I–Kashmir Institute of Medical Sciences, Srinagar, Government
General Hospital, Guntur; SMS Medical College & Hospital; AIIMS, Bhopal and IPGMER & SSKM
Hospital) gave discharge summary to patients, 9 hospitals had policy on handling cases of death,
6 hospitals had documented disaster management plan, and only 5 hospitals (AIIMS, Bhopal;
Rajiv Gandhi Government General Hospital, Madras Medical College; JIPMER, Pondicherry;
Government Medical College, Thiruvanananthapuram and IPGMER & SSKM Hospital) had triage
policy in ED (table 22 and figure 23).
It was observed that 7 district hospitals had documented emergency manual, 3 district hospitals had
documented policies and procedures for patient transfer in, 2 district hospitals had documented
policies and procedures for patient transfer out, 11 district hospitals gave discharge summary
to patients, 15 district hospitals had policy on handling cases of death, 9 district hospitals had
documented disaster management plan, and only 6 district hospitals (Jamanabai General Hospital,
Gujarat; Civil Hospital, Aizawl, Mizoram; District Hospital, Pasighat, Arunachal Pradesh; District
Hospital, Singtam, Sikkim; Southern Railways Hospital, Chennai and HNB Base Hospital,
Uttarakhand) had triage policy in ED. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 70
Figure 23: Comparison of ED Protocol / SOP / Guidelines by Hospital Categories 71
Observations and Results with Suggestions
B. Zone-wise comparison
Table 23: Zone-wise Summary of ED Protocol / SOP / Guidelines in Hospitals
ED Protocol / SOP
/ Guidelines
North (n=30)South (n=21) East (n=11)West (n= 16)
North East
(n=22)
NoPartialYesNoPartialYesNoPartialYesNoPartialYesNoPartialYes
Emergency Manual9 417113 55 2 47 4 5103 9
Policies and
procedures for
patient transfer in
13611114 45 0 64 6 6155 2
Policies and
procedures for
patient transfer out
126129 5 65 1 55 7 4118 3
Discharge Summary
to patients
5 5206 4 93 1 70 5117 7 8
Policy on handling
death cases
3 7204 3122 1 82 4106 9 6
Disaster
Management Plan
8 418101 75 2 45 4 7121 7
Triage Policy in ED151149 0 94 1 69 0 6170 5
*n=number of hospitals
Figure 24: Zone-wise Comparison of ED Protocol / SOP / Guidelines in hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 72
C. NABH Acrcreditation-wise comparison:
Figure 25: Overall Comparison of ED Protocol / SOP / Guidelines in NABH accredited and
non-NABH Accredited Hospitals
14. EMERGENCY CARE PROTOCOLS
A. Hospital-wise comparison
In Emergency Department, some emergency care protocols are present which have emergency
care protocol for different diseases. 38% hospitals had alert system for cardiac arrest, 16% had
alert system for trauma, 15% had alert system for chest pain, only 10% had for sepsis and 23%
had alert system for stroke (table 24 and figure 26).
Figure 26: Comparison of Emergency Care Protocols by Hospital Categories 73
Observations and Results with Suggestions
In medical college, 2 hospitals (Rajiv Gandhi Government General Hospital, Madras Medical
College and IPGMER & SSKM Hospital) have alert system for cardiac arrest and for trauma, only
1 hospital (IPGMER & SSKM Hospital) have alert system for chest pain, for sepsis and for stroke.
In government hospitals >300 beds, 4 hospitals (District Hospital, Baramulla, J&K; Government
District Hospital, Tenali; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow and Government
Multispeciality Hospital, Sector 16, Chandigarh) have alert system for cardiac arrest, 1 hospital
(District Hospital, Baramulla, J&K) have alert system for trauma, 1 hospital (District Hospital,
Baramulla, J&K) have alert system for chest pain, only 1 hospital (District Hospital, Karim Nagar)
have alert system for sepsis and 2 hospitals (District Hospital, Baramulla, J&K and Government
District Hospital, Tenali) have alert system for stroke.
In government hospitals <300 beds, only 1 hospital (Dr Jogalekar Hospital, Pune) have alert
system for cardiac arrest, for trauma, for chest pain for stroke.
Table 24: Overall Summary of Emergency Care protocols by Category of Hospitals
Emergency
Care
Protocols
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Blue:
Cardiac
Arrest
2 2 164 0 161 0 1914 1 417 0 3
Trauma 2 0 181 1 181 0 199 0 103 2 15
Chest Pain1 0 181 0 191 0 195 2 127 3 9
Sepsis 1 0 181 2 170 0 204 0 154 2 13
Stroke 1 0 182 0 181 0 1910 0 99 2 8
*n: number of hospitals
B. Zone-wise comparison:
Table 25 depicts the comparison of emergency care protocols at the assessed healthcare facilities.
Table 25: Zone-wise Summary of Emergency Care protocols in Hospitals
Emergency
Care
Protocols
North (n=30) South (n=21) East (n=11) West (n= 16)
North East
(n=22)
NoPartialYesNoPartialYesNoPartialYesNoPartialYesNoPartialYes
Cardiac
Arrest
12 0 1812 1 77 0 49 1 619 1 1
Trauma 24 1 515 0 58 1 212 1 321 0 0
Chest Pain 22 2 615 1 27 2 212 0 420 0 1
Sepsis 26 3 114 0 47 1 314 0 221 0 0
Stroke 20 1 912 0 67 1 312 0 420 0 1
*n=number of hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 74
Figure 27: Zone-wise Comparison of Emergency Care Protocols in Hospitals
C. NABH and non-NABH Accredited Hospitals comparison:
Figure 28 depicts the comparison of NABH and non-NABH accredited hospitals for the emergency
care protocols.
Figure 28: Overall Comparison of Emergency Care protocols in NABH accredited and non-NABH
Accredited Hospitals
Suggestions:
1. Develop standardized evidence based emergency care protocols (administrative and
clinical).
2. Development of academic residency programme.
3. Implementation of triage policy in each hospital. 75
Observations and Results with Suggestions
4. NABH Accreditation.
5. Increase the scope of Good Samaritan Law from road traffic injuries to other time
sensitive conditions.
15. MEASURES ENSURING SAFETY & SECURITY IN HOSPITALS
Several safety aspects were assessed for Emergency Department which is mentioned in the below
tables and figure. It was observed that majority of hospitals did not have periodic training of staff
and periodic mock drill was also not conducted regularly.
Nearly all private hospitals had periodic training programmes in their hospitals while most of
the government hospitals including medical colleges did not have regular periodic training of
staff. Similarly, mock drill conducted in most of the private hospitals while mostly government
hospitals did not conduct mock drill.
These aspects also assessed according to hospital bed strength
a. Category wise (table 26and figure 29)
b. 5 Zones of our country (zone wise) (table 27 and figure 30)
c. NABH accredited and non-NABH accredited hospitals (figure 31).
A. Hospital-wise comparison
Table 26: Overall Summary of measures ensuring Safety & Security by Category of Hospitals
Safety &
Security
measures
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Fire Safety 13 7 09 10 17 10 219 1 017 3 0
Building Safety12 3 49 7 48 6 515 3 117 2 1
Electrical
Safety
12 7 110 7 311 6 319 1 019 1 0
Patient and
Provider
Safety
12 7 08 9 38 6 517 3 020 0 0
Chemical
Safety
9 10 17 7 58 8 320 0 018 1 0
Periodic
Training of
Staff
7 5 84 9 73 13 416 3 118 2 0
Periodic Mock
Drill
6 5 94 7 93 11 616 3 117 3 0
Police Post
Available in
Premises
15 2 315 0 55 4 114 3 132 2 16
Alarm
Bell/Code
Announcement
in ED
3 7 94 2 132 2 1614 1 516 2 1
*n: number of hospitals, ED: Emergency Department Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 76
Figure 29: Comparison of measures ensuring Safety & Security by Hospital Categories 77
Observations and Results with Suggestions
B. Zone-wise comparison
Figure 30: Zone-wise comparison of measures ensuring Safety & Security in Hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 78
Table 27: Zone-wise measures ensuring Summary of Safety & Security in Hospitals
Safety &
Security
North (n=30)South (n=21) East (n=11) West (n= 16)
North East
(n=22)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Fire Safety 245 1108 28 3 012 3 010120
Building Safety224 4114 57 2 212 3 18 8 3
Electrical Safety235 2107 38 2 112 4 0165 1
Patient and
Provider Safety
227 1107 26 2 39 6 1164 1
Chemical Safety228 0105 48 2 110 5 0106 5
Periodic
Training of
Staff
187 59 3 83 7 110 6 08 8 6
Periodic Mock
Drill
186 67 2113 6 210 5 17 9 6
Police Post
Available in
Premises
126129 2 93 1 79 0 77 312
Alarm Bell/
Code
Announcement
in ED
164 96 3 94 1 67 4 54 216
*n=number of hospitals, ED=Emergency Department
C. NABH Accreditation comparison
Figure 31: Comparison of Safety & Security in NABH and Non-NABH Accredited Hospitals 79
Observations and Results with Suggestions
16. DISASTER MANAGEMENT
Hospital disaster management provides the opportunity to plan, prepare and when needed enables
a rational response in case of disasters/ mass casualty incidents (MCI). Disasters and mass casualties
can cause great confusion and inefficiency in the hospitals.
A. Hospital-wise comparison
The preparedness/readyness of hospitals for disaster management were analysed according to the
categories of hospitals as depicted in the below table and graph.
Figure 32: Comparison of preparedness/readyness for Disaster Management by Hospital Categories
It was observed that only 33 hospitals have documented disease outbreak management plan,
38 hospitals have surge capacity, only 14 hospitals (2 government hospitals: Government
Multispeciality hospital, Sector-16 and Dr Jogalekar Hospital) have separate decontamination
area for ED entrance, 35 hospitals have separate disease stock in ED, 32 hospitals conducted
drill and debriefing for disaster management, and 38 hospitals have system to redistribution of
patients to other hospitals during disaster. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 80
Table 28: Summary of preparedness/readyness for Disaster Management by
Category of Hospitals
Disaster
Management
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Disease
Management
Outbreak Plan
4 4127 4 92 71113 3 47 7 6
Surge Capacity 5 8 78 5 72 9 913 3 310 6 4
Separate
Decontamination
Area at ED entrance
0 2181 1181 2177 2105 510
Separate Disaster
Stock in ED
4 2147 1122 51311 2 711 5 4
Drill and Debriefing
for Disaster
Management
2 5135 4112 31513 3 410 5 5
Redistribution of pts
to other hospitals
4 2146 5 85 41114 2 49 8 3
*n: number of hospitals, ED: Emergency Department
B. Zone-wise comparison
Mostly healthcare facilities did not have separate decontamination area at ED entrance. Government
hospitals and medical colleges did not conducted drill and debriefing for disaster management.
The government healthcare facilities also lack the system for redistribution of patients to other
network hospitals during disaster (Zone wise-table 29 and figure 33).
Table 29: Zone-wise Summary of preparedness/readyness for Disaster Management in Hospitals
Disaster
Management
North (n=30)South (n=21)East (n=11)West (n= 16)
North East
(n=22)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Surge Capacity 189 37 4 83 5 38 3 52 812
Separate
Decontamination
Area at ED entrance
7 4191 2161 3 74 1111 219
Separate Disaster
Stock in ED
145118 2105 2 43 4 94 315
Drill and Debriefing
for Disaster
Management
147 98 1113 3 54 3 93 613
Redistribution of pts
to other hospitals
164 96 2124 3 48 5 33 712
*n: number of hospitals, ED: Emergency Department 81
Observations and Results with Suggestions
It was observed during analysis that north-east was the weakest zone in disaster management in
all the required aspects as mentioned in table 29 and figure 33.
Figure 33: Zone-wise Comparison of preparedness/readyness for Disaster Management in Hospitals
C. NABH Accreditation comparison
In addition, it was also observed that the hospitals which were NABH accredited had good disaster
management system when compared with non-NABH accredited hospitals (figure 34).
Best Practices for preparedness/readiness for Disaster
Management
Fortis Hospital, Punjab, Government Multispecialty Hospital, Sector 16, Apollo Hospital, Paras
HMRI Hospital, Ramakrishna Care Hospital, Medeor Hospital, and Sri Ganga Ram Hospital
had all the required stocks and requirements needed for disaster management. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 82
Figure 34: Overall Comparison of preparedness/readyness for Disaster Management in NABH
and Non-NABH Accredited Hospitals
Suggestions:
1. There should be standard protocols for implementation of in-hospital disaster management
plan
2. Implementation of hospitals preparedness for both external and internal disaster
management.
3. There should be separate decontamination area at entrance of emergency department.
4. Every hospital should have surge capacity with separate disaster stock in emergency
department.
5. There should be periodic drills and debriefing for disaster management.
6. Regular monitoring and evaluation of implementation of disaster management protocols
should be done by national disaster management authority.
17. CONTINUOUS QUALITY IMPROVEMENT
It is a process of creating an environment in which management and workers strive to create
constantly improving quality. The purpose of continuous quality improvement programs is to
improve health care by identifying problems, implementing and monitoring corrective action
and studying its effectiveness.
A. Hospital-wise comparison
It was observed that 40% hospitals had dedicated staff for identification and loop closure, 52%
hospitals undergo regular audits, 42% hospitals had continuous education and training programs,
42% hospitals had key indicators for quality monitored, only 22% hospitals had quality indicators
for urgent and interventional procedures monitored, 50% hospitals had death review committee,
and 42% hospitals had central empowered hospital committee for continuous quality improvement
for emergency services.
Most of the government hospitals and medical colleges do not run continuous quality improvement
programmes and training while on the other hand; private hospitals showed good performance
in continuous quality improvement (table 30 and figure 35). 83
Observations and Results with Suggestions
Table 30: Summary of Continuous Quality Improvement by Category of Hospitals
Continuous Quality
Improvement
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt.
hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Dedicated Staff for
gap identification &
loop closure
2 6115 5104 412145 1155 0
Regular audits in
hospital
7 7 66 4106 8 6154 1181 0
Continuous
Education and
Training programs
4 7 96 7 71 910144 2173 0
Key Indicators of
Quality Monitored
5 7 85 9 65132125 2155 0
Quality Indicators
for urgent and
interventional
procedures
monitored
1 4152 0172 2169 6 58 6 6
Death Review
Committee
6 6 86 4104 511162 2180 2
Central Empowered
Hospital Committee
4 3134 6105 411136 1163 1
*n: number of hospitals
Out of 20 medical colleges, 2 hospitals (Civil Hospital, Ahmedabad and JIPMER Pondicherry) had
dedicated staff for identification and loop closure, 7 hospitals undergo regular audits, 4 hospitals
(Regional Institute of Medical Sciences, Imphal; Rajiv Gandhi Government General Hospital,
Madras Medical College; JIPMER, Pondicherry and IPGMER & SSKM Hospital) had continuous
education and training programs, 5 hospitals had key indicators for quality monitored, only 1
hospital (Gauhati Medical College & Hospital) had quality indicators for urgent and interventional
procedures monitored, 6 hospitals had death review committee, and 4 hospitals (Civil Hospital,
Ahemdabad; Rajiv Gandhi Government General Hospital, Madras Medical College; JIPMER,
Pondicherry and IPGMER & SSKM Hospital) had central empowered hospital committee for
continuous quality improvement for emergency services. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 84
Figure 35: Comparison of Continuous Quality Improvement by Hospital Categories
Out of 20 government hospitals >300 beds, following were observed:
1. 5 hospitals had dedicated staff for identification and loop closure (Jallianwala Bagh
Matyr Memorial Hospital, Amritsar; District Hospital, Baramulla, J&K; Dr Shyam Prasad
Mukharji Civil Hospital, Lucknow; Government Multispeciality Hospital, Sector 16 and
Deen Dayal Upadhyay Hospital, H.P.)
2. 6 hospitals undergo regular audits (Jallianwala Bagh Matyr Memorial Hospital, Amritsar;
District Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow;
Government Multispeciality Hospital, Sector 16; HNB Base Hospital and Deen Dayal
Upadhyay Hospital, H.P.)
3. 6 hospitals had continuous education and training programs (Civil Hospital, Shillong; Dr
Shyam Prasad Mukharji Civil Hospital, Lucknow; Southern Railways Hospital, Chennai; 85
Observations and Results with Suggestions
District Hospital, Baramulla, J&K, AIIMS, Patna and Deen Dayal Upadhyay Hospital,
H.P.)
4. 5 hospitals had key indicators for quality monitored (Civil Hospital, Shillong; District
Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow; Southern
Railways Hospital, Chennai and Deen Dayal Upadhyay Hospital, H.P.)
5. 2 hospitals had quality indicators for urgent and interventional procedures monitored
(District Hospital, Baramulla, J&K and Government Multispeciality Hospital, Sector 16)
6. 6 hospitals had death review committee (Jallianwala Bagh Matyr Memorial Hospital,
Amritsar; District Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital,
Lucknow; Government Multispeciality Hospital, Sector 16; AIIMS, Patna and Deen
Dayal Upadhyay Hospital, H.P.)
7. 4 hospitals had central empowered hospital committee for continuous quality
improvement for emergency services (Jallianwala Bagh Matyr Memorial Hospital,
Amritsar; District Hospital, Baramulla, J&K; AIIMS, Bhubneshwar and Government
Multispeciality Hospital, Sector 16)
Out of 20 government hospitals <300 beds, following were observed:
1. 4 hospitals had dedicated staff for identification and loop closure (Civil Hospital, Aizawl,
Mizoram; District Hospital, Ganderbal; Dr Jogalekar Hospital, Pune and District Hospital,
Singtam)
2. 6 hospitals undergo regular audits (Civil Hospital, Aizawl, Mizoram; District Hospital,
Pasighat; District Hospital, Singtam; District Hospital, King Koti; Dr Jogalekar Hospital,
Pune and North Goa District Hospital)
3. Only 1 hospital had continuous education and training programs (Dr Jogalekar Hospital,
Pune)
4. 5 hospitals had key indicators for quality monitored (Civil Hospital, Aizawl, Mizoram;
District Hospital, Singtam; District Hospital, King Koti; Dr Jogalekar Hospital, Pune and
North Goa District Hospital)
5. 2 hospitals had quality indicators for urgent and interventional procedures monitored
(North Goa District Hospital and Dr Jogalekar Hospital, Pune)
6. 4 hospitals had death review committee (Civil Hospital, Aizawl, Mizoram; District
Hospital, Pasighat; District Hospital, Singtam and North Goa District Hospital)
7. 5 hospitals had central empowered hospital committee for continuous quality
improvement for emergency services (Civil Hospital, Aizawl, Mizoram; District Hospital,
Singtam; District Hospital, King Koti; Dr Jogalekar Hospital, Pune and North Goa District
Hospital)
B. Zone-wise comparison
It was observed that North zone performed best out of all 5 zones in continuous quality
improvement while the rest of the zones performed below average (table 31 and figure 36). Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 86
Table 31: Zone-wise Summary of Continuous Quality Improvement in Hospitals
Continuous Quality
Improvement
North
(n=30)
South (n=21)East (n=11)West (n=16)
North East
(n=22)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Dedicated Staff for gap
identification & loop
closure
19566862546376411
Regular audits in hospital22538474436641066
Continuous Education
and Training programs
15123839533655868
Key Indicators of Quality
Monitored
17936104452754895
Quality Indicators for
urgent and interventional
procedures monitored
1151333142454391318
Death Review Committee19299563265381048
Central Empowered
Hospital Committee
18487494526556313
*n: number of hospitals
Figure 36: Zone-wise Comparison of Continuous Quality Improvement in Hospitals 87
Observations and Results with Suggestions
C. NABH and non-NABH Accredited Hospitals comparison:
In addition, it was observed that NABH accredited hospitals had good performance in continuous
quality improvement when compared to non-NABH accredited (figure 37).
Figure 37: Overall Comparison of Continuous Quality Improvement in NABH and Non-NABH
Accredited Hospitals
NABH accredited healthcare facilities had regular audits in their facility, dedicated staff for
loop closure, runs training program cycles for skill development, had key indicators and quality
indicators for urgent and interventional procedures monitored. They had death review committee
to review the cause of patient’s death. Most of the NABH accredited hospitals followed the above
procedures for quality improvement.
Best Practices for Continuous Quality Management
Best practices for continuous quality management were observed in District Hospital,
Baramulla; Manipal Hospital; Fortis hospital, Jaipur; Max Super Speciality Hospital; Apollo
Hospital; Care Hospital; Yashoda Hospital, Malakpet; Paras HMRI Hospital; Ramakrishna Care
Hospital; Medeor Hospital and Artemis Hospital.
Suggestions:
1. There should be dedicated quality manager for gap identification and loop closure.
2. Develop a quality council among emergency care providers.
3. Mandatory Emerald certification under NABH.
4. Regular mortality and morbidity meeting.
5. Regular third-party audit of external agencies by using KPI and the funding of the
hospital should be linked with it.
6. Continuous training of quality council provider as well as manager.
18. COMPUTERIZED DATA MANAGEMENT SYSTEM
Healthcare data management is the process of storing, protecting, and analysing data pulled from
diverse sources. Managing the wealth of available healthcare data allows health systems to create
holistic views of patients, personalize treatments, improve communication, and enhance health
outcomes. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 88
A. Hospital-wise comparison:
Out of 100 studied hospitals 52 hospitals did not had any electronic health record (EHR) and
other hospitals had EHR system.
Table 32: Summary of Data Management System by Category of Hospitals
Computerized Data
Management System
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
EHR61137 6 75 6 9128 0182 0
Patient Registration
System
152 3170 3102 8200 0200 0
Patient Clinical
Examination Notes
2 1173 1160 1196 5 96 5 9
Patient Investigation Lab
Reports
103 77 4 94 313162 2181 1
Patient Radiological
Investigation Reports
123 5102 83 511182 0162 2
Trauma Registry 2 5133 5121 2176 3117 5 7
Injury Surveillance
System
0 2180 3172 0182 3144 411
ED Surveillance System1 3160 4161 1189 1107 3 9
Data Retrieval System3 4134 8 82 315122 6122 5
*n: number of hospitals, ED: Emergency Department, EHR: Electronic Health Record
In addition, it was also observed that 19 hospitals have trauma registry, only 8 hospitals have
injury surveillance system, 18 hospitals have emergency department surveillance system, and 33
hospitals have data retrieval system for quality improvement & research.
Out of 20 medical colleges, 6 hospitals had electronic health record (EHR), 15 hospitals had
computerized patient registration system, only 2 hospitals (AIIMS, Bhopal and IPGMER & SSKM
Hospital) had computerized patient clinical examination notes, 10 hospitals had computerized
patient investigation lab reports and 12 hospitals had computerized patient radiological
investigation reports.(Note: Though hospitals have answered yes for trauma registry but many of
them do not understood it’s meaning).
In addition, it was also observed that 2 hospitals (AIIMS, Bhopal and IPGMER & SSKM Hospital)
had trauma registry, none of them had injury surveillance system, 1 hospital (AIIMS, Bhopal) had
emergency department surveillance system, and 3 hospitals (Civil Hospital, Ahemdabad; AIIMS,
Bhopal and JIPMER, Pondicherry) had data retrieval system for quality improvement & research
(table 32 and figure 38). 89
Observations and Results with Suggestions
Figure 38: Comparison of Data Management System by Hospital Categories
Out of 20 government hospital >300 beds, 7 hospitals had electronic health record (EHR),
17 hospitals had computerized patient registration system, only 3 hospitals (Dr Shyam Prasad
Mukharji Civil Hospital, Lucknow; AIIMS, Patna and Jai Prakash Narayan District Hospital, Bhopal)
had computerized patient clinical examination notes, 7 hospitals had computerized patient
investigation lab reports and 10 hospitals had computerized patient radiological investigation
reports. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 90
In addition, it was also observed that 3 hospitals (AIIMS, Patna; Civil Hospital, Shillong and
HNB Base Hospital) had trauma registry, none of them had injury surveillance system and
emergency department surveillance system, and 4 hospitals (AIIMS, Bhubneshwar; District
Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow and Deen Dayal
Upadhyay Hospital, H.P.) had data retrieval system for quality improvement & research.
Out of 20 government hospital <300 beds, 5 hospitals had electronic health record (EHR), 10
hospitals had computerized patient registration system, none of them had computerized patient
clinical examination notes, 4 hospitals had computerized patient investigation lab reports and 3
hospitals had computerized patient radiological investigation reports.
In addition, it was also observed that 1 hospital (Puri District Headquarter Hospital, Orissa)
had trauma registry, 2 hospitals (Puri District Headquarter Hospital, Orissa and Dr Jogalekar
Hospital, Pune) had injury surveillance system, 1 hospital (Dr Jogalekar Hospital, Pune) had
emergency department surveillance system, and 2 hospitals (Civil Hospital, Aizawl, Mizoram
and Dr Jogalekar Hospital, Pune) had data retrieval system for quality improvement & research.
Computerized data management system found weak in government sector
especially in government hospitals less than 300 bed strength.
Trauma registry, injury surveillance system, emergency department surveillance system, and data
retrieval system for quality improvement & research were found weak in all categories of the
healthcare facilities (table 32 and figure 38).
B. Zone-wise comparison
Table 33: Zone-wise Summary of Data Management System in Hospitals
Data Management
System
North (n=30)South (n=21)East (n=11)West (n=16)
North East
(n=22)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
EHR167 77 9 47 2 2114 16115
Patient Registration
System
250 5170 39 0 2141 1163 3
Patient Clinical
Examination Notes
4 4222 5134 2 55 2 91 120
Patient Investigation
Lab Reports
203 78 5 76 1 4112 39 112
Patient Radiological
Investigation Reports
15510122 67 1 3103 3134 4
Trauma Registry 510152 4146 1 44 2 91 219
Injury Surveillance
System
3 4230 3163 3 41 2120 022
ED Surveillance
System
7 4193 4123 3 54 0110 022
Data Retrieval
System
143135 7 75 2 46 4 52 317
*n: number of hospitals, ED: Emergency department, EHR: Electronic Health Record 91
Observations and Results with Suggestions
Figure 39: Zone-wise Comparison of Data Management System in Hospitals
Out of all five zones of India, north east was found weak in sector of computerized data
management system. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 92
C. NABH and non-NABH Accredited Hospitals comparison:
In addition, it was observed that data management is good in NABH Accredited Hospitals but
the data for research was found below average (figure 40).
Figure 40: Comparison of Data Management System in NABH and Non-NABH Accredited Hospitals
Best Practices for Data Management System was observed in Ruban Memorial Hospital, Asian
Hospital, and Primus Super Speciality Hospital (with 100% score).
Suggestions:
1. Develop National Emergency Department Information System (EDIS)
2. Implement and integrate the computerized care delivery template which will serve as
clinical notes, registry and surveillance
3. It will use the data for quality improvement initiative and research
4. Develop various emergency conditions registries such as cardiac arrest, poisoning, snake
bite including trauma registry
19. FINANCING
Availability of dedicated funds for emergency department assessed for all hospitals. Out of 60
government healthcare facilities, only 2hospitals received sufficient central government funds,
13 did not received sufficient central government funds and the rest did not received any fund
at all for ED services.
A. Hospital-wise comparison
It was observed that none of the hospitals received dedicated funds for emergency department
because of lack of dedicated emergency department in hospitals. Some hospitals received funds
from state such as funds for trauma. 93
Observations and Results with Suggestions
Table 34: Overall Summary of Financing by Category of Hospitals
Financing for
Emergency
Department
Medical
Colleges with ED
Academics (n=3)
Medical Colleges
with Emergency
Services (n=17)
Govt. hospitals
(<300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
SFNSFNF SFNSFNF SFNSFNF SFNSFNF
Central Govt Funds
for ED Services
0 1 1 2 3 12 0 4 15 0 4 14
State Govt Funds for
ED Services
2 0 1 3 7 7 5 7 7 3 7 8
(**SF: Sufficient Funds, NSF: Not Sufficient Funds, NF: No Funds, n: number of hospitals)
Figure 41: Comparison of Financing by Hospital Categories
Out of 3 medical colleges with academic emergency department, 2 had received sufficient funds
from state government- a) funds for trauma (JIPMER, Pondicherry) b) funds from Government of
Gujarat(Civil Hospital, Ahmedabad).
Out of 17 medical colleges without academic emergency department, 2 hospitals (Regional
Institute of Medical Sciences, Imphal and AIIMS, Bhopal) had sufficient funds, 3 hospitals
(Government General Hospital, Guntur; Government Medical College, Thiruvanananthapuram
and Patna Medical College & Hospital, Patna) had funds but not sufficient and 12 hospitals had
no funds from central government.
B. Zone-wise comparison
Out of 100 hospitals from five zones of country, it was observed that east zone was the weakest
zone for receiving funds from government either state or central.
Table 35: Zone-wise Summary of Financing in Hospitals
Financing for ED
North (n=15)South (n=15) East (n=5) West (n=10)
North East
(n=14)
SFNSFNFSFNSFNFSFNSFNFSFNSFNFSFNSFNF
Central Govt Funds
for ED Services
0 3121 5 9 0 3 2 1 0 6 1 211
State Govt Funds
for ED Services
2 7 6 4 3 8 0 3 2 3 1 3 3 7 4
(* n= number of government hospitals in respective zones, ED= Emergency Department)
(**SF: Sufficient Funds, NSF: Not Sufficient Funds, NF: No Funds) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 94
Figure 42: Zone-wise ccomparison of Financing in Hospitals
C. Status of funds
It was observed that some hospitals received funds on time others did not received on time and
in most of the hospital’s funds are not fully utilized as depicted in the below table and figure.
Table 36: Overall Summary of Financial Status by Category of Hospitals
Financial Status
Medical
Colleges
(n=19)
Govt. hospitals
(>300 bed
strength)
(n=15)
Govt. hospitals
(<300 bed
strength)
(n=17)
Pvt. hospitals
(>300 bed
strength)
(n=10)
Pvt. hospitals
(<300 bed
strength)
(n=16)
Yes No Yes No Yes No Yes No Yes No
Full Utilisation
of Funds
8 10 6 9 6 11 1 9 4 9
Delay in Release
of Funds
5 14 4 11 2 15 0 10 2 14
(* n= number of government hospitals in respective zones) 95
Observations and Results with Suggestions
Figure 43: Overall Comparison of Financial Status by Hospital Categories
D. Funding Schemes
The studied hospitals received funds from central and state government under several funding
schemes. Most of the funding schemes cover trauma care services and other hospital services.
From the entire studied funding schemes, one major funding scheme was Ayushman Bharat. Out
of 100 hospitals, 66 hospitals received funds from either state or central government.
Figure 44: Funding Schemes by Category of Hospitals
E. Ayushman Bharat (PMJAY)
Ayushman Bharat provides coverage for 35 hospitals in both government and private sector out of
100 hospitals. It covers 8 medical college, 9 government hospitals (>300 beds), 12 government
hospitals (<300 beds), 4 private hospitals (>300 beds), and 2 private hospitals (<300 beds) as
shown in figure 45.
Figure 45: Comparison of Ayushman Bharat Scheme by Category of Hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 96
Suggestions:
1. Protected funding for emergency and injury care services and for establishment of
residency programme in emergency medicine, emergency nursing and EMT (Emergency
Medical Technician) course.
2. Integration and aggregation of financial schemes for emergency and injury care.
3. Cashless scheme- Increase Ayushman Bharat scheme for all red-triaged patients in all
hospitals.
20. PHYSICAL INFRASTRUCTURE
In hospitals, patients seek medical treatment and staff members provide continuous support by
creating a healing environment with the support of appropriate physical aspects. A healthy hospital
environmental is found to have an impact on the quick recovery of diseases.
In this study, consensus based tool was developed which includes a checklist for physical
infrastructure of Emergency Department. The observations of physical infrastructure are given in
the table 37and figure 46.
Table 37: Summary of Physical Infrastructure by Hospital Categories
Hospital
Category
Medical
Colleges
(n=20)
Govt. Hosp.
(>300 bed
strength)
(n=20)
Govt. Hosp.
(<300 bed
strength)
(n=20)
Pvt. Hosp.
(>300 bed
strength)
(n=20)
Pvt. Hosp.
(<300 bed
strength)
(n=20)
Physical
Infrastructure
55.5% 56% 53.5% 76% 74.5%
*n=number of hospitals
Figure 46: Comparison of Physical Infrastructure for Emergency Department by Category of Hospitals 97
Observations and Results with Suggestions
Out of 10 critical checklist points assessed for emergency department for all the hospitals, the
overall compliance was as follows:
Separate access for ambulance services (45%)
Designated area for ambulances (58%)
Demarcated triage area (35%)
Emergency department with adequate space (48%)
Dedicated minor OT (63%)
Point of care lab (26%)
Police control room (44%)
Smooth entry area with wheel chair, etc (63%)
Adequate waiting area (63%)
Safe drinking water (63%)
Other Standard for physical infrastructure emergency mainly defines the access to ER, parking, staff
service at doorstep, clinical services provided, facilities available, information display and facility
upkeep. The hospitals conformed to the parameters of easy and direct access to ER, designated
parking for ambulance, staff and public, but 37% hospitals parked vehicle in front of ER and 25%
hospitals showed partial compliance to this objective.
The hospitals (48%) showed compliance, 26% however partial compliance to parameter of
smooth entry to emergency like ramp for stretchers, canopy and availability of staff at entrance
to help patient with wheelchair and stretchers.
The patient care assistant of most government hospitals was found to attend only critical
and unattended patients from ambulances. The information board displaying services
being provided was found missing from 13% hospitals and 24% hospitals partially fulfilled
the requirement by exhibiting only partial information.
Similarly display of names of doctors and staff on duty, important telephone numbers along
with relevant information were found missing from most of the government hospitals. 51%
hospitals have adequate waiting area. Mostly hospitals had functional male and female
toilets but only 38% hospitals have functional toilets with wheel chair. Police post was
available in 56% of hospitals.
Out of 100 hospitals, 48 hospitals had designated emergency rooms, 29 hospitals did not
have proper designated emergency room and 23 hospitals did not have any emergency
room. Only 34 hospitals had demarcated area for triage.
Only 23 hospitals had isolation room in emergency. Similarly the point of care lab
was found in only 26 hospitals (6 medical colleges, 3 government hospital >300 beds, 1
government hospital <300 beds, 10 private hospitals >300 beds and 6 private hospitals <300
beds).
Out of 100 hospitals, no separate room was present for sexual assault victim in 64 hospitals,
no availability of forensic evidence kit for them in 58 hospitals and no counselling service
for sexual assault / domestic violence cases in 57 hospitals. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 98
Suggestions:
1. Uniformity of name (Emergency/Emergency Medicine Department) in every hospital
for emergency / casualty / injury care etc.
2. The capacity and capability of ED should be standardizing based on the tier of facility,
footfall of patients and academic programme.
3. Availability of either point of care lab or hospital lab (24*7) for emergency services
4. Adequate space for ambulance drop zone.
5. There should be demarcated triage area.
6. There should be ICU in each hospital.
21. MANPOWER IN EMERGENCY DEPARTMENT
In Emergency Department, manpower plays a very crucial role in providing care to the patients.
It was observed that emergency department did not have adequate manpower that’s why the
quality of care is compromised in most of the government hospitals.
The manpower in emergency was recorded and it was observed that many government hospitals
had very less manpower in emergency. The percentage of manpower was calculated as per the
footfall of patients in emergency department as well as per emergency beds available in hospitals.
Table 38: Summary of Manpower in Emergency Department Category of Hospitals
Hospital
Categories
Medical
Colleges
(n=20)
Govt. Hosp.
(>300 bed
strength)
(n=20)
Govt. Hosp.
(<300 bed
strength)
(n=20)
Pvt. Hosp.
(>300 bed
strength)
(n=20)
Pvt. Hosp.
(<300 bed
strength)
(n=20)
Doctors37 15 12 50
Nurses234 10 11
Technicians 166 11 17
Support Staff 34 10 14 22 99
Observations and Results with Suggestions
Table 39: Detailed Summary of Manpower in Emergency Department by Category
of Hospitals
Overall
Manpower in
Emergency
Medical
Colleges
(n=20)
Govt. Hosp.
(>300 bed
strength)
(n=20)
Govt. Hosp.
(<300 bed
strength)
(n=20)
Pvt. Hosp.
(>300 bed
strength)
(n=20)
Pvt. Hosp.
(<300 bed
strength)
(n=20)
Median [IQR]
Min-Max
% Per footfall of
100 patients in ED
Median [IQR]
Min-Max
% Per footfall of
100 patients in ED
Median [IQR]
Min-Max
% Per footfall of
100 patients in ED
Median [IQR]
Min-Max
% Per footfall of
100 patients in ED
Median [IQR]
Min-Max
% Per footfall of
100 patients in ED
Faculty /
Consultant
3 [3]
1-8
0.19
6 [7.7]
1-39
2.53
2 [3.7]
1-33
6.41
2 [2]
1-138
1.19
2 [4]
1-80
9.44
Casualty
Medical
Officer
5.5
[3.5]
1-20
0.23
5 [6.5]
1-16
0.46
2 [4.2]
1-12
1.27
4 [2]
1-13
1.80
2 [5]
1-9
1.71
Senior
Resident
8 [8]
2-20
0.43
7 [2.5]
3-18
1.57 0 0
1.5
[13]
1-30
1.50
3 [3]
1-20
6.79
Junior
Resident
9.5
[6.2]
2-24
0.81
7 [9.5]
2-30
1.10
1 [0]
1-1
0.39
4 [7]
1-167
2.72
5 [9]
2-26
14.47
Medical
Officer
4 [4]
1-51
0.23
4 [3.5]
3-9
0.51
6 [4]
1-8
3.09
4 [7.2]
1-11
2.40
2 [5]
1-18
3.76
Intern
6.5
[3.7]
2-18
0.69
5 [6]
2-40
0.97
12 [8]
4-20
4.34
4 [85]
3-100
2.24
22 [0]
22-22
13.47
Nursing
officer
Incharge
3 [2]
1-33
0.19
2 [1]
1-18
0.30
1 [1.7]
1-10
0.61
2 [2]
1-4
0.75
1 [2]
1-4
0.85
Staff Nurse
/ Nursing
officer
21
[11.5]
4-70
2.25
12 [9]
3-165
3.25
7 [6.2]
1-31
3.09
17.5
[24.7]
3-50
8.94
15
[5.7]
3-35
10.24
Radiology
Technician
4 [4]
1-4
0.32
3 [2]
1-6
1.79
1 [2]
1-4
0.55
3 [6]
1-18
0.72
2 [2]
1-10
4.14
Lab
Technician
3 [2]
1-18
0.20
3 [4]
2-12
1.29
3 [3.7]
1-12
2.28
9 [12]
1-31
2.67
3 [3]
1-12
5.52
OT
Technician
3 [5.5]
1-10
0.39
2 [0]
1-2
0.87
2 [1]
1-3
2.73
10 [3]
6-12
4.79
2 [2]
1-14
3.78
H.A. / G.D. A.
6.5
[8.2]
1-19
0.92
4 [0]
4-4
1.30
1 [0.5]
1-2
2.46
4.5 [2]
3-10
4.60
4 [4]
1-12
8.05 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 100
Housekeeping
Staff
12
[20.2]
2-60
0.57
3 [3]
1-20
1.20
3 [1.5]
1-4
3.72
7 [3.5]
2-152
4.08
7.5
[8.5]
3-20
3.27
EMT
6 [6.5]
2-27
0.46
3 [1]
1-30
1.67
3 [0.5]
1-16
0.65
6
[15.2]
2-55
2.60
5 [3.5]
1-30
3.67
Security
8.5
[10.5]
2-83
1.03
4 [5]
1-30
0.97
3 [2.7]
1-6
1.07
4 [3]
2-25
2.25
4 [3]
1-10
3.24
Registration
Staff
3 [3.5]
1-19
0.26
3 [3.5]
1-35
0.50
2 [2.5]
1-5
0.88
4.5
[3.7]
1-22
2.04
3 [1]
1-10
2.49
Any Other
4 [0]
4-4
0.33
1.5
[0.5]
1-2
0.13
4 [0]
4-4
1.52
3 [0]
3-3
0.78
4 [2]
2-6
4.70
(*n-number of hospitals, GDA- General Duty Assistant, SA- Sanitary Attendant, HA- Housekeeping Attendant)
Note: A total of 357 staff members including doctors were recorded for Civil Hospital,
Ahemdabad (Medical College) in ED.
21.1 Other Specialist / Super Specialist Available in Hospital
In this study, the number of specialist and super specialist were also recorded for the whole
healthcare facility. It was observed that the hospitals were having adequate number of specialist
and super specialist in the hospital (Annexure VI) but the number of doctors in the emergency
department was not enough.
The median of consultants as well as residents was found high in medical colleges during OPD
hours. Emergency department is manned by junior doctors for caring of the sickest patients even
though the hospitals had adequate specialists.
21.2 Discussion for Manpower in Emergency
Table 40 depicts the gaps in manpower present in emergency or emergency department for the
existing annual footfall. There are several gaps like, less number of available emergency beds
and manpower, to manage patients in emergency department. 101
Observations and Results with Suggestions
Table 40: Comparison of Emergency Cases and Manpower in categories of Hospitals
Healthcare
Facilites
Bed
Strength
Emergency and Injury Care Patients% of
Emergency
and injury
care Patients
(One Year)
% of
Emergency
and injury
care Patients
(One Day)
% of
Available
Emergency
Beds
nMedian IQR Min-Max
Medical
colleges
<500 15119461140435
3560-
477845
13% 17% 3%
Government
Hospitals
>300 1743001118984
876-
3088834
14% 11% 4%
Government
Hospitals
<300 1618738 35139
1560-
227364
15% 11% 4%
Private
Hospitals
>300 1720161 22118
3676-
103524
9% 10% 4%
Private
Hospitals
<300 1113800 4908
4800-
8778
12% 30% 5%
Suggestions:
1. Round the clock physical posting of Consultants/Faculty in emergency department for
providing quality acute care.
2. Rotatory posting of doctors and nursing students from different disciplines including
interns for a defined period in emergency under the administrative control of ED.
3. Creation of dedicated post of doctors, nurses and paramedics for emergency department.
4. Establish academic emergency medicine, emergency nursing and EMT.
5. Capacity building of emergency care providers.
22. EQUIPMENT AND SUPPLIES IN ED
22.1 Biomedical Equipment
It assesses the availability of the equipment in accordance with the scope of service, inventory
maintenance and periodic inspection & calibration of equipment. It was observed that the
equipments are available according to the available services in 69 hospitals and the inventory
and log books are maintained properly in 67 hospitals. The records of periodically inspection
and calibration were found in 66 hospitals out of 100 (Table 41). Figure 47 illustrates the above-
mentioned points by category of hospitals.
Table 41: Summary of Biomedical Equipment by Category of Hospitals
Biomedical
Equipment
List of equipments
according to available
services
Medical equipment
inventory and log book
Periodically inspected &
calibrated equipment Record
Yes696766
Partial202318
No6511 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 102
Figure 47: Compliance of Biomedical Equipment by Hospital Categories
It was observed that the equipments and supplies for ED were mostly present in private hospitals
in comparison with the government hospitals as shown in the figure 48.
22.2 Compliance of critical available equipments
It was observed that most of the hospitals had all resuscitation/airway management equipments
but basic items like cervical collar, pelvic binder and bed-sheets, broselow tape, fluid warmer
were missing from most of the hospitals. It was also observed that only 59% hospitals had mobile
resuscitation beds, 39% hospitals had transport ventilators, 43% had Laryngeal Mask Airway, 50%
hospitals had vaginal speculum, and only 24% hospitals had capnography.
In addition, 28% hospitals had incubators, 28% hospitals had emergency cricothyroidotomy kit,
25% hospitals had emergency thoracotomy set, 23% hospitals had emergency decompressive
craniotomy set, only 17% hospitals had emergency thrombectomy sets, and 25% hospitals had
phototherapy unit (table 42). 103
Observations and Results with Suggestions
Figure 48: Comparison of Equipments and Supplies present in ED by Category of Hospitals i) on the basis of
Percentage range ii) Ranking on the basis of Overall Performance
Table 42: Overall Summary of Equipments and Supplies list in ED for 100
Healthcare Facilities by Category
Equipments&
Supplies in ED
Medical
Colleges
(n=20)
Govt.
Hospitals
(>300 bed
strength)
(n=20)
Govt.
Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Mobile bed for
resuscitation
10 2 810 4 64 21417 1 219 0 1
Crash cart 12 5 311 5 411 5 417 2 119 0 1
Hard cervical
collar
9 0115 3123 01616 0 416 1 3
Oxygen supply
by pipeline
15 2 315 0 54 11519 1 018 0 2
Oxygen cylinder18 1 119 1 019 0 119 1 020 0 0
Suction machine16 3 019 1 018 1 118 2 020 0 0
Multipara
monitor
1512 413 1 69 4 718 1 118 1 1
Simple/transport
monitor
10 3 712 1 77 31016 1 319 0 1
Defibrillator 13 5 213 2 58 6 618 1 118 1 1
All types of
forceps
11 3 610 5 49 5 617 3 018 2 0
Transport
ventilator
7 1124 1152 21614 2 413 2 5
AMBU bag 17 2 115 5 016 2 218 2 017 1 1 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 104
Suprapubic
cathetor
8 4 84 1152 11714 1 513 0 7
Light source 10 1 912 2 612 2 616 1 318 1 1
Stethoscopoe 14 3 318 0 119 1 018 1 119 0 0
Oropharyngeal
airway blades
14 3 314 4 210 4 620 0 019 0 1
LMA (Lanryngeal
Mask Airway)
9 0113 2152 11615 0 514 0 6
Tourniquet 12 1 712 2 69 01116 1 319 0 0
Pelvic binder &
bed-sheets with
clips
6 4102 3154 11512 0 813 0 7
Needle holder
and suture
material
15 3 217 1 113 6 119 1 020 0 0
Vaginal speculum8 3 96 3109 3 813 2 514 0 5
Ryles tubes 13 6 113 7 013 6 119 1 018 0 2
Foley’s catheter13 5 213 7 012 7 119 1 018 0 2
Laryngoscope 14 6 015 4 112 5 319 1 018 1 1
Endotracheal
tubes
14 6 016 4 010 6 418 2 019 0 1
Chest tubes with
water seal drain
11 5 47 4 83 31418 1 116 1 3
Blood pressure
monitor
17 2 117 2 117 3 019 1 020 0 0
ECG machine 17 3 017 2 117 1 220 0 020 0 0
Ultrasonic
nebulizer
12 3 510 4 57 21115 2 318 0 2
IV cannula and
IV infusion sets
16 2 215 5 019 1 019 1 019 1 0
Syringes and
disposable
needles
17 2 119 1 020 0 020 0 019 1 0
Broselow tape 1 2160 1182 11611 0 910 010
Protoscope 14 1 58 1118 21016 1 315 0 5
Fluid Warmer 3 2153 0172 4147 21110 010
Dressing sets 6 4 017 2 111 5 419 1 020 0 0
Personal
protecting
equipments
11 8 114 4 210 7 218 2 018 1 1
Central line of all
sizes
9 3 82 5122 21616 3 117 1 2
Capnography 5 3122 1161 2178 3 99 110 105
Observations and Results with Suggestions
Infusion pump
and syringe
drivers
10 2 87 1125 11418 2 019 0 1
Spine board with
sling & scotch
tape all sizes
5 2136 2121 11713 0 716 0 4
Splints for all
fractures
9 8 3510 53 71014 3 315 3 2
Non-invasive
and invasive
ventilators
10 2 83 4133 21516 3 115 1 4
Incubators 9 2 72 1171 2178 3 99 2 9
Emergency
Cricothyroidotomy
kit
7 1122 1171 2178 21011 1 8
Emergency
Thoracotomy set
7 0132 1161 0198 1118 210
Emergency
Decompressive
craniotomy sets
7 1112 1171 0196 3118 210
Emergency
Thrombectomy
sets
4 0150 2180 0207 1126 211
Phototherapy
unit
9 2 71 1173 2155 3128 210
*n-number of hospitals, AMBU- Artificial Manual Breathing Unit, ECG- Electrocardiography, IV- Intravenous, ED-Emergency
Department
All hospital emergency departments should ensure 100% availability of all these equipments:
1. Airway equipments:
Laryngeal Mask Airway (43%)
Endotracheal tubes (76%)
AMBU bag (84%)
Transport ventilator (39%)
Laryngoscope (77%)
Oropharyngeal airway blades (75%)
Capnography (24%)
Emergency Cricothyroidotomy kit (28%)
Peak Expiratory Flow (16%)
2. Breathing equipments:
Emergency Thoracotomy set (25%)
Chest tube with seal drain (53%)
Ultrasonic nebulizer (61%)
Oxygen cylinder (93%)
Oxygen supply by pipeline (70%)
Suction machine (90%)
Non-invasive and invasive ventilator (45%) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 106
All hospital emergency departments should
ensure 100% availability of all these
equipments:
1. Airway equipments:
Laryngeal Mask Airway (43%)
Endotracheal tubes (76%)
AMBU bag (84%)
Transport ventilator (39%)
Laryngoscope (77%)
Oropharyngeal airway blades
(75%)
Capnography (24%)
Emergency Cricothyroidotomy kit
(28%)
Peak Expiratory Flow (16%)
2. Breathing equipments:
Emergency Thoracotomy set (25%)
Chest tube with seal drain (53%)
Ultrasonic nebulizer (61%)
Oxygen cylinder (93%)
Oxygen supply by pipeline (70%)
Suction machine (90%)
Non-invasive and invasive ventilator
(45%)
3. Circulation equipments:
Multipara monitor (68%)
Transport monitor (39%)
Pelvic binder or bed-sheets with clips
(37%)
Fluid warmer (25%)
Portable Ultrasound machine (36%)
Central line of all sizes (44%)
Infusion pumps and syringe driver
(58%)
Defibrillator (68%)
4. General equipments:
Mobile bed for resuscitation (59%)
Crash cart (70%)
ED blood storage (18%)
Hard cervical collar (48%)
Spine board with slings (40%)
5. Pediatric equipments:
Broselow tape (24%)
Phototherapy Unit (25%)
Incubators (28%)
Suggestions:
1. All essential equipments and supplies should be present in emergency department of
every hospital.
2. There should be dedicated staff for maintenance of equipments in emergency.
3. There should be dedicated training of staff regarding the maintenance of equipments
(how to use and maintain).
4. Maintain checklist of supplies and equipments, they should be checked before end of
every shift and beginning of every shift
5. Maintain a checklist of non-functional equipments and consumed supplies and should
be communicated during handovers 107
Observations and Results with Suggestions
23. POINT OF CARE LAB
Point of care lab for ED was observed in only 18 hospitals out of all 100 hospitals. Most of the
hospitals performed these tests in emergency labs:
1. Random blood sugar (74%)
2. Pregnancy test (56%)
3. Urinary ketones (49%)
4. Hemogram (46%)
5. Electrolyte (44%)
6. Blood urea & serum creatinine (44%)
Point of care lab and hospital labs did not perform the entire listed test of annexure-4 of study
tool. D-dimer, Pro-BNP, plasma ketones, toxicology screening-urinary, serum osmolality, urine
osmolality, TEG and PEF also did not performed by most of the hospitals as shown in table 43,
44 and figure 49.
Figure 49: Overall Compliance of Point of Care Lab for ED & Hospital
Best Practices for Point of Care Lab in ED: It was observed that only 2 hospitals performed
all types of laboratory investigations for emergency department; Ramakrishna Care hospital
and Primus Super Speciality Hospital. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 108
Table 43: Summary of Point of Care Lab by Category of Hospitals
Point of care lab in
ED
Medical Colleges
(n=20)
Govt. Hospitals
(>300 bed
strength)
(n=20)
Govt. Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Hemogram- Hb,
Hct, TLC, DLC,
Platelet
100 88 0 89 0109 3 7100 7
Random blood Sugar160 3130 4141 4170 2140 3
Coagulation profile:
PT, APTT, INR
3 0115 1106 0137 2 9100 7
Electrolytes: Na, K,
Cl,Ca
9 0107 0 97 111112 6100 7
Blood Urea & Serum
Creatinine
110 86 0 98 0118 3 7100 7
Blood Gas Analysis6 2116 1 91 117132 4110 6
Cardiac enzymes,
Trop-I, Trop-T
7 3 94 1115 014114 3110 6
Serum Amylase 7 1115 0102 2155 310100 7
D-Dimer1 1162 0131 0186 2109 0 8
Pro-BNP0 1172 0131 0184 212100 7
Urinary ketones 9 1 99 0 87 111122 5120 5
Plasma Ketones 1 1162 0130 0194 2127 010
Toxicology
Screening-Urinary
0 0180 0150 0190 2164 013
Serum osmolality 1 0173 0120 0193 2138 0 9
Urine osmolality 1 0172 0130 0193 2139 0 8
Pregnancy test 102 79 0 7130 6131 4110 6
Thromboelastogram
(TEG)
0 0190 0140 0191 2162 114
Peak Expiratory
Flowmeter
0 0190 1140 0196 111100 7
Microscopy: Thin &
Thick Smear
3 1136 0108 0117 2 9100 7
Rapid Diagnostic
Test (Malaria)
6 0125 1108 0117 2 9100 7
CSF: Microscopy &
Gram staining
4 1123 1112 1166 2109 0 8
Portable USG 4 1123 1110 118151 4140 4
Echocardiography 7 0104 1112 017132 4131 4
Portable X ray 111 77 1 73 412171 2132 3
CT Scan 100 77 0 83 0148 3 8100 7
*n-number of hospitals, ED-Emergency Department, Hb- Hemoglobin , Hct- Hematocrit, TLC- Total Leukocyte Count,
DLC- Differential Leukocyte Count, PT- Prothrombin Time, APTT- Activated partial thromboplastin time, INR- International
Normalized Ratio, BNP- Brain Natriuretic Peptide, USG- Ultrasonography, CT- Computerized Tomography 109
Observations and Results with Suggestions
Table 44: Overall Summary of Hospital labs by Category of Hospitals
Hospital Labs
Medical Colleges
(n=20)
Govt. Hospitals
(>300 bed
strength)
(n=20)
Govt. Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Hemogram- Hb,
Hct, TLC, DLC,
Platelet
190 1190 0190 0160 1150 0
Random blood Sugar170 2170 2180 1150 2140 1
Coagulation profile:
PT, APTT, INR
170 3132 4110 8180 0150 0
Electrolytes: Na, K,
Cl,Ca
170 2170 2150 4170 0150 0
Blood Urea & Serum
Creatinine
190 0181 0170 2170 0150 0
Blood Gas Analysis121 6101 81 117160 1140 1
Cardiac enzymes,
Trop-I, Trop-T
114 49 4 66 013170 1140 1
Serum Amylase 161 2121 56 112170 1150 0
D-Dimer 100104 0141 018151 2140 1
Pro-BNP8 0124 0141 018141 3140 1
Urinary ketones 142 3160 3141 4170 0140 1
Plasma Ketones 101 96 1112 017130 5110 4
Toxicology
Screening-Urinary
7 1122 0161 018111 66 1 9
Serum osmolality 8 1115 0131 018150 3140 1
Urine osmolality 8 2108 0101 117150 3150 0
Pregnancy test 180 1170 2180 1170 1140 1
Thromboelastogram
(TEG)
3 0161 0161 0189 0 84 011
Peak Expiratory
Flowmeter
4 1145 0132 017150 39 0 6
Microscopy: Thin &
Thick Smear
181 1181 0162 1180 0150 0
Rapid Diagnostic
Test (Malaria)
160 3181 0170 2180 0140 1
CSF: Microscopy &
Gram staining
142 4131 44 213180 0140 1
Portable USG 132 57 1102 116131 2120 3
Echocardiography 181 19 1 92 116161 0140 1
Portable X ray 142 2103 54 6 9150 1140 1
CT Scan 161 1100 86 011170 0130 2
*n-number of hospitals, ED-Emergency Department, Hb- Hemoglobin, Hct- Hematocrit, TLC- Total Leukocyte Count,
DLC- Differential Leukocyte Count, PT- Prothrombin Time, APTT- Activated partial thromboplastin time, INR- International
Normalized Ratio, BNP- Brain Natriuretic Peptide, USG- Ultrasonography, CT- Computerized Tomography Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 110
Figure 50: Comparison of Point of Care Lab for ED & for Hospital on % basis of compliance 111
Observations and Results with Suggestions
Suggestions:
All healthcare facilities should have either basic point of care lab in emergency department or
emergency lab in hospital for 24*7
24. ESSENTIAL MEDICINES FOR EMERGENCY
Out of 100 hospitals only 9 hospitals had all essential medicines required at emergency
department. In addition, it was found that only 11 hospitals had essential medicines used in
resuscitation out of all 100 hospitals.
Most of the hospitals did not have essential drugs used for emergency. The checklist contains
101 essential medicines required in emergency department. Out of these 101 medicines, 30
medicines are categorized as resuscitation medicines (medicines used in resuscitation).
We had calculated the percentages of all essential equipment and medicines. The availability of
essential medicines was calculated on three different scales: 50% or less (Score-0), 50% to 99%
(Score-1), and 100% (Score-2).
For resuscitation medicines, the scoring was based on two scales: the score was zero if even
one drug was missing from list (Score 0) and the score was two if all 30 medicines were present
(Score-2). Resuscitation drugs should be must in all hospitals.
Essential Medicines: The medicines that “satisfy the priority health care
needs of the population”. These are the medications to which people
should have access at all times in sufficient amounts. (WHO)
Resuscitation Medicines (n=30): The medicines
which are used during resuscitation process.
Resuscitation Medicine Package: It is a package
of 30 medicines. Even if one drug is deficient at
time of assessment, the score is zero.
Other essential
medicines (n=71):
The essential
medicines other
than resuscitation
medicines included in
this category
Only 2
medical
colleges have
complete
package of
resuscitation
medicines
None of the
government
hospitals have
complete
package of
resuscitation
medicines
9 private
hospitals have
complete
package of
resuscitation
medicines
9 private hospitals
have complete
package of
resuscitation
medicines
Figure 51: Chart of Essential medicines for Hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 112
Most of the hospitals did not have essential drugs used for emergency especially in government
hospitals when compared to the private ones. Not all private hospitals had all the enlisted drugs
for emergency as in annexure (figure 51).
Table 45: Overall Summary of Essential Medicines for Emergency:
Essential Medicines/
Drugs for Emergency
Medical
Colleges
(N=20)
Govt. Hosp.
(>300 bed
strength)
(N=20)
Govt. Hosp.
(<300 bed
strength)
(N=20)
Pvt. Hosp.
(>300 bed
strength)
(N=20)
Pvt. Hosp.
(<300 bed
strength)
(N=20)
Resuscitation Drugs 2 (10%) 0 (0%) 0 (0%) 3 (15%) 6 (30%)
Other Essential Drugs 72% 71% 63% 86% 87%
Only 2 medical colleges (Government Medical College, Thiruvanananthapuram and AIIMS, Bhopal)
had complete package of resuscitation drugs, other than these none of the government hospitals
had complete package of resuscitation drugs out of 60 hospitals.
For private hospitals >300 beds, 3 hospitals (Grant Medical Foundation Ruby Hall Clinic,
Pune; Kasturi Medical College & Hospital and Fortis Hospital, Jaipur) had complete package of
resuscitation drugs.
For private hospitals >300 beds, 6 hospitals (Bhailal Amin General Hospital; Birla CK Hospital,
Jaipur; Charak Hospital & Research Centre, Lucknow; Ruban Memorial Hospital; Ramakrishna
Care Hospital and Primus Super Speciality Hospital) had complete package of resuscitation drugs.
Figure 52: Comparison of Essential Medicines for Emergency by Category of Hospitals i) on the basis of Percentage
range ii) on the basis of Overall Performance/Compliance
Overall the small private hospitals performed best out of the 5 category of hospitals. Only 2
medical colleges have all essential medicines out of all 60 government hospitals. 113
Observations and Results with Suggestions
Suggestions:
1. Complete package of resuscitation medicines should be present in all hospitals for 24*7
2. Other essential medicines should also be present in all hospitals for 24*7
3. During third party audits, if any essential drug is missing from the resuscitation package
then the license of the hospital may be cancelled
Best Practices for Essential Medicines in ED
100% compliance was observed in following hospitals for essential medicines which
are required for emergency department:
Medical College: AIIMS, Bhopal, Government Medical College,
Thiruvanananthapuram
Private Hospital: Grant Medical Foundation Ruby Hall Clinic, Kasturi Medical
College & Hospital, Fortis Hospital, Jaipur, Birla CK Hospital, Ruban Memorial
Hospital, Ramakrishna Care Hospital, and Primus Super Speciality Hospital Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 114
II. LIVE OBSERVATION
1. DISPOSITION TIME
The time from entry of patient at emergency department to admission/transfer-out/discharge is
disposition time.
Ideally for time sensitive conditions (STEMI, stroke, trauma, cardiac arrest), patients should be
immediately seen after arrival in emergency department. For red triage, patient should be seen
within 10 min; for yellow triage, patient should be seen within 30 min and for green triage,
patient should be seen within 4 hours after arrival in emergency.
Ideal disposition time for red triage patients should be within 6 hours, for yellow triage patients
should be within 12 hours.
Table 46: Summary of Disposition Time of Patients Visited in Emergency Department
Disposition time
(in minutes)
Medical
Colleges
(n=20)
Govt. Hospitals
(>300 bed
strength)
(n=20)
Govt. Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
Red triaged
patients
90 [686]
7-4680
30 [44]
5-1440
17 [31]
5-60
45 [102]
6-240
15 [20]
5-48
Yellow triaged
patients
200 [307]
12-1440
90 [315]
10-3060
120 [121]
8-360
120 [210]
7-1920
30 [63]
10-225
Green triaged
patients
60 [214]
6-1450
45 [145]
1-720
46 [188]
10-900
75 [91]
4-575
32 [162]
7-420
*n-number of hospitals, Median [IQR] Min-Max
Figure 53: Chart of Disposition time of Patients by Hospitals Category 115
Observations and Results with Suggestions
The disposition time of red triaged patients was high in medical colleges with median of 90
minutes and low in private hospitals (<300 beds) with median of 15 minutes.
For yellow triaged patients the disposition time was high in medical college with median of 200
minutes and low in private hospitals (<300 beds) with median of 30 minutes.
Similarly, for green triaged patients it was high in private hospitals (>300 beds) with a median
of 75 minutes and low in private hospitals (<300 beds) with median of 32 minutes.
The disposition time of red triaged patients was high in medical college. It was due to various
factors observed as such:
1. Lack of emergency care provider
2. High patient load
3. Need of multi-speciality reviews
4. Multiple investigations being conducted
5. Lack of dedicated department leads todelayed decision making from definitive care/
disposal
6. Not availability of buffer beds for addressing surge capacity under emergency department
7. Mismatch between available emergency beds and patient load and manpower
8. Not availability of triage policy in most of the hospitals
Figure 54: Comparison of Disposal Time of Patients visited in Emergency by Hospital Category
Suggestions:
1. Implementation of triage policy in all hospitals (Prioritization of patient)
2. Adequate manpower should be present in hospitals as per footfall of patients and
emergency beds
3. Optimum utilization of resources
4. There should be a dedicated emergency nurse coordination (ENC) system
5. Empowered hospital committee comprising of members of emergency department and
allied medical and surgical speciality to address the issues and challenges pertaining to
emergency department Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 116
2. CHEST PAIN
A. Hospital-wise comparison:
In this study, a total of 201 patients of chest pain were observed by our assessor’s team from all
zones and categories of our country.
Percutaneous coronary intervention (PCI) is a non-surgical procedure used to treat narrowing
(stenosis) of the coronary arteries of the heart found in coronary artery disease. PCI is also used
in people after other forms of myocardial infarction or unstable angina where there is a high risk
of further events.
Firstly, 53% hospitals did not have triage. Secondly, ECG was not performed within 10 min in
30% hospitals. Some hospitals don’t even have ECG machine. Thirdly, Door to needle was not
performed 54% hospitals within 30 minutes. Lastly, Door to PCI was also absent in 68% hospitals.
Figure 55: Overall Comparison of Chest Pain Management by Category of Hospitals
*N=Number of red patients of chest pain, 65 patients were observed from 20 Medical Colleges, 33 patients were observed
from 20 Govt. Hosp. (>300 bed strength), 34 patients were observed from 20 Govt. Hosp. (<300 bed strength), 44 patients
were observed from 20 Pvt. Hosp. (>300 bed strength) and 25 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
The management of chest pain was observed best in the private hospitals (<300 beds) among
all the categories of healthcare facilities as shown in table 47 and figure 55. Overall door to PCI
was not done in most of the hospitals. 117
Observations and Results with Suggestions
Table 47: Summary of Chest Pain Management by Category of Hospitals: N (%)
Chest Pain
Management
Medical
Colleges
(N=65 Pts)
Govt. Hosp.
(>300 bed
strength)
(N=33 Pts)
Govt. Hosp.
(<300 bed
strength)
(N=34 Pts)
Pvt. Hosp.
(>300 bed
strength)
(N=44 Pts)
Pvt. Hosp.
(<300 bed
strength)
(N=25 Pts)
Yes No Yes No Yes No Yes No Yes No
Triage
22
(34)
43
(66)
14
(42)
19
(58)
7 (21)
27
(79)
28
(64)
16
(36)
24
(96)
1 (4)
Door to ECG
(<10 min)
37
(59)
26
(41)
23
(70)
10
(30)
16
(48)
17
(52)
39
(89)
5 (11)
24
(96)
1 (4)
Door to Needle
(<30 min)
17
(42)
23
(58)
8 (36)
14
(64)
1 (5)
20
(95)
16
(57)
12
(43)
18
(90)
2 (10)
Door to PCI
(<90 min)
6 (27)
16
(73)
5 (29)
12
(71)
0 (0)
16
(100)
11
(38)
18
(62)
10
(67)
5 (33)
*N=Number of red patients of chest pain, 65 patients were observed from 20 Medical Colleges, 33 patients were observed
from 20 Govt. Hosp. (>300 bed strength), 34 patients were observed from 20 Govt. Hosp. (<300 bed strength), 44 patients
were observed from 20 Pvt. Hosp. (>300 bed strength) and 25 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
Figure 56: Chart of Chest Pain Management of patients by Category of Hospitals
B. Zone-wise comparison
In addition, it was observed that the east zone performed best and the north zone performed
worst out of all zones.
In the east zone, 35 patients of chest pain had observed in 11 different hospitals and 17 patients
managed within the timeframe.
Similarly, 47 patients of chest pain had observed in 11 different hospitals of north zone and only
3 patients managed within the timeframe. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 118
Table 48: Zone-wise Summary of Chest Pain Management in Hospitals: N (%)
Chest Pain
Management
North (N=47
Pts.)
South (N=48
Pts.)
East (N=35
Pts.)
West (N=44
Pts.)
North East
(N=27 Pts.)
Yes No Yes No Yes No Yes No Yes No
Triage
16
(34)
31
(66)
17
(35)
31 (65)
25
(71)
10
(29)
27
(61)
17
(39)
10
(37)
17
(63)
Door to ECG
(<10 min)
34
(72)
13
(28)
26
(55)
21(45)
26
(76)
8 (24)
38
(88)
5 (12)
15
(56)
12
(44)
Door to
Needle (<30
min)
9 (32)
19
(68)
14
(33)
28 (67)
17
(74)
6 (26)
13
(57)
10
(43)
7 (47)8 (53)
Door to PCI
(<90 min)
3 (14)
18
(86)
8 (20)32 (80)
17
(74)
6 (26)3 (75)1 (25)1 (9)
10
(91)
*N=Number of red patients of chest pain, 47 patients were observed from 30 hospitals of north zone, 48 patients were
observed from 21 hospitals of south zone, 35 patients were observed from 11 hospitals of east zone, 44 patients were observed
from 16 hospitals of west zone and 27 patients were observed from 22 hospitals of north-east zone
Figure 57: Zone-wise Comparison of Chest Pain Management in Hospitals
*N=Number of red patients of chest pain, 47 patients were observed from 30 hospitals of north zone, 48 patients were
observed from 21 hospitals of south zone, 35 patients were observed from 11 hospitals of east zone, 44 patients were observed
from 16 hospitals of west zone and 27 patients were observed from 22 hospitals of north-east zone 119
Observations and Results with Suggestions
C. NABH Accreditation-wise comparison:
Also, it was observed that NABH accredited hospitals performed better than non-NABH accredited
hospitals for management of chest pain (table 49 and figure 58).
Table 49: Overall Summary of Chest Pain Management in NABH accredited and
non-NABH accredited hospitals: N (%)
Chest Pain Management
NABH Accredited Hospitals
(Pt.= 49)
Non-NABH Accredited Hospitals
(Pt.= 152)
YesNoYesNo
Triage38 (78) 11 (22) 57 (37) 95 (63)
Door to ECG (<10 min) 44 (90) 5 (10) 95 (64) 54 (36)
Door to Needle (<30 min) 22 (69) 10 (31) 38 (38) 61 (62)
Door to PCI (<90 min) 16 (52) 15 (48) 16 (24) 52 (76)
Figure 58: Overall Comparison of Chest Pain Management in NABH accredited and non-NABH accredited hospitals
Factors affecting Chest Pain Management:
1. Lack of manpower (such as ECG technician)
2. Lack of training
3. Lack of supplies (such as ECG machine)
4. Lack of infrastructure
5. Lack of policy
Suggestions for Management of Chest pain:
1. Upgrade them for thrombolysis.
2. Adequately trained emergency care provider.
3. All district hospitals must have ECG machine and technician.
4. Establish Tele-ECG and Tele-Medicine programme.
5. Resuscitate patient in district hospital and refer them to other higher government hospital.
6. Develop a STEMI Programme by Hub and Spoke Model (figure 59)
7. Develop PCI centres in multi-speciality hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 120
Figure 59: Hub and Spoke model for Thrombolysis near home – STEMI
Requirements for STEMI Hub and Spoke Model:
1. MOU (Memorandum of Understanding) with Local Government
2. Training
3. Supplies
4. Consent of patient
5. Governance
6. Budget Allocation
7. Cashless care in all hospitals for red triaged patients
Best practice in District Hospitals for Thrombolysis
1. District Hospital, Baramulla, J&K
2. North Goa District Hospital, Goa
3. Jai Prakash Narayan District Hospital, Bhopal
4. Southern Railway Hospital, Madras
3. STROKE
A stroke is a medical condition in which poor blood flow to the brain results in cell death. There
are two main types of stroke: ischemic, due to lack of blood flow, and haemorrhagic, due to
bleeding. Both result in parts of the brain not functioning properly. 121
Observations and Results with Suggestions
A. Hospital-wise comparison
The management of stroke was observed best in the small private hospitals and worst observed in
small government hospitals among all the categories of healthcare facilities due to lack of facilities
as shown in table 50 and figure 60.
Figure 60: Comparison of Stroke Management by Category of Hospitals
*N=Number of red patients of stroke, 50 patients were observed from 20 Medical Colleges, 17 patients were observed from
20 Govt. Hosp. (>300 bed strength), 14 patients were observed from 20 Govt. Hosp. (<300 bed strength), 25 patients were
observed from 20 Pvt. Hosp. (>300 bed strength) and 20 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
The management of stroke was also not observed well in district hospitals due to lack of
thrombolysis and CT scan machine.
Door to Doctor was achieved within 10 minutes in 79% hospitals. But Door to CT completion
was not performed within 25 minutes in 47% hospitals. Door to CT reading was not achieved
within 45 minutes in 52% hospitals. Door to thrombolysis was absent in 74% hospitals as shown
in figure 61. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 122
Table 50: Summary of Stroke Management by Category of Hospitals: N (%)
Stroke
Management
Medical
Colleges
(N=50 Pts)
Govt. hospitals
(>300 bed
strength)
(N=17 Pts)
Govt. hospitals
(<300 bed
strength)
(N=14 Pts)
Pvt. hospitals
(>300 bed
strength)
(N=25 Pts)
Pvt. hospitals
(<300 bed
strength)
(N=20 Pts)
Yes No Yes No Yes No Yes No Yes No
Door to Doctor
(<10 min)
38
(76)
12
(24)
15
(88)
2 (12)9 (64)5 (36)
20
(80)
5 (20)
18
(90)
2 (10)
Door to CT
Completion
(<25 min)
16
(34)
31
(66)
10
(63)
6 (37)1 (8)
12
(92)
19
(76)
6 (24)
17
(89)
2 (11)
Door to CT
reading
(<45 min)
15
(31)
33
(69)
10
(63)
6 (37)1 (8)
12
(92)
15
(60)
10
(40)
17
(94)
1 (6)
Door to
Thrombolytic
(<60 min)
6 (16)
32
(84)
6 (40)9 (60)0 (0)
9
(100)
7 (33)
14
(67)
6 (50)6 (50)
Door to First
Pass (<90 min)
6 (23)
20
(77)
6 (50)6 (50)1 (10)9 (90)5 (31)
11
(69)
8 (73)3 (27)
*N=Number of red patients of stroke, 50 patients were observed from 20 Medical Colleges, 17 patients were observed from
20 Govt. Hosp. (>300 bed strength), 14 patients were observed from 20 Govt. Hosp. (<300 bed strength), 25 patients were
observed from 20 Pvt. Hosp. (>300 bed strength) and 20 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
Figure 61: Chart of Stroke Management of patients by Hospital Category
B. Zone-wise comparison
In addition, it was observed that the east zone performed best and the north zone performed
worst out of all zones (table 51 and figure 62). 123
Observations and Results with Suggestions
Table 51: Zone-wise Summary of Stroke Management in Hospitals: N (%)
Stroke
Management
North (N=19
Pts.)
South (N=43
Pts.)
East (N=24
Pts.)
West (N=16
Pts.)
North East
(N=24 Pts.)
Yes No Yes No Yes No Yes No Yes No
Door to Doctor
(<10 min)
18
(95)
1 (5)
33
(77)
10
(23)
18
(75)
6 (25)
11
(69)
5 (31)
20
(83)
4 (17
Door to CT
Completion
(<25 min)
9 (47)
10
(53)
22
(51)
21
(49)
17
(71)
7 (29)6 (46)7 (54)9 (42)
12
(57)
Door to CT
reading (<45
min)
6 (33)
12
(67)
23
(53)
20
(47)
18
(75)
6 (25)6 (46)7 (54)5 (23)
17
(77)
Door to
Thrombolytic
(<60 min)
3 (27)8 (73)6 (15)
34
(85
16
(73)
6 (27)0 (0)
6
(100)
0 (0)
16
(100)
Door to First Pass
(<90 min)
3 (30)7 (70)7 (22)
25
(78)
15
(71)
6 (29)0 (0)
4
(100)
1 (13)7 (87)
*N=Number of red patients of stroke, 19 patients were observed from 30 hospitals of north zone, 43 patients were observed
from 21 hospitals of south zone, 24 patients were observed from 11 hospitals of east zone, 16 patients were observed from
16 hospitals of west zone and 24 patients were observed from 22 hospitals of north-east zone
Figure 62: Zone-wise Comparison of Stroke Management in Hospitals
*N=Number of red patients of stroke, 19 patients were observed from 30 hospitals of north zone, 43 patients were observed
from 21 hospitals of south zone, 24 patients were observed from 11 hospitals of east zone, 16 patients were observed from
16 hospitals of west zone and 24 patients were observed from 22 hospitals of north-east zone Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 124
C. NABH Accreditation-wise comparison
Also, it was observed that NABH accredited hospitals performed better than non-NABH accredited
hospitals for management of stroke (table 52 and figure 63).
Table 52: Overall Summary of Stroke Management in NABH accredited and non-
NABH accredited hospitals: N (%)
Stroke Management
NABH Accredited Hospitals (N=28)
(Pts.= 31)
Non-NABH Accredited Hospitals
(N=72) (Pts.= 95)
YesNoYesNo
Door to Doctor
(<10 min)
24 77% 7 23% 76 80% 19 20%
Door to CT Completion
(<25 min)
23 77% 7 23% 40 44% 50 56%
Door to CT reading
(<45 min)
23 79% 6 31% 35 38% 56 62%
Door to Thrombolytic
(<60 min)
10 43% 13 57% 15 21% 57 79%
Door to First Pass
(<90 min)
10 56% 8 44% 16 28% 41 72%
Figure 63: Overall Summary of Stroke Management in NABH accredited and non-NABH accredited hospitals
Factors affecting Stroke Management:
1. Lack of manpower
2. Lack of training
3. Lack of supplies (such as CT Scan machine)
4. Lack of infrastructure
5. Lack of policy
Best Practice for CT Scan in District Hospitals:
!District Hospital, Tenali
!Deen Dayal Upadhyay Hospital, Shimla
!Morigaon Civil Hospital, Assam 125
Observations and Results with Suggestions
Suggestions:
1. Thrombolysis near home – Hub and Spoke Model (figure 59)
2. Develop Tele-stroke programme
3. Stroke management by PPP (Public-Private Partnership) model in district hospitals
4. TRAUMA
A. Hospital-wise comparison
It was observed that trauma management was good in private hospitals when compared to the
government ones as shown in table 53and figure64, because the disposal of patients was delayed
in government hospitals.
Table 53: Summary of Trauma Management by Category of Hospitals: N (%)
Trauma Management
Medical
Colleges
(N=57 Pts)
Govt.
hospitals
(>300 bed
strength)
(N=30 Pts)
Govt.
hospitals
(<300 bed
strength)
(N=21 Pts)
Pvt. hospitals
(>300 bed
strength)
(N=24 Pts)
Pvt. hospitals
(<300 bed
strength)
(N=12 Pts)
Yes No Yes No Yes No Yes No Yes No
Door to Resuscitation time
(<15 min)
34
(60)
23
(40)
20
(67)
10
(33)
9 (43)
12
(57)
19
(73)
5 (21)
12
(100)
0 (0)
Door to CT Completion
time in Head Injury
(<45 min)
26
(50)
26
(50)
9 (31)
20
(69)
2 (11)
16
(89)
11
(69)
5 (31)
10
(83)
2 (17)
Disposal Time (in minutes)185 150 60 62 30
*N=Number of red patients of trauma, 57 patients were observed from 20 Medical Colleges, 30 patients were observed from
20 Govt. Hosp. (>300 bed strength), 21 patients were observed from 20 Govt. Hosp. (<300 bed strength), 24 patients were
observed from 20 Pvt. Hosp. (>300 bed strength) and 12 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
Figure 64: Comparison of Trauma Management by Hospital Categories
*N=Number of red patients of trauma, 57 patients were observed from 20 Medical Colleges, 30 patients were observed from
20 Govt. Hosp. (>300 bed strength), 21 patients were observed from 20 Govt. Hosp. (<300 bed strength), 24 patients were
observed from 20 Pvt. Hosp. (>300 bed strength) and 12 patients were observed from 20 Pvt. Hosp. (<300 bed strength) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 126
B. Zone-wise comparison
Table 54: Zone-wise Summary of Trauma Management in Hospitals: N(%)
Trauma Management
North (N=43
Pts.)
South (N=42
Pts.)
East (N=16
Pts.)
West (N=26
Pts.)
North East
(N=17 Pts.)
Yes No Yes No Yes No Yes No Yes No
Door to Resuscitation
time (<15 min)
26
(60)
17
(40)
25
(60)
17
(40)
15
(94)
1 (6)
20
(77)
6
(23)
8
(47)
9 (53)
Door to CT
Completion time in
Head Injury (<45
min)
11
(30)
26
(70)
20
(49)
21
(51)
11
(79)
3
(21)
13
(62)
8
(38)
3
(21)
11
(79)
Disposal Time
(in minutes)
498 635 — 103 110
*N=Number of red patients of trauma, 43 patients were observed from 30 hospitals of north zone, 42 patients were observed
from 21 hospitals of south zone, 16 patients were observed from 11 hospitals of east zone, 26 patients were observed from 16
hospitals of west zone and 17 patients were observed from 22 hospitals of north-east zone.
Figure 65: Zone-wise Comparison of Trauma Management in Hospitals
*N=Number of red patients of trauma, 43 patients were observed from 30 hospitals of north zone, 42 patients were observed
from 21 hospitals of south zone, 16 patients were observed from 11 hospitals of east zone, 26 patients were observed from 16
hospitals of west zone and 17 patients were observed from 22 hospitals of north-east zone. 127
Observations and Results with Suggestions
C. NABH Accreditation comparison:
Table 55: Summary of Trauma Management in NABH accredited and non-NABH
accredited hospitals
Trauma Management
NABH Accredited Hospitals (N=28)
(Pt.= 37)
Non-NABH Accredited Hospitals
(N=72) (Pt.= 107)
YesNoYesNo
Door to Resuscitation time
(<15 min)
29 78% 8 22% 65 61% 42 39%
Door to CT Completion
time in Head Injury
(<45 min)
17 63% 1 37% 41 41% 59 59%
Disposal Time (in minutes)74395
Figure 66: Comparison of Trauma Management in NABH accredited and non-NABH accredited hospitals
Best Practice for CT Scan in District Hospitals:
1. District Hospital, Tenali
2. Deen Dayal Upadhyay Hospital, Shimla
3. HNB Base Hospital, Shimla
Factors affecting Trauma management:
1. Lack of staff
2. Lack of policy
3. Lack of training
4. Lack of resources (such as CT Scan machine)
Suggestions:
1. Adequate staff
2. Training
3. NABH Accreditation Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 128
5. INCIDENCE OF VIOLENCE
During assessment, incidence of violence was observed in the hospital and assessors noted the
observation in the given study tool. In the given table 56 and figure 67 the ratio of incidence of
violence is shown by category of hospitals.
Table 56: Summary of incidence of Violence by Hospital Categories: N (%)
Live
Observation
Medical
Colleges
(n=15)
Govt. hospitals
(>300 bed
strength)
(n=17)
Govt. hospitals
(<300 bed
strength)
(n=18)
Pvt. hospitals
(>300 bed
strength)
(n=18)
Pvt. hospitals
(<300 bed
strength)
(n=16)
Yes No Yes No Yes No Yes No Yes No
Incidence of
Violence
7 (47)8 (53)6 (35)
11
(65)
8 (44)
10
(56)
4 (22)
14
(78)
5 (31)11 (69)
Figure 67: Representation of Incidence of Violence Observed by Category of Hospitals
5.1 Reason of Violence
It was also observed during live observation about the reason of violence incident in hospitals.
The reason of violence was found either communication failure or care delay.
Figure 68: Representation of the reason of Violence by Category of Hospitals 129
Observations and Results with Suggestions
5.2 Mitigation measures
Mitigation measures were also recorded like availability of security guard in hospital, availability
of police in hospital and availability of anti-violence mitigation policy.
Table 57: Summary of Mitigation measures available by Category of Hospitals: N (%)
Mitigation
measures
Medical
Colleges
(N=20)
Govt. hospitals
(>300 bed
strength)
(N=20)
Govt. hospitals
(<300 bed
strength)
(N=20)
Pvt. hospitals
(>300 bed
strength)
(N=20)
Pvt. hospitals
(<300 bed
strength)
(N=20)
Yes No Yes No Yes No Yes No Yes No
Private security
guard
12
(86)
2 (14)8 (53)7 (47)
10
(63)
6 (37)
15
(94)
1 (6)
13
(87)
2 (13)
Private Security
Guard 24*7
10
(91)
1 (9)8 (80)2 (20)4 (43)3 (57)14 (0)
2
(100)
9 (18)2 (82)
Police Available
13
(93)
1 (7)9 (60)6 (40)7 (47)8 (53)4 (29)
10
(71)
7 (54)6 (46)
Police Available
Guard 24*7
11
(32)
1 (8)7 (78)2 (22)5 (63)3 (37)5 (56)4 (44)4 (50)4 (50)
Anti-violence
mitigation policy
available
6 (46)7 (54)1 (8)
11
(92)
2 (15)
11
(85)
7 (64)4 (36)9 (64)5 (36)
Figure 69: Representation of Mitigation measures available by Category of Hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 130
6. COMMUNICATION SKILLS IN EMERGENCY DEPARTMENT
During/after treatment of any patient, the health care provider/staff/nurses communicate with the
patient/patient attendant/relative to inform them about the condition of patient. It was observed
that sometimes the health care provider/staff/nurses did not communicate properly with the
patient/patient attendant/relative.
For knowing the way of communication, assessor’s team observed the communication between
hospital staff and patient during live observation and the summary of communication skills is
shown in table 58 and figure 70.
Table 58: Summary of Communication Skills in Emergency Department by
Category of Hospitals: N(%)
Communication Skills in ED
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt.
hospitals
(>300 bed
strength)
(n=20)
Pvt.
hospitals
(<300 bed
strength)
(n=20)
Full content with empathy and
share decision making
7 (44) 9 (50) 8 (47) 16 (89) 13 (93)
Full content with empathy and
no share decision making
2 (13) 4 (22) 6 (35) 2 (11) 0 (0)
Full content with no empathy 3 (19) 5 (28) 1 (6) 0 (0) 1 (7)
Minimal Communication and
inappropriate behaviour
4 (25) 0 (0) 2 (12) 0 (0) 0 (0)
*n- number of hospitals
Figure 70: Representation of Communication Skills in Emergency Department of Hospital Category
Suggestions:
1. Create a cadre of emergency nurse coordinator (ENC) from the existing pool of nursing
officers with defined roles and responsibility.
2. Training of staff on communication skills from under-graduate level (for doctors, nurses
and paramedics).
3. Establish a concept of shared decision making. 131
Observations and Results with Suggestions
7. PATIENT SATISFACTION
During live observation by assessor’s team for 24 hours, 3-5 random patients from each triage
category (red, yellow and green) were asked few questions about the care (in terms of satisfaction)
provided in the hospital.
Table 59: Summary of Patient Satisfaction by Category of N(%) Hospitals N(%)
Patient
Satisfaction
Medical
Colleges (n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
Red
Triage
Yellow
Triage
Green
triage
Red
Triage
Yellow
Triage
Green
triage
Red
Triage
Yellow
Triage
Green
triage
Red
Triage
Yellow
Triage
Green
triage
Red
Triage
Yellow
Triage
Green
triage
Extremely
satisfied
1 (6)1 (7)0 (0)3 (21)2 (13)3 (20)1 (8)2 (15)5 (36)4 (24)5 (26)7 (39)2 (18)3 (23)4 (29)
Very
satisfied
6 (40)6 (40)5 (33)3 (22)6 (40)6 (40)3 (23)4 (31)4 (29)7 (41)9 (47)5 (28)7 (64)7 (54)6 (43)
Moderately
satisfied
4 (27)4 (27)5 (33)7 (50)7 (47)4 (27)5 (38)4 (31)3 (21)5 (29)3 (16)4 (22)2 (18)2 (15)3 (21)
Slightly
satisfied
3 (20)3 (20)4 (27)1 (7)0 (0)2 (13)4 (31)3 (23)2 (14)1 (6)2 (11)2 (11)0 (0)0 (0)1 (7)
Not at all
satisfied
1 (7)1 (6)1 (7)0 (0)0 (0)0 (0)0 (0)0 (0)0 (0)0 (0)0 (0)0 (0)0 (0)1 (8)0 (0)
*n- number of hospitals
Figure 71: Chart of Patient Satisfaction by Hospitals Categories
*Note: Patient satisfaction was individually observed and calculated for red, yellow and green triaged patients. The percentage
in brackets shows extremely satisfied and very satisfied patients/ patient attendant from the level of care provided by healthcare
facility Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 132
Figure 72: Representation of Triaged Patient Satisfaction for care provided by Hospital Categories 133
Observations and Results with Suggestions
Suggestions
1. Establish a suggestion box in the hospital, especially within the emergency department
premises.
2. Establish patient information display system.
3. Train emergency care providers on communication skills including grief counselling
and shared decision making.
8. REFERRAL OF THE PATIENT
During live observation, referral of patient was observed. Organization referral policy was checked.
It was also observed that the hospital provides proper arrangement to the patient or not and the
patient was assisted with any assistance or not from the hospital during referral.
It is clear from the table 60 and figure 73 that 55%hospitals have some referral policy, 53%
hospitals provide proper arrangement to patients and assistance was provided in only 49%
hospitals during referral.
Table 60: Summary of Referral of Patient by Hospital Categories: N (%)
Referral of
Patients
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
Yes No Yes No Yes No Yes No Yes No
Any referral
policy
2 (15)
11
(85)
11
(61)
7 (39)
12
(71)
5 (29)
15
(83)
3 (17)
15
(94)
1 (6)
Any proper
arrangement
3 (23)
10
(77)
10
(56)
8 (44)9 (53)8 (47)
17
(94)
1 (6)
14
(93)
1 (7)
Any assistance
during referral
4 (31)9 (69)8 (44)
10
(56)
7 (41)
10
(59)
15
(88)
2 (12)
15
(94)
1 (6)
*n- number of hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 134
Figure 73: Graphically representation of Referral of Patient by Category of Hospitals
Suggestions:
1. Develop National Forward and Backward Referral Policy with safe transport integrated with
local EMS system
a. Hub and Spoke Model (figure 74)
b. Structured referral protocols
c. There should be informed transfer.
2. NABH Accreditation
There should be a Standard Referral back policy (Standard Forward & Backward Policy) and it
has to be in the form of hub and spoke model. In this policy, there should be a MOU of tertiary
care centres with mid-level government hospitals with multi-speciality district hospitals as well
as with private hospitals (cashless scheme).
In this policy, the referral should be on the basis of lack of facilities in secondary care. The tertiary
care should mandate to admit all red triaged patients as well as yellow triaged patients.
In case of fully utilized tertiary care centres, they need to admit patients through emergency then
they need to stabilize the patients and then they can transfer the stabilized yellow patient to other
middle level government hospital for further care to cater the load.
The red triaged patients need to admit through emergency in tertiary care then after stabilization
of patient transfer it either to ICU (who require ventilator) or HDU (who do not need ventilator).
It will vacant the red triaged beds in emergency and be available for other patients. 135
Observations and Results with Suggestions
Figure 74: Hub and Spoke Model for National Forward and Backward Referral Policy
Requirements:
1. MOU with Government and EMS
2. There should be trade-off between tertiary and secondary care system for management
of complex cases which are resource intensive in tertiary care with cases, which can
be stabilized in secondary care centres.
3. Optimal utilization of all tiers of healthcare system based on capacity and capabilities. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 136
III. LIVE OBSERVATION
(One Day Data of Emergency)
1. BURDEN OF PATIENTS (OPD AND EMERGENCY)
One day data (24 hours data either of previous day or same day) was collected by assessor’s team
from registration desk of the hospital containing information regarding total visits of patients in
hospital both OPD and emergency, admissions/transfer-out/discharge, death etc.
The burden of patients needing emergency came in 24 hours was 23% in medical colleges, 8%
in government hospitals more than 300 beds, 13% in government hospitals less than 300 beds,
6% in private hospitals more than 300 beds and 25% in private hospitals less than 300 beds as
shown in table 61.
The comparison of patients in OPD and emergency is represented in figure 75 for different
categories of hospitals.
In medical college, the burden of patients needing emergency for 24 hours was maximum at
SMS Medical College & Hospital and minimum at AIIMS, Bhopal.
In government hospitals >300 beds, the burden of patients in emergency was maximum at Indira
Gandhi Government General Hospital, Puducherry and minimum at District Hospital, Dhamtari
(for emergency) and Southern Railways Hospital, Chennai (for OPD).
In government hospitals <300 beds, the burden of patients in emergency was maximum at Puri
District Headquarter Hospital and minimum at Jamanabai General Hospital, Gujarat.
In private hospitals >300 beds, the burden of patients in emergency was maximum at Dr Ram
Manohar Lohia Hospital, Lucknow and minimum at Fortis Hospital, Rajasthan.
In private hospitals <300 beds, the burden of patients in emergency was maximum at Primus
Super Speciality Hospital, Delhi and minimum at Jaipur Golden Hospital, Delhi.
Table 61: Summary of number of patients at OPD and Emergency during Single day (24 hours)
Hospital Categories
Total Emergency and Injury
care Patients
OPD Patients other than
emergency cases
% of ED
Patients out
of all patients
visited in
hospital
n
Median [IQR]
Min-Max
n
Median [IQR]
Min-Max
Medical Colleges 16
446 [376]
55-7450
15
1942 [1374]
250-7545
17%
Govt. Hosp.
(>300 bed strength)
19
103 [92]
22-769
18
1223 [1095]
54-5164
11%
Govt. Hosp.
(<300 bed strength)
15
103 [103]
15-960
14
820 [1261]
40-2769
11%
Pvt. Hosp.
(>300 bed strength)
18
57 [87]
22-315
17
988 [1184]
27-3460
10%
Pvt. Hosp.
(<300 bed strength)
16
25 [24]
13-285
14 102 [332] 22-476 30%
*n: number of hospitals which shared data with assessor’s team, IQR: Interquartile range 137
Observations and Results with Suggestions
Figure 75: Comparison of Patients visited in OPD and Emergency in different Categories of Hospitals (ONE DAY)
*M. C.- Medical College, G. H.- Government Hospital, P. H.- Private Hospital, ED- Emergency department, OPD- Out patient
visit department
2. DISPOSITION SUMMARY
The disposition of patients in emergency department was also recorded by the team of assessors.
In this, number of admissions, LAMA (Leave against Medical Advice), discharge, Death in ED for
24 hours was recorded by the team. The summary of the patient disposal from ED is shown in
table 62 by categories of healthcare facilities. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 138
Table 62: Summary of Disposition of Patients at emergency department (24 hours)
by Category in the Healthcare Facilities: Median (% per total ED Visits)
Disposition of
Patients from ED
Medical
Colleges
Govt. Hosp.
(>300 bed
strength)
Govt. Hosp.
(<300 bed
strength)
Pvt. Hosp.
(>300 bed
strength)
Pvt. Hosp.
(<300 bed
strength)
n
Median
(% Out
of total
ED
visits)
n
Median
(% Out
of total
ED
visits)
n
Median
(% Out
of total
ED
visits)
n
Median
(% Out
of total
ED
visits)
n
Median
(% Out
of total
ED
visits)
Total Admissions 16
66
(15%)
16
24.5
(24%)
16
14
(13%)
1521(37%)15
13.5
(54%)
LAMA193.5 (1%)193 (3%)193.5 (3%)181 (2%)183 (12%)
Discharge 15
55
(12%)
15
50
(49%)
15
17
(17%)
15
22.5
(39%)
156.5 (26%)
Death 182 (0%)181.5 (1%)171 (1%)161 (2%)161 (4%)
Death due to Trauma
/ injury / Road traffic
accidents
152 (0%)141 (1%)163 (3%)130 (0%)13 1 (4%)
*n: Number of Hospitals, ED: Emergency department, LAMA: Leave against medical advice
3. SPECTRUM OF DISEASES
According to World Health Organization a state in which normal procedures are suspended and
extra-ordinary measures are taken is termed as emergency condition.
The spectrum of diseases present at ED were assessed for adult (10 diseases) and pediatric patients
(9 diseases) separately. Most of the hospitals maintained separate data for adult and pediatric,
while others did not have pediatric patient data.
3.1 Adult Patients
In table 63, the summary of adult diseases reported at the emergency department for all categories
of hospitals is depicted. 139
Observations and Results with Suggestions
Table 63: Summary of Spectrum of Diseases for Adults by Category of Hospitals
Spectrum
of Diseases
for Adults
Medical Colleges
(n=20)
Govt. Hosp.
(>300 bed
strength)
(n=20)
Govt. Hosp.
(<300 bed
strength)
(n=20)
Pvt. Hosp.
(>300 bed
strength)
(n=20)
Pvt. Hosp.
(<300 bed
strength)
(n=20)
N
Median [IQR]
Min-Max
(% Out of total
ED visits)
N
Median [IQR]
Min-Max
(% Out of total
ED visits)
N
Median [IQR]
Min-Max
(% Out of total
ED visits)
N
Median [IQR]
Min-Max
(% Out of total
ED visits)
N
Median [IQR]
Min-Max
(% Out of total
ED visits)
Chest Pain144
5.5
[10.2]
1-46
1.2385
3 [4.5]
1-28
2.9151
3 [4.2]
2-15
2.9184
4 [4.2]
1-13
7.0240
2 [2.5]
1-15
8
Stroke 75
5 [5]
1-42
1.1219
1 [1]
1-10
0.9725
3 [3]
1-9
2.9130
2 [1.5]
1-9
3.5114
1 [1.5]
1-5
4
Altered
Mental
Status
136
18 [25]
1-70
4.0459
3 [3]
1-17
2.9120
3 [1.5]
1-5
2.9127
2 [1]
1-6
3.5116
1 [1]
1-4
4
Trauma/
Road traffic
accident/
injuries
599
18 [25]
1-210
4.04175
5
[10.5]
1-45
4.85130
4.5 [6]
1-40
4.37143
3 [10]
1-35
5.2660
3 [4]
1-20
12
Respiratory
Distress
165
9 [21]
2-40
2.02144
6.5
[8.2]
1-38
6.3162
4 [9]
1-17
3.8883
6.5
[4.5]
2-22
11.4041
4 [4]
1-7
16
Pain in
Abdomen
232
13 [13]
2-72
2.91164
7 [7.5]
1-36
6.80161
15 [17]
1-27
14.56123
8 [5]
2-18
14.0448
3 [4]
1-11
12
Poisoning67
2.5
[6.7]
1-30
0.56115
2 [3.5]
1-79
1.946
1 [0.5]
1-3
0.9720
3 [4.7]
1-6
5.263
1 [0]
1-1
4
Snake Bite38
1 [4]
1-21
0.2224
4 [2]
2-10
3.884
1 [0.5]
1-2
0.9710
4 [2]
1-5
7.021
1 [0]
1-1
4
Fever 206
8 [24]
1-36
1.79262
11.5
[12.7]
1-72
11.17251
12 [15]
2-80
11.65148
6 [7]
1-42
10.5365
4 [7]
1-13
16
Pregnancy
related
200
26 [25]
1-140
5.8341
4.5 [3]
2-10
4.3715
2 [0.7]
1-5
1.9443
2 [2]
1-30
3.513
1.5
[0.5]
1-2
6
*n: number of hospitals, N: total number of patients recorded in 24 hours from district hospitals, IQR: Interquartile range
It was observed that the trauma care (1101 patients) accounted for the maximum number
of patients visiting in hospital emergency department followed by those with complaints
of fever (932 patients). Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 140
In medical colleges, the trauma care accounted for the maximum number of patients visiting in
hospital emergency department followed by those with complaints of pain in abdomen.
In government hospitals >300 beds, the maximum number of patients visiting in hospital
emergency department accounted for complaints of fever followed by those of trauma care
patients.
In government hospitals <300 beds, the maximum number of patients visiting in hospital
emergency department accounted for complaints of fever followed by those with complaints of
pain in abdomen.
In private hospitals (both >300 beds and <300 beds), the maximum number of patients visiting
in hospital emergency department accounted for complaints of fever followed by those of trauma
care patients.
3.2 Pediatric Patients
In table 64, the summary of pediatric diseases reported for all categories of hospitals is depicted.
Amongst pediatric patients, it was observed that the maximum number of patients visiting in
hospital emergency department accounted for complaints of fever (443 patients) followed by
those of diarrheal diseases (290 patients).
Table 64: Summary of Spectrum of Diseases for Pediatrics in all Categories of Hospitals
Spectrum
of Diseases
for
Pediatrics
Medical Colleges
(n=20)
Govt. Hosp.
(>300 bed
strength)
(n=20)
Govt. Hosp.
(<300 bed
strength)
(n=20)
Pvt. Hosp.
(>300 bed
strength)
(n=20)
Pvt. Hosp.
(<300 bed
strength)
(n=20)
N
Median (IQR)
Min-Max
(% Out of total
ED visits)
N
Median (IQR)
Min-Max
(% Out of total
ED visits)
N
Median (IQR)
Min-Max
(% Out of total
ED visits)
N
Median (IQR)
Min-Max
(% Out of total
ED visits)
N
Median (IQR)
Min-Max
(% Out of total
ED visits)
Respiratory
Distress
115
6
[11.5]
1-35
1.3547
4 [5.5]
1-21
3.8811
2 [1]
1-3
1.9428
1 [3.7]
1-18
1.7535
2
[14.5]
2-31
8
Diarrheal
Disease
86
3.5
[11.7]
1-25
0.7834
3 [2]
1-7
2.9135
3 [2]
2-9
2.9129
2 [2]
1-16
3.51106
2
[26.5]
1-101
8
Altered
Mental
Status
19
1.5
[1.5]
1-7
0.342
1 [0]
1-1
0.973
1.5
[0.5]
1-2
1.466
3 [2]
1-5
5.261
1 [0]
1-1
4
Trauma/
Road
traffic
accident/
injuries
43
6 [5]
1-10
1.3516
2 [2]
1-5
1.9434
4 [3]
1-17
3.8811
1 [1]
1-4
1.7518
3 [6.5]
1-14
12 141
Observations and Results with Suggestions
Seizure 29
2 [4]
1-10
0.4512
1.5 [1]
1-5
1.467
2 [0.2]
1-2
1.9410
1 [1]
1-5
1.753
1.5
[0.5]
1-2
6
Pain in
Abdomen
102
2 [4]
1-12
0.4533
2 [1]
1, 12
1.9420
3 [2.5]
1-5
2.9124
2 [1.2]
1-12
3.5115
15 [0]
15-15
60
Poisoning13
4 [0.5]
4-5
0.900 0 0.000 0 0.002
2 [0]
2-2
3.512
2 [0]
2-2
8
Snake Bite4
1 [0.5]
1-2
0.220 0 0.004
2 [1]
1-3
1.941
1 [0]
1-1
1.750 0 0
Fever 159
6
[23.5]
1-47
1.3570
3 [4]
1-26
2.9135
2 [2.5]
1-11
1.9467
5 [10]
1-21
8.77112
2 [2]
1-105
8
*n: number of hospitals, N: total number of patients recorded in 24 hours from district hospitals, IQR: Interquartile range
In medical colleges, the maximum number of patients visiting in hospital emergency department
accounted for complaints of fever followed by those with respiratory distress.
In government hospitals >300 beds, the maximum number of patients visiting in hospital
emergency department accounted for complaints of fever followed by those with respiratory
distress.
In government hospitals <300 beds, the maximum number of visiting in hospital emergency
department patients accounted for complaints of fever and diarrheal disease followed by those
of trauma patients.
In private hospitals (both >300 beds and <300 beds), the maximum number of patients visiting
in hospital emergency department accounted for complaints of fever followed by those with
diarrheal patients. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 142
IV. COMPARISON OF EMERGENCY CARE IN VARIOUS SYSTEMS
1. HOSPITALS WITH ACADEMIC EMERGENCY MEDICINE (N=5)
In this study, 5 medical colleges were selected which have academic emergency medicine in
their Post-Graduation programme.
The following observations were obtained during assessment from these hospitals with
academic emergency medicines:
Strengths at Hospitals with Academic Emergency Medicine:
1. They have 24*7 blood bank facility available (figure 76)
2. Adequate manpower in emergency
3. Definitive care services were observed well with proper ICU facilities in hospitals
with academic emergency medicine (figure 77)
4. They have disaster management plan with surge capacity, also conduct drill and
debriefing (figure 78)
5. Majority of them have triage policy
6. They conduct continuous education and periodic training programs for staff to
improve quality (figure 79)
7. They have dedicated staff for gap identification and loop closure.
8. They have key indicators for quality monitored.
9. They have computerized data management system (figure 80)
10. They have good communication skills in ED with satisfaction of majority of patients
(figure 83)
11. They have referral policy due to tie-up with local EMS system (figure 84)
Need to improve:
1. Emergency care protocols were missing (figure 84)
2. Lack of separate decontamination area (figure 78)
Figure 76: Summary of Hospital Blood bank in hospitals with academic emergency medicine and without academic
emergency medicine 143
Observations and Results with Suggestions
Figure 77: Summary of Definitive Care Services in hospitals with academic emergency medicine and without
academic emergency medicine Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 144
Figure 78: Summary of Disaster Managementin hospitals with academic emergency medicine and without
academic emergency medicine
Figure 79: Summary of Continuous Quality Improvement in hospitals with academic emergency medicine and
without academic emergency medicine 145
Observations and Results with Suggestions
Figure 80: Summary of Computerized Data Management System in hospitals with academic emergency
medicine and without academic emergency medicine
Figure 81: Summary of Communication Skills in ED in hospitals with academic emergency medicine and without
academic emergency medicine
Figure 82: Summary of Referral Policy in hospitals with academic emergency medicine and without
academic emergency medicine Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 146
Figure 83: Summary of Emergency Care Protocols in hospitals with academic emergency medicine
and without academic emergency medicine
2. GOVT. SECONDARY CARE V/S TERTIARY CARE HOSPITALS
Out of 100 hospitals, 34 were district hospitals (secondary care centres) and 25 were government
tertiary care centres from various states of our country. The following observations were obtained
during assessment from district hospitals:
Strengths
50% have 24*7 blood bank facility available (figure 84)
Some of hospitals (6) have separate ED blood storage (figure 85)
25% have 24*7 emergency operative services (figure 86)
Compliance for ED protocol/SOP/guidelines were good, when compared to tertiary care
government hospitals (figure 87)
Some of them conducted periodic mock drill and training of staff (figure 88)
Regular audits conducted in mostly district hospitals
Communication in ED and patient satisfaction of district hospitals were good, when
compared to tertiary care government hospitals
Majority have good referral policy with assistance during referral (figure 89)
Figure 84: Summary of Hospital Blood Bank in Secondary Care Centres 147
Observations and Results with Suggestions
Figure 85: Summary of Hospital Blood protocols in Secondary Care Centres
Figure 86: Summary of Emergency Operative Services in Secondary Care Centres Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 148
Figure 87: Summary of ED Protocols / SOP / Guidelines in Secondary Care Centres
Figure 88: Summary of Continuous Quality Improvement in Secondary Care Centres 149
Observations and Results with Suggestions
Figure 89: Summary of Referral Policy in Secondary Care Centres
Need to improve:
Lack of blood transfusion protocols (figure 85)
Lack of common ICU with PICU and NICU (figure 90)
Lack of computerized data management system (figure 91)
Figure 90: Summary of Critical Care Services in Secondary Care Centres Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 150
Figure 91: Summary of Computerized Data Management System in Secondary Care Centres
**Note: Comparison of District Hospitals >300 beds and <300 beds has done as a separate study 151
Observations and Results with Suggestions
3. PRIVATE HOSPITALS VS GOVERNMENT HOSPITALS
In this study, 60 hospitals were government hospitals and 40 hospitals were private hospitals
out of 100 hospitals. The following observations were obtained during assessment from these
hospitals were as follows:
Key point of checklist
Government
hospitals (n=60)
Private hospitals
(n=40)
Figure
Blood bank facility availability65%75%10
ED and massive blood transfusion protocol 17%25%10
Emergency operative services37%77%12
Periodic mock drill15%57%29
Periodic training programs for staff 18%77%29
Regular audits32%82%35
Communication in ED40%72%71
Referral policy42%75%74
4. NABH ACCREDITED VS NON-NABH ACCREDITED HOSPITALS
In this study, 28 hospitals were NABH accredited out of 100 hospitals; all NABH accredited
hospitals were private. The following observations were obtained during assessment from these
hospitals having NABH Accreditation:
Strength
They have 24*7 blood bank facility available.
They have ED and massive blood transfusion protocols.
They have good definitive care services.
They have all types of ED protocols/SOP/guidelines with triage (figure 25).
These hospitals conduct continuous education and periodic training programs for staff
(figure 37).
Periodic mock drill also conducted in these hospitals (figure 31).
Majority have computerized data management system (figure 40).
Management of time sensitive conditions is good as compared to non-NABH accredited
hospitals (figure 58, 63, 67)
They also have referral policy Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 152
V. COMPLIANCE OF INDIVIDUAL HOSPITALS TO
THE CHECKLIST
A checklist encompasses the following parameters was checked for all the hospitals studied. The
details are attached as Annexure VII.
The hospitals which scored 75% or above were found satisfactory and marked green, the score
of 50% to 74% requiring improvement was marked yellow and score of less than 50% in an area
were marked red. The areas in red suggested the need for an intervention on priority.
DISCUSSION 153
Observations and Results with Suggestions
DISCUSSION07 155
Discussion
DISCUSSION07
This study is the first cross-sectional stratified multi stage comprehensive assessment of emergency
and trauma care facilities using consensus based study tool in India. We found significant gaps
in whole system at various levels.
According to Medical Council of India, each hospital must have 5% emergency beds. It was
observed that all hospitals have an average of 3%-5% emergency beds. On the other hand, the
annual burden of patients visited in emergency is 10-30%, which is much more than the available
emergency beds present in hospitals.
A major concern was that only a few facilities at any level of care had ED blood storage, protocols
for massive blood transfusion and ED blood transfusion. A major gap in definitive care services
was that nearly all government hospitals (<300 bed strength) do not have common ICU.
Another major concern was the lack of protocols/SOP/guidelines for emergency department.
Nearly all government hospitals and medical colleges do not have emergency care protocols
(alert system for different diseases) and most of the government hospitals and medical colleges
do not have alarm bell/code announcement in ED.
The major gaps in disaster management in the healthcare facilities assessed were lack of separate
decontamination area in ED, separate disaster stock in ED, absence of drill and debriefing for
disaster management and the system for redistribution of patients to other network hospitals
during disaster was present in few hospitals. The quality indicators for urgent and interventional
procedures monitored were found missing at most of the hospital at any levels of care.
Also, gaps were observed in data management systems: most of the government hospitals and
medical colleges do not have trauma registry systems; while ~40% private hospitals have trauma
registry system. Nearly all government hospitals and medical colleges do not have injury and ED
surveillance system and most of the private hospitals also do not have injury and ED surveillance
system.
A major concern was lack of-provision of allocated budget (Central/ State Government) to finance
emergency care systems were observed at nearly all facilities at all tiers. The available few
allocated budget at a few locations pertained specifically for delivery of goals related to trauma Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 156
care.
There were lack of optimal availability of human resource, essential medicines, critical care
equipments and supplies at various levels. Of these, the most critical gaps were scarcities related
to doctors, paramedics, adherence to essential drug list at ED and essential emergency care
equipments such as cervical collar, transport ventilator, resuscitation medicines, etc. Many of the
frequently absent equipment were inexpensive items, which would save lives in many emergency
conditions.
Amongst the issues related to human resource, it was found that most of the hospitals had adequate
number of general duty doctors and specialists; deficiencies still prevailed in the emergency
department. This was probably due to lack of importance given to the emergency care services as
a separate standalone independent unit/department. Further, most of the posted doctors at the ED
were the most junior doctors, with least experience, that too on a rotational basis-corroborating
further with the aforementioned facts. The recent MCI mandate to develop standalone EDs at all
Medical Colleges should at least partially address these issues. But a larger change in attitude of
administrators, policy makers and doctors is required to bring about significant changes.
Additionally, major gaps were found in physical infrastructure both within and in immediate outside
surrounding areas of emergency departments that could be easily rectified with minimal budget.
These gaps such as independent direct access to ambulance services from the ED and demarcated
area for triage amongst others would be able to save lives by improving efficiency of delivery of
care. Most of these could be achieved by minimally altering the prevailing infrastructures.
Of the prevailing gaps in the infrastructure, lack of availability of a separate 24*7 point of care lab
for ED was prevalent at most of the health facilities. This is a critical deficiency, since availability
of timely lab results is crucial for management of patients with medical emergency conditions,
wherein time is of paramount importance.
The strengths of this study were the fact that this was the first systematic study of prevailing facility
based emergency and trauma care services in the country. The study has been conducted in a
robust manner covering all zones of the country by assessors trained in pre-specified standardized
tools in an unbiased way. The health facilities assessed covered all possible strata and levels of
care.
There are a few limitations to the study. First, most of the information of the healthcare facilities
was obtained from the direct interviews with one or two administrative official per facility.
However, this was partially compensated by live observations by the assessors. Second, most of
the facilities did not have inherent electronic data systems to capture historic information and
these had to be culled from other sources and by Delphi methods.
CONCLUSIONS 157
Discussion
CONCLUSIONS08 159
Conclusions
CONCLUSIONS08
Facility-level physical infrastructure, human resource, equipment & supplies, point of care lab
and essential medicines gaps existed in the current emergency care system at different healthcare
levels in India. Gaps in financing, protocols, blood bank, etc also existed in the current emergency
care system different healthcare facilities.
Gaps also existed between pre-hospital care and definitive care services, proper linkage should
be there. A major gap is lack of academic emergency medicine department at different healthcare
levels in India. All these gaps are likely to compromise the provisions of quality emergency care.
These findings point towards the implementation of a comprehensive programme of emergency
care system reforms in the country of India.
KEY
SUGGESTIONS KEY SUGGESTIONS 161
Conclusions
KEY SUGGESTIONS09 163
Summary Of Key Suggestions Emerging from the Study
SUMMARY OF KEY
SUGGESTIONS
EMERGING FROM
THE STUDY09
HEADINGSUGGESTIONS
Huge Mismatch between
Emergency Beds & Burden
of Emergency and Injury
Cases
We need to increase the emergency beds (12% emergency beds +10%
buffer beds) as per the existing and expected footfall.
Develop Cashless emergency care scheme for all red triaged patients
because of out of pocket expenditure during emergency conditions
To provide quality of care as per the existing and expected footfall we
need to strengthen district hospitals by-
Upgrade them into medical college
Develop residency programme (DNB)
Initiate incentivization and decentivization according to the performance
of hospital
Burden of Medico-legal
Cases
Develop Forensic Nursing in nursing college / dedicated EMO (Emergency
Medical Officer) / Senior Resident (Forensic Medicine) to deal with MLC
documentation and representation to court
In-house or nearby police post for mitigating violence and protection
of emergency care provider and for better co-ordination of MLC
documentation and legal service
Hospital Blood Bank
Services
But for running acute care services, we need blood bank services for
24*7 in all hospitals.
Majority of district hospitals have blood bank however the round the
clock service is missing in many of them, due to lack of staff.
Emergency blood storage is mandatory for those medical college and
district hospitals (>300 beds) which deals with more trauma cases Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 164
HEADINGSUGGESTIONS
Hospital Definitive Care
Services
Medical colleges should have all types of emergency operative, critical
care as well as specialized care services for 24*7
District hospitals >300 beds should have trauma, non-trauma operative
services, general ICU (Intensive Care Unit), HDU (High Dependency
Unit), NICU (Neonatal ICU) and PICU (Pediatric ICU).
District hospitals <300 beds should have general operative services,
general ICU (Intensive Care Unit) / HDU (High Dependency Unit) and
NICU (Neonatal ICU).
District hospitals may be upgraded into multi-speciality hospitals to
improve the quality of care
Hospital Ambulance
Services
The in-hospital ambulances should be optimally utilized in the common
resource pool of EMS (Emergency medical Service) of the region as per
requirement.
Regular maintenance of ambulance should be done.
The ALS ambulances can be used for mobile stroke unit as well as for
STEMI programme.
Creation of EMT (Emergency Medical Technician) course as a residency
programme
Dedicating job creation
Paramedic Council
ED Protocols / SOP /
Guidelines
Development of academic residency programme
Implementation of triage policy in each hospital
NABH Accreditation
Increase the scope of Good Samaritan Law from road traffic injuries to
other time sensitive conditions
Disaster Management
There should be standard protocols for implementation of in-hospital
disaster management plan
Implementation of hospitals prepared for disaster management for both
external and internal
Establish academic emergency medicine
There should be separate decontamination area at entrance of emergency
Every hospital should have surge capacity with separate disaster stock in
emergency
There should be drill and debriefing for disaster management
Regular monitoring and evaluation of implementation of disaster
management should be done from NDMA
Continuous Quality
Improvement
There should be dedicated quality manager for gap identification and loop
closure
Develop a quality council among emergency care providers
Mandatory Emerald certification under NABH
Regular mortality and morbidity meeting
Regular third party audit of external agencies by using KPI and the
funding of the hospital should be linked with it
Continuous training of quality council provider as well as manager 165
Summary Of Key Suggestions Emerging from the Study
HEADINGSUGGESTIONS
Computerized Data
Management System
Develop National Emergency Department Information System (EDIS)
Implement and integrate the computerized care delivery template which
will serve as clinical notes, registry and surveillance
It will use the data for quality improvement initiative and research
Develop various emergency conditions registries such as cardiac arrest,
poisoning, snake bite including trauma registry
Financing
Protected funding for emergency and injury care services and for
establishment of residency programme in emergency medicine,
emergency nursing and EMT (Emergency Medical Technician) course
Integration and aggregation of financial schemes for emergency and injury
care
Cashless scheme- Increase Ayushman Bharat scheme for all red-triaged
patients in all hospitals to save out of pocket expenditure
Physical Infrastructure
Uniformity of name (Emergency/Emergency Medicine Department) in
every hospital for emergency / casualty / injury care etc.
The capacity and capability of ED should be standardize based on the tier
of facility, footfall of patients and academic programme
Availability of either point of care lab or hospital lab (24*7) for
emergency services
Adequate space for ambulance drop zone
There should be demarcated triage area
There should be small ICU in each hospital
Manpower in Emergency
Department
Rotator posting of doctors and nursing students from different disciplines
including interns for a defined period in emergency
Creation of dedicated post for emergency department of doctors, nurses
and paramedics
NABH Accreditation
Establish academic emergency medicine, emergency nursing and EMT
Equipments and Supplies
in ED
All essential equipments and supplies should be present in every hospital
to improve the quality of care
There should be dedicated staff for maintenance of equipments in
emergency
There should be dedicated training of staff regarding the maintenance of
equipments (how to use and maintain)
Maintain checklist of supplies and equipments, they should be checked
before end of every shift and beginning of every shift
Maintain a checklist of non-functional equipments and consumed supplies
and should be communicated during handovers
Point of Care Lab
All healthcare facilities should have either basic point of care lab or
emergency lab in hospital for 24*7 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 166
HEADINGSUGGESTIONS
Essential Medicines for
Emergency
Complete package of resuscitation medicines should be present in all
hospitals for 24*7
Other essential medicines should also be present in all hospitals for 24*7
During third party audits, if any essential drug is missing from the
resuscitation package then the license of the hospital may be cancelled
Entry to Admission/
Transfer-out/Discharge
Time of Patients Visited in
Emergency Department
It should be a sovereign department
Implementation of triage policy in all hospitals (Prioritization of patient)
Adequate manpower should be present in hospitals as per footfall of
patients and emergency beds
Optimum utilization of resources
There should be a dedicated emergency nurse coordination (ENC) system
Chest Pain Management
Upgrade them for thrombolysis
Adequate trained emergency care provider
All district hospitals must have ECG machine and technician
Use Tele-ECG and Tele-Medicine programme
Resuscitate patient in district hospital and refer them to other higher
government hospital
Develop a STEMI Programme by Hub and Spoke Model
Develop PCI centres in multi-speciality hospitals
Stroke Management
Thrombolysis near home – Hub and Spoke Model
Develop Tele-stroke programme
Stroke management by PPP (Public-Private Partnership) model in district
hospitals
Communication Skills in
Emergency Department
Dedicated emergency nurse coordinator (ENC)
Training of staff on communication skills from under-graduate level (for
doctors, nurses and paramedics)
Referral of the Patient
Develop National Forward and Backward Referral Policy with safe
transport integrated with local EMS system
Hub and Spoke Model
Structured referral protocols
There should be informed transfer
NABH Accreditation
Burden of Death of
Trauma Patients
Develop a robust integrated emergency care system which includes injuries
Burden of Brought Dead
Patients
Develop preventive emergency healthcare strategy such as National Injury
Prevention Programme
Developing a robust emergency injury care initiative
There should be installation of public access device of AED (Automated
external Defibrillator) as a national policy in mass gathering areas such as
schools, shopping mall, railway station, etc. 167
Summary Of Key Suggestions Emerging from the Study
KEY POLICY
RECOMMENDATIONS10 169
Suggested Key Policy Recommendations
SUGGESTED
KEY POLICY
RECOMMENDATIONS10
These findings were suggestive for the following suggestions:
1. Develop a robust integrated emergency care system including injuries: The current
policy focus (which is predominately trauma-centric) should be leveraged to deliver
comprehensive emergency and trauma care services in an integrated manner, without
losing the gains achieved in delivery of trauma care services through-out the Nation.
2. Standardize the Protocols / SOP and Guidelines including Triage: The policies, protocols
and guidelines for emergency department should be standardized across all EDs in the
country, irrespective of their levels of care. The key for achieving this is a availability of
standardized universal emergency-care manual at the point of care. This manual should
contain- information for management of all anticipated emergency medical conditions
with updated SOPs, protocols and flow charts. Specific focus should also be given for
critical issues such as triage, handling of critical equipments, norms for optimal care
delivery. If feasible, these should also be available in a ready-to-use handy app format,
which can be downloaded on a mobile phone.
3. Adequate Space allocation for Emergency and Injury Care: Adequate space should be
allotted for emergency department in each hospital as per the footfall. The critical needs
for establishment of such a department should be met at all hospitals.
4. Develop Standardize Emergency Department: There is a need to develop a blue print
for a standalone standardized department of emergency medicine for various levels of
care, for the Nation. These norms need to be adapted after a consensus is achieved.
5. Establish Academic Emergency Medicine departments: This is the need of the hour to
ensure continuous ongoing medical education and development of skills for doctors,
nurses and paramedics. Further, development of such departments will be the key to
enhance research to provide further policy directions.
6. Continuous Training and Skill Development of ED Staff: There should be capacity
building of doctors, nurses and paramedics. The emergency care providers should be
trained for life saving skills with structured courses such as: ACLS, BLS, PALS, ATLS or Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 170
NELS, Point of care emergency ultrasound; with periodic refresher courses, to ensure
continuous skilling of defined core competencies.
7. Accreditation of all Emergency and the health facility for providing quality care: There
should be accreditation of all EDs and health facility for delivering and improving the
quality care. Regular quality checks on a specified format should be ensured to enhance
the performance of emergency care.
8. Upgradation and maintenance of existed Emergency and Health facility: The ED is like
a mini-hospital and in itself requires separate wide variety of resources. The availability
of resources should be supported with optimum utilization for maximum output. The
management of staff for 24 hours in right number should be a policy and same should be
followed for equipments and medicines. An effort should be made to integrate the EMS
with pre-hospital notification, so that the patients could be transferred to appropriate
health facility based on the level care needed for the underlying disease condition.
9. Pooling of Ambulances (Integration and aggregation of ambulances): The in-hospital
ambulances should be optimally utilized as a common resource pool for providing EMS
services for the entire -local region, as per requirement.
10. Optimization of Resources (manpower, infrastructure, supplies and medicines): Since
many of the gaps in optimization of resources needed for optimal emergency care
services can be achieved with minimal budgetary requirements, it is recommended
that phasing of the needs be done, so as to achieve early low hanging fruits. Some of
these examples include reallocation of available human resources, minimal alteration
of existing infrastructure to provide access to ambulance vehicles and creation of a
demarcated area for triaging.
11. Protected Funding for Emergency and Injury Care as well as for developing academic
department / DNB Emergency Medicine: Separate budget head needs to be created
for emergency care services. One option is to augment the prevailing funds for trauma
care to encompass overall emergency care delivery.
12. Cashless care for all red triaged patients in all hospitals: Policy for caring of all
emergency conditions for all citizens of the Nation for the initial critical period to
ensure early clinical stabilization is a way forward to achieve Health for all and SDGs.
NOTE: To carry forward the above recommendations, it is suggested that in the first phase, these
may be implemented at 30 existing facilities which have a functional emergency department and
trauma care facility. The lessons learnt from this endeavour can act as template to give further
directions. 171
Suggested Key Policy Recommendations
PHASE-I SUGGESTED KEY POLICY RECOMMENDATIONS
Uniformity of name–Emergency or Emergency Medicine Department
Create an empowered Hospital Committee, which have composition of different
disciplines and headed by Hospital in-charge/Medical Superintendent. The member
secretary should be Head of the Emergency Department.
Reorganize of the existing emergency department for comprehensive management of all
emergency conditions, at all tiers of healthcare facilities depending on the anticipated
footfall of patients.
Initiate Quality Improvement (QI) programmes.
Implement triage policy.
Initiate processes to capture data related to emergency care at each hospital.
Ensure 24*7 availability of adequate dedicated emergency staff such as doctors, nurses
and paramedics.
Optimize infrastructure and supplies from within the available resources and create a
roadmap for futuristic needs with timelines.
Ensure on-going training and skilling of doctors, nurses and paramedics.
Develop standardized care delivery template for time sensitive conditions.
Develop a robust pre-hospital care system linked with facility based emergency care
services.
Create a separate protected fund/ budget to address the immediate concerns regarding
critical supplies and equipment’s needs of the Emergency Department. REFERENCES 173
Suggested Key Policy Recommendations
REFERENCES11 175
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References
ANNEXURES12 181
Annexure-I: List of Hospitals
ANNEXURE-I:
LIST OF HOSPITALS12
Zone
S.
No.
State
Medical
College
Government
Hospital more
than 300 beds
Government
Hospital less
than 300
beds
Private
Hospital
more than
300 beds
Private
Hospital less
than 300 beds
NORTH
ZONE
1
Jammu &
Kashmir
Sher-i-Kashmir
Institute of
Medical
Sciences,
Srinagar
District
Hospital
Hospital,
Barahmulla
District
Hospital
Ganderbal,
Ganderbal
- -
2
Himachal
Pradesh
IGMC, Shimla
District
Hospital
(Deen Dayal
Upadhyay
Hospital),
Shimla
- - -
3Punjab
Guru Nanak
Dev Hospital
& Govt.
Medical
College,
Amritsar
Jallianwala
Bagh Martyr’s
Memorial
Civil Hospital,
Rambagh
-
Fortis
Hospital,
Mohali
Shivam
Hospital,
Multi Super
Speciality
Hospital,
Hoshiarpur
4Uttarakhand -
HNB Base
Hospital
Coronation
Hospital,
Dehradun
- -
5
Utttar
Pradesh
-
Civil Hospital-
Lucknow
-
RML
Hospital,
Lucknow
Charak
Hospital
Dubagga
6Chandigarh -
Government
Superspeciality
Hospital,
Sector-16
Civil
Hospital
Sector-22,
Chandigarh
-
Max
Superspeciality
Hospital,
Mohali Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 182
7Rajasthan
SMS Medical
College &
Hospital, Jaipur
Hari Baksh
Kanwatia
Hospital, Jaipur
Govt. BDM
Hospital,
Kotputli
Fortis
Hospital,
Jaipur
Birla Hospital-
CK Birla,
Jaipur
8Delhi- - -
Yashoda
hospital,
Kaushambi
Indian Spinal
Injuries Centre
Asian
Hospital
Medeor
Hospital,
Manesar
Sri Ganga
Ram Hospital
Jaipur Golden
Hospital
Artemis
Hospital
Primus Super
Speciality
Hospital
WEST
ZONE
1Gujarat
BJ Medical
College &
Civil Hospital,
Ahemdabad
GMERS
Medical
College &
Hospital, Gotri,
Vadodara
Jamanabai
Government
Hospital,
Mandvi
Parul
Sewasharam
Hospital,
Vadodara
Bhailal Amin
General
Hospital,
Vadodara
2Maharashtra
BJ Medical
College &
Sassoon
General
Hospital, Pune
-
Sri Seva
Medical
foundation
Dr Jogalekar
Hospital,
Shirwal,
Pune
Grant
Medical
Foundation
Ruby Hall
Clinic, Pune
-
3
Madhya
Pradesh
AIIMS, Bhopal
Jai Prakash
District
Hospital,
Shivaji Nagar,
Bhopal
- -
Bhopal
Fracture
Hospital,
Bhopal
4Chhattisgarh-
District
Hospital,
Dhamtari
District
Hospital,
Tikarpara,
Raipur
-
Ramkrishna
CARE
Hospital,
Pachpedhi
5Goa
Goa Medical
College, Panaji
-
North Goa
District
Hospital,
Mapusa
- -
EAST
ZONE
1Bihar PMCH, Patna AIIMS Patna
Sadar
Hospital,
Gaya
Paras HMRI
Hospital,
Patna
Ruban
Memorial
Hospital
Patliputra
3Orissa -
AIIMS,
Bhubneshwar
District
Headquarter
Hospital,
Puri
Capital
Hospital,
Bhubneshwar
Care Hospital,
Bhubneshwar
4West Bengal
IPGMER &
SSKM
- - -
Ruby General
Hospital 183
Annexure-I: List of Hospitals
NORTH
EAST
ZONE
1Sikkim
New STNM-
Govt- medical
college, Sikkim
-
Singtam
District
Hospital
Central
Referral
Hospital,
Gangtok
-
2
Arunachal
Pradesh
TomoRiba
Institute of
Health &
Medical
Sciences,
Papumpare
-
BakinPertin
General
Hospital,
Pasighat
-
Ramakrishna
Mission
Hospital,
Itanagar
3Assam
Gauhati
Medical
College and
Hospital,
Guwahati
-
Morigaon
Civil
Hospital
GNRC
Hospital,
Guwahati
Nemcare
Superspecialty
Hospital,
Guwahati
4Meghalaya -
Civil Hospital
Shillong
- - -
5Nagaland - -
District
Hospital,
Peren
-
Christian
Institute
of Health
Science and
Research
6Manipur RIMS, Imphal -
District
Hospital,
Bishnupur
-
Shija Hospital
& Research
Institute,
Lamphelpat,
Imphal
7Tripura
Agartala
Government
Medical
College & G B
Pant Hospital
-
Gomti
District
Hospital,
Udaipur
Tripura
medical
college&
BRAM
Teaching
Hospital,
Agartala
-
8Mizoram -
Zoram Medical
College
Civil
Hospital,
Aizawl
Synod
Hospital
(Presbyterian
Hospital)
- Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 184
SOUTH
ZONE
1Telangana -
District
Hospital,
Karim Nagar,
Hyderabad
District
Hospital,
King Koti,
Hyderabad
Yashoda
Hospital,
Malakpet,
Hyderabad
-
2Karnataka
Mysore
Medical
College
& Krishna
Rajendra
Hospital,
Mysuru
Victoria
Hospital,
Bengaluru
Government
Hospital,
Virajpet
Manipal
Hospital,
Bengaluru
-
3
Andhra
Pradesh
Guntur
Medical
college &
Government
General
Hospital
Government
District
Hospital,
Tenali
-
Kasturi
Medical
College &
Hospital
Lalitha Super
Specialty
Hospital,
Kothapet,
Guntur
4Kerala
Trivandrum
Govt Medical
College
District
Hospital,
Neyyattinkara
District
Hospital,
Peroorkada
Cosmopolitan
Hospitals Pvt
Ltd
G G Hospital
5Tamil Nadu
Madras
Medical
College
Madras
Railway
Hospital,
Madras
(Southern
Railway
Headquarters
Hospital)
-
Apollo
Hospital
-
6Pondicherry
JIPMER,
Pondicherry
Indira Gandhi
Government
General
Hospital,
Pondicherry
- - - 185
Annexure-II: Study Tool
ANNEXURE-II:
STUDY TOOL
Section A: Background Information of the Hospital:
Date of Inspection:
1.
Name of the
hospital:
Name of Inspection Team Member:
1.
2.
3.
2.
Address of the
hospital:
3.
Type of Health
Care Facility
Government/Non Govt. (Trust/society/
Corporate/…………………... Specify)
Large Tertiary( >500 Beds) /
Secondary (300-500 Beds) /
Secondary (100-300 Beds)
4.Total no of
Inpatient
Beds in the
hospital
Total no. of beds in Emergency care
area
Red (ESI:1-2)
Yellow (ESI: 3-4)
Green (ESI: 5)
5.Total number of patients visited in hospital outpatient
department (OPD ) (During 1st Jan 2018 to 31st Dec 2018)
Adult Pediatric
(Age - 0 to …..)
6.Total number of patients visited in emergency (During 1st
Jan 2018 to 31st Dec 2018)
Adult Pediatric
(Age - 0 to …..) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 186
7.Total number of death of trauma patients in emergency
department (During 1st Jan 2018 to 31st Dec 2018)
Adult Pediatric
(Age - 0 to …..)
8.Total number of patient’s death due to road traffic injury in
emergency department (During 1st Jan 2018 to 31st Dec
2018)
Adult Pediatric
(Age - 0 to …..)
9.Total number of patients which are brought dead to the
hospital (During 1st Jan 2018 to 31st Dec 2018)
Adult Pediatric
(Age - 0 to …..)
10.Total number of Medicolegal cases attended in Emergency
(During 1st Jan 2018 to 31st Dec 2018)
11.Total Number of admissions through Emergency (last 1yr)
Section-B: Hospital Services
1. BLOOD BANK(SCORE- 1: Full Compliance, 2: Partial Compliance, 3: Non
Compliance)
S.No. OBJECTIVE ELEMENTSCheck point SCORE
REMARKS
(If any)
1.
Does the facility have a licensed in-
house blood bank?
Admin Interview/
Facility Visit
SCORE
2.
If yes, does the blood bank available
for 24x7?
Admin Interview/
Facility Visit
SCORE
3.
If no, any tie up with external Blood
bank facility?
Admin Interview/
Facility Visit
SCORE
4.
Does the emergency have separate
component facility: Packed cell (RBC),
FFP, Platelet, Cryoprecipitate?
Admin Interview /
Blood bank Visit/
Stock Register
SCORE
5.
Does the facility have 0-Negative
Blood availability?
Blood bank Visit/
Stock Register
SCORE
6.ED Blood storage
Facility available in
ED
SCORE
7.ED Blood Transfusion Protocol Written protocol SCORE
8.Massive Blood Transfusion ProtocolWritten protocol SCORE 187
Annexure-II: Study Tool
Definitive Care Services (Score: 1-No, 2- Partial, 3- Yes)
*NOTE: Question no 12 to 16 is not applicable for district hospital
S.
No.
OBJECTIVE ELEMENTSCheck point SCORE
REMARKS
(If Any)
1.
Emergency operative services for
Trauma patients
Admin interview / 24 hours
available facility/OT Register
SCORE
2.
Emergency operative services
for Non-Trauma (Surgical,
Orthopedics etc.) patients
Admin interview / 24 hours
available facility/OT Register
SCORE
3.
Emergency operative services for
Obstetrics patients
Admin interview / 24 hours
available facility/OT Register
SCORE
4.
Elective Operative services for
Orthopedic patients
Admin interview / OT
facility/OT Register
SCORE
5.
Elective Operative services for
neurosurgical patients
Admin interview / OT
facility/OT Register
SCORE
6.
Common Intensive care services
(ICU)
Admin interview / facility/
Facility Register
SCORE
7.
Common High dependency Unit
(HDU)
Admin interview / facility/
Facility Register
SCORE
8.Pediatric ICU
Admin interview / facility/
Facility Register
SCORE
9.Neonatal ICU
Admin interview / facility/
Facility Register
SCORE
10.Neurosurgery ICU
Admin interview / facility/
Facility Register
SCORE
11.Cardiac Intensive care Unit
Admin interview / facility/
Facility Register
SCORE
12.Cardiac Cath lab*
Admin interview / facility/
Facility Register
SCORE
13.Intervention Radiology*
Admin interview / facility/
Facility Register
SCORE
14.
Intervention Neuroradiology
service with DSA*
Admin interview / facility/
Facility Register
SCORE
15.
Facility for Emergency CABG
services*
Admin interview / facility/
Facility Register
SCORE
16.
Facility for Radiofrequency
ablation services*
Admin interview / facility/
Facility Register
SCORE Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 188
Hospital Ambulance Services(Score: 1-No, 2- Partial, 3- Yes)
SN. OBJECTIVE ELEMENTS Check point SCORE
REMARKS
(if any)
1.
Do you have ambulances
in your hospital?
Admin interview /
Facility/Ambulance visit
SCORE
2.
If Yes, total number of
ambulances.
Admin interview /
Facility/Ambulance visit
NUMBERS
3.
Total Number of
Functional ambulances
and Non-Functional
ambulances.
Admin interview /
Facility/Ambulance visit
Functional-
Numbers
Non-functional-
Numbers
4.
Number of BLS/ALS
(Advance life support)
ambulances.
Admin interview/
Ambulance visit
ALS- (Numbers
only)
BLS- (Numbers
only)
5.
For what purpose, hospital
uses these ambulances?
Admin interview/
Ambulance driver
Pick up the patient/
Drop Patient /
Intra-transfer of
patient in hospital
/ Inter transfer of
patient to other
hospital
6.
If hospital doesn’t have
any ambulance, then how
you transfer patient from
your hospital to other
hospital?
Admin interview COMMENT
7.
Do you get Pre-Hospital
Notification (Prior
information about patient’s
condition is communicated
to ED)?
Admin interview /
Paramedic/Ambulance
driver/Patient Interview
SCORE
8.
Does the ambulance is
manned with appropriately
trained paramedics as per
the level of ambulance
services?
Admin interview /
Paramedic Interview
SCORE
9.
Do you have mobile stroke
unit?
Admin interview /
Mobile stroke unit visit
SCORE
10.
a) Do you have Tele-
Medicine facility?
b) If no, did you start this
facility in coming days?
c) If Yes, how are you
using it for patient care?
d) Does it have minimum
requirements?
Admin interview /
Tele-stroke facility
visit (whether the
facility is mentoring
the thrombolysis in at
district hospital via tele
technology platform)
a. YES/NO
b. SCORE
c. COMMENT
d. sSCORE 189
Annexure-II: Study Tool
Section-C: Ed Protocol/Sop and Guidelines (Score: 1-No, 2- Partial,
3- Yes)
SN. OBJECTIVE ELEMENTSCheck Point SCORE
Remarks
(If any)
1.
a. Do you have documented
Emergency Manual at the
point of care?
b. If yes, only documented/
implemented?
c. If implemented, off-on
implemented/regular?
d. If no, what is the protocol?
Protocol /SOP and
procedures for emergency
care are documented and
operations in ED must
be guided by them (e.g.
Clinical Protocol/Treatment
guidelines.)
SCORE
SCORE
SCORE
REMARKS
2.
e. Do you have documented
triage guidelines and
protocol?
f. If no, how you manage
patients in emergency
department?
Triage protocol /SOP and
procedures for emergency
care are documented and
operations in ED must be
guided by them
SCORE REMARKS
3.
g. Do you have documented
policies and procedures
which guide the transfer
of patients into the
organization?
h. If yes, only documented/
implemented?
i. If implemented, off-on
implemented/ regular?
j. If no, what is the protocol?
Outside patients are
admitted only after proper
referral by a doctor with
prior communication
depending on the services
provided and bed
availability.
SCORE
SCORE
SCORE
REMARKS
4.
k. Do you have documented
policies and procedures
which guide the transfer-out/
referral of stable and unstable
patients after stabilization to
another facility in appropriate
manner with documentation?
l. If yes, only documented/
implemented?
m. If implemented, off-on
implemented/ regular?
n. If no, what is the protocol?
Documentation of referrals,
advance communication,
written orders by treating
doctor and consent of the
attendant/patient taken.
SCORE
SCORE
SCORE
d) REMARKS
5.
a. Do you give discharge
summary to all patients?
b. If no, which procedure you
follow?
Discharge with regard
to LAMA, DAMA, MLC,
Abscond (Clearly mentions
the treatment given, name
of the treating doctor etc.)
SCORE b) REMARKS Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 190
6.
a. Do you have policy on
handling cases of death
(outside and inside hospital)
mentioned in manual?
b. If no, how you manage death
cases?
To make MLC, intimate
police, dead body hand
over etc.
SCORE b) REMARKS
7.
a. Do you have documented
disaster management plan?
b. If no, which procedure you
follow?
SCORE b) REMARKS
8.
Is there a triage policy/system at
your emergency department? If
Yes then:
a. Are you using triage?
b. Is there a dedicated triage
nurse?
c. Is there a colour triage band
available?
d. Is there any regular audit of
your triage system?
Verify written SOP &
Interview
YES/ NO
a) SCORE
b) SCORE
c) SCORE
d) SCORE
9.
Do you have alert system: code
Blue?
Verify written SOP &
Interview
SCORE
10.
Do you have alert system:
Trauma?
Verify written SOP &
Interview
SCORE
11.
Do you have alert system: Chest
Pain?
Verify written SOP &
Interview
SCORE
12.Do you have alert system: Sepsis?
Verify written SOP &
Interview
SCORE
13.Do you have alert system: Stroke?
Verify written SOP &
Interview
SCORE
Section-D: Safety & Security (Score: 1-No, 2- Partial, 3- Yes)
S. No. Objective ElementsCheck PointScore Remarks (If Any)
1.Do you have fire safety?
Admin interview/smoke detectors, fire
extinguishers (class A, B , C or ABC
type) Sign postings, Fire exits etc.
SCORE
2.
Do you have building
safety?
Admin InterviewSCORE
3.
Do you have electrical
safety?
Admin interview/UPS, Generators for
monitors and ventilators etc.
SCORE
4.
Do you have patient and
provider safety?
Side rails, window grills, etc. SCORE
5.
Do you have chemical
safety?
Regular sterilization, safety hazard
specially PEP, Pre-exposure
immunization such as swine flow, etc.
SCORE 191
Annexure-II: Study Tool
6.
a) Do you have periodic
training of staff? (Every 6
months )
b) Do you have periodic
mock drill? (Every 6
months )
Admin interview/Response time
measured and corrective measures
taken (Record maintained)
SCORE
5
Do you have police
post available within the
premises?
Admin interview/Facility visit SCORE
6
Do you have alarm bell
in Emergency/ Code
announcement available
for extra help?
Admin interview/ Facility visit/Security
system is in place in case of violence,
mass situation in ED
SCORE
Section-E: Disaster Management (Score: 1-No, 2- Partial, 3- Yes)
S.
No.
Objective ElementsCheck PointScore Remarks
1
Do you have disease outbreak
management plan?
Admin interview/ See Plan
document [e.g. for Dengue,
malaria etc. and other community
emergencies]
SCORE
2
Do you have surge capacity in
your hospital?
Admin interview/ Facility visit
[Triage area is marked, expansion
of care area, line of authority is
clear, internal communication
system]
SCORE
3
Do you have separate
decontamination area at ED
entrance?
Admin interview/ Facility visit
[Provision for flexible and
expandable facility]
YES/NO
4
Do you have separate disaster
stock in ED?
If yes, for how many patients
(e.g. 50, 100)?
Admin interview/ Facility visit
[Medical supplies, manpower,
medicines etc.]
SCORE
NUMBER
5
Does drill is conducted and
debriefing is done for disaster
management?
Admin interview/ See Plan
document [Role and responsibility
of staff in disaster is checked and
recorded]
SCORE
6
Do you have system to
redistribution of patients to
other network hospitals during
disaster?
Admin interview/ See Plan
document [Prior plan for increased
load of patients]
SCORE Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 192
Section-F: Continuous Quality Improvement (Score: 1-No,
2- Partial, 3- Yes)
S.No. Objective ElementsCheck Point Score
Remarks
(If Any)
1.
Do you have dedicated staff
for gap identification and loop
closure?
Admin interview
(Dedicated staff can be: Patient
safety nurse, Infection control nurse,
Emergency nurse coordinators,
Quality manager)
SCORE
2.
Do you have regular audits in
your hospital?
Admin interview
[Death audits and post event
analysis etc./
Clinical audit]
SCORE
3.
Do you have continuous
education and training
programs cycles for
professional development and
skill improvement?
Admin interview
(Trainings like- ACLS, BLS, ATLS,
etc.)
SCORE
4.
Do you have key indicators of
quality monitored?
Admin interview
[Key Indicators are Mortality rate,
Referral rate, Return to ER, LAMA,
Absconding rate]
SCORE
5.
Are quality indicators for
urgent and interventional
procedures monitored?
(% of patients receiving
interventions is documented,
at-least 50%)
Admin interview
[e.g. 1. MI- (Door to needle -30
mins thrombolysis, door to balloon
time 90 mins PCI) 2. Stroke: (door
to needle time 60 mins) 3. Trauma
resuscitation (30 min of arrival) ]
SCORE
6.
Do you have death review
committee?
Admin interviewSCORE
7.
Do you have Central
Empowered Hospital
committee for continuous
quality improvement of
Emergency services?
Admin interviewSCORE 193
Annexure-II: Study Tool
Section-G: Data Management System (Score: 1-No,
2- Partial, 3- Yes)
S.No.Objective ElementsCheck Point Score
Remarks
(If Any)
1.
Do you have Integrated Computerized EHR
(Registration, Clinical care, Lab, Radiology,
Others and Disposal)?
Admin interview SCORE
2.
Do you have Computerized Patient
Registration system?
Admin interview SCORE
3.
Do you have Computerized Patient clinical
examination notes?
Admin interview SCORE
4.
Do you have Computerized Patients
investigation Lab reports?
Admin interview SCORE
5.
Do you have Computerized Patients
radiological investigation reports?
Admin interview SCORE
6.Do you have Trauma registry?Admin interview SCORE
7.Do you have Injury Surveillance system? Admin interview SCORE
8.
Do you have Emergency Department
Surveillance system?
Admin interview SCORE
9.
Do you have data retrieval system for Quality
Improvement & Research?
Admin interview SCORE
Section-H: Financing (Score: 1-No Funds, 2-Not Sufficient,
3-Sufficient)
Sn. Objective ElementsCheck Point Score Remarks
1.
Do you have Central Govt. funds for
Emergency and Trauma services?
Admin interviewSCORE
2.
Do you have dedicated State Govt. funds
for Emergency and Trauma services?
Admin interviewSCORE
3.
If funds are available, which health
protection schemes are covering your
emergency care system?
Admin interview —
NAME THE
SCHEME
4.
Full Utilization of funds (Annual
utilization)?
Admin interviewSCORE
5.Is there any delay in release of funds?Admin interviewSCORE Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 194
ANNEXURE-1: PHYSICAL INFRASTRUCTURE
1. OUTSIDE EMERGENCY (SCORE: 1-NO, 2- PARTIAL, 3- YES)
S.N. Objective pointsCheck pointScore
1.
Does the hospital have easy and
direct access to the Emergency
Department?
Adequate Signage on the major road and
boundary of the Hospital, E.D Board is
prominently
displayed with illumination in night facility
Score
2.
Does the access road of hospital is
wide enough?
Can pass three ambulances at a time Score
3.
Does the vehicles parked on
the way /in front of emergency
department?
People are using as parking lotScore
4.
Does the hospital have separate
access for ambulance services?
Sufficient space for Ambulance offloading and
turn-around
Score
5.
Does the hospital have designated
parking area for Ambulance, Staff
and Public?
No vehicles parked on the way/in front of
emergency
parking, “No Parking Board” placed outside
emergency
Score
6.
Does the hospital have smooth entry
area with adequate wheel chair,
trolley and stretcher bay?
Entrance have a canopy, ramp for stretchers
and wheelchairs
with Demarcated space for trolleys and
wheelchair
Score
7.
Does the hospital have patient
attendant at the entrance of hospital
to help the patient with the wheel
chair, stretcher, etc.?
Staff Responds with a wheel chair, stretcher,
trolley promptly
Score
8.Seamless flow of the patient
Unidirectional flow, separate entrance, no
crisscross.
Score
9.
Does the services provided to
the patients are clearly defined,
displayed prominently?
signage/ boardsScore
10.
Does the names of the doctors and
nursing staff on shift/duty/call are
displayed and updated?
Score
11.
Is important Telephone numbers are
displayed in hospital?
numbers including emergency no, ambulance,
blood bank, police, referral centers etc.
displayed
Score
12.
Does all relevant information is
displayed for the patients and
visitors including user charges
wherever applicable at the time of
procedure/ investigation/admission?
Service charges/ User charges are displayed
on a board/printed on pamphlet/ personally
counseled, enquiry counter/Help desk/
registration counter / designated staff.
Score 195
Annexure-II: Study Tool
13.Do you have adequate waiting area?It has comfortable seating , information boardScore
14.
Do you have safe drinking water
facility?
24hrs drinking water facilityScore
15.
Do you have functional male toilets?
Do you have functional female
toilets?
Do you have functional toilets for
differently able person with wheel
chair?
Male toilet, Female toilet, Toilet for differently
able with ( at least 1 wheelchair accessible
W.C and wash basins present)
Score
16.
Do you have clean facility and is
that maintained adequately?
Building is painted, plastered, no cracks and
seepage visible and furniture fixtures clean and
intact with no junk around
Score
17.
Do you have Cafeteria facility for
the family members/ attendants?
Score
18.Do you have police control room?Score
19.
Do you have Emergency Registration
Counter?
Score
20.
Do you have ambulance driver’s
room?
Ambulance driversScore
Remarks (if any):
2. INSIDE EMERGENCY (SCORE: 1-NO, 2- PARTIAL, 3- YES)
SN Objective ElementsCheck PointScore
1.
Do you have emergency department
with adequate space as per patient load
(Circulation space and open space)?
Admin interview / 1000 m2 per 100patient
daily load (NQAS standards),Corridors are
broad enough (2-3m) for easy movement
of stretcher and Trolley
Score
2.
Does your department has proper layout
and demarcated areas as per Triage?
1.Resuscitation Area(Red)
2.Observation Area(Yellow)
3 Ambulatory Area (Green)
Score
3.
Do you have demarcated station for
doctors and nurses?
Preferably in the center from where all
beds are visible
Score
4.Do you have demarcated plaster room?Score
5.
Do you have dedicated Isolation rooms
(Emergency Infections)?
Negative pressure and separate AHUe.g.
Swine flu/Ebola pts.
Score
6.Do you have dedicated minor OT?Score
7.
Do you have provision for Emergency
OT?
Score Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 196
8.Do you have point of care lab? Designated lab area in emergency Score
9.
Do you have linkage to other facility on
the same floor?
Radiology department, OT, Lab etc.
Score
10.
Do you have separate room for
examination of rape / sexual assault
victim?
As per One stop Centre
Score
11.
Do you have availability of sexual assault
forensic evidence kit?
Kit has protocols and guidelines for
collection of forensic evidence.
Score
12.
Do you have counselling services for
Sexual assault / domestic violence cases?
Score
13.
Do you have demarcated area for
keeping dead bodies?
Score
14.
Do you have availability of clean utility
room?
Score
15.
Do you have availability of dirty utility
room?
Score
16.
Do you have store?Storage to refrigerate, keep equipment &
Emergency supplies
Score
17.
Do you have curtains/screens at point of
care?
Privacy and dignity of patients maintained.
Score
18.
Do you have demarcated duty room for
doctors?
Score
19.
Do you have demarcated duty room for
nursing staff?
Score 197
Annexure-II: Study Tool
ANNEXURE-2: MANPOWER IN EMERGENCY
S.N. Category
Private Govt. Hospitals Medical Colleges
Less than
300 beds
More
than 300
beds
Less than
300 beds
More
than 300
beds
Govt.
Medical
Private
Medical
1.Faculty/Consultant
2.CMO (casualty medical
officer)
3.SR ( Senior Residents )
4.JR ( Junior Residents)
5.MO (medical officer)
6.Intern
7.Nursing officer In charge /
Team leader
8.Staff Nurse/ Nursing Officer
9.Radiology technician/
Radiographer
10.Lab Technician
11.OT. Technician
12.H.A*/ GDA*/ Orderly
13.SA*/ Housekeeping staff
14.EMT
15.Security
16.Registration staff
17.Any other
*
GDA-General Duty Assistant, SA- Sanitary Attendant HA- Hospital Attendant
Other Specialist/ Super Specialist
S.N. Specialty Designation Timings
24x7 Physically
present
On-Call
Empanelled
(As and when
Required)
1.Medicine Consultant
Resident
2.General Surgery Consultant
Resident
3.Pediatrics Consultant
Resident Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 198
4.
Gynecology&
Obstetrics
Consultant
Resident
5.Orthopedics Consultant
Resident
6.Radiology Consultant
Resident
7.Anesthesia Consultant
Resident
8.Critical care Consultant
Resident
9.Ophthalmology Consultant
Resident
10.ENTConsultant
Resident
11.Psychiatry Consultant
Resident
12.Dermatology Consultant
Resident
13.
Forensic
Medicine
Consultant
Resident
14.Lab Medicine Consultant
Resident
15.
Transfusion
Medicine/ Blood
Bank
Consultant
Resident
16.Cardiology Consultant
Resident
17.
CTVS (Cardiac
Surgery)
Consultant
Resident
18.Neurology Consultant 199
Annexure-II: Study Tool
Resident
19.Neurosurgery Consultant
Resident
20.Plastic Surgery Consultant
Resident
21.
Maxillofacial
Surgery
Consultant
Resident
22.Gastroenterology Consultant
Resident
23.Nephrology Consultant
Resident
24.Urology Consultant
Resident
25.Neuro Radiology Consultant
Resident
26.Pediatric SurgeryConsultant
Resident
27.Neonatology Consultant
Resident
28.Hematology Consultant
Resident
29.Oncology Consultant
Resident Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 200
ANNEXURE-3: EQUIPMENTS & SUPPLIES IN ED
BIO MEDICAL EQUIPMENT (SCORE: 1-NO, 2- PARTIAL, 3- YES)
S.N.OBJECTIVE ELEMENTCheck points SCORE
1.
Do you have list of equipment in accordance with its
scope of services available?
SCORE
2.
Do you have medical equipment inventory and log
book?
Logs are maintained for
operational
and maintenance purposes
SCORE
3.
Do you have periodically inspected and calibrated
equipment record?
SCORE
EQUIPMENTS & SUPPLIES IN ED (SCORE: 1-NO, 2- PARTIAL, 3- YES)
S. No.24x7 availability of Score Remarks
1. Do you have mobile bed for Resuscitation?Score Remarks
2. Do you have crash cart (specialized cart for resuscitation)? Score Remarks
3. Do you have Hard Cervical collar?Score Remarks
4. Do you have Central Oxygen Supply through pipeline?Score Remarks
5. Do you have Oxygen cylinder?Score Remarks
6. Do you have suction machine?Score Remarks
7. Do you have Multipara Monitor (To monitor Heart rate, BP,
SPO2[Essential] ECG, Respiration Rate [Desirable] etc)?
Score Remarks
8. Do you have simple monitor/transport monitor?Score Remarks
9. Do you have defibrillator with external pacer?Score Remarks
10.Do you have Toothed Forceps, Kocher Forceps, Magill’s forceps,
Artery forceps?
Score Remarks
11.Do you have transport ventilator?Score Remarks
12.Do you have AMBU Bag for adult and Paediatric?Score Remarks
13.Do you have suprapubic catheter?Score Remarks
14.Do you have light source to ensure visibility (lamp and flash light)?Score Remarks
15.Do you have stethoscope?Score Remarks
16.Do you have oropharyngeal airway adult and pediatric blades? Score Remarks
17.Do you have LMA?Score Remarks
18.Do you have tourniquet?Score Remarks
19.Do you have pelvic binder or bed sheets with clips?Score Remarks
20.Do you have needle holder and suture material (absorbable and non
absorbable)?
Score Remarks 201
Annexure-II: Study Tool
21.Do you have vaginal speculum?Score Remarks
22.Do you have different sizes of Ryles tube?Score Remarks
23.Do you have different sizes of Foley’s catheter?Score Remarks
24.Do you have laryngoscope with all sized blades?Score Remarks
25.Do you have Endotracheal Tubes of all sizes?Score Remarks
26.Do you have Laryngeal Mask Airway (LMA)?Score Remarks
27.Do you have Chest Tubes with Water seal drain?Score Remarks
28.Do you have Blood Pressure monitor?Score Remarks
29.Do you have ECG machine?Score Remarks
30.Do you have ultrasonic nebulizer?Score Remarks
31.Do you have IV cannula and IV infusion sets?Score Remarks
32.Do you have syringes and disposable needles?Score Remarks
33.Do you have broselow tape?Score Remarks
34.Do you have proctoscope?Score Remarks
35.Do you have fluid warmer?Score Remarks
36.Do you have dressing sets (Alcohol based solution, Betadinesolution
gauze, roller, adhesive tape)?
Score Remarks
37.Do you have personal protecting equipment’s (Apron, glove, face
mask, eye protection)?
Score Remarks
38.Do you have central line of all sizes?Score Remarks
39.Do you have capnography?Score Remarks
40.Do you have Infusion pump and Syringe Drivers?Score Remarks
41.Do you have spine board with sling and scotch tapes all sizes? Score Remarks
42.Do you have splints for all types of fracture?Score Remarks
43.Do you have non-invasive and invasive ventilators?Score Remarks
44.Do you have incubators?Score Remarks
45.Do you have emergency cricothyroidotomy kit?Score Remarks
46.Do you have emergency thoracotomy set?Score Remarks
47.Do you have emergency decompressive craniotomy sets?Score Remarks
48.Do you have emergency thrombectomysets?Score Remarks
49.Do you have phototherapy unit?Score Remarks
Remarks (if any): Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 202
ANNEXURE-4: POINT OF CARE LAB
(SCORE: 1-NO, 2- PARTIAL, 3- YES)
S. No.Point of Care Lab In ED In HospitalRemarks
1.Hemogram- Hb, Hct, TLC, DLC, PlateletScore Score Remarks
2.Random Blood SugarScore Score Remarks
3.Coagulation Profile: PT, APTT, INRScore Score Remarks
4.Electrolytes: Na, K, Cl, CaScore Score Remarks
5.Blood Urea & Serum CreatinineScore Score Remarks
6.Blood Gas AnalysisScore Score Remarks
7.Cardiac enzymes, Trop-I, Trop-T, Score Score Remarks
8.Serum AmylaseScore Score Remarks
9.D-dimer, Score Score Remarks
10.Pro-BNPScore Score Remarks
11.Urinary KetonesScore Score Remarks
12.Plasma KetonesScore Score Remarks
13.Toxicology screening- UrinaryScore Score Remarks
14.Serum osmolalityScore Score Remarks
15.Urine osmolalityScore Score Remarks
16.Pregnancy testScore Score Remarks
17.Thromboelastogram (TEG)Score Score Remarks
18.Peak expiratory FlowmeterScore Score Remarks
19.Microscopy: Thick & Thin smear (For Malaria parasite &
Gram staining)
Score Score Remarks
20.Rapid diagnostic test for Malaria (Card test) Score Score Remarks
21.CSF: Microscopy & Gram stainingScore Score Remarks
22.Portable USG (Bed side/Point of Care) Score Score Remarks
23.EchocardiographyScore Score Remarks
24.Portable X-ray (Bed side/Point of Care)Score Score Remarks
25.CT scanScore Score Remarks
Remarks (if any): 203
Annexure-II: Study Tool
ANNEXURE-5: ESSENTIAL MEDICINES FOR EMERGENCY
(SCORE: 1-NO, 2- PARTIAL, 3- YES)
S. No. Drug Name ScoreS. No. Drug Name Score
1.Oxygen medicinal gas Score 27.PhenobarbitoneScore
2.Thiopentone sodiumScore 28.PhenytoinScore
3.
Lignocaine hydrochloride (Jelly
sterile)
Score 29.Amoxicillin + Clavulanic acidScore
4.Lignocaine hydrochloride (Inj.)Score 30.Ampicillin sodiumScore
5.AtropineScore 31.Benzathine penicillin Score
6.DiazepamScore 32.CefotaximeScore
7.DiclofenacScore 33 Ceftriaxone powder Score
8.IbuprofenScore 34.AmikacinScore
9.Paracetamol (Tablet) Score 35.CiprofloxacinScore
10.Paracetamol (Syrup) Score 36.Gentamycin sulphate Score
11.Paracetamol (Inj.)Score 37.MetronidazoleScore
12.Morphine sulphateScore 38.Heparin sodiumScore
13.Tramadol hydrochloride (Tablet)Score 39.EthamsylateScore
14.Tramadol hydrochloride (Inj.)Score 40.Vitamin KScore
15.CetrizineScore 41.Plasma volume exppander Score
16..Pheniramine maleate Score 42.DiltiazemScore
17.Dexamethasone disodium Score 43.Glycerinetrinitrate Score
18.Hydrocortisone sodium SuccinateScore 44.GlycerinetrinitratenitroglycerineScore
19.AdrenalineScore 45.Isosorbidemononitrate Score
20.Charcoal activatedScore 46.Isosorbidedinitrate Score
21.Antisnake venomScore 47.Adenosine phosphate Score
22.Calcium gluconateScore 48.DobutamineScore
23.Naloxone hydrochloride Score 49.Dopamine hydrochloride Score
24.Pralidoxime (PAM)Score 50.StreptokinaseScore
25.LorazepamScore 51.Potassium permanganate Score
26.Magnesium sulphateScore 52.Silver sulfadiazine Score
53.Calamine lotionScore 78.XylometazolineScore
54.Povidone iodine (Solution) Score 79.GlycerineScore
55.Povidone iodine (Ointment) Score 80.OxytocinScore
56.FurosemideScore 81.HaloperidolScore
57.MannitolScore 82.AlprazolamScore
58.RantidineScore 83.AminophyllineScore
59.Metoclopramide hydrochloride Score 84.Ipratropium bromide – aerosolScore Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 204
60.ProchlorperazineScore 85.Salbutamol sulphate Score
61.OndansetronScore 86.Etophylline + Theophylline Score
62.Promethazine hydrochloride Score 87.BudesonideScore
63.PromethazineScore 88.Glucose/dextroseScore
64.Hyiscine butyl bromide Score 89.
Glucose with sodium chloride/
saline
Score
65.Glycerine salineScore 90.Potassium chloride Score
66.Oral rehydration salts Score 91.Ringer lactateScore
67.Insulin (soluble)Score 92.Sodium bicarbonate Score
68.Intermediate-acting insulin (Lente)Score 93.Sodium chlorideScore
69.Anti-Rabies Immunoglobulin Score 94.Water for injection Score
70.Tetanus vaccineScore 95.ArtesunateScore
71.Anti-Rabies vaccine Score 96.ArtemetherScore
72.NeostigmineScore 97.Quinine (Dihydrochloride) Score
73.CiprofloxacinScore 98.Chloroquinine phosphate Score
74.Atropine sulphateScore 99.AmiodaroneScore
75.Tropicamide + Phenylepherine Score100.DigoxinScore
76.Sodium carboxymethyl celluloseScore101.PantoprazoleScore
77.SalineScore
Remarks (if any): 205
Annexure-II: Study Tool
LIVE OBSERVATION
1.Name of the hospital: Name of Inspection Team Member:
1.
2.
3.
2.Type of Health Care
Facility
District Hospital
Tertiary Care
Apex Tertiary CarDate of Inspection:
INITIAL ASSESSMENT AND REASSESSMENT
(Score: 1-No/Never, 2- Partial, 3- Yes (24X7 basis)
S.N.Objective ElementsCheck Point Score
1.Does the emergency department priorities initial
assessment of the patient?
Time: Red – 10 mins, Yellow- 30
mins, Green- 4 hours of arrival
SCORE
2.Does the hospital staff record all treatment,
assessment and reassessment details in patient
record sheet?
Direct Observation & Patient
records (Only few samples)
SCORE
3.Record the disposition time of patients from their
arrival to departure from hospital [in minutes].
Minimum number of patients to be recorded:
RedYellowGreenDisposal Time
(Emergency
Department)
= Arrival time
(Registration time)
to Admission/
discharge/ transfer
out time
>500 beds 5 5 10
300-500
beds
2 2 5
100-300
Beds
2 2 5
Red Yellow Green
P1:
Disposal
Time
P1:
Disposal
Time
P1:
Disposal
Time
P6:
Disposal
Time
P2:
Disposal
Time
P2:
Disposal
Time
P2:
Disposal
Time
P7:
Disposal
Time
P3:
Disposal
Time
P3:
Disposal
Time
P3:
Disposal
Time
P8:
Disposal
Time
P4:
Disposal
Time
P4:
Disposal
Time
P4:
Disposal
Time
P9:
Disposal
Time
P5:
Disposal
Time
P5:
Disposal
Time
P5:
Disposal
Time
P10:
Disposal
Time
1. CHEST PAIN
Instructions: Please, score YES/ NO below the objective elements (check points) in the table.
If No, than reason should be score for the categories provided below based on scale (1-5). The
scale score for each category will be as follows: Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 206
a. Manpower (Score 1-5) – 1: Minimal manpower, 2: Inadequate manpower in all shifts, 3:
Inadequate manpower in some shifts, 4: Adequate manpower with coverage5: Adequate
manpower available for 24*7
b. Training (Score 1-5) –1: None, 2: Only few are trained, 3:Only doctors are trained, 4: Mostly
staff are trained, 5: All are trained
c. Supply (Score 1-5)–1:No supply available, 2: Minimal Supply available, 3: Inadequate supply
available only in some shifts, 4: Inadequate supply available on 24*7 basis, 5: Adequate
supply available for 24*7
d. Infrastructure (Score 1-5)–1: No infrastructure and no tie up with other facilities, 2: Not
having any infrastructure but tie up with other facilities, 3: Infrastructure available but
not functioning at all, 4: Infrastructure available but functioning only for limited hours, 5:
Infrastructure available for 24*7
e. Policy (Score 1-5)–1: No policy available, 2: Some policy is available but not standard, 3:
Organizational policy in place but not in use, 4: Organizational policy in place but sometime
in use, 5: Organizational policy in place and in use
Objective ElementsPatient 1
Triage (Red)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to ECG (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door To
Needle(<30min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to PCI; wire
crossing (<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify 207
Annexure-II: Study Tool
Objective ElementsPatient 2
Triage (Red)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to ECG (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door To Needle(<30min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to PCI; wire crossing
(<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 3
Triage (Red)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to ECG (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door To Needle(<30min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 208
Door to PCI; wire crossing
(<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 4
Triage (Red)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to ECG (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door To Needle(<30min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to PCI; wire crossing
(<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 5
Triage (Red)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to ECG (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify 209
Annexure-II: Study Tool
Door To Needle(<30min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to PCI; wire crossing
(<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
2. STROKE
Instructions: Please, score YES/ NO below the objective elements (check points) in the table.
If No, than reason should be score for the categories provided below based on scale (1-5). The
scale score for each category will be as follows:
a. Manpower (Score 1-5) – 1: Minimal manpower, 2: Inadequate manpower in all shifts, 3:
Inadequate manpower in some shifts, 4: Adequate manpower with coverage5: Adequate
manpower available for 24*7
b. Training (Score 1-5) –1: None, 2: Only few are trained, 3:Only doctors are trained, 4: Mostly
staff are trained, 5: All are trained
c. Supply (Score 1-5)–1:No supply available, 2: Minimal Supply available, 3: Inadequate supply
available only in some shifts, 4: Inadequate supply available on 24*7 basis, 5: Adequate
supply available for 24*7
d. Infrastructure (Score 1-5)–1: No infrastructure and no tie up with other facilities, 2: Not
having any infrastructure but tie up with other facilities, 3: Infrastructure available but
not functioning at all, 4: Infrastructure available but functioning only for limited hours, 5:
Infrastructure available for 24*7
e. Policy (Score 1-5)–1: No policy available, 2: Some policy is available but not standard, 3:
Organizational policy in place but not in use, 4: Organizational policy in place but sometime
in use, 5: Organizational policy in place and in use Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 210
Objective ElementsPatient 1
Door to Doctor (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion
(<25min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT reading (<45
min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to Thrombolytic
(<60 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to first pass
(<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 2
Door to Doctor (<10min)YES/ NO
If No, than score the reasons
Manpower Training SuppliesInfrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion
(<25min)
YES/ NO
If No, than score the reasons
Manpower Training SuppliesInfrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify 211
Annexure-II: Study Tool
Door to CT reading (<45 min)YES/ NO
If No, than score the reasons
Manpower Training SuppliesInfrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to Thrombolytic (<60
min)
YES/ NO
If No, than score the reasons
Manpower Training SuppliesInfrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to first pass (<90min)YES/ NO
If No, than score the reasons
Manpower Training SuppliesInfrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 3
Door to Doctor (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion
(<25min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT reading
(<45 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to Thrombolytic
(<60 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 212
Door to first pass (<90min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 4
Door to Doctor (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion
(<25min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT reading
(<45 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to Thrombolytic
(<60 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to first pass (<90min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify 213
Annexure-II: Study Tool
Objective ElementsPatient 5
Door to Doctor (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion
(<25min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT reading
(<45 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to Thrombolytic
(<60 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to first pass (<90min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
3. TRAUMA (RED CATEGORY)
Instructions: Please, score YES/ NO below the objective elements (check points) in the table.
If No, than reason should be score for the categories provided below based on scale (1-5). The
scale score for each category will be as follows:
a. Manpower (Score 1-5) – 1: Minimal manpower, 2: Inadequate manpower in all shifts, 3:
Inadequate manpower in some shifts, 4: Adequate manpower with coverage5: Adequate
manpower available for 24*7 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 214
b. Training (Score 1-5) –1: None, 2: Only few are trained, 3:Only doctors are trained, 4: Mostly
staff are trained, 5: All are trained
c. Supply (Score 1-5)–1:No supply available, 2: Minimal Supply available, 3: Inadequate supply
available only in some shifts, 4: Inadequate supply available on 24*7 basis, 5: Adequate
supply available for 24*7
d. Infrastructure (Score 1-5)–1: No infrastructure and no tie up with other facilities, 2: Not
having any infrastructure but tie up with other facilities, 3: Infrastructure available but
not functioning at all, 4: Infrastructure available but functioning only for limited hours, 5:
Infrastructure available for 24*7
e. Policy (Score 1-5)–1: No policy available, 2: Some policy is available but not standard, 3:
Organizational policy in place but not in use, 4: Organizational policy in place but sometime
in use, 5: Organizational policy in place and in use
Objective ElementsPatient 1
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion time
in Head Injury (<45min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Disposal time (Arrival time
to Admission/Transfer out/
Death declaration time)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify 215
Annexure-II: Study Tool
Objective ElementsPatient 2
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion time
in Head Injury (<45min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Disposal time (Arrival time
to Admission/Transfer out/
Death declaration time)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 3
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion time
in Head Injury (<45min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Disposal time (Arrival time
to Admission/Transfer out/
Death declaration time)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 216
Objective ElementsPatient 4
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion time
in Head Injury (<45min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Disposal time (Arrival time
to Admission/Transfer out/
Death declaration time)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 5
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion time
in Head Injury (<45min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Disposal time (Arrival time
to Admission/Transfer out/
Death declaration time)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify 217
Annexure-II: Study Tool
Incidence of Violence
Is there any violence with patient or healthcare provider observed?
1.1. If yes, than violence observed (please tick) was: (1) Verbal (2) Physical (3) Both
1.2. Please tick the reason of the violence that was observed; (1) Communication Failure
(2) Care Delay (3) Inappropriate Care (4) Inappropriate Behavior of healthcare
professional
1.3. Mitigation measures available:
Private Security Guard Yes/No
If yes, Available for 24*7 basis Yes/No
Police Available Yes/No
If yes, Available for 24*7 basis Yes/No
Anti-violence mitigation policy available Yes/No
Communication in Emergency Department
Mention the type of communication followed by the healthcare providers/staff/nurses with the
patients in emergency department (Please tick below).
1. Full content with empathy and share decision making
2. Full content with empathy and no share decision making
3. Full content with no empathy
4. Minimal communication and inappropriate behaviour
5. No communication at all
Patient Satisfaction
Perform one interview with patient or relative of the patient and please ask the following questions:
1. For Patient in Red Triage;
1.1. Does the patient/relative is satisfied with the emergency department services?Yes/No
If yes, please ask the patient satisfaction level based on the scale:
Extremely
Satisfied
Very
Satisfied
Moderately
Satisfied
Slightly
Satisfied
Not at all
Satisfied
If not satisfied, reason ............................................
2. For Patient in Yellow Triage;
2.1 Does the patient/relative is satisfied with the emergency department services?Yes/No
If yes, please ask the patient satisfaction level based on the scale: Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 218
Extremely
Satisfied
Very
Satisfied
Moderately
Satisfied
Slightly
Satisfied
Not at all
Satisfied
If not satisfied, reason ............................................
3. For Patient in Green Triage;
3.1 Does the patient/relative is satisfied with the emergency department services?Yes/No
If yes, please ask the patient satisfaction level based on the scale:
Extremely
Satisfied
Very
Satisfied
Moderately
Satisfied
Slightly
Satisfied
Not at all
Satisfied
If not satisfied, reason ............................................
Referral of the Patient
What is the referral policy of patient in the organization? Please answer (Yes/No) the following
questions:
1. Is there any referral policy in the organization? Yes/No
2. Is there any proper arrangement of patient referral? Yes/No
3. Is there any assistance during the patient referral? Yes/No
3.1. If Yes, type of assistance
(1) Technician (2) Nurse (3) Doctor (4) Other
(If other, please specify ............................................)
Details of the patient to be filled by registration desk for last
24 Hours
Health Facility Name:Time:Date:
Total Patients visited in Hospital for last 24
Hours
Numbers
Adult- Pediatric-
(please write the cut off
age)
Total Number of Patients visited in Emergency
Department for last 24 Hours
Numbers
Adult- Pediatric-
(please write the cut off
age)
Total admissions in emergency department
Numbers
Adult- Pediatric-
(please write the cut off
age) 219
Annexure-II: Study Tool
Total Leaving Against Medical Advice (LAMA)
from emergency department
Numbers
Adult- Pediatric-
(please write the cut off
age)
Total discharge from emergency department
Numbers
Adult- Pediatric-
(please write the cut off
age)
Total Death in emergency department
Numbers
Adult- Pediatric-
(please write the cut off
age)
Total Death in emergency department-
Trauma/Injury/Road Traffic Accidents
Numbers
Adult- Pediatric-
(please write the cut off
age) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 220
Adult Patients
(Please tick one check box for one patient)
Pediatric Patients
(Please tick one check box for one patient)
1. Chest Pain Patients1. Respiratory distress
2. Stroke2. Diarrheal disease
3. Altered Mental status3. Altered Mental status 221
Annexure-II: Study Tool
Adult Patients
(Please tick one check box for one patient)
Pediatric Patients
(Please tick one check box for one patient)
4. Trauma/ Road Traffic Accidents/
Injuries
4. Trauma/ Road Traffic Accidents/
Injuries
5. Respiratory Distress5. Seizure
6. Pain abdomen6. Pain abdomen Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 222
Adult Patients
(Please tick one check box for one patient)
Pediatric Patients
(Please tick one check box for one patient)
7. Poisoning7. Poisoning
8. Snake Bite8. Snake Bite
9. Fever9. Fever 223
Annexure-II: Study Tool
Adult Patients
(Please tick one check box for one patient)
10. Pregnancy Related Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 224
ANNEXURE-III:
LIST OF SCIENTIFIC ADVISORY
COMMITTEE MEMBERS
S.
No.
Name of Member DesignationE-mail ID
1.
Dr. Prof. Anurag
Srivastava
Professor & Head of
Department of Surgical
Disciplines, AIIMS, New
Delhi
dr.anuragsrivastava@gmail.com
2.
Dr. Prof. Ashish
Bhalla
Professor, Department of
Internal Medicine, PGIMER,
Chandigarh
bhalla.chd@gmail.com
3.
Dr. Prof. Ashok
Deorari
Department of Neonatology,
AIIMS, New Delhi
ashokdeorari_56@hotmail.com
4.
Dr. Prof. D.
Prabhakaran
Vice President (Research&
Policy), Public Health
Foundation of India
Executive Director of Centre
for Chronic Disease Control
New Delhi
dprabhakaran@phfi.org
5.
Dr. Prof. Deepak
Agarwal
Professor, Department of
Neurosurgery, JPNATC,
New Delhi
drdeepak@gmail.com
6.
Dr. Gururaj
Gopalakrishnan
Department of Epidemiology
WHO Collabrating Centre
for Injury Prevention &
Safety Promotion Centre for
Public Health
epiguru@yahoo.com, guru@
nimhans.kar.nic.in 225
Annexure-III: List of Scientific Advisory Committee Members
S.
No.
Name of Member DesignationE-mail ID
7.
Dr. Jayaraj
Mymbilly
Balakrishnan
Professor & Head of
Department of Emergency
Medicine, KMC, Mangalore
jayarajmb2004@gmail.com
8.
Dr. Jayashree
Muralidharan
Department of Pediatrics,
Advanced Pediatrics Centre,
PGIMER, Chandigarh
mjshree@hotmail.com
9.
Dr. Prof.
Kameshwar
Prasad
Professor Ex- HOD,
Department of Neurology,
AIIMS, New Delhi, Chief
Neurosciences Centre,
AIIMS, New Delhi
drkameshwarprasad@gmail.com
10.
Dr. Mathew
Varghese
Orthopedist, Department of
Orthopedics, St. Stephen’s
Hospital
mathewvarghese.ms@gmail.com
11.
Dr Prof.
Narendra K.
Arora
Executive Director, INCLEN
Trust International
nkarora@inclentrust.org
12.Dr. Nobhojit Roy
Advisor, Public Health
Planning, NHSRC, MoHFW,
Government of India
nobsroy@gmail.com
13.
Dr. Patanjali Dev
Nair
Department of Non-
communicable Diseases and
Environment Health (NDE)
WHO Regional Officer for
South-East Asia,
I.P. Estate, New Delhi
nayarp@who.int
14.
Dr. Prof. Rajesh
Malhotra
Professor & Head of
Department of Orthopedics,
AIIMS, New Delhi Chief of
JPNATC, New Delhi
chiefoffice06@gmail.com
15.
Dr. Prof. Shakti
Gupta
Professor, Department of
Hospital Administration,
AIIMS, New Delhi
shakti810505@gmail.com
16.
Dr. Prof. Vivek
Trikha
Professor, Department of
Orthopedics, JPNATC,
AIIMS, New Delhi
vivektrikha@gmail.com
17.Dr. Yogesh Suri
Senior Advisor, NITI Aayog,
New Delhi
yogesh.suri@nic.in Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 226
ANNEXURE-IV:
PATIENT INFORMATION
SHEET
Study Title: “A country-level Gap Analysis of the current status of emergency and injury care
at secondary and tertiary care centres in India”
SUBJECT INFORMATION SHEET & INFORMED CONSENT
DOCUMENT
Purpose of the study: This study is being conducted as a country level assessment of emergency
and injury current status of facility based Emergency and Injury care in prefixed 50 government
medical colleges (75%), large private hospitals (25%) and 50 district hospitals in India. Department
of Emergency Medicine JPN Apex Trauma Centre, AIIMS, New Delhi is conducting this national
level assessment in collaboration with NITI Aayog and Ministry of Health and Family Welfare,
New Delhi. This project is introduction of current status of emergency and injury care at tertiary
care (both public and private) and district hospitals through gap analysis in India. This project is
documenting the current status of emergency and injury care in the tertiary care and district health
care facilities through collection of data sets from the hospitals including live data recording of
de-identified clinical cases for 24 hours.
Participation: For the study, we have received the administrative approval from state and district
authorities. As the concerned health staff of the health facility, we wish to obtain your feedback on
few aspects of emergency and injury care. Thus, we are inviting you to participate in the project.
Study Procedures:
For the participation, you will be asked to sign a consent form and one copy of the
signed consent form will be given to you.
Then the assessor shall discuss with you on few issues related to the emergency and
injury care.
The information and opinion shared by you shall be treated as confidential. Your
identifiers shall not be collected. 227
Annexure-IV: Patient Information Sheet
Duration of participation: Your participation for this study is limited to one time contact only
and shall end with end of the interaction. No further contact shall be required.
Data collection during contact: The assessors shall collect the practices followed and opinions
related to emergency and injury care at your facility. The assessors shall use a guide to collect
the information and the process is expected to take about 2 days.
Risks and Benefit: Your identification shall not be collected and used in analysis. The information
shared by you shall be treated as confidential and shall not be shared with any identifier with the
administration or any other person. There is no financial benefit to you. But your participation shall
assist understanding the current gaps for strengthening and expanding the linkages of emergency
and injuries care at national level.
Confidentiality: Your identification and information shared by you will be treated as confidential.
All information collected will be labeled with a unique ID and not with your name or any other
identifying information. All project documents and records will be kept under lock and key or
computers with passwords under supervision of the Investigators. This information may be looked
at ethics committee members reviewing the study.
Compensation for participation: There will be no monetary compensation provided for
participation in this study.
Contact details: If you have a concern about any aspect of participation, contact the investigator(s)
from the hospital or related to the project. Their telephone numbers and address are listed below.
Name and address of responsible persons:
Dr Sanjeev Kumar Bhoi
Principal Investigator
Professor
Department of Emergency
Medicine JPN Apex Trauma
Centre, AIIMS, New Delhi
Email:sanjeevbhoi@gmail.com
Dr. Tej Prakash Sinha
Co-Investigator
Associate Professor
Department of Emergency
Medicine JPN Apex Trauma
Centre, AIIMS, New Delhi
Email:drsinha1234@gmail.com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 228
ANNEXURE-V:
CONFIDENTIALITY /
CONFLICT OF INTEREST
AGREEMENT FORM FOR
NATIONAL ASSESSOR
In recognition of the fact, that I…………………. (Name and Designation),and his/her
affiliation……………herein referred to as the “Undersigned”, has been engaged as a National
Assessor of the AIIMS, has been asked to assess a national project titled “A country level assessment
of current status of emergency and injury care at secondary and tertiary level centers in India”
to be conduct by Department of Emergency Medicine JPN Apex Trauma Centre, AIIMS, New
Delhi funded by the NITI Aayog.
This Agreement thus encompasses any information deemed Confidential or Proprietary provided
to the Undersigned in conjunction with the duties as a National Assessor. Any written information
provided to the Undersigned that is of a Confidential, Proprietary, or Privileged nature shall be
identified accordingly.
As such, the Undersigned agrees to hold all Confidential or Proprietary trade secrets (“information”)
in trust or confidence and agrees that it shall be used only for contemplated purposes, shall not
be used for any other purpose or disclosed to any third party. Written Confidential information
provided shall not be copied or retained. All Confidential information (and any copies and notes
thereof) shall remain the sole property of the Department of Emergency Medicine JPN Apex
Trauma Centre, AIIMS, New Delhi.
The Undersigned agrees not to disclose or utilize, directly or indirectly, any Confidential or
Proprietary information belonging to a third party in fulfilling this agreement. Furthermore, the
Undersigned confirms that his/her performance of this agreement is consistent with the institute’s
policies and any contractual obligations they may have to third parties.
The Undersigned will immediately disclose to the Principal Investigator of project, any actual or
potential conflict of interest that he/she may have in relation to any particular and to abstain from
any participation in the project.
When a National Assessor has a conflict of interest, the assessor should notify the Principal
Investigator and except to provide information requested by the Principal Investigator. 229
Annexure-V: Confidentiality / Conflict of Interest Agreement Form for National Assessor
AGREEMENT ON CONFIDENTIALITY AND CONFLICT OF INTEREST
Please sign and date this Agreement, if the Undersigned agrees with the terms and conditions
set forth above. The original (signed and dated Agreement) will be kept on file in the custody
of the JPNATC, Department of Emergency (WHO collaborated Centre) AIIMS. A copy will be
given to you for your records.
In the course of my activities as a National Assessor for this countrywide project for onsite
assessments, I may be provided with confidential information and documentation (which we
will refer to as the “Confidential Information”). I agree to take reasonable measures to protect the
Confidential Information; subject to applicable legislation, including the Access to Information Act,
not to disclose the Confidential Information to any person; not to use the Confidential Information
for any purpose outside the mandate, and in particular, in a manner which would result in a
benefit to myself or any third party; and to return all Confidential Information (including any
minutes or notes I have made as part of my duties) to the Principal Investigator upon termination
of my functions as a National Assessor.
Whenever I have a conflict of interest, I shall immediately inform the Principal Investigator not
to count me toward a quorum for candidate.
Upon signing this agreement, I agree to take reasonable measures and full responsibility to keep
the information as confidential.
I, …………………………………., have read and accept the aforementioned terms and conditions
as explained in this Agreement.
_____________________ _____________________
Undersigned Principal Investigator
(National Assessor)
_____________________ _____________________
Date & Place Date &Place Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 230
ANNEXURE-VI:
OVERALL SUMMARY OF OTHER
SPECIALIST / SUPER SPECIALIST
AVAILABLE IN HOSPITAL
{MEDIAN [IQR] MIN-MAX} BY
CATEGORY OF HOSPITALS
DepartmentDesignation
Timings
Medical
Colleges
(N=20)
Govt.
Hosp.
(>300 bed
strength)
(N=20)
Govt. Hosp.
(<300 bed
strength)
(N=20)
Pvt. Hosp.
(>300 bed
strength)
(N=20)
Pvt. Hosp.
(<300 bed
strength)
(N=20)
Medicine
Consultant
During OPD Hours
only
12 [7] 2-214 [2] 1-72 [2] 1-84.5 [4] 2-114 [2] 2-6
24 x 7 Physically
Present
3 [1] 1-33 [0] 1-32 [1] 1-3 3 [0] 3-5 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 1-33 [0] 3-4 3 [0] 3-3 3 [0] 2-3
Empanelled / As and
when required
0 3 [0] 3-3 0 5 [0] 5-5 0
Resident
During OPD Hours
only
14 [18]
4-64
5 [5] 2-153 [1] 2-4
10.5 [10.2]
1-15
4.5 [3.5] 1-6
24 x 7 Physically
Present
3 [0] 2-33 [1] 1-32.5 [0.5] 2-33 [0] 3-5 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 3-33 [0] 3-3 3 [0] 3-3 0
Empanelled / As and
when required
0 5 [0] 5-5 0 0 0
General Surgery
Consultant
During OPD Hours
only
12 [8] 2-246 [3] 1-92 [2] 1-6
6.5 [5.7]
2-11
3 [2.5] 1-4
24 x 7 Physically
Present
3 [1] 1-33 [1] 2-43 [0.5] 2-33 [0] 3-7 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 1-33 [0] 3-3 3 [0] 3-33 [0.7] 1-3
Empanelled / As and
when required
0 3 [0] 3-3 0 3 [0] 3-3 0 231
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
General Surgery
Resident
During OPD Hours
only
20 [22]
2-53
4 [7] 2-142 [2.5] 1-6
14 [5.5]
4-15
3 [1] 2-6
24 x 7 Physically
Present
3 [0] 3-33 [1] 1-31 [0] 1-1 3 [0] 3-6 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Pediatrics
Consultant
During OPD Hours
only
6 [1] 2-103 [4] 1-92 [1] 1-63 [2.5] 1-73 [1] 1-5
24 x 7 Physically
Present
2 [1] 1-32 [2] 1-32 [0] 2-2 3 [0] 3-7 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [1] 1-33 [0] 3-3 3 [0] 3-33 [0.5] 1-3
Empanelled / As and
when required
0 3 [0] 3-3 0 2 [0] 2-2 3 [0] 3-3
Resident
During OPD Hours
only
7 [6] 2-206 [2.5] 4-94 [1.5] 1-48.5 [0.5] 8-93.5 [0.5] 3-4
24 x 7 Physically
Present
3 [0] 3-33 [0.5] 1-32 [1] 1-3 3 [0] 3-8 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Gynaecology & Obstetrics
Consultant
During OPD Hours
only
8 [10.7]
1-16
3 [2.5] 1-72 [1] 1-105 [2.7] 1-183 [0.7] 3-6
24 x 7 Physically
Present
2 [1] 1-33 [0.2] 2-33 [0.2] 2-33 [0] 3-7 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [1] 1-33 [0] 3-7 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 10 [0] 10-103 [0] 3-3
Resident
During OPD Hours
only
9 [9.5]
1-33
5 [1.5] 2-84 [1] 1-5
10 [4.5]
2-11
3.5 [0.5] 3-4
24 x 7 Physically
Present
3 [0] 3-43 [0.5] 2-33 [0.5] 2-33 [0] 3-103 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-3
1.5 [0.5]
1-2
3 [0] 3-3 3 [0] 3-3 0
Empanelled / As and
when required
0 0 0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 232
Orthopedics
Consultant
During OPD Hours
only
6.5 [6.2]
2-14
3 [4] 1-61 [2] 1-54.5 [4.2] 1-82 [1.5] 1-4
24 x 7 Physically
Present
3 [1] 1-33 [0.2] 2-32 [1] 1-3 3 [0] 3-9 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [1] 1-33 [0] 2-3 3 [0] 3-3 3 [0] 2-3
Empanelled / As and
when required
0 3 [0] 3-3 0 4 [0] 4-4 0
Resident
During OPD Hours
only
3 [11] 1-386 [2] 5-9 0 7.5 [1.5] 6-92 [1] 1-3
24 x 7 Physically
Present
3 [0] 3-43 [1.5] 1-31 [0] 1-1 3 [0] 3-5 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-3 0 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Radiology
Consultant
During OPD Hours
only
5 [5.2]
1-16
1.5 [1] 1-41 [1.5] 1-43 [1.5] 1-41.5 [1.7] 1-5
24 x 7 Physically
Present
3 [0] 3-32 [1] 1-33 [0] 3-3 3 [0] 3-4 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0.5] 1-32 [1] 1-3 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0
Resident
During OPD Hours
only
7 [9.7]
1-16
2 [0] 2-21 [0] 1-1 4 [1] 3-5
6.5 [3.5]
3-10
24 x 7 Physically
Present
3 [0] 3-52 [2] 1-31 [0] 1-1 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-3 0 0 3 [0] 3-3 0
Empanelled / As and
when required
0 0 0 0 0
AnesthesiaConsultant
During OPD Hours
only
11 [9.5]
2-39
4 [5.5] 1-102 [2.2] 1-7
7.5 [5.2]
3-23
3 [4.5] 1-11
24 x 7 Physically
Present
3 [0] 3-33 [0] 1-43 [1] 1-3 3 [0] 3-5 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0.5] 1-33 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0 233
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
Anesthesia
Resident
During OPD Hours
only
10 [22.7]
1-45
6.5 [5.5]
2-9
2 [1.5] 1-46 [2] 6-10
6.5 [3.5]
3-10
24 x 7 Physically
Present
3 [0] 3-43 [1] 1-42 [1] 1-3 3 [0] 3-8 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Critical Care
Consultant
During OPD Hours
only
3 [2.5] 1-6
2.5 [1.5]
1-4
4 [4] 1-7 3 [0] 1-43 [3] 1-13
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-33 [0] 3-3 3 [0] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Resident
During OPD Hours
only
3.5 [2.5]
1-6
0 2 [0] 2-24.5 [1.5] 3-64 [1] 3-5
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Ophthalmology
Consultant
During OPD Hours
only
3 [3] 1-102 [1] 1-51 [2.2] 1-53 [2.5] 1-52 [1.5] 1-6
24 x 7 Physically
Present
3 [0] 3-32 [2] 1-32.5 [0.5] 2-32 [1] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 3-33 [0] 3-6 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 4 [0] 4-4 0
Resident
During OPD Hours
only
1 [5.2]
1-22
5 [2] 1-5 0 2 [0] 2-2 2 [0] 2-2
24 x 7 Physically
Present
3 [0] 3-33 [0.5] 1-31 [0] 1-1 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0.2] 2-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 234
ENT
Consultant
During OPD Hours
only
5 [4.2]
1-10
2 [1.5] 1-41 [1.5] 1-63 [2] 1-62 [0.5] 1-3
24 x 7 Physically
Present
3 [0] 3-31 [1] 1-32 [0] 2-23.5 [0.5] 3-43 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 1-33 [0] 3-3 3 [0] 3-3 3 [0] 2-3
Empanelled / As and
when required
0 0 0 1 [0] 1-1 0
Resident
During OPD Hours
only
4 [7] 1-232 [1.5] 1-4 0 4 [2] 2-6 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 1-32 [0] 2-2 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0.2] 2-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Psychiatry
Consultant
During OPD Hours
only
2.5 [3.2]
1-5
2 [0.5] 1-31 [0] 1-43 (1.5] 1-52 [2] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 2 [1] 1, 3 0
On Call during
Non-OPD Hours
3 [0] 1-33 [0] 1-33 [0] 1-3 3 [0] 3-3 3 [0] 1-3
Empanelled / As and
when required
0 0 0 0 3 [0] 3-3
Resident
During OPD Hours
only
2.5 [3]
1-10
2.5 [0.5]
2-3
0 4.5 [2.5] 2-7 0
24 x 7 Physically
Present
3 [0] 3-33 [0.5] 1-3 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0.5] 1-3
2.5 [0.5]
2-3
0 3 [0] 3-3 0
Empanelled / As and
when required
0 0 0 0 0
Dermatology
Consultant
During OPD Hours
only
3 [5.5] 1-72 [1.5] 1-41 [0.2] 1-42 [0.7] 2-33 [1] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [1] 1-3 0 2.5 [0.5] 2-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0] 1-33 [0.5] 1-33 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 5 [0] 5-5 0 235
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
Dermatology
Resident
During OPD Hours
only
6 [6] 2-14
3.5 [0.5]
3-4
0 2.5 [0.5] 2-3 0
24 x 7 Physically
Present
3 [0] 3-33 [1] 1-31 [0] 1-1 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0.5] 1-3
2.5 [0.5]
2-3
0 0 0
Empanelled / As and
when required
0 0 0 0 0
Forensic Medicine
Consultant
During OPD Hours
only
2 [9] 1-101 [2] 1-61 [0] 1-1 3 [2] 1-4 0
24 x 7 Physically
Present
3 [0] 3-33 [1] 1-3 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 1-33 [0] 1-33 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0
Resident
During OPD Hours
only
3.5 [2.5]
1-6
1 [0] 1-1 0 1 [0] 1-1 0
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [1] 1-3
2.5 [0.5]
2-3
0 0 0
Empanelled / As and
when required
0 0 0 0 0
Lab Medicine
Consultant
During OPD Hours
only
2 [0] 2-24 [5.5] 3-252 [1] 1-5
3.5 [1.7]
1-11
2 [0] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 3-33 [0.5] 3-43 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0
Resident
During OPD Hours
only
1 [0] 1-1 0 1 [0] 1-1 0 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-33 [0] 3-3 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
0 0 0 0 0
Empanelled / As and
when required
0 0 0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 236
Transfusion Medicine / Blood Bank
Consultant
During OPD Hours
only
2 [2.2] 1-41 [2] 1-41 [0.5] 1-51 [1.5] 1-41 [1] 1-4
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [1.5] 1-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 3-33 [0] 3-3 3 [0] 1-3 0
Empanelled / As and
when required
0 0 0 0 0
Resident
During OPD Hours
only
2.5 [1.5]
1-4
0 1 [0] 1-1 0 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-3 0 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Cardiology
Consultant
During OPD Hours
only
2 [3] 1-64 [2] 2-63 [1] 2-43 [2] 1-111 [1.5] 1-4
24 x 7 Physically
Present
0 0 0 0 0
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-3 0 3 [0] 3-3 3 [0] 1-3
Empanelled / As and
when required
0 3 [0] 3-3 0 1 [0] 1-1 0
Resident
During OPD Hours
only
6 [0] 6-6 0 0 4 [0] 4-4 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [1] 1-3
2.5 [0.5]
2-3
0 0 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
CTVS (Cardiac Surgery)
Consultant
During OPD Hours
only
2.5 [1.7]
1-5
1 [0] 1-11 [0] 1-1 3 [2] 1-61.5 [1.2] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0.5] 1-31 [0] 1-1 3 [0] 1-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0 237
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
CTVS (Cardiac Surgery)
Resident
During OPD Hours
only
6 [0] 6-61 [0] 1-1 0 3 [0] 3-3 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [1] 1-3 0 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Neurology
Consultant
During OPD Hours
only
2.5 [1.5]
1-4
0 1 [0] 1-1 3 [0] 2-32 [0.5] 2-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0.2] 3-43 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-31 [0] 1-1 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 1 [0] 1-1 3 [0] 3-3
Resident
During OPD Hours
only
3.5 [2.5]
1-6
0 0 4 [0] 4-4 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [1] 1-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Neurosurgery
Consultant
During OPD Hours
only
3 [2.2] 2-51 [0] 1-12 [0] 2-2 3 [1] 2-4 2 [2] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [1] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-31 [0] 1-1 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0
Resident
During OPD Hours
only
2.5 [1.2]
1-3
1 [0] 1-1 0 4 [0] 4-4 0
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 238
Plastic Surgery
Consultant
During OPD Hours
only
3 [2.7] 1-51 [0] 1-11 [0] 1-1 1 [1] 1-3 2 [1] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 2.5 [0.5] 2-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-31 [0] 1-1 3 [0] 3-3 3 [0] 1-3
Empanelled / As and
when required
0 3 [0] 3-3 0 2 [0] 2-2 0
Resident
During OPD Hours
only
2.5 [3] 1-41 [0] 1-1 0 0 2.5 [1.5] 1-4
24 x 7 Physically
Present
3 [0] 2-33 [0] 3-3 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Maxillofacial Surgery
Consultant
During OPD Hours
only
1.5 [0.5]
1-2
2 [0] 2-21 [0] 1-11 [0.5] 1-31 [0.2] 1-2
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-31 [0] 1-1 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-32 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Resident
During OPD Hours
only
0 2 [0] 2-2 0 0 0
24 x 7 Physically
Present
3 [0] 3-31 [0] 1-1 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
2 [1] 1-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Gastroenterology
Consultant
During OPD Hours
only
1.5 [1.7]
1-5
2 [0] 2-22 [0] 2-2 1 [2] 1-4 1 [2] 1-5
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0.5] 3-43 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-3 3 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 4 [0] 4-4 0 239
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
Gastroenterology
Resident
During OPD Hours
only
10 [0] 10-
10
2 [0] 2-2 0 1 [0] 1-1 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Nephrology
Consultant
During OPD Hours
only
1 [1] 1-32 [0] 2-21 [0] 1-1 2 [2] 1-42 [2.5] 1-5
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0.2] 2-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0] 1-31 [0] 1-1 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 1 [0] 1-1 0
Resident
During OPD Hours
only
3 [1] 2-41 [0] 1-1 0 0 0
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-21 [0] 1-1 0 2 [1] 1-3
Empanelled / As and
when required
0 0 0 0 0
Urology
Consultant
During OPD Hours
only
3 [2.5] 1-41 [0] 1-11 [0] 1-13 [0.7] 1-31 [1] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-33 [0] 3-3 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 1 [0] 1-1 0
Resident
During OPD Hours
only
3 [3.2] 1-81 [0] 1-1 0 0 0
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 3-3 0 0 0
Empanelled / As and
when required
0
2.5 [0.5]
2-3
0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 240
Neuro Radiology
Consultant
During OPD Hours
only
0 0 0 2 [1] 1-3 0
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
2 [1] 1-31 [0] 1-1 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0
Resident
During OPD Hours
only
0 0 0 0 0
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
0 0 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Pediatric Surgery
Consultant
During OPD Hours
only
2 [2.2] 1-41 [0] 1-1 0 1 [1] 1-3 1 [1] 1, 3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-3 0 3 [0] 3-3 3 [0] 2-3
Empanelled / As and
when required
0 0 0 1 [0] 1-1 0
Resident
During OPD Hours
only
4.5 [3.5]
1-8
1 [0] 1-1 0 0 0
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-3
2.5 [0.5]
2-3
0 0 0
Empanelled / As and
when required
0 0 0 0 0
Neonatology
Consultant
During OPD Hours
only
1.5 [0.5]
1-2
1 [0] 1-1 0 3.5 [1.2] 2-41 [0.5] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0.5] 1-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [1] 1-33 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0 241
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
Neonatology
Resident
During OPD Hours
only
2 [0] 2-2 0 0 0 0
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Hematology
Consultant
During OPD Hours
only
3 [0] 3-3
1.5 [0.5]
1-2
0 2.5 [1.7] 1-52 [1] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0.5] 2-3 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Resident
During OPD Hours
only
4 [0] 4-41 [0] 1-1 0 0 0
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
0 2 [0] 2-2 0 0 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Oncology
Consultant
During OPD Hours
only
1 [0.5] 1-2 0 1 [0] 1-12 [2.2] 1-41 [3.5] 1-8
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0.5] 1-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 5 [0] 5-5 0
Resident
During OPD Hours
only
6 [0] 6-6 0 0 0 2 (0) 2, 2
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
2 [1] 1-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 242
Annexure-VII:
List of National
Assessors
S.N. NameDesignation StateEmail
1 Dr Adarsh S B
Senior Resident , Dept of
Emergency Medicine, JSS
Medical College, JSS Academy
of Higher Education, Mysuru,
Karnataka
Karnatakaadarshashu6789@gmail.com
2 Dr Ajay
MD, Emergency Medicine,
JIPMER, Puducherry
Puducherryaj.ai.inn@gmail.com
3 Dr Ajit Baviskar
Professor, Dept of Emergency
Medicine, DY Patil Medical
college
Maharashtradrbaviskar@hotmail.com
4
Dr Ajith
Venugopalan
HOD, Dept of Emergency
Medicine, MOSC kolenchery,
Ernakulam
Kerala ajith.v123@gmail.com
5
Dr Akilan
Elangovan
Assistant Professor, Department
of Emergency Medicine
Tamil Naduakey6986@gmail.com
6
Dr Amit Kumar
Singh
Junior Resident, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi dr.aks2888@gmail.com
7 Dr Anil Kumar
Associate Professor and
HOD, Dept of Trauma and
Emergency Medicine, AIIMS
Patna
Patna dranil4@gmail.com
8 Dr Ankit Sharma
Junior Resident, Dept of
Trauma and Emergency
Medicine, AIIMS Bhubaneswar
Orissa
chetan91_sharma@rediffmail.
com
9
Dr Apoorva
Gomber
Junior Resident, Dept of
Pathology, RML Hospital, New
Delhi
Delhi
drapoorvagomber@gmail.
com 243
Annexure-VII: List of National Assessors
10Dr Arun Prasad
Associate Professor, Dept
of Trauma and Emergency
Medicine, AIIMS Patna
Patna drarunpd@gmail.com
11Dr Arushi Ghai
MD, Community Medicine,
AIIMS, New Delhi
Delhi ritin.mohindra@gmail.com
12Dr Ashok Kumar
Associate Professor/ CNO
AIIMS, Jodhpur
Rajasthanashokbishnoi11@gmail.com
13
Dr Awaneesh
Katiyar
Dept of Trauma and
Emergency Medicine, AIIMS
Rishikesh
Uttarakhand-
14
Dr Bharat
Bhushan
Bhardwaj
Assistant Professor, Dept
of Trauma and Emergency
Medicine, AIIMS Rishikesh
Uttarakhandbharatbbhardwaj@gmail.com
15
Dr Bharat
Choudhary
Assistant Professor, Dept
of Trauma & Emergency
(Pediatrics), AIIMS, Jodhpur
Rajasthandrbharatpaeder@gmail.com
16Dr Bharath G
Junior Resident, JPNATC,
AIIMS, New Delhi
Delhi bharathg531@gmail.com
17Dr Brunda R L
Junior Resident, JPNATC,
AIIMS, New Delhi
Delhi bru1471992@gmail.com
18
Dr Chandra
Prakash
Senior Resident, Dept of
Emergency Medicine, AIIMS
New Delhi
Delhi
chandraprakashpatlauni@
gmail.com
19
Dr Cyril G
Cherian
Emergency department, District
Hospital, Aluva, Ernakulum
Kerala cyrilgc@gmail.com
20Dr D Srikanth
Consultant Surgeon & Nodal
Officer for Trauma Care
Emergency, Trivandrum District
Hospital
Kerala drdsrikanth@gmail.com
21
Dr Debayan Sinha
Roy
Junior Resident, SSKM
Hospital, Calcutta
West Bengaldebayansinharoy@gmail.com
22Dr Deepti
Junior Resident, AIIMS, New
Delhi
Delhi ritin.mohindra@gmail.com
23
Dr Dipak Kumar
Sharma
Professor of Surgery & HOD
of Emergency Medicine, Govt.
Medical college, Guwahati
Assam
dipakkumarsarma@hotmail.
com
24Dr Gaurav Kumar
Senior Resident, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi gauravmuvalia07@gmail.com
25
Dr Ghanashyam
Timilsina
Junior Resident, Dept. of
Emergency Medicines,
JPNATC, AIIMS, New Delhi
Delhi
ghanashyam.timilsina@gmail.
com
26
Dr Gummadidala
Manoj kumar
Senior Resident, Dept of
Emergency Medicine, AIIMS,
New Delhi
Delhi drmanoj2k8@gmail.com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 244
27
Dr Harshad
Dongare
Associate Professor, Dept
of Anaesthesia, Incharge of
Emergency Dept, SSMF Dr
Jogalekar Hospital Shirwal
Maharashtraharshaddoc@gmail.com
28Dr Kalyan Bora
1st Year, PGT, GMCH,
Guwahati
Assam
kalyanborah1987@gmail.
com
29Dr Kishen Goel
Senior Resident, Dept
of Critical Care, AIIMS
Bhubaneswar
Orissa goelkishen@gmail.com
30Dr Linu Sekhar
Assistant Professor and
Incharge, Sree Gokulam
Medical college, Trivandrum
Kerala linu24886@gmail.com
31Dr M Sukumar
Senior Resident, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi mrsuku@gmail.com
32
Dr Madhu
Srinivasarangan
Assistant Professor, Dept of
Emergency Medicine, JSS
Medical College, JSS Academy
of Higher Education, Mysuru,
Karnataka
Karnatakamadhu@jssuni.edu.in
33
Dr Mahaveer
Singh Rodha
Associate Professor, Dept of
Trauma & Emergency, AIIMS,
Jodhpur
Rajasthanmsrodha@gmail.com
34Dr Manoj Nagar
Assistant Professor, Dept
of Trauma and Emergency
Medicine, AIIMS Bhopal
MP
manoj.ortho@aiimsbhopal.
edu.in
35
Dr Manzoor
Ahmed Rather
Consultant Anaesthesia in
Critical Care, Directorate of
Health Services, Jammu &
Kashmir
Kashmir drmanzoor22@gmail.com
36Dr Mayuri Mhatre
Senior Resident, Dept. of
Emergency Medicine, MGM
Medical College, Navi Mumbai
Maharashtradr_mayuri@hotmail.com
37
Dr Md Sabah
Siddiqui
Associate Professor, Dept
of Internal Medicine, AIIMS
Raipur
Chhattisgarhdr.sabahsiddiqui@gmail.com
38
Dr Md Sharjeel
Khan
Junior Resident, SSKM
Hospital, Calcutta
West Bengalmdsharjeelkhan@gmail.com
39
Dr Meenaloshni
Jayaseelan
Junior ResidentDelhi sinna.loshi@gmail.com
40
Dr Megha
Yashwant
Solasakar
Register, ICU, Joglekar
Hospital, Shirwal
Maharashtra
dr.meghasolasakar@gmail.
com
41
Dr Midhun
Mohan N
Provisional Assistant Professor,
Govt Medical College,
Kozhikode
Kerala midhun6486@gmail.com 245
Annexure-VII: List of National Assessors
42
Dr Mohameed
Haneef M
HOD and Consultant, Dept of
Emergency Medicine, Medical
Trust Hospital, Ernakulam
Kerala
haneef_farook@rediffmail.
com
43
Dr Monesh
Bhandari
Medical Officer (Academics),
Symbiosis Institute of Health
Sciences
Maharashtramoneshbhandari@gmail.com
44Dr Nazrul Islam
3rd Year, PGT, GMCH,
Guwahati
Assam nazrulislam3009@gmail.com
45Dr Nidhi Kaeley
Assistant Professor, Dept of
Emergency Medicine, AIIMS
Rishikesh
Uttarakhanddrnidhi_kaeley@yahoo.com
46Dr Nipin Kalal
Assistant Professor/ ANS AIIMS,
Jodhpur
Rajasthankalalnipin@gmail.com
47Dr Nirjala DeviJunior Resident, JNIMS, ImphalManipur nirjalawayenbam@gmail.com
48Dr Nisarg S
Senior Resident , Dept of
Emergency Medicine, JSS
Medical College, JSS Academy
of Higher Education, Mysuru,
Karnataka
KarnatakaSnisarg84@gmail.com
49Dr Nitin Borker
Associate Professor, Dept of
Pediatric Surgery, AIIMS Raipur
Chhattisgarhdrnitinborkar25@gmail.com
50Dr Nitin Kashyap
Associate Professor, Dept of
CTVS, AIIMS Raipur
Chhattisgarhnitinkashyap1@yahoo.com
51
Dr Paresh
Mahabal
Medical Officer, Goa Goa ritin.mohindra@gmail.com
52Dr Prabin
Medical Officer, UPHC,
Kakching, Imphal
Manipur prabinkh@gmail.com
53Dr Prawal Shrimal
Junior Resident, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi prawalaiimspulse@gmail.com
54Dr R. Surendar
Senior Resident, Emergency
Medicine, JIPMER, Puducherry
Puducherrydrsurendar18@gmail.com
55Dr Rachana
Assistant Professor, Dept of
Emergency Medicine, KMC
Mangalore
Karnatakarachana2806@gmail.com
56
Dr Rajeshwari
Vhora
Consultant, Emergency and
Critical Care, Global Hospital
Maharashtra
drrajeshwarivhora@gmail.
com
57
Dr Ramkaran
Chaudhary
Associate Professor, Dept of
surgery, AIIMS, Jodhpur
Rajasthanrkmoond@gmail.com
58
Dr Ravindra
Vishwakarma
Register, ICU, Vishwaraj
Hospital, Pune
Maharashtraramashrayv@gmail.com
59Dr Rina Parikh
Assistant Professor, Dept of
Emergency Medicine, SSG
Hospital and Medical college,
Baroda
Gujaratdrrinaparikh77@gmail.com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 246
60Dr Ritin Mohindra
Assistant Professor, Dept of
Emergency Medicine, AIIMS
New Delhi
Delhi ritin.mohindra@gmail.com
61Dr Sakshi Yadav
MD, Emergency Medicine,
AIIMS, New Delhi
Delhi sakshiyadav788@gmail.com
62
Dr Sangeeta
Sahoo
Assistant Professor, Dept
of Trauma and Emergency
Medicine, AIIMS Bhubaneswar
Orissa drsangeeta.asth@gmail.com
63Dr Saurabh Saigal
Associate Professor, Dept of
Anesthesia and Critical Care,
AIIMS Bhopal
MP
saurabh.criticalcare@
aiimsbhopal.edu.in
64
Dr Shandeep
Singh
Medical Officer, Medical
Directorate, Lamchel, Imphal
Manipur shaninsunville@gmail.com
65
Dr Shivasheesh
Rath
Junior Resident, Dept of
Trauma and Emergency
Medicine, AIIMS Bhubaneswar
Orissa drsrath8@gmail.com
66Dr Shreyas Patel
Assistant Professor, Dept of
Emergency Medicine, SSG
Hospital and Medical college,
Baroda
Gujaratshreyas384@gmail.com
67
Dr Subhankar
Paul
Senior Resident, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi subhankargmch@gmail.com
68
Dr Sudhanshu
Agarwal
Senior Resident, Emergency,
AIIMS, Bhopal
MP
sudhanshu.mgmc@gmail.
com
69Dr Suprith C
Senior Resident, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi c.suprith@gmail.com
70
Dr Suvan Kanti
Chowdhury
Senior Resident, Dept. of
Emergency Medicine, GMCH,
Guwahati
Assam suvanchowdhary@gmail.com
71Dr Tanmay Dutta
Associate Professor, Dept of
Orthopedics, SSKM Hospital,
Calcutta
West Bengaltanmayortho@yahoo.com
72
Dr Vignan
Kappagantu
Junior Resident, Department of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi vignan_1504@yahoo.co.in
73Dr Y. Tato
Assistant Professor and Surgical
Specialist, TRIHMS Hospital
Naharlagun
Arunachal
Pradesh
yijum@yahoo.com
74
Dr. Bansi Dilip
bhai Trambadia
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratbansitrambadia@yahoo.co.in
75
Dr.Bhumiben
Mukeshbhai Patel
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratpatelbhumi0703@gmail.com 247
Annexure-VII: List of National Assessors
76
Dr. Himanshu
Rameshchandra
Patel
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujarat
Himanshupatel9061@gmail.
com
77
Dr. Hiren
Dahyabhai
Vaghela
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujarathirenvaghela28@gmail.com
78
Dr. Krunal Kumar
Pancholi
Assistant Professor, Dept of
Emergency Medicine, SSG
Hospital and Medical college,
Baroda
Gujarat
krunalpancholi90@gmail.
com
79
Dr. Madhur
Uniyal
Assistant Professor, Dept.
of Trauma Surgery, AIIMS,
Rishikesh
Uttarakhanddrmadhuruniyal@gmail.com
80
Dr. Malay
Mukeshbhai
Rathod
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratmalayrathod22@gmail.com
81
Dr. Mihir Haresh
kumar Patel
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratmihirpatel1265@gmail.com
82Dr. Shivani Patel
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratshivanip4796@gmail.com
83
Dr. Shreya Rajiv
Dholakia
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratshreya.d125@gmail.com
84
Dr.Sojitra Amit
kumar Ramnik
bhai
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratamit.sojitra42@gmail.com
85
Dr.Tapan Jitendra
kumar Patel
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratpateltapan2404@gmail.com
86Mr A. Ahamed
Tutor, Emergency & Trauma
care Technology, SRM Medical
College Hospital & Research
Centre, Kattankulathur
Tamil Naduahamedkhan108@gmail.com
87
Mr Arun kumar
T A
Nursing officer, Dept of
Trauma & Emergency, AIIMS
Raipur
Chhattisgarh
arunthekkumkovil@gmail.
com
88Mr Aswin S Pillai
Nursing officer, Dept of
Trauma & Emergency, AIIMS
Raipur
Chhattisgarhaswinspillai009@gmail.com
89
Mr Bhanwar Lal
Dewna
Senior Nursing Officer,
Department of Emergency
Medicine, AIIMS, Jodhpur
Rajasthanbldewna@gmail.com
90
Mr Dheeneshbabu
Lakshminarayanan
Nursing Officer, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi dheeneshbabu@gmail.com
91Mr Dinesh Sridhar
Nursing Officer, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi
dinodinesh.s1991@gmail.
com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 248
92Mr J Jayamurugan
Manager-Clinical Operations,
SRM University Hospital,
Potheri, Chennai
Tamil Nadujay202398@gmail.com
93
Mr Prakash
Mahala
Senior Nursing Officer,
Incharge Emergency Medicine,
AIIMS, Rishikesh
Uttarakhand
prakashjpmmahala@gmail.
com
94Mr Rashad
Nursing Officer, WHO CC for
Emergency & Trauma Care,
SEAR, JPNATC, AIIMS, New
Delhi
Delhi—
95
Mr Sreekanth
Vijayan
Nursing officer, Dept of
Trauma & Emergency, AIIMS
Raipur
Chhattisgarh
Sreekanthvijayan4@gmail.
com
96Mr Srinivas SHRI
Nursing Officer, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi mrsuku@gmail.com
97Mr Suneesh S
Staff Nurse, General Hospital,
Neyyattinkara
Kerala
Email_suneeshbadari@gmail.
com
98
Mr Vikas
Choudhary
Nursing Tutor/ ANS, AIIMS,
Jodhpur
Rajasthanvikasss.1988@gmail.com
99Mrs Jincy Jose
Nursing officer, Dept of
Trauma & Emergency, AIIMS
Raipur
ChhattisgarhJinjose06@gmail.com
100Mrs Pratibha S L
Staff Nurse, Gr1, General
Hospital, Neyyattinkara
Kerala prathibhantanta@gmail.com
101Ms Isha Kaushik
Nursing Officer, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi ishukaushik28@gmail.com
102Ms Nirmal Thakur
Public Relation Officer,
Department of Emergency
Medicine, AIIMS, New Delhi
Delhi Neeru.rjpt.2007@gmail.com
103
Ms Ramandeep
kaur
Nursing Officer, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi bhangoo0073@gmail.com
104Ms Roopa Rawat
Nursing Officer, WHO CC for
Emergency & Trauma Care,
SEAR, JPNATC, AIIMS, New
Delhi
Delhi rooparawat84@gmail.com
105
Ms Stephy
Kennady
Nursing Officer, Dept. of
Emergency Medicines,
JPNATC, AIIMS, New Delhi
Delhi
stephykennady95@gmail.
com
106Ms. Varsha Devi
Nursing Officer, Department of
pediatrics, AIIMS, New Delhi
Delhi varshaniepgi@gmail.com
107
Pulimela Aswan
Kumar
Nursing Officer, AIIMS, RaipurChhattisgarhaswansunny239@gmail.com 249
Annexure-VIII: Contact Details of Hospitals
ANNEXURE-VIII:
CONTACT DETAILS OF
HOSPITALS
S. No. State Hospital Name Contact Person Email ID
1.
Jammu &
Kashmir
Sher-i-Kashmir Institute
of Medical Sciences,
Srinagar
-contactus@skims.ac.in
District Hospital,
Barahmulla
Dr B.A.Chalkoo
Dr Syed Masood
cmobaramulla123@gmail.
com
drmasood3788@gmail.com
District Hospital,
Ganderbal
-msdhganderbal@gmail.com
2.
Himachal
Pradesh
IGMC, Shimla
Dr Mukand Lal
(Principal)
principal-igmc-hp@gov.in
District Hospital, ShimlaDr Ganga Sharma
dirhealthdhs@gmail.
com(DHS)
dr.ravicsharma@gmail.com
(DME)
3. Punjab
Govt. Medical College,
Amritsar
Dr Shiv Charan
sgtbasr@gmail.com,
drsharma1947@yahoo.com
Jallianwala Bagh Martyr’s
Memorial Civil Hospital,
Rambagh, Amritsar
Dr Varun Joshi
(Admin)
-
Fortis Hospital, MohaliDr Sunil
bhavna.ahuja@
fortishealthcare.com
Shivam Multi Super
Speciality Hospital,
Hoshiarpur
Navtej Bassa
navtej.bassan@gmail.com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 250
4. Uttarakhand
HNB Base Hospital
01346 244706
Sandeep (AO)
medicalsuprintendent@
gmail.com
principalvcsg@gmail.com
Coronation Hospital,
Dehradun
Dr S K Gupta
(CMO)
Dr Ramola (CMS)
cmodehradun@gmail.com
coronationhosp@gmail.com
5. Uttar Pradesh
Civil Hospital, Lucknow
Dr Ashok Kumar
Singh (CMO)
-
RML Hospital, Lucknow
Dr A S Tripathi
(Q/A)
Admin Block
director@drrmlims.ac.in,
directordrrmlims@gmail.com
Charak Hospital,
Lucknow
Manik Kumar
Saxena
-
6. Chandigarh
Government
Superspeciality Hospital
Dr Satbir -
Civil Hospital, Sec-22Dr Mandeep -
Max Superspeciality
Hospital
Lalit Kumar Sharma
-
7. Rajasthan
SMS Medical College &
Hospital
Dr Sudhir Bhandari
(Principal)
Dr D S Meena
(MS)
principalsmsmc@rajasthan.
gov.in
Hari Baksh Kanwatia
Hospital, Jaipur
Dr Harashwardhan
(MS)
sahai.dr@gmail.com
District Hospital,
Kothputli
Dr. Rati Ram
Yadav (PMO)
bdm.hospitalkotputli@gmail.
com
Fortis Hospital, Jaipur
Dr. Shri Kant
Swami (MS)
shrikant.swami@
fortishealthcare.com
Birla Hospital- CK Birla,
Jaipur
Dr. Ajeet Singh
(Senior Consultant
in EM)
ajeet.singh@rbhri.in 251
Annexure-VIII: Contact Details of Hospitals
8. Gujarat
B J Medical College,
Vadodara
-
dean-bjmc-ahm@gujarat.
gov.in
dean.bjmc@hotmail.com
drmmprabhakar@gmail.com
GMERS Medical College
and Hospital, Gotri
-
deanmcgv@gmail.com
dean@gmersmcgv.ac.in
Jamanabai Hospital-
cdmo.health.jamnabai@
gmail.com
ParulSevashram Hospital,
Vadodara
-
psh@paruluniversity.ac.in
parulsevashram@gmail.com
medical@paruluniversity.
ac.in
Bhailal Amin General
Hospital, Vadodara
- contact@baghospital.com
9. Maharashtra
BJ Medical College, Pune
Dr. Satyanarayan-
(MS)
drajaytaware@yahoo.com
sbpunpale@gmail.com
Sri Seva Medical
foundation Dr Jogalekar
Hospital, Shirwal, Pune
- drom2002@gmail.com
Grant Medical
Foundation Ruby Hall
Clinic, Pune
- drspathare@rubyhall.com
10.
Madhya
Pradesh
AIIMS, Bhopal- -
Jai Prakash District
Hospital, Bhopal
- cmhobho@nic.in
Bhopal fracture hospital,
Bhopal
-
rabbina.tamu@gmail.com
kamleshvarma@hotmail.com
11.Chhattisgarh
District Hospital,
Tikarpara, Raipur
Dr. Ravi Tiwari -
District Hospital,
Dhamtari
Dr. P.C. Thakur csdhamtari2012@gmail.com
Ramkrishna CARE
Hospital, Pachpedhi
Dr. Sujoy Das
Thakur (HOD)
dr.tanushree.sidharth@
carehospitals.com
12.Goa
Goa Medical College,
Panaji
Dr Rajesh Patil
Dr. S M Bandekar
(Dean)
dean_gmc.goa@nic.in
msgmcgoa@gmail.com
North Goa District
Hospital, Mapusa
Shailendra Munz
Dr. Geeta
Kakodkar (MS)
- Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 252
13.Bihar
PMCH, Patna -
principalsoffice@rediffmail.
com
info@patnamedicalcollege.
com
AIIMS, Patna -admin@aiimspatna.org
Sadar Hospital, Gaya --
Paras HMRI Hospital,
Patna
-infopat@parashospitals.com
Ruban Memorial
Hospital, Patliputra
14.Orissa
AIIMS, Bhubneshwar
info@aiimsbhubaneswar.
edu.in
District Headquarter
Hospital, Puri
Dr. Narahari
Moharana (CMO)
-
Capital Hospital,
Bhubneshwar
Dr Ashok K
Pattnaik (Director)
Dr Narayan Sethi-
(MS)
info@capitalhospital.in
Care Hospital,
Bhubneshwar
-
leads.BBSR@carehospitals.
com
15.West Bengal
IPGMER, SSKM Hospital,
Kolkata
Dr Manimoy
Bandopadhyay
(Director)
director.ipgmer@gmail.com
Ruby General Hospital,
Kolkata
Dr Sujoy Ranjan ruby@rubyhospital.com
16.Sikkim
New STNM, Arithang,
Gangtok, Sikkim
Dr N Senga -
Singtam District Hospital,
Sikkim
--
Central Referral Hospital,
Gangtok
Bunty Agarwal
(Admin)
-
17.
Arunachal
Pradesh
TRIHMS, Papumparetrihmsap@gmail.com
Bakin Pertin General
Hospital, Pasighat
Dr Y Darang -
Ramakrishanan Mission
Hospital, Itanagar
-
rkmitanagar@gmail.com
itanagar@rkmm.org 253
Annexure-VIII: Contact Details of Hospitals
18.Assam
Gauhati Medical College
and Hospital, Guwahati
-
superintendentgmch@gmail.
com
Morigaon Civil hospital,
Guwahati
-
jtdhsmorigaon2017@gmail.
com
GNRC Hospital,
Guwahati
-info@gnrchospitals.com
Nemcare Superspecialty
Hospital, Guwahati
-info@nemcarehospital.in
19.Meghalaya
Civil Hospital Shillong,
Meghalaya
-dc-ekh-meg@nic.in
20.Nagaland
District Hospital, Peren,
Nagaland
Dr Hatlhing
Hangsing
-
Christian Institute of
Health Science and
Research
Dr Clement -
21.Manipur
RIMS, Imphal -
dean@rims.edu.in
drsanta@rediffmail.com
District Hospital,
Bishnupur
--
Shija Hospital &
Research Institute, Meitei
longol, Imphal
-contact@shijahospitals.com
22.Tripura
Agartala Government
Medical College
Dr Sukomal Sarkar
agmc@rediffmail.com
principalagmc@gmail.com
msagmcgbph@gmail.com
Gomti District Hospital,
Udaipur
--
Tripura medical college&
BRAM Teaching
Hospital, Agartala
Dr Anarsh tmc.agt@gmail.com
23.Mizoram
Zoram Medical CollegeDr Debbie
director@mimerfalkawn.
edu.in
Civil Hospital, Aizawl
Dr John
Zohmingthanga
-
Synod Hospital
(Presbyterian Hospital)
Dr Zothua
preshospital_durtlang@
rediffmail.com
presdrt05@bsnl.in
24.Telangana
District Hospital, Karim
Nagar
-
disthospitalkarimnagar@
gmail.com
District Hospital, King
Koti, Hyderabad
--
Yashoda Hospital,
Malakpet, Hyderabad
Dr Ajith Singh
(Medical Admin)
dr.ajithsingh@yashodamail.
com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 254
25.Karnataka
Mysore Medical College,
Mysore
--
Victoria Hospital,
Bengaluru
-
victoriahospitalbangalore@
ymail.com
msvh1900@gmail.com
Govt. Taluk Hospital,
Virajapet
-amovirajpetgh@gmail.com
Manipal Hospital -info@manipalhospitals.com
26.
Andhra
Pradesh
Guntur Medical College,
Guntur
-gmc_gtr@ap.nic.in
District Hospital Tenali--
Kasturi Medical College
& Hospital
-kmchgnt@gmail.com
Lalitha Super Specialty
Hospital, Kothapet,
Guntur
-
lalithahospitals@gmail.com
27.Kerala
Trivandrum medical
college
Dr Thomas
Mathew (Principal)
Dr Sharmath (MS)
principalmct@gmail.com,
supdt.mcht@gmail.com
Neyyatinkara General
Hospital
-dhneyyattinkara@gmail.com
District Model
Hopital, Perooraada,
Trivantapuram
-
dmhperoorkkada@gmail.
com
dhskerala.hlth@kerala.gov.
in(DHS)
Cosmopolitan Hospital,
Trivandrum
Ashok P Menon
(CEO)
ceo@cosmopolitanhospitals.
in
coo@cosmopolitanhospitals.
in
G G Hospital,
Trivandrum
-phkplgghospital@gmail.com
28.Tamil Nadu
Madras Medical college
Dr R Jayanthi
(Dean)
Dr Narayanasamy-
(MS)
deanmmc@tn.gov.in ,
gghdean@gmail.com
Southern Railway
Headquarters Hospital
Dr Nirmala
(Medical Director)
nirmala.deviv1959@gmail.
com
mdrhper@sr.railnet.gov
Apollo Hospital, Greams
Road, Chennai
-info@apollohospitals.com 255
Annexure-VIII: Contact Details of Hospitals
29.Pondicherry
JIPMER Pondicherry
Dr Rakesh
Aggarwal (Director)
director@jipmer.edu.in,
ashok1956badhe@gmail.
com
Indira Gandhi
Government General
Hospital, Pondicherry
Vizeacoumary
(Deputy Director)
Dr Simon (HOD)
vizeacoumary@gmail.com
30.Delhi
Primus Super Speciality
Hospital, Chanakyapuri
Dr Subrata Gorai
(MS)
casualty@primushospital.
com
ms@primushospital.com
Medeor Hospital,
Manesar
Mr Shastry vgr.shastry@medeor.in
Yashoda Hospital,
Kaushambi
Dr Anuj (MS)
dranujagarwal@rediffmail.
com
Indian Spinal Injury
Centre
Dr H S Chhabra
(Medical Director)
cma@isiconline.org
drhschhabra@isiconline.org
Asian Hospital
Dr Hilal Ahmed
(Director)
hilal.ahmed@aimsindia.com
Sri Ganga Ram Hospital
Dr Reena Kumar
(Addl Director
Medical)
Dr Sucheta (ED
Head)
dr.reena.kr@gmail.com
Artemis Hospital
Dr Sumit Ray
(Chief of Medical
Services)
sumit.ray@artemishospitals.
com
Jaipur Golden Hospital-drnishithmittal@yahoo.co.in Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 256
ANNEXURE-IX: COMPARATIVE
COMPLIANCE OF HOSPITALS
AMONG CATEGORIES 257
Annexure-IX: Comparative compliance of Hospitals among categories
COMPARATIVE OF COMPLIANCE AMONG MEDICAL COLLEGE
S.
No.
Name of Hospitals
Hospital Services
ED Protocol/
SOP/
Guidelines
Safety & Security
Disaster
management
Continuous
Quality
Management
Data
Management
System
Financing
Physical
Infrastructure
Equipment & Supplies
in ED
Essential medicine
in ED
Overall
Compliance
1
Civil Hospital, Ahemdabad
66%
21%
94%
67%
71%
50%
75%
56%
92%
88%
68%
2
Agartala Government Medical College & G B Pant Hospital
41%
17%
39%
0%
21%
39%
38%
76%
23%
67%
36%
3
Guru Nanak Dev Hospital, GMC, Amritsar, Punjab
45%
13%
28%
0%
7%
0%
38%
78%
30%
16%
26%
4
Tomo Riba Institute if Health & Medical Sciences, Papumpare
22%
0%
56%
0%
14%
17%
38%
56%
36%
35%
27%
5
B J Medical College & Sassoon General Hospital, Pune
57%
13%
72%
0%
7%
28%
50%
88%
56%
63%
43%
6
Sher - I - Kashmir Institute of Medical Sciences, Srinagar
57%
21%
56%
42%
50%
22%
38%
61%
63%
51%
46%
7
Regional Institute of Medical Sciences, Imphal
48%
13%
83%
25%
29%
28%
63%
92%
35%
43%
46%
8
Gauhati medical College & Hospital
62%
29%
50%
33%
43%
50%
38%
78%
60%
62%
51%
9
Mysore Medical College & Krishna Rajendra Hospital
40%
0%
33%
0%
7%
39%
0%
51%
34%
58%
26% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 258
10
New STNM Hospital
36%
0%
50%
0%
29%
44%
38%
47%
55%
77%
38%
11
Government General Hospital, Guntur
52%
17%
44%
0%
14%
33%
13%
58%
55%
77%
36%
12
SMS Medical College & Hospital
74%
13%
50%
42%
0%
39%
38%
69%
88%
91%
50%
13
Goa Medical College
72%
25%
83%
17%
57%
44%
25%
81%
49%
78%
53%
14
AIIMS, Bhopal
53%
25%
89%
17%
7%
89%
50%
44%
100%
100%
57%
15
Rajiv Gandhi Government General Hospital, Madras Medical College
69%
46%
100%
75%
79%
44%
75%
93%
82%
95%
76%
16
JIPMER, Pondicherry
72%
33%
89%
67%
86%
78%
25%
69%
70%
83%
67%
17
Government Medical College, Thiruvanananthapuram
57%
33%
78%
42%
43%
17%
75%
67%
80%
100%
59%
18
Patna Medical College & Hospital
36%
8%
22%
8%
29%
6%
38%
92%
59%
89%
39%
19
IPGMER & SSKM Hospital
91%
100%
89%
67%
86%
83%
38%
81%
92%
98%
83%
20
IGMC, Shimla
60%
4%
78%
8%
21%
6%
38%
71%
72%
87%
45%
0 to 49%
50 to 74%
75 to 100%
259
Annexure-IX: Comparative compliance of Hospitals among categories
COMPARATIVE OF COMPLIANCE AMONG GOVERNMENT HOSPITALS MORE THAN 300 BEDS
S.
No.
Name of Hospitals
Hospital Services
ED
Protocol/
SOP/
Guidelines
Safety
&
Security
Disaster
management
Continuous
Quality
Management
Data
Management
System
Financing
Physical
Infrastructure
Equipment & Supplies
in ED
Essential medicine
in ED
Overall
Compliance
1
GMERS Medical College & Hospital
48%
29%
56%
50%
14%
33%
0%
88%
72%
79%
47%
2
Civil Hospital, Shillong
21%
50%
78%
67%
29%
22%
0%
72%
58%
26%
42%
3
Jallianwala Bagh Matyr Memorial Hospital, Amritsar
31%
29%
78%
42%
79%
0%
38%
57%
41%
53%
45%
4
Zoram Medical College
21%
4%
22%
0%
0%
0%
13%
55%
52%
53%
22%
5
District Hospital, Baramulla, Jammu & Kashmir
47%
71%
100%
92%
100%
72%
38%
74%
53%
74%
72%
6
Victoria Hospital, Bangalore
66%
4%
33%
8%
29%
39%
25%
76%
44%
59%
38%
7
District Hospital, Karim Nagar
43%
21%
0%
0%
0%
0%
63%
67%
27%
56%
28%
8
Government District Hospital, Tenali
50%
50%
56%
17%
21%
39%
63%
85%
48%
80%
51%
9
Hari Baksh Kanwatia Hospital
19%
0%
28%
8%
7%
17%
50%
68%
34%
67%
30%
10
Dr Shyam Prasad Mukharji Civil Hospital, Lucknow
38%
29%
72%
50%
71%
50%
25%
64%
33%
78%
51% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 260
11
Government Multispeciality Hospital, Sector 16
28%
58%
100%
100%
93%
50%
25%
82%
49%
61%
65%
12
Jai Prakash Narayan District Hospital, Bhopal
26%
29%
72%
67%
7%
56%
75%
65%
60%
87%
54%
13
Southern Railways Hospital, Chennai
52%
38%
61%
83%
21%
61%
38%
60%
58%
69%
54%
14
AIIMS, Bhubneswar
41%
33%
67%
0%
36%
50%
75%
90%
71%
61%
52%
15
Indira Gandhi Government General Hospital, Pondicherry
48%
0%
33%
17%
21%
33%
50%
65%
49%
88%
40%
16
AIIMS, Patna
62%
25%
67%
17%
57%
83%
0%
66%
94%
94%
57%
17
General Hospital, Neyyatinkara
19%
8%
22%
17%
29%
11%
38%
72%
45%
65%
33%
18
District Hospital, Dhamtari
26%
21%
39%
17%
7%
28%
0%
67%
40%
60%
31%
19
HNB Base Hospital
33%
21%
39%
42%
36%
44%
0%
75%
76%
73%
44%
20
Deen Dayal Upadhyay Hospital
17%
8%
78%
42%
79%
61%
25%
66%
58%
79%
51%
0 to 49%
50 to 74%
75 to 100% 261
Annexure-IX: Comparative compliance of Hospitals among categories
COMPARATIVE OF COMPLIANCE AMONG GOVERNMENT HOSPITALS LESS THAN 300 BEDS
S.
No
Name of Hospitals
Hospital Services
ED
Protocol/
SOP/
Guidelines
Safety & Security
Disaster
management
Continuous
Quality
Management
Data
Management
System
Financing
Physical
Infrastructure
Equipment & Supplies
in ED
Essential medicine
in ED
Overall
Compliance
1
Jamanabai General Hospital
21%
38%
44%
0%
36%
28%
63%
81%
37%
72%
42%
2
Gomti District Hospital
26%
8%
61%
8%
14%
28%
50%
60%
32%
62%
35%
3
District Hospital, Peren, Nagaland
7%
17%
28%
0%
14%
0%
50%
83%
27%
16%
24%
4
Civil Hospital, Aizawl, Mizoram
28%
54%
83%
67%
86%
39%
75%
61%
57%
62%
61%
5
District Hospital, Pasighat
33%
21%
56%
8%
43%
17%
38%
53%
31%
56%
36%
6
Dr Jogalekar Hospital
38%
83%
67%
83%
86%
78%
0%
86%
94%
50%
67%
7
District Hospital, Ganderbal
17%
25%
67%
33%
36%
28%
38%
85%
55%
82%
47%
8
District Hospital, Bishnupur, Manipur
10%
8%
22%
25%
21%
11%
63%
63%
24%
50%
30%
9
Morigaon Civil Hospital, Assam
14%
8%
33%
25%
0%
39%
0%
69%
33%
63%
28%
10
Government Hospital Virajpet
33%
4%
28%
8%
29%
0%
25%
57%
43%
70%
30%
11
District Hospital, Singtam
28%
21%
56%
17%
71%
0%
25%
76%
53%
66%
41% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 262
12
District Hospital, King Koti
41%
13%
50%
0%
43%
44%
0%
73%
70%
57%
39%
13
Govt. BDM Hospital, Kotputli
28%
17%
22%
8%
21%
0%
38%
74%
37%
29%
27%
14
North Goa District Hospital
31%
21%
83%
8%
79%
33%
0%
60%
51%
83%
45%
15
Civil Hospital, Sector 22
7%
13%
67%
50%
21%
0%
38%
81%
53%
49%
38%
16
Puri District Headquarter Hospital, Orissa
34%
0%
72%
50%
43%
56%
63%
69%
61%
55%
50%
17
Sadar Hospital, Gaya
9%
0%
17%
0%
14%
0%
0%
44%
27%
40%
15%
18
District Hospital, Peroorkada
21%
8%
28%
0%
21%
33%
0%
73%
42%
53%
28%
19
District Hospital, Raipur
21%
38%
72%
33%
21%
0%
0%
76%
41%
59%
36%
20
Coronation Hospital, Dehradun
14%
21%
22%
58%
7%
6%
63%
58%
31%
68%
35%
0 to 49%
50 to 74%
75 to 100%
263
Annexure-IX: Comparative compliance of Hospitals among categories
COMPARATIVE OF COMPLIANCE AMONG PRIVATE HOSPITALS MORE THAN 300 BEDS
S.
No
Name of Hospitals
Hospital Services
ED Protocol/
SOP/
Guidelines
Safety & Security
Disaster
management
Continuous
Quality
Management
Data
Management
System
Financing
Physical
Infrastructure
Equipment & Supplies
in ED
Essential medicine
in ED
Overall
Compliance
1
Parul Sewasharam Hospital
52%
13%
78%
42%
50%
44%
0%
87%
90%
92%
55%
2
Tripura Medical College & BRAM Teaching Hospital
52%
21%
78%
50%
79%
39%
25%
76%
37%
76%
53%
3
Synod Hospital, Aizawl, Mizoram
38%
13%
50%
0%
7%
33%
0%
91%
88%
83%
40%
4
Grant Medical Foundation Ruby Hall Clinic
91%
100%
89%
92%
93%
89%
0%
89%
90%
100%
83%
5
GNRC, Guwahati, Assam
40%
21%
61%
50%
57%
33%
0%
91%
42%
54%
45%
6
Manipal Hospital, Bangaluru
86%
83%
89%
67%
100%
56%
0%
96%
88%
70%
74%
7
Central Referral Hospital, Sikkim
62%
8%
67%
8%
71%
44%
13%
87%
72%
94%
53%
8
Kasturi Medical College & Hospital
59%
38%
78%
17%
57%
44%
0%
89%
66%
100%
55%
9
Fortis Hospital, Jaipur
33%
92%
100%
83%
100%
94%
0%
84%
100%
100%
79%
10
Dr Ram Manohar Lohia Hospital
45%
38%
100%
67%
86%
44%
25%
63%
58%
67%
59%
11
Fortis Hospital, Punjab
86%
92%
89%
100%
86%
50%
0%
70%
76%
98%
75% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 264
12
Apollo Hospitals, Chennai
76%
96%
94%
100%
100%
94%
0%
72%
85%
87%
80%
13
Capital Hospital, Orissa
52%
54%
72%
92%
43%
83%
38%
94%
65%
80%
67%
14
Yashoda Hospital, Malakpet
83%
83%
89%
67%
100%
83%
0%
79%
100%
89%
77%
15
Paras HMRI Hospital
41%
96%
89%
100%
100%
67%
0%
93%
92%
97%
78%
16
Cosmopolitan Hospitals Privatre Limited
76%
38%
78%
25%
79%
56%
0%
85%
89%
91%
62%
17
Yashoda Hospital, Kaushambi
66%
75%
83%
75%
64%
67%
0%
76%
79%
91%
68%
18
Asian Hospital
88%
67%
94%
92%
93%
100%
0%
87%
96%
84%
80%
19
Sri Ganga Ram Hospital
84%
100%
89%
100%
93%
67%
0%
93%
94%
81%
80%
20
Artemis Hospital
84%
92%
89%
83%
100%
78%
0%
75%
94%
92%
79%
0 to 49%
50 to 74%
75 to 100%
265
Annexure-IX: Comparative compliance of Hospitals among categories
COMPARATIVE OF COMPLIANCE AMONG PRIVATE HOSPITALS LESS THAN 300 BEDS
S.
No
Name of Hospitals
Hospital Services
ED Protocol/
SOP/
Guidelines
Safety
&
Security
Disaster
management
Continuous
Quality
Management
Data
Management
System
Financing
Physical
Infrastructure
Equipment & Supplies
in ED
Essential medicine
in ED
Overall
Compliance
1
Bhailal Amin General Hospital
74%
63%
89%
83%
93%
72%
0%
92%
78%
98%
74%
2
Christian Institute of Health Sciences & Research, Dimapur
21%
33%
61%
25%
93%
56%
0%
84%
67%
77%
52%
3
Shivam Hospital, Hoshiarpur, Punjab
50%
38%
83%
17%
93%
44%
13%
86%
61%
66%
55%
4
Ramakrishna Mission Hospital, Arunachal Pradesh
43%
46%
78%
42%
86%
44%
0%
84%
78%
97%
60%
5
Shija Hospital & Research Institute, Meitei longol, Imphal
62%
42%
72%
33%
79%
33%
25%
85%
22%
71%
52%
6
Nemcare Superspeciality Hospital, Assam
79%
67%
89%
50%
36%
56%
50%
89%
80%
85%
68%
7
Lalitha Super Speciality Private Hospital
55%
75%
83%
25%
86%
89%
25%
88%
67%
94%
69%
8
Birla CK Hospital, Jaipur
41%
75%
78%
58%
79%
78%
0%
84%
100%
100%
69% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 266
9
Charak Hospital & Research Centre, Lucknow
59%
67%
94%
83%
93%
50%
0%
73%
98%
98%
72%
10
Max Super Speciality Hospital
86%
75%
89%
50%
100%
56%
13%
84%
92%
96%
74%
11
Bhopal Fracture Hospital, Bhopal
26%
67%
78%
17%
57%
67%
38%
97%
96%
68%
61%
12
Care Hospital, Orissa
69%
79%
89%
75%
100%
78%
0%
82%
73%
93%
74%
13
G G Hospital
62%
83%
89%
67%
79%
67%
0%
77%
82%
93%
70%
14
Ruban Memorial Hospital
57%
88%
89%
50%
79%
100%
0%
77%
99%
100%
74%
15
Ramakrishna Care Hospital
93%
75%
89%
100%
100%
94%
100%
80%
100%
100%
93%
16
Ruby General Hospital
53%
63%
78%
42%
79%
72%
25%
92%
76%
83%
66%
17
Indian Spinal Injuries Centre
62%
67%
89%
83%
93%
72%
0%
78%
90%
86%
72%
18
Medeor Hospital
76%
92%
89%
100%
100%
56%
0%
67%
88%
74%
74%
19
Jaipur Golden Hospital
74%
71%
83%
92%
86%
50%
0%
84%
83%
79%
70%
20
Primus Super Speciality Hospital
100%
100%
100%
75%
86%
100%
100%
72%
92%
100%
93%
0 to 49%
50 to 74%
75 to 100%
267
Annexure-IX: Comparative compliance of Hospitals among categories
MASTER SHEET DEPICTING COMPLIANCE AMONG HOSPITAL CATEGORIES
S.No.
Area of Concern
Medical College
Government
Hospitals more than
300 beds
Government
Hospitals less than
300 beds
Private Hospitals
more than 300
beds
Private Hospitals
less than 300 beds
Overall
Compliance
1
Hospital Services
56%
37%
23%
65%
62%
49%
2
ED Protocol/ SOP/ Guidelines
22%
26%
21%
61%
68%
40%
3
Safety & Security
64%
55%
49%
83%
84%
67%
4
Disaster management
26%
37%
24%
66%
58%
42%
5
Continuous Quality Management
35%
37%
35%
78%
85%
54%
6
Data Management System
38%
37%
22%
63%
67%
45%
7
Financing
42%
32%
31%
5%
19%
26%
8
Physical Infrastructure
70%
71%
69%
84%
83%
75%
9
Equipment & Supplies in ED
62%
53%
45%
80%
81%
64%
10
Essential medicine in ED
73%
68%
57%
86%
88%
74%
0 to 49%
50 to 74%
75 to 100% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 268
MASTER SHEET DEPICTING OVERALL COMPLIANCE OF INDIVIDUAL HOSPITAL AMONG ALL CATEGORIES
Zone
S.
No.
State
Medical College
Government Hospital (more
than 300 beds)
Government Hospital
(less than 300 beds)
Private Hospital
(more than 300 beds)
Private Hospital (less
than 300 beds)
NORTH
ZONE
1
Jammu & Kashmir
Sher-i-Kashmir Institute of Medical Sciences, Srinagar (46%)
District Hospital Hospital, Barahmulla, Jammu & Kashmir(72%)
District Hospital Ganderbal, Ganderbal(47%)
-
-
2
Himachal Pradesh
IGMC, Shimla
(45%)
District Hospital,Shimla (Deen Dayal Upadhyay Hospital)(51%)
-
-
-
3
Punjab
Guru Nanak Dev Hospital & Govt. Medical College, Amritsar (26%)
Jallianwala Bagh Martyr’s Memorial Civil Hospital, Rambagh, Amritsar(45%)
-
Fortis Hospital, Mohali (75%)
Shivam Multi Super Speciality Hospital, Hoshiarpur (55%)
4
Haryana
-
-
-
-
-
5
Uttarakhand
-
HNB Base Hospital(44%)
Coronation Hospital, Dehradun (35%)
-
-
6
Utttar Pradesh
-
Civil Hospital- Lucknow(51%)
-
RML Hospital, Lucknow (59%)
Charak Hospital Hardoi road, near Safed Masjid, Dubagga
(72%)
7
Chandigarh
-
Government Superspeciality Hospital, Sector-16(65%)
Civil Hospital Sector-22, Chandigarh(38%)
-
Max Superspeciality Hospital, Mohali(74%) 269
Annexure-IX: Comparative compliance of Hospitals among categories
8
Rajasthan
SMS Medical College & Hospital, Jaipur (50%)
Hari Baksh Kanwatia Hospital, Shastri Nagar, Jaipur(30%)
Govt. BDM Hospital, Kotputli, Rajasthan(27%)
Fortis Hospital, Jaipur(79%)
Birla Hospital- CK Birla, Shanthi Nagar, Jaipur (69%)
9
Delhi
-
-
-
Yashoda Hospital, Kaushambi (68%)
Indian Spinal Injuries Centre (72%)
Asian Hospital(80%)
Medeor Hospital, Manesar (74%)
Sri Ganga Ram Hospital (80%)
Jaipur Golden Hospital (70%)
Artemis Hospital(79%)
Primus Super Speciality Hospital(93%)
WEST ZONE
1
Gujarat
BJ Medical College & Civil Hospital, Ahemdabad
(68%)
GMERS Medical College & Hospital, Gotri, Vadodara(47%)
Jamanabai Government Hospital, Mandvi(42%)
Parul Sewasharam Hospital, Vadodara(55%)
Bhailal Amin General Hospital, Vadodara(74%)
2
Maharashtra
BJ Medical College & Sassoon General Hospital, Pune (43%)
-
Sri Seva Medical foundation Dr Jogalekar Hospital, Shirwal, Pune (67%)
Grant Medical Foundation Ruby Hall Clinic, Pune(83%)
-
3
Madhya Pradesh
AIIMS, Bhopal (57%)
Jai Prakash District Hospital, Shivaji Nagar, Bhopal (54%)
-
-
Bhopal Fracture Hospital, Bhopal(61%) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 270
4
Chhattisgarh
-
District Hospital, Dhamtari, Chhattisgarh(31%)
District Hospital, Tikarpara, Raipur, Chhattisgarh(36%)
-
Ramkrishna CARE Hospital (93%)
5
Goa
Goa Medical College, Panaji (53%)
-
North Goa District Hospital, Mapusa(45%)
-
-
EAST
ZONE
1
Bihar
PMCH, Patna(39%)
AIIMS Patna(57%)
Sadar Hospital, Gaya(15%)
Paras HMRI Hospital, Patna (78%)
Ruban Memorial hospital patliputra(74%)
3
Orissa
-
AIIMS, Bhubneshwar(52%)
District Headquarter Hospital, Puri(50%)
Capital Hospital, Bhubneshwar(67%)
Care Hospital, Bhubneshwar(74%)
4
West Bengal
IPGMER & SSKM(83%)
-
-
-
Ruby General Hospital (66%)
NORTH
EAST
ZONE
1
Sikkim
New STNM- Govt- medical college, Sikkim (38%)
-
Singtam District Hospital (41%)
Central Referral hospital, Gangtok (53%)
-
2
Arunachal Pradesh
Tomo Riba Institute of Health & Medical Sciences, Papumpare(27%)
-
Bakin Pertin General Hospital, Medog, Pasighat (36%)
-
Ramakrishna Mission Hospital, Itanagar(60%)
3
Assam
Gauhati Medical College and Hospital, Guwahati
(51%)
-
Morigaon Civil Hospital(28%)
GNRC Hospital, Guwahati (45%)
Nemcare Superspecialty Hospital, Guwahati(68%) 271
Annexure-IX: Comparative compliance of Hospitals among categories
4
Meghalaya
-
Civil Hospital Shillong, Meghalaya (42%)
-
-
-
5
Nagaland
-
-
-
District Hospital, Peren, Nagaland (24%)
-
-
Christian Institute of Health Science and Research (52%)
6
Manipur
RIMS, Imphal(46%)
-
-
District Hospital, Bishnupur (30%)
-
Shija Hospital & Research Institute, Imphal (52%)
7
Tripura
Agartala Government Medical College & G B Pant Hospital(36%)
-
-
Gomti District Hospital, Udaipur (35%)
Tripura medical college& BRAM Teaching Hospital, Agartala (53%)
-
8
Mizoram
-
Zoram Medical College(22%)
Civil Hospital, Aizawl(61%)
Synod Hospital(40%)
-
SOUTH
ZONE
1
Telangana
-
District Hospital, Karim Nagar, Hyderabad (28%)
District Hospital, King Koti, Hyderabad(39%)
Yashoda Hospital, Malakpet, Hyderabad(77%)
-
2
Karnataka
Mysore Medical College & Krishna Rajendra Hospital, Mysuru (26%)
Victoria Hospital, Bengaluru(38%)
Government Hospital, Virajpet (30%)
Manipal Hospital, Bengaluru (74%)
- Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 272
3
Andhra Pradesh
Guntur Medical college & Government General Hospital(36%)
Government District Hospital, Tenali (51%)
-
Kasturi Medical College & Hospital(55%)
Lalitha Super Specialty Hospital, Kothapet, Guntur (69%)
4
Kerala
Trivandrum Govt Mediacl College(59%)
District Hospital, Neyyattinkara(33%)
District Hospital, Peroorkada (28%)
Cosmopolitan Hospitals Pvt Ltd(62%)
G G Hospital(70%)
5
Tamil Nadu
Madras Medical College
(76%)
Madras Railway Hospital, Madras (Southern Railway Headquarters Hospital)(54%)
-
Apollo Hospital(80%)
-
6
Pondicherry
JIPMER, Pondicherry (67%)
Indira Gandhi Government General Hospital, Pondicherry(40%)
-
-
-
0 to 49%
50 to 74%
75 to 100%
Emergency and Injury Care
at Secondary and Tertiary
Level Centres in India
A Report of Current Status on
Country Level Assessment
Emergency and Injury Care at Secondary and Tertiary Level Centres in India
A Report of Current Status on Country Level Assessment Phone Number: 011-26731068
Email: Office@whoccemcare.org
Office: Room No. 117, First Floor, Department of
Emergency Medicine, JPNATC, AIIMS, Ring Rd.,
Raj Nagar, New Delhi-110029
Emergency and Injury Care
at Secondary and Tertiary
Level Centres in India
A Report of Current Status on
Country Level Assessment
Emergency and Injury Care at Secondary and Tertiary Level Centres in India
A Report of Current Status on Country Level Assessment This study was carried out with the financial support of
NITI Aayog, Government of India,
and conducted by
Department of Emergency Medicine ,
JPNATC, AIIMS.
PROJECT REPORT SUBMITTED TO
NITI Aayog, New Delhi
Emergency and Injury
Care at Secondary
and Tertiary Level
Centres in India
A REPORT OF CURRENT STATUS ON
COUNTRY LEVEL ASSESSMENT DISCLAIMER
Department of Emergency Medicine, JPNATC, AIIMS has received the
financial assistance under the Research Scheme of NITI Aayog (RSNA 2018)
to prepare this report. While due care has been exercised to prepare the
report using the data from various sources, NITI Aayog does not confirm
the authenticity of data and accuracy of the methodology to prepare the
report. NITI Aayog shall not be held responsible for findings or opinions
expressed in the document. This responsibility completely rests with the
Department of Emergency Medicine, JPNATC, AIIMS.
Copyright: © 2020 Department of Emergency Medicine, JPNATC, AIIMS,
New Delhi
All rights reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording or any information storage and retrieval system,
without permission in writing from the publisher.
This book and the individual contributions contained in it are protected
under copyright by the Department of Emergency Medicine, JPNATC,
AIIMS, New Delhi. iii
LIST OF
INVESTIGATORS AND
CONTRIBUTORS
S. No.Name Designation Organization
PRINCIPAL INVESTIGATOR
1Dr Sanjeev Kumar BhoiProfessor
Department of Emergency
Medicine, JPNATC,
AIIMS, New Delhi
CO-INVESTIGATORS
2Dr Praveen Aggrawal
Professor &
HOD
Department of Emergency
Medicine, AIIMS, New
Delhi
3Dr Tej Prakash Sinha
Associate
Professor
Department of Emergency
Medicine, JPNATC,
AIIMS, New Delhi
CONTRIBUTORS
4Dr Tanu Jain
Deputy Director
General
Directorate General of
Health Services, Nirman
Bhawan, New Delhi Emergency and Injury Care at Secondary
and Tertiary Level Centres in India iv
5Dr S Rajesh
IFS, Chief
Conservator of
Forests
Former Director
(Health)
Govt. of Arunachal
Pradesh
NITI Aayog, Govt. Of
India, New Delhi
6Dr K Venkatnarayan
Officer on
Special Duty
National Institute of
Transforming India (NITI)
Aayog
RESEARCH OFFICERS
7Ms Dolly Sharma Research Officer
Department of Emergency
Medicine, JPNATC,
AIIMS, New Delhi
8Dr Monica Sindhu Research Officer Foreword
Care of emergency and accident patients is of paramount importance in saving
lives, preventing disability and for achieving the intended health goals of the Nation.
However, accident and emergency services in India has witnessed uneven progress.
Given its extraordinary importance, it is time that India embarks on creating a world-
class, efficient, professional and integrated system, enabled by technology, for the care
any victim of accident, emergency or trauma in any part of the country.
To understand the imperatives in realizing this goal, NITI Aayog, jointly with
Ministry of Health & Family Welfare (MoHFW) conducted field visits and held multi-
stake holder meetings. It emerged from these deliberations that a pan-lndia study to
assess gaps in optimal delivery of emergency care services was a crucial starting point.
Accordingly, NITI Aayog commissioned Emergency Medicine Department, AllMS, New
Delhi to conduct a Nation-wide assessment of prevailing emergency care system in
India.
I am happy to note this study, which involved 100 Secondary and Tertiary level
health facility sites of government and private hospitals of all zones of the Nation,
has been completed. Besides highlighting the spectrum and load of emergency cases,
it brings out the prevailing gaps in ambulance services, health infrastructure, human
resources and equipment in the provision of optimal care. I complement the team for
conducting live observations of various processes involving efficiency of time-bound
procedures, patient satisfaction reports. Medico-legal burden, adherence to protocols
and data-entry operations.
My congratulations to the AllMS team for successful completion of the project and
the teams from NITI Aayog and Ministry of Health & Family Welfare for their useful
contribution In bringing out this timely report. The learnings from this study would be
useful for developing vision and plans toward creating world-class emergency care in
the country. Emergency conditions such as Acute coronary syndrome, stroke, respiratory diseases,
maternal and pediatric emergencies and injuries are the leading causes of death and
disabilities in India. Trauma is the leading cause of death among young, who often are
the sole bread earner of the family.
The landscape of emergency care includes timely access and acute care delivery to
critically ill and injured patients. Premature death and Disability Adjusted Life Years
(DALYs) can be prevented by establishing robust integrated emergency care system with
definitive care.
In this study, 100 healthcare facilities were randomly selected from 28 states and 2 union
territories of our Country and were assessed by team of assessors.
This study aims to find the available gaps in the emergency and injury care system in the
healthcare facilities, both in government and private sector. It also studied the linkages
between pre-hospital care and hospital care in India.
I strongly believe that the outcomes of this study will provide the policy inputs to improve
and strengthen the emergency care services at all tiers of the healthcare facilities in India.
I congratulate the researchers for conducting this very important study.
MESSAGE ix
ACKNOWLEDGEMENT
ACKNOWLEDGEMENT
We wish to express our sincere gratitude to all who helped us to complete this project in an
efficient time-bound manner. This study was carried out by Department of Emergency Medicine,
JPNATC, AIIMS, with the financial support of NITI Aayog, Government of India.
At the outset, we like to thank Dr V K Paul, Member, National Institution for Transforming India
who provided useful insights in conceiving this study and guiding throughout various processes.
We would like to thank to Dr Madan Gopal, Sr. Consultant, NITI Aayog for his kind support and
co-operation both during this study and submission of its report.
This study would not have been possible without the continued support. dedication and constant
engagement of all our research staff and team of national assessors, especially given the limited
time frame.
We would also thank all the nodal officials and all the staff of various hospital sites, who were
immensely cooperative in providing the needful inputs for the study, whenever our team reached
out to them.
Our special thanks to the teams representing our key stakeholders from the Ministry of Health
and Family Welfare and NITI Aayog, for their valuable contribution and time.
Finally, we thank the God almighty for giving this opportunity to successfully conduct this study;
which we hope, would bear an important imprint for making key policy decisions to deliver
optimal emergency care for the Nation.
Team of Investigators
JPNATC
AIIMS, New Delhi xi
TABLE OF CONTENTS
List of Investigators and Contributors iii
Foreword v
Message vii
Acknowledgement ix
Abbreviations xv
1. EXECUTIVE SUMMARY 1
1. Salient Findings of the Study 4
2. Key Recommendations 8
2. INTRODUCTION 11
3. REVIEW OF LITERATURE 15
1. Burden of Emergency Conditions in the South-East Asian Region 16
2. Burden in India 18
3. Current Status of Emergency Care in the India 19
4. WHO Emergency Care System Framework 20
5. Hospital Based Emergency Care in the Government Sector in India 22
6. Training 22
7. Academic Emergency Medicine 23
8. Gaps 23
8.1 Research and Development for Emergency Services 23
8.2 Organization and financing 24
4. AIMS AND OBJECTIVES 27
5. METHODOLOGY 31
6. OBSERVATIONS AND RESULTS WITH SUGGESTIONS 39
I. FIELD VISIT: ADMINISTRATIVE INTERVIEW/ONE YEAR DATA COLLECTION 39
1. Background Information of the Hospitals 39
2. Available Beds at Assessed Facilities 39 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India xii
3. Burden of Patients (OPD and Emergency) 41
4. Huge Mismatch between Emergency Beds & Burden of Emergency and Injury Cases: 44
5. Burden of Medico-legal Cases 46
6. Burden of Admissions through Emergency 48
7. Burden of Death of Trauma Patients 49
8. Burden of Patient’s Death due to Road traffic Injury 50
9. Burden of Brought Dead Patients 50
10. Blood Bank Services 51
11. Definitive Care Services 57
12. Ambulance Services 62
12.1 Available ambulances in hospitals 62
12.2 Hospital Ambulance Services 65
12.3 Use of Ambulances by Hospitals 67
12.4 Patient transfer in absence of hospital ambulance: 67
13. ED Protocol / SOP / Guidelines 68
14. Emergency care protocols 72
15. Measures ensuring Safety & Security in Hospitals 75
16. Disaster Management 78
17. Continuous Quality Improvement 82
18. Computerized Data Management System 87
19. Financing 92
20. Physical Infrastructure 96
21. Manpower in Emergency Department 98
22. Equipment and Supplies in ED 101
22.1 Biomedical Equipment 101
22.2 Compliance of critical available equipments 102
23. Point of Care Lab 107
24. Essential Medicines for Emergency 111
II. LIVE OBSERVATION 114
1. Disposition Time 114
2. Chest Pain 116
3. Stroke 120
4. Trauma 125
5. Incidence of Violence 128
5.1 Reason of Violence 128
5.2 Mitigation measures 129
6. Communication Skills in Emergency Department 130
7. Patient Satisfaction 131
8. Referral of the Patient 133
III. LIVE OBSERVATION (ONE DAY DATA OF EMERGENCY) 136
1. Burden of Patients (OPD and Emergency) 136
2. Disposition Summary 137 xiii
Table of Contents
3. Spectrum of Diseases 138
3.1 Adult Patients 138
3.2 Pediatric Patients 140
IV. COMPARISON OF EMERGENCY CARE IN VARIOUS SYSTEMS 142
1. Hospitals with Academic Emergency Medicine (n=5) 142
2. Govt. Secondary care v/s Tertiary care Hospitals 146
3. Private Hospitals vs Government Hospitals 151
4. NABH accredited vs non-NABH accredited Hospitals 151
V. COMPLIANCE OF INDIVIDUAL HOSPITALS TO THE CHECKLIST 152
7. DISCUSSION 155
8. CONCLUSIONS 159
9. SUMMARY OF KEY SUGGESTIONS EMERGING FROM THE STUDY 163
10. SUGGESTED KEY POLICY RECOMMENDATIONS 169
11. REFERENCES 175
12. ANNEXURE 179
Annexure-I: List of Hospitals 181
Annexure-II: Study Tool 185
Annexure-III: List of Scientific Advisory Committee Members 224
Annexure-IV: Patient Information Sheet 226
Annexure-V: Confidentiality / Conflict of Interest Agreement Form for National Assessor 228
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital 230
Annexure-VII: List of National Assessors 242
Annexure-VIII: Contact Details of Hospitals 249
Annexure-IX: Comparative compliance of Hospitals among categories 256 ABBREVIATIONS
xv
ACLSAdvanced Cardiac Life Support
AIIMSAll India Institute of Medical Sciences
ALSAdvanced Life Support
AMBUArtificial Manual Breathing Unit
APTTActivated Partial Thromboplastin Time
ATLSAdvanced Trauma Life Support
BLS Basic Life Support
CaCalcium
CABGCoronary Artery Bypass Grafting
CCUCritical Care Unit
CDCommunicable Disease
ClChlorine
CMOChief medical officer
CTComputerized Tomography
DALYsDisability-Adjusted Life Years
DLCDifferential Leucocyte Count
DNBDiplomat of National Board
DSADigital Subtraction Angiography
ECGElectrocardiogram
ECSEmergency Care System
EDEmergency Department
EHRElectronic Health Record
EMEmergency Medicine Emergency and Injury Care at Secondary
and Tertiary Level Centres in India xvi
EMSEmergency Medical Services
EMTEmergency Medical Technician
EREmergency Room
ETATEmergency Triage Assessment and Treatment
FFPFresh Frozen Plasma
GDAGeneral Duty Attendant
GDPGross Domestic Product
GHEGlobal Health Estimates
HAHospital Attendant
HbHemoglobin
HctHematocrit
HDUHigh Dependency Unit
HMRIHai Medicare and Research Institute
ICUIntensive Care Unit
INDUSEMINDO-US Emergency Medicine
INRInternational Normalized ratio
IPDIn-Patient Department
IPGMERInstitute of Post-Graduate Medical Education and Research
ITUIntensive Treatment Unit
IVIntra-venous
JPNATCJai Prakash Narayan AIIMS Trauma Centre
JRJunior Residents
KPotassium
LAMALeft Against medical Advice
LMALaryngeal Mask Airway
LMICsLower Middle Income Countries
MCIMedical Council of India
MLCMedico legal Cases
MOMedical Officer
NaSodium
NABHNational Accreditation Board for Hospitals & healthcare Providers
NCDNon-Communicable Disease
NITI Aayog National Institution for Transforming India
OPDOut Patient Department
OTOperation Theatre xvii
Abbreviations
PALSPediatric Advanced life Support
PCIPercutaneous Coronary Intervention
PEFPeak Expiratory Flowmeter
Pro-BNPN-terminal B-type Natriuretic Peptide
PTPlatelet Transfusion
RBCRed blood Corpuscles
RTIRoad Traffic Injury
SASanitary Attendant
SACScientific Advisory Committee
SDStandard Deviation
SEARSouth East Asian Regions
SOPStandard Operating Procedures
SPSSStatistical Package for the Social Sciences
SRSenior Residents
SSGSir Sayaji General
SSKMSeth SukhlalKarnani Memorial
STNMSir ThutobNamgyal Memorial
TEGThromboelastogram
TLCTotal Leucocyte Count
Trop-ITroponin I
Trop-TTroponin T
U.S.United States
USGUltrasound/Sonography
WHOWorld Health Organization EXECUTIVE SUMMARY
Non- Trauma Trauma
Symptoms/ History/ Exam finding based Injuries identified Mechanism of injury
R
E
D
1. Breathlessness / Pallor with Edema
2. Active Bleeding (Hematemesis, Hemoptysis, Epistaxis,
Hematuria, etc)
3. Active seizures
4. H/o Fainting / Syncope
5. Fever with Delirium
6. Poisoning with unstable vital sign
7. Snake / Scorpion bite
8. Burn >20% BSA (Burn of special areas)
9. Hanging /Drowning / Electrocution / Heat Stroke
R
E
D
1. Gun-shot wound
2. Major Vascular injury
3. Stab wounds
(Head/Neck/Chest/Abdomen/Groin)
4. Multiple injuries
5. Open fractures excluding fractures of
hand and feet
6. Two or more long bone fracture
7. Pelvic fracture
8. Visible neck swelling
9. Suspected sexual assault
10. Flail chest with paradoxical respiration
11. Chest trauma with
• Surgical Emphysema
• Seat Belt Mark
• CCT Positive
12. Traumatic Amputation
1. Fall from
• >3 times height of patient
• >5 stairs
2. Roll over vehicle
3. Co-passenger death
4. Ejection from vehicle
5. Railway track injuries
6. Steering wheel injury
7. Prolonged extrication time from
vehicle
8. Roll over vehicle
9. Stuck between 2 heavy vehicles
Y
E
L
L
O
W
1. Post-seizure stage
2. Pain abdomen / Loose motions (>3episodes)
3. Painful Bleeding P/R
4. H/o Bleeding
5. Pallor/ Known Anaemia for Transfusion
6. Fever with Headache/ chest Pain / Jaundice
7. Fever in patient on chemotherapy / HIV Patients /
Diabetic patients
8. Drug overdose, Poisoning with stable vital signs
9. Painful swelling / wound
10. Headache, dizziness
11. Unable to pass stool
12.Unable to pass urine
Y
E
L
L
O
W
1. Minor Head Injury
2. Open or closed fractures of hand & feet
3. Isolated long bone fracture
4. GCS-15 with -
• Alcohol
• Anticoagulant
• LOC and vomiting
• Nasal & ENT bleed
• Limb Weakness
1. Suspected abuse
(Child/Women/Elderly)
2. Significant assault
G
R
E
E
N
1. Minor symptoms of existing illness
2. Fitness urticaria / Skin rash
3. Fever
4. For medico-legal examination
5. Minor conditions and low risk conditions (cough, cold,
etc.)
G
R
E
E
N
1. Abrasions
2. Lacerations
3. Isolated fracture of small bones of hand and foot
4. Contusions and Bruises
NO DELAY!!
A
Noisy Breathing/Stridor;
Angioedema
Active seizures C
Radial Pulse - Present / Absent;
Pulse<50 or >120/min;
SBP <90 mm Hg or >220mm Hg;
Capillary refill >2 sec
Shock index > 1
B
Talking incomplete sentence;
RR<10 or >22/min;
SPO2 <90%
D
Altered sensorium,
Responding only to pain on AVPU-Scale of GCS < 12
C-Spine Injury with Single Breath count < 15
RED Physiology
Criteria >>
(If any one of these mentioned
vital criteria is present on the
assessment) >>
TTRRIIAAGGEE
EXECUTIVE SUMMARY01 EXECUTIVE SUMMARY01
3
Medical emergencies including Road Traffic Injuries are one of the major leading causes of deaths
in India. RTIs alone contribute to 1.5 Lakh deaths annually. Approximately 2 persons died of
heart attack every hour in 2015-16. Currently, Non Communicable Diseases alone account for
~62% of deaths in India and Communicable infections, Maternal, New born account for ~27%
of deaths. Most of these deaths present as emergency conditions. In fact, as per one estimate
more than 50% of deaths and 40% of total burden of disease in Low Middle Income Countries
could be averted with pre-hospital and emergency care. The global total addressable deaths and
DALYs that can be averted amount to 24.3 million and 1023 million lives respectively. In fact,
in South-East Asia alone, 90% of deaths and 84% of disability-adjusted life years (DALYs) are due
to emergency and trauma conditions.
Emergency care system in our country has seen uneven progress. Some states have done well,
while others are still in the budding stages. Overall, it suffers from fragmentation of services from
pre-hospital care to facility-based care in government as well as in the private sector. The system
also suffers from lack of trained human resource, finances, legislation and regulations governing
the system.
Absence of standalone academic department since its inception is another factor for the current
ails in the system.
In the light of the above, the present study was conducted. The study aimed to assess the prevailing
status of emergency and trauma care at government and private hospital settings of India to bring
out the existing gaps and provide a framework for further improvement and the needed policy
directions. Towards achieving this goal, a country-wide study of emergency and trauma care
services of 100 tertiary and secondary level hospitals in 29 States and 2 Union Territories from
5 regions of India was conducted.
The selected health facilities consisted of 20 hospitals each under the following categories: Govt.
Medical Colleges, Private hospitals>300 bed strength, Private hospitals<300 bed strength,
Government hospitals >300 bed strength and Government hospitals <300 bed strength. The
assessments were conducted by trained assessors, selected from all over country who followed
by the investigators and research team. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 4
SALIENT FINDINGS OF THE STUDY
Case load
Emergency and injury cases annually accounted for 9-13% of all patients presenting to
a health facility and 19-24% of admissions in Govt Hospitals and 31-39% admissions
in Private Hospitals.
Live observations revealed that emergency cases accounted for 11-30% of all OPD
patients on a given day.
Spectrum of major medical conditions presenting at Emergency
Departments
During live observations conducted for 24 hours at the study centres, the following
were the most common spectrum of cases encountered at the EDs:
Adult patients (n=4677): Trauma and road-traffic injuries (24%), Fever (20%), Pain
Abdomen (16%), Respiratory Distress (11%), Chest Pain (9%), Pregnancy-related
(6%), altered mental status (5%), Poisoning (4%), Stroke (3%) and Snake bite (2%)
Pediatric patients (n=1403): Fever (31%), Diarrhoea (21%), Respiratory distress
(17%), Pain abdomen (14%), Trauma and road traffic injuries (9%), Seizures (4%),
altered mental status (2%), poisoning (1%) and Snake bite (1%).
Ambulance Services
Even though 91% of hospitals had in-house ambulances, trained paramedics needed to
assist ambulance services were present only in 34%.
Provision of specialized care during ambulance transport were largely poor: only 19%
hospitals had mobile Stroke/ STEMI (for heart attack) program, with only 4% having a
mobile Stroke unit.
Most of the hospitals lacked Pre-hospital arrival notification system, with larger
representation of Government over Private Hospitals.
Physical Infrastructure
Despite high patient load reporting to the EDs, the number of beds available at Emergency
Departments accounted for only 3-5% of total hospital beds.
Amongst the critical infra-related quality parameters assessed in the EDs, the following
were important deficiencies: absence of point of care lab (73%), demarcated triage area
(65%), police control room (56%), separate access for ambulance (55%) and adequate
spacing for emergency department (52%).
Overall, on a standard matrix of assessment, Private Hospitals ranked better than
Government Hospitals. 5
Executive Summary
Human Resource
Most of the hospitals lacked presence of general doctors, specialists and nursing staff
dedicated for Emergency Departments vis-à-vis the average footfall of patients, even
though, the hospitals as such, had sufficient overall numbers of required human resource.
Besides, when present, most of the EDs were manned by junior doctors rather than
specialists.
Equipment status
Compliance with availability of overall recommended biomedical equipment and critical
equipment were largely found satisfactory at all private hospitals (86-93%) and Govt
medical college hospitals (68%), with deficiencies found largely in smaller government
hospitals (45-60%).
Specifically, equipment deficiencies pertained largely to the category of Pediatric-care
(75%). Equipments pertaining to Airway, Breathing, Circulation and General categories
had deficiencies pertaining to a few sets of specific equipments (10-72%).
Essential Medicines
Since it is essential to have the complete list of all recommended emergency medicines
24*7 in the emergency departments, assessment done for this aspect revealed that only
9% of all hospitals, fulfilled this criterion.
Overall, Private colleges fared better in maintaining the recommended inventory of
recommended medicines (86-89%) compared to Govt Hospitals (52-72%).
Definitive Emergency Specialized Care
Amongst study of definitive care services, availability of emergency operative care
services (for trauma, non-trauma, orthopedic, neurosurgical, obstetric care) varied
between 47-60% depending on the type of services and hospital facility.
Similarly, critical care services (involving intensive care services such as ICU, HDU,
PICU, NICU, CCU, Neuro ICU) varied across hospital facilities, but were typically
largely deficient at smaller Govt Hospitals.
Many Govt Medical Colleges lacked common HDU (55%), Cardiac ICU (55%) and
Neuro ICU (55%). In addition, they also lacked facilities for Coronary Artery By-pass
Graft (55%), Cardiac Cath Labs (30%) and interventional radiology (40%).
Blood Bank services
An in-house 24*7 functional Blood Banks were available in 90% of Govt Medical
Colleges, 70% of Govt Hospitals with >300 beds and 35% of Govt Hospitals with <
300 beds. While in Private there were present in 85% of Hospitals with > 300 beds
and 65% of Hospitals <300 beds.
Most of the Hospitals did not have a dedicated Blood Bank in the Emergency Department
nor an existing standard protocol for massive blood transfusion. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 6
Patient disposition time (Live observation)
The patient disposition time for the sickest group (Red zone) was high at Government
Medical Colleges (90 Minutes) vis-à-vis Private Hospital (15 minutes). The reasons for
this delay amongst others were due to: high patient load, lack of in-house specialists
in the ED, need for multiple cross referrals, with an overarching lack of a dedicated
department for emergency services.
On study of efficiency of various time-bound procedures that need to be conducted for
optimal management of Chest Pain, Stroke and Trauma; generally Private Hospitals fared
better than Government Hospitals. And amongst the latter, smaller hospitals fared worse.
Violence between relatives of the care-seekers and health care providers were noticed
22-47% of hospitals, with higher representations from Government Hospitals. The
reasons were largely due to delay in providing care in Government Hospitals and
failure of appropriate communication in the Private set-ups.
Most of the Private Hospitals and smaller Government Hospitals lacked facilities such
as presence of Police/ private security guards, to mitigate such violence episodes.
Patient Satisfaction (Live observation)
Patients availing emergency care at Private Hospitals were largely satisfied with the
services provided (65-82%) in contrast to Government Hospitals (31% to 65%)
MLC Burden
The burden of Medico-legal cases (MLC) was 2-9% of all admissions.
They were disproportionately more MLCs at Government Medical College Hospitals
than others (9% Vs 3%), probably due to higher selective transfer of such cases form
other hospitals to avoid procedural issues.
ED protocols, Quality measures and Disaster planning
Most of the Government Hospitals lacked SOPs/standard manuals for emergency care,
patient transfer-in/out and handling of death. Further, policies for triaging and disaster
management were found only in ~50% of Government Hospitals and were largely
present in Private Hospitals.
Specific protocols for definitive care for chest pain, suspected sepsis, stroke, trauma and
cardiac arrest were found lacking across the spectrum of hospitals, with a higher share
of Government Hospitals. Similar patterns were seen for Disaster management planning
and systems to enforce continuous quality improvements.
Computerized data entry systems
Though computerized electronic health records, patient registration system were present
at most of the hospitals; specific computerized systems for patient clinical examination
notes, lab investigation reports and for data retrieval for research were largely deficient
in the Government Hospitals. 7
Executive Summary
Most of the hospitals across the spectrum lacked trauma registry and systems for
surveillance of trauma and Emergency Care.
Financing
None of the Hospitals had funds dedicated for emergency care services. A few of the
Hospitals received funds as part for delivery of trauma-care. Of the zones, the Eastern
Zone was the worst afflicted in terms of receipt of funds from Central/ State Government.
On assessing funding for overall hospital services, Ayushman Bharat as the major funding
Scheme (53%) followed by NHM (15%), Other State, Central Government and PSU
Schemes (11% each)
Comparison of various Hospital set-ups
NABH accredited vs non-accredited Hospitals
Overall, NABH accredited Hospitals fared better on all counts that required maintenance
of rigour of quality and services to deliver optimal patient care and functioning of
systems.
Presence of ongoing academic program in Emergency Medicine
Hospitals conducting structured academic programs in the subject of Emergency
Medicine have comprehensive robust systems in place for efficient patient care services
including critical care and definitive care, tackling imminent disasters and continuous
quality improvement.
These systems also ensure effective communication skills amongst care givers and timely
delivery of care, translating into higher patient satisfaction levels.
Secondary Vs Tertiary level Government Hospitals
Secondary level Government Hospitals (District Hospitals) fared better than tertiary level
hospitals (Medical Colleges) in terms of having standard SOPs for management of cases,
mock-drills, regular audits, referral policies and better patient satisfaction responses.
However, most of them needed further strengthening of following services: Blood Bank
facilities and definitive care such as operative procedures and critical care.
Private Vs Government Hospitals
Private Hospitals fared better than the Government Hospitals in terms of having
emergency operative services, mock drills, training programmes, regular audits and
referral policies.
Private Hospitals also ensure effective communication skills amongst care givers and
timely delivery of care, translating into higher patient satisfaction levels. REVIEW OF LITERATUREEmergency and Injury Care at Secondary
and Tertiary Level Centres in India
8
KEY RECOMMENDATIONS
1. Develop a robust integrated emergency care service system which can comprehensively
address all medical. Surgical emergencies inclusive of trauma-related care.
2. Standardize protocols, SOPs for emergency care, inclusive of triage to have a common
optimal nation-wide policy.
3. Strengthen the prevailing pre-hospital services such that a world-class ambulance services
are made available 24*7, encompassing on-going definitive care through effective
paramedics, for all citizens of the country and, these should be optimally integrated
with hospital care with an efficient pre-hospital arrival system using latest Information
Technologies.
4. Create adequate space for emergency care systems at the prevailing health facilities
such that standardized emergency departments with recommended proportion of beds,
infrastructure, equipment, drugs and human resources become a norm.
5. Systems to ensure efficient handling of medical care during disasters need to be ensured
at all hospitals.
6. Expand Blood Bank related services such that even smaller Government Hospitals are
ensured timely availability of on-demand blood and its related products.
7. Upgrade all the prevailing emergency care services to meet the standardized norms,
with efforts made to accredit all the existing emergency departments. All medical
colleges should attain self-sufficiency in providing definitive care for all emergency-
related conditions.
8. Establish Academic Emergency Medicine departments to ensure continuous ongoing
medical education and development of skills for doctors, nurses and paramedics.
9. Create standalone Central/ State level efficient funding mechanisms to ensure continuous
upgradation of emergency related issues at all hospitals, with built-in mechanisms for
periodic assessments to check optimal delivery of services.
10. Develop mechanisms to ensure free treatment for emergency care services for all citizens
covering the minimal required period for early stabilization. SCENETRANSPORTFACILITY
EMERGENCY CARE
SYSTEM FRAMEWORK
All around the world, acutely ill and injured people seek care every day.
Frontline providers manage children and adults with injuries and infec-
tions, heart attacks and strokes, asthma and acute complications of
pregnancy. An integrated approach to early recognition and manage-
ment saves lives. This visual summary illustrates the essential functions
of a responsive emergency care system, and the key human resources,
equipment, and information technologies needed to execute them. The
reverse side adresses elements of governance and oversight.
? BYSTANDER RESPONSE
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EMERGENCY UNIT
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D REVIEW OF LITERATURE02 The emergency care system and facility-based care in India are in its infancy. It suffers from the
fragmentation of services from pre-hospital care to facility-based care both in government as well
as in private sectors. The system also suffers from the lack of trained human resources, finances,
legislation, and regulations governing the system.
The facility-based care in tertiary care lacks trained human resources due to the stunted growth of
academic emergency medicine since its inception. The other allied disciplines such as emergency
nursing and emergency medical technician are yet to take shape. Hence it is important to assess
the existing gaps in facility-based emergency care and the linkages to the emergency care system
in a representative stratified multi-stage random sample of 100 healthcare facilities across India.
The study was a cross-sectional survey across the five regions of the country.
In the survey, a total of 100 healthcare facilities were assessed with the help of a Consensus-based
tool (predesigned pretested data collection tool) for the data collection.
The project aims at country-level assessment of the gaps and linkages in emergency and injury
care at government medical colleges, private hospitals and district hospitals of India. This study
proposes:
1. To describe the burden of emergencies and injuries in the country
2. To identify and describe current gaps and suggest interventions to strengthen the
emergency/injury care (Pre-hospital care, definitive care, referral and rehabilitation
services)
3. Suggesting strategies to strengthen the emergency/injury care at the tertiary center level
4. Identification of prospects on strengthening/ establishing academic Emergency Medicine
at Medical Colleges
The purpose of the report is to identify the gaps in emergency and injury care systems in healthcare
facilities as well as to find out the linkages between the pre-hospital care and facility-based care
system in our country. Based on the findings and outcomes from the study, suitable policies will
be made to strengthen the emergency and injury care at the national level.
INTRODUCTION02
11 REVIEW OF LITERATURE03 03 REVIEW OF
LITERATURE
Emergency care can be defined as the delivery of time-sensitive interventions needed to avert
death and disability and for which delays of hours can worsen prognosis or render care less
effective.
All around the world, acutely ill and injured people seek care every day. Goal of an effective
emergency medical system should be to provide universal emergency care — that is, timely quality
emergency care should be available to all who need it.
However, there are many unfounded myths about emergency medical care, and these are often
used as a rationale for giving it a low priority in the health sector, especially in low- and middle-
income countries. These myths include equating emergency care to ambulances and focusing on
transport alone while neglecting the role of care that can be provided in the community and at
a health-care facility. Perhaps most common is the perception that emergency care is inherently
expensive; this myth focuses attention on the high-technology end of clinical care as opposed to
the strategies that are simple and effective. Efforts to improve emergency care, however, need not
lead to increased costs for many people around the world, emergency care is the primary point
of access to the health system, and is thus, essential to universal health coverage.
As per a study, injuries alone accounted for 14% of the burden of disease among adult in 2002.
It is thus challenging to define the burden of disease addressed by emergency medical systems.
Emergency medical system is a set of diseases encompasses of communicable infections, non-
communicable conditions, obstetrics and injuries. Patients with all these conditions may present
to the emergency medical system either in the acute stages (such as diabetic hypoglycaemia,
septicaemia, premature labour or asthma) or may present with conditions that are acute in their
natural presentation (such as myocardial infarction, acute haemorrhage or injuries)
(1)
.
A recent study showed that all 15 leading causes of death and disability-adjusted life years (DALYs)
globally were the conditions with potential emergent manifestations.
(2)
By ensuring early recognition of acute conditions and timely access to needed care, organized
emergency care systems save lives and amplify the impact of many other parts of the health
system. The World Bank Disease Control Priorities Project estimates that Emergency care system
(ECS) with sound organization, have the potential to address over half of deaths and a third of Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 16
disability in low- and middle-income countries.
(3)
Simple, low-cost interventions to strengthen timely emergency care delivery can have dramatic
impact on clinical outcomes, and well-integrated emergency care has enormous potential to save
lives even with limited input of new material resources.
BURDEN OF EMERGENCY CONDITIONS IN THE SOUTH-EAST
ASIAN REGION
Despite tremendous improvement in health care delivery in the SEAR over recent decades, high
rates of injuries and cardiovascular emergencies, now among the leading causes of death, co-exist
with persistent high rates of infectious disease and maternal and infant mortality in some areas.
Timely, quality emergency care prevents death and disability from all of these conditions, but
ECS are still under-developed in many SEAR countries. 90% of deaths and 84% of DALYs were
attributable to emergency conditions with South-East Asia having the second highest burden of
emergency conditions (Figure1).
Figure 1: DALYs per 100,000 population attributable to emergency conditions, by etiology: separated by income
level (A) and region (B). Distribution of deaths was similar. NCDs, non-communicable diseases; CDs, communicable
diseases; DALYs, disability-adjusted life years
(2)
**Source: Reference (2)
WHO has projected the rise in the burden of various diseases causing death in SEAR in 2015
and 2030 (Table 1).This projection shows a significant decrease in mortality from communicable,
maternal, perinatal and nutritional causes from 25.2% to 16.1%. However, there is a projected
rise in deaths due to non-communicable diseases (NCD) from 63.5% in 2015 to 72.5% in 2030,
which is a cause for concern.
(4) 17
Review of Literature
Table 1: Projections of mortality by cause for 2015 and 2030
(4)
Deaths (thousands) by cause projected to 2015 and 2030 in SEAR
Year20152030
Population (thousands)19207612205146
GHE 2012 cause category Deaths % Total Deaths % Total
All Causes14851 100 18595 100
I.Communicable, maternal, perinatal
and nutritional conditions
3748 25.2 2998 16.1
II.Non-communicable diseases9428 63.5 13472 72.5
A.Cardiovascular diseases 4159 28.0 5872 31.6
B.Respiratory diseases1712 11.5 2561 13.8
C.Malignant neoplasms1412 9.5 2310 12.4
D.Diabetes mellitus434 2.9 690 3.7
III.Injuries1676 11.3 2125 11.4
(Based on the GHE 2012 estimates of causes of death for 2011, the regional projections
of mortality by cause for years 2015 and 2030 were carried out in 2012.
(4)
**Source: Reference (4)
Injuries came at 6
th
in the list of common causes of death and are responsible for 11.3% of all
deaths in SEAR (Table 1). Road injuries are the commonest cause of death in SEAR increasing
from 24.7% to 28.9% from 2015 to 2030, respectively.
(4)
With 90% of deaths occurring in LMICs
which only account for 54% of the world’s vehicles, these deaths and injuries are unevenly
distributed.
(5)
Figure 2 illustrates country-specific road traffic fatality rates. Amongst people 15
to 29 years of age, road traffic injuries are the leading cause of death, and cost governments
approximately 5% of GDP in LMICs. Other notable areas of injuries are falls (18.5%) and self-
harm (19.4%) leading to deaths in SEAR (Table 2)
(4)
.
Figure 2: Road traffic fatalities per 100,000 populations in SEAR
(5)
**Source: Reference (5) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 18
BURDEN IN INDIA
The top five individual causes of disease burden in India were Communicable, maternal, perinatal
and nutritional conditions in 1990, whereas in 2016, three of the top five causes were Non-
communicable diseases(NCDs), showing a shift toward NCDs (Table 2). From 1990 to 2016 the
number of DALYs due to most NCDs increased. The increase in all-age DALYs rate between
1990 and 2016 was highest for diabetes (80·0% [95% UI 71·6–88·5]), ischaemic heart disease
(33·9% [24·7–43·6]), and sense organ diseases (mainly vision and hearing loss disorders; 21·7%
[20·1–23·3]). Of the individual NCDs that are in the top 30 leading causes of DALYs in 2016.
(6)
Table 2: Percentage contribution of disease categories to total deaths
by age groups for all of India, 2016
(6)
Year2016
Population (thousands)1324200
GHE 2012 cause categoryTotal (%)
All Causes100
I.Communicable, maternal, perinatal and nutritional conditions 27.5
II.Non-communicable diseases61.8
A.Cardiovascular diseases28.1
B.Respiratory diseases10.9
C.Malignant neoplasms8.3
D.Diabetes mellitus6.5
III.Injuries10.7
Data are % (95% uncertainty interval).
**Source: Reference (6)
Figure 3: Percent of total DALYs by age groups in India, 2016(6)
**Source: Reference (6)
The higher proportion of the total DALY burden relative to their proportion of the population 19
Review of Literature
was observed in the age groups of younger than 5 years and 45 years or older. The age group
of younger than 5 years group constituted 8.5% of the population and had 17.6% of the DALYs.
The highest proportion of DALYs were in children younger than 5 years (83·4%) attributed to
Communicable, maternal, perinatal and nutritional conditions%), and the lowest was in the
50–54 years age group (14·7%).The proportion of DALYs due to Non-communicable diseases
was highest at 78·8% in the 65–69 years group and exceeded 50% in the 30–34 years group
(Figure 3).The proportion of total DALYs due to injuries was highest in the age groups from 15
years to 39 years(range 18·3–28·1%).
(6)
CURRENT STATUS OF EMERGENCY CARE IN THE INDIA
Emergencies and accidents are common place in all parts of India. Though India is a developing
country, due to rapid economic growth and urbanization, it faces the ills of both an under-
developed as well as developed economy. Every day, India faces the dual challenges posed
by emergencies related to infections and communicable diseases and those related to chronic
diseases and trauma.
Pre-hospital care is being provided by the state government regulated ambulances in many states
by Emergency Management and Research Institute with a common toll-free number 108. The
command centre is however not situated or run by the government or the Emergency Departments.
108 do not provide any pre-hospital notification to the Emergency Departments.
Thus it is a rudimentary form of pre-hospital EMS that exists in India and needs modernization
and integration with the hospitals at state and national level. India also lacks a universal toll
free number and there are more than one numbers that lead to ambulance services for different
emergency conditions.
With more than 150,000 road traffic related deaths, 98.5% ‘ambulance runs’ transporting dead
bodies, 90% of ambulances without any equipment/oxygen, 95% of ambulances having untrained
personnel, most ED doctors having no formal training in EMS, misuse of government ambulances
and 30% mortality due to delay in emergency care, India portrays a mirror image of the U.S. of
the 1960s.
EMS has changed since the time it was commonly stated that, “EMS systems in India are best
described as fragmented.”
(7)
India has two different yet overlapping publicly funded ambulance
systems, with both popularly known by their helpline numbers, 108 and 102. Between them,
they have more than 17,000 ambulances across the union of 31 states and union territories. The
allocated federal fund for the ambulance services in 2013-2014 was $59 million.
(8)
The provision of emergency services is enshrined in India’s Constitution. As per the Article 21 of
India’s Constitution “right to life”, if any hospital fails to provide timely medical treatment to a
person result’s in the violation of person’s “right to life”.
(8)
India always had a disproportionately
small health budget because of its ambitious growth aspiration and fastest growing population,
with one doctor for every 1,700 people and 21% of the world’s burden of disease.
(9)
In India
almost 23% of all trauma is transportation-related, with 13,74 accidents and 400 deaths every day
on roads.
(10)
The rest of the 77.2% of trauma is related to other events such as falls, drowning,
agriculture related, burns, etc.
(11)
According to World Health Organization, India has the highest
snakebite mortality in the world estimates it at 30,000 every year.
(12) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 20
WHO EMERGENCY CARE SYSTEM FRAMEWORK
The WHO info graphics below (Figure 4 a & b) are visual representations of the WHO Emergency
Care System Framework, designed to support policy-makers wishing to assess or strengthen
national emergency care systems. It is the result of global consultations with policy-makers and
emergency care providers across all regions, and provides a reference framework to characterize
system capacity, set planning and funding priorities, and establishes monitoring and evaluation
strategies.
Figure 4a illustrates the essential functions of an effective emergency care system, and the key
human resources, equipment, and information technologies needed to execute them (organized
by health systems building blocks).
Figure 4b info graphic complements this by locating critical governance and oversight elements—
including system protocols, certification and accreditation mechanisms, and key process metrics—
within the Framework. Also identified in the figure are essential overarching laws and regulations
that govern access to emergency care, ensure coordination of system components, and regulate
relationships between patients and providers.
(a) 21
Review of Literature
(b)
Figure 4: WHO Emergency Care System Framework
(13)
**Source: WHO info-graphics
Figure 5: Integrated Model: The roots feeding the Emergency Care System
Patients may
access any level
of care directly Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 22
HOSPITAL BASED EMERGENCY CARE IN THE GOVERNMENT
SECTOR IN INDIA
Definitive care for victims with emergencies is offered by government hospitals, corporate hospitals
and a large number of small clinics. Government hospitals generally offer free care, but the quality
of that care differs between centres. Most university hospitals provide a reasonable level of
emergency care. District hospitals often lack trained staff, adequate infrastructure, and supply of
consumables.
(14)
Triage is rarely practiced. As a result, impressive but non-life-threatening extremity
trauma may take precedence over bacterial meningitis or myocardial infarction.
There are no dedicated trauma surgeons and very few designated trauma centres in India.
Orthopedic surgeons lead the trauma response in 50% of facilities.
(15)
In the remainder; the
responsibility is not clearly defined. In the absence of defined roles amongst specialists, clinical
decisions are often delayed. Multi-system injury patients are at the greatest risk.
Typically, most of the “emergency care” in the hospitals in India is provided in areas known
as Casualty or Accident rooms. Formal education and specialty training in emergency care are
neither available nor mandatory for personnel involved in emergency care. These Causality/
Accident room physicians lack any specific training in emergency medicine.
(14)
Proceedings have
only recently been initiated to recognize Emergency medicine as a distinct medical discipline.
Residents posted in these ‘rooms’ often rotate from various specialties such as surgery, orthopedics,
and medicine and have little commitment towards patient management. These physicians are
often waiting to retake the All India Entrance Examination in the hope of securing postgraduate
position in established fields recognized by the MCI.
(16)
In some hospitals, emergency rooms
(ERs) are traditionally divided into separately run medical and surgical teams. With this division
it becomes very difficult to deliver quality, cost-effective care. In many hospitals, physicians
staffing the emergency rooms lack the resources and knowledge to manage the wide variety of
emergencies. They therefore function as ‘postal carriers’ who ‘deliver ‘victims to the respective
specialties. The most junior and inexperienced staff frequently treat the most seriously injured
patients.
TRAINING
Husum et al. have demonstrated that laypeople trained in first aid can effectively respond to
emergencies in a community within a high trauma burden
(17, 18)
. In hospitals, most in-service
training for emergency care professionals is designed to address particular problems, such as
severe injuries, pediatric emergencies or obstetric emergencies. Yet because of the resource
constraints of low-income countries, the same personnel will be confronted with all of these
conditions. Unfortunately, few courses in emergency care have been rigorously evaluated
(19, 20)
.
The Advanced Trauma Life Support course, a meticulously controlled training course in clinical
skills for doctors that was devised by the American College of Surgeons, has improved patients’
outcomes in some settings, although it may be too expensive for most low- and middle-income
countries, and it is clearly inappropriate for settings where most patients are not seen by doctors.
In a tertiary hospital in Trinidad and Tobago, mortality from injury fell by 50% after doctors
attended this course
(21)
.Training in life-saving obstetric skills was found to contribute towards
reducing maternal deaths in Kebbistate, Nigeria, and in other sites where the intervention was
implemented
(22,23)
. 23
Review of Literature
Emergency Triage Assessment and Treatment (ETAT) training, part of WHO’s Integrated Management
of Childhood Illnesses strategy, has been used in many countries to improve pediatric emergency
care
(24)
. Other examples of training courses are Primary Trauma Care
(25)
, devised by the World
Federation of Societies of Anaesthesiologists, and Advanced Life Support in Obstetrics, devised
by the American Academy of Family Physicians
(26)
.The above courses are used to standardize
protocol-based emergency care but evaluations of their outcomes are still awaited. The National
Trauma Management Course in India
(27)
costs US $50.00 per trainee and is taught by local
trainers. This course has now become a national training standard for immediate trauma care in
India. The courses described above are all examples used to show that even in the absence of
ambulances it is possible to improve emergency medical systems. Low-income countries need to
identify training models that are appropriate for their emergency care personnel, who may need
to take on a variety of roles, especially those working at middle-level facilities, who respond to
different types of emergencies.
ACADEMIC EMERGENCY MEDICINE
Academic emergency medicine is a recognized post-graduate program since 2009. Presently,
more than 28 medical colleges are offering a total of 60 seats, a diplomat of national board (DNB)
offering more than 120 residency seats in Emergency Medicine in a year. This number is highly
inadequate and not enough to cater the needs of even one state of India. Indo-US collaborative
INDUSEM played a major role in shaping the academic emergency medicine in India and now
in SEAR and rest of the world too.
Emergency Medicine (EM) is a new academic discipline in its infancy in India. Dedicated
emergency medicine faculty will be the keys for developing a national skilled emergency care
workforce. A strategy for integrated, coordinated trauma care and injury prevention activities must
be developed in India. Gujarat has become the first state to pass legislation addressing emergency
medical services.
Emergency Medicine (EM) Departments are the front line for the community during a disaster.
A disaster is defined as that time, when the need for staff, supplies and space exceed resources
due to an extraordinary stress on a community, e.g. earthquake, biological outbreak or terrorist
attack. As a result, Disaster Medicine has been, and continues to be, an important focus for
Emergency Medicine. The Emergency Department (ED) is the place to train, set standards for
response, and create a culture of preparedness not only for the Hospital but the community as
well. As the Emergency Department heads the Hospital’s Committee on Disaster Preparedness
by establishing protocols, conducting training, and facilitating exercises, they also create the
opportunity for a good relationship between the hospital administration and the community. This
proactive involvement validates the EM program and creates added value for those involved:
physicians, residents, and students, thus improving better patient care.
(28)
GAPS
Research and Development for Emergency Services
As a neglected topic, emergency medical systems are part of the 10/90 gap in health research
whereby less than 10% of global research investment is spent on problems affecting 90% of the AIMS AND OBJECTIVESEmergency and Injury Care at Secondary
and Tertiary Level Centres in India
24
world’s population
(29)
. A review of the evidence on emergency medical systems as applicable to
low- and middle- income countries reveals many gaps in global knowledge. There is a need to
better understand the epidemiology of conditions that may be addressed by emergency systems
in these countries and to better understand which interventions may address them adequately.
Intervention trials in low- and middle-income countries are research priority in the field of
emergency medical systems. Well-designed, locally appropriate studies that establish effectiveness
are urgently needed, and they should include both those interventions that may be available in
high-income countries and newer interventions. Economic analysis is another area where research
is needed, especially in places where cost and cost–effectiveness information from low- and
middle-income countries is scant
(30)
. These gaps reflect the need for a more systematic analysis
of the areas towards which research investments should be directed in order that systems can be
based on credible evidence.
Organization and financing
An emergency medical system must be sensitive to and meet the needs of the poor. Issues of
access to the system become critical because a lack of money often deters people from using
emergency services. Different means of achieving this financial protection need to be explored,
including community financing
(31, 32)
.As a result, emergencies often lead to financial ruin for poor
families, and the implementation of some sort of financial protection for emergency health care
has not received adequate attention. Such protection would ensure that those with limited finances
are not deterred from using emergency services and that they do not get tipped into extreme
poverty by having to meet costs entirely out of their own pocket Community loan funds to cover
transportation and other requirements for emergencies, especially for obstetrics, have been used
in various setting, especially in Africa.
(33, 34) AIMS AND OBJECTIVES04 2704
AIMS AND OBJECTIVESAIMS AND OBJECTIVES
PRIMARY OBJECTIVE
1. To assess current status of facility based Emergency and Injury care in government
medical colleges & large private hospitals
SECONDARY OBJECTIVE
To assess the following:
1. Burden of emergency conditions including injuries
2. Assess the current status of Emergency and Injury care system linkages
a. Pre-hospital care (including intra-specific referral to ambulance services)
b. Hospital Care (Definitive care)
c. Measures of Academic Emergency medicine departments METHODOLOGY METHODOLOGY05 31
Methodology 05
METHODOLOGYMETHODOLOGY
The study was initially proposed and approved for the assessment of 50 tertiary care centres
(government medical colleges and large private hospitals) and 50 secondary care centres (district
hospitals) of India.
In consultation with NITI Aayog, it was decided that the health facilities to be assessed be
categorized in 5 categories for the study purpose: Medical College more than 500-bed strength
(20), Government hospitals more than 300-bed strength (20), Government hospitals less than
300-bed strength (20), Private hospitals more than 300-bed strength (20) and Private hospitals
less than 300-bed strength (20).
Figure 6: Map showing hospitals (tagged red) selected for this study from different states and different zones Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 32
Selection ofHealthcareFacilities
Finalization ofHealthcareFacilities
Teamformation ofNationalAssessors
Development ofStudyTool
Finalization ofStudyToolthrough
ScientificAdvisoryCommittee
TrainingofAssessors bytele/
video-conference
Field visitacross countryfor
DATACOLLECTION
• Oneyeardatacollection
• Basedonadministrativeinterview
• Basedonfacilityvisit
•Livedatacollectionfor24hours
•Basedonlive observation
•Data collectionofSpecific
Diseases
Categorization**:
A)Hospital-wise
B)Zone-wise
C)NABHAccreditation-wise
DataAnalysis
DraftReport
Figure 7: (a) Flow chart of Methodology
**where applicable
The study was carried out in five regions of India (North, South, East, West, and North-East)
including 29 States and 2 Union Territories, from which a total of 100 private and government
healthcare facilities were randomly selected from each zone.
This cross-section study was undertaken in two phases: 33
Methodology
1. Scientific Advisory Committee (SAC) meeting for the finalization of the tool by the
experts of various health departments
2. Quantitative and qualitative data collection as a pilot testing from two hospitals
Pilot testing was followed by collecting of data from the 100 randomly selected healthcare facilities
by a team of 3 assessors. The assessment was done by conducting administrative interview, facility
visit and live observation of the healthcare facility.
1. Identification of potential healthcare facilities: While selecting the institutions for
assessment, we had discussed with the experts’ group. After a series of meetings and
discussions with the experts’ team, it was decided that there should be no overlapping
of healthcare facilities.
We identified 100 healthcare facilities from five regions of the country and contacted
the respective state health dignitaries to nominate a suitable nodal person for obtaining
information about the healthcare facilities to assess suitability. These healthcare facilities
were visited by the assessors’ team for assessment.
2. Finalization of the sites: We started the formal process of site selection from 20th May
2019. The process of selection took 2 weeks and by 3rd June 2019, the sites were
finalized.
3. Development of study tools, standard operating procedures:
Study tools: The study tool was developed and finalized after SAC meeting and
beta testing. The beta testing was done in two healthcare facilities (AIIMS, New
Delhi and Sri Sayaji General [SSG] Hospital, Gujarat) before the assessment being
conducted at the proposed healthcare facilities. The study tool was divided into
three major categories: lead assessor tool, live observation tool, and emergency
burden tool. These categories were further subdivided into sections: background
information of hospital, hospital services, ED protocol/SOP and guidelines, safety
and security, disaster management, quality improvement, data management system,
financing, physical infrastructure, manpower, equipments and supplies, point of
care lab in ED and hospital, and essential medicines.
Standard operating procedures /manual: The study operational manual for data
collection was developed and acted as a guide.
4. Establishment of governance structure and a project implementation: Scientific
Advisory Committee (SAC) members were identified, which included 22 national
experts from emergency and trauma, public health, research, and epidemiology. They
provided technical guidance in study tool development, protocol development, and
quality assurance.
5. Training of assessors: A tele/video-conference was organized every week to train the
assessors. Based on the received data from sites, the assessors were trained subsequently
for the challenges and the problems/issues faced by the other assessors’ team during
the assessment.
6. Data Collection: Healthcare facilities data were collected by a team of assessors (one
lead assessor and two co-assessors) at each site visit. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 34
a. One Lead assessor (overall in-charge) was responsible for the conduct of survey and
major observations/assessment mainly through local administrator interview, data
source (hospital records) and site/facility visit, etc. He/she acted as a nodal person
for communication with the central project team at JPNATC, AIIMS, New Delhi.
b. Two other Co-Assessors were responsible for emergency department data collection
by live observation (mainly assessing the emergency department processes &
infrastructure [manpower, equipment, supplies, etc.]).
These assessors were trained for this study and were not blinded regarding the purpose
of the study. The assessors were trained with the study tool and assessors training manual
for the assessment of healthcare facilities. Data for the assessment of healthcare facilities
were obtained from face-to-face interviews with key staff at each facility.
The presence of supplies including medications and equipment was assessed through
direct observations. Assessors also checked the inventory of supplies in facilities which
allowed them to do so.
7. Definition and process of Live Data Recording: The assessment done by two Co-
assessors included continuous observation for 24 hours in healthcare facility without
any direct contact with patients admitted in the same premises. The live data recording
done by the Co-assessors was observation of the treatment process and procedures of
patients especially having three conditions: chest pain, stroke and trauma.
The process involved for live data collection (as per the data collection tool) was as
follows:
Arrival of the
patient at
healthcare facility
Final Disposal (Discharge/
referral/ admission to general
ward/ to ICU/to OT/ to Cathlab)
Triage Resuscitation
Relevant
Investigation
Relevant
Consultation
Disposal
Decis ion
8. Data analysis: Data collected from the health-facilities was entered using a Microsoft
Excel-based database. The analysis was done by using SPSS (Statistical Package for the
Social Sciences). The level of analysis for the assessment is the facility, and for overall
analysis it is category of the hospital.
Frequencies were computed for different sections of the study tool such as emergency
equipment, essential medicines and written protocols for the management whereas
median with IQR and minimum, maximum were computed to present the distribution
of continuous variables, for example, doctors per facility.
We had calculated the percentages of all essential equipment and medicines. We
assessed availability of equipments and essential medicines on three different scales:
50% or less (Score-0), 50% to 99% (Score-1), and 100% (Score-2). 35
Methodology
Figure 7b: Overall representation of strategy and procedures of Data Collection 37
Methodology
OBSERVATIONS AND
RESULTS WITH
SUGGESTIONS
06 39
Observations and Results with Suggestions 06
OBSERVATIONS
AND RESULTS WITH
SUGGESTIONS
I. FIELD VISIT: ADMINISTRATIVE INTERVIEW/ONE YEAR DATA
COLLECTION
We are presenting the observations based on the findings from both qualitative and quantitative
components of the assessment research.
1. BACKGROUND INFORMATION OF THE HOSPITALS
Out of 100 hospitals studied, 20 hospitals were medical colleges (more than 500 bedded), 20
hospitals were government hospitals (more than 300 bedded), 20 hospitals were government
hospitals (less than 300 bedded), 20 hospitals were private hospitals (more than 300 bedded) and
20 hospitals were private hospitals (less than 300 bedded).
Out of the 100 hospitals, NABH accredited hospitals were 28. There were only 5 hospitals that had
academic emergency medicine out of all 100 hospitals. Among all the assessed hospitals, 25 were
tertiary care government hospitals, 34 were secondary care (district) hospitals, 1 was secondary
care (trust) hospital and 40 were private hospitals (20 tertiary and 20 secondary care hospitals).
2. AVAILABLE BEDS AT ASSESSED FACILITIES:
The data of hospital bed strength was collected from each hospital such as hospital in-patient
beds and emergency beds separately. Out of 100 hospitals, 32 hospitals had triage beds and
follows triage policy.
The median [IQR] min-max of in-patient beds and emergency beds (the beds assigned for emergency
/ emergency department) for all categories of hospitals is shown in table 3 and represented in
figure 8. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 40
Table 3: Overall Summary of available Beds in Hospitals: Emergency Department
Beds and Inpatient Beds
Categories of
Healthcare Facilities
n
Emergency Department
beds in Hospital
Median [IQR] Min-Max
Total Inpatient beds
in Hospital
Median [IQR] Min-
Max
% of Emergency
Beds out of all
Beds at ED
Medical Colleges
(>500 bed strength)
20
46 [28]
10-210
1233[1147]
252-3500
3%
Govt. Hosp.
(>300 bed strength)
20
17 [25]
2-183
418 [306]
200-1079
4%
Govt. Hosp.
(<300 bed strength)
20
5 [6]
1-22
145 [182]
47-380
4%
Pvt. Hosp.
(>300 bed strength)
19
15 [14]
5-44
467 [196]
150-1000
4%
Pvt. Hosp.
(<300 bed strength)
19
10 [4]
3-15
200 [54]
48-400
5%
*n: number of hospitals which shared data with assessor’s team, IQR: Interquartile range
As mentioned in table 3, the percentage of beds in the emergency department accounted for 3%
of all hospital beds in medical colleges, 4% in government hospitals (>300 beds strength), 4%
in government hospitals (<300 beds strength), 4% in private hospitals (>300 beds strength) and
5% in private hospitals (<300 beds strength).
In medical colleges, maximum number of emergency beds was observed at JIPMER, Pondicherry
(210 beds out of 2137 in-patient beds), while minimum number of emergency beds was observed
at Tomo Riba Institute of Health & Medical Sciences, Papumpare (10 beds out of 252 in-patient
beds).
In government hospitals (>300 beds), maximum number of emergency beds was observed at
Indira Gandhi Government General Hospital, Pondicherry (183 beds out of 626 in-patient beds),
while minimum was observed at District Hospital, Dhamtari (2 beds out of 200 in-patients beds).
In government hospitals (<300 beds), maximum number of emergency beds was observed at
District Hospital, Ganderal (22 beds out of 200 in-patient beds), while minimum was observed at
District Hospital, Bishnupur & District Hospital, Peren both had 1 bed out of 50 in-patients beds). 41
Observations and Results with Suggestions
Figure 8: Overall representation of beds distribution in different categories of hospitals
The majority of hospitals did not have system for triage in their emergency department. Only 32
hospitals of all 100 hospitals had triage systems.
Systems for triage were present at 5 medical colleges (Government General Hospital, Guntur;
AIIMS, Bhopal; Rajiv Gandhi Government General Hospital, Madras Medical College; JIPMER,
Pondicherry and IPGMER & SSKM Hospital), 4 government hospitals more than 300 beds,
14 private hospitals more than 300 beds, 9 private hospitals less than 300 beds and
government hospitals less than 300 beds did not have any system for triage in their
hospital emergency or emergency department.
3. BURDEN OF PATIENTS (OPD AND EMERGENCY)
The annual census of the year 2018 (from 1
st
January 2018 to 31
st
December 2018) was collected
from all the hospitals, which includes number of patients visited in OPD, emergency, number
of medico-legal cases attended in emergency, number of admissions through emergency, etc.
In table 4, summary of patients visited in OPD and emergency at hospitals is reported with median
[IQR] and min-max (figure 9). The annual burden of patients visited in emergency department of
hospitals was calculated by dividing the total number of patients visiting in emergency with the
total number of patients visiting in the hospital (OPD + Emergency) and the median value of
percentage is reported in table. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 42
Table 4: Summary of Patients visited in Emergency and OPD in different Categories
of Hospitals (1
st
Jan 2018 to 31
st
Dec 2018)
Categories of
Healthcare Facilities
Emergency and Injury Care
Patients
OPD Patients
% of ED Patients
out of all
patients visited
in hospital
n
Median [IQR]
Min-Max
n
Median [IQR]
Min-Max
Medical Colleges
(>500 bed strength)
15
119461 [140435]
3560-477845
18
794860 [499481]
146000-3382591
13%
Govt. Hosp.
(>300 bed strength)
17
43001 [118984]
4876-308883
17
435229 [447465]
22000-1463635
14%
Govt. Hosp.
(<300 bed strength)
16
18738
[35140]1560-
227364
18
224897 [145985]
44400-743278
15%
Pvt. Hosp.
(>300 bed strength)
17
20861 [22118]
3676-103524
17
255000 [308000]
28278-749145
9%
Pvt. Hosp.
(<300 bed strength)
11
13800 [4908]
3699-43304
12
94292 [53143]
7188-170938
12%
*n: number of hospitals which shared data with assessor’s team, IQR: Interquartile range
In medical college, the burden of patients in emergency as well as in OPD were maximum at
SMS Medical College & Hospital and minimum at AIIMS, Bhopal (for emergency) and Regional
Institute of Medical Sciences, Imphal (for OPD).
In government hospitals >300 beds, the burden of patients in emergency as well as in OPD
were maximum at Indira Gandhi Government General Hospital, Puducherry and minimum at
District Hospital, Dhamtari (for emergency) and Southern Railways Hospital, Chennai (for OPD).
In government hospitals <300 beds, the burden of patients in emergency were maximum at Puri
District Headquarter Hospital and minimum at Sadar Hospital, Gaya; the burden of patients in
OPD was maximum at Government BDM Hospital, Kotputli and minimum at District Hospital,
Bishnupur, Manipur.
In private hospitals >300 beds, the burden of patients in emergency as well as in OPD were
maximum at Dr Ram Manohar Lohia Hospital, Lucknow and minimum at GNRC, Guwahati,
Assam. In private hospitals <300 beds, the burden of patients in emergency as well as in OPD
were maximum at Ramakrishna Mission Hospital, Arunachal Pradesh and minimum at Medeor
Hospital, Manesar.
The annual burden of patients who presented as emergency case, out of all patients visited the
hospital for the year 2018 were: 13% in medical colleges, 14% in government hospitals with more
than 300 beds, 15% in government hospitals with less than 300 beds, 9% in private hospitals
with more than 300 beds and 12% in private hospitals with less than 300 beds. 43
Observations and Results with Suggestions
Figure 9: Comparison of Patients visited in OPD and Emergency in different Categories of Hospitals
(1
st
Jan 2018 to 31
st
Dec 2018)
*M. C.- Medical College, G. H.- Government Hospital, P. H.- Private Hospital, OPD- Out-patient Department
Data maintained regarding adult/pediatric patients were heterogenous across the studied hospitals.
Only 43 hospitals maintained OPD data of adult patients and 37 hospitals maintained data of
pediatric patients. Similarly, 36 hospitals maintained ED data of adult patients and 28 hospitals
maintained data of pediatric patients respectively.
In table 5, separate adult and pediatric patient’s data for OPD and emergency is reported with
median [IQR] and min-max. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 44
Table 5: Summary of Patients visited in OPD and Emergency (Adult and Pediatric)
in different Categories of Hospitals (1st Jan 2018 to 31st Dec 2018)
Categories of
Healthcare
Facilities
Emergency and Injury care PatientsOPD Patients
Adult Pediatric AdultPediatric
n
Median [IQR]
Min-Max
n
Median [IQR]
Min-Max
n
Median [IQR]
Min-Max
n
Median [IQR]
Min-Max
Medical
Colleges
(>500 bed
strength)
9
80418
[141265]
11961-
347264
6
21849
[18019]
6429-130581
11
737333
[694550]
220097-
2937193
10
61418
[37814]
8900-445398
Govt. Hosp.
(>300 bed
strength)
10
23671
[12983]
7495-281011
9
3650 [25872]
461-30204
10
384335
[194085]
21000-1388295
9
46812
[41308]
1000-127688
Govt. Hosp.
(<300 bed
strength)
6
11809
[41883]
836-150007
5
687 [550]
311-22688
7
149737
[129722]
5889-586632
6
23035
[19350]
1479-96725
Pvt. Hosp.
(>300 bed
strength)
7
14326
[18854]
3667-32304
6
2201 [3899]
225-13378
9
220631
[331418]
28278-872227
7
33106
[27192]
9293-52612
Pvt. Hosp.
(<300 bed
strength)
4
7555 [2234]
4800-8778
2
763 [248]
515-1011
6
67096 [19035]
30000-150534
5
10908
[11471]
3285-30431
*n: number of hospitals which shared data with assessor’s team, IQR: Interquartile range
In addition, the definition for pediatric age group also varied among the assessed hospitals. Out of
100 hospitals, 28 hospitals were following 0-12 years age for pediatric patients, 20 hospitals were
following 0-14 years age, 10 hospitals were following 0-15 years age, 1 was following 0-16 years
age, 11 were following 0-18 years age, and 30 hospitals did not have the details for the same.
4. HUGE MISMATCH BETWEEN EMERGENCY BEDS & BURDEN OF
EMERGENCY AND INJURY CASES:
Table 6 depicts the gap between the emergency beds and burden of patients in emergency, it is
clear that there is a huge mismatch between emergency beds and burden of emergency cases. 45
Observations and Results with Suggestions
Table 6: Huge Mismatch between Emergency Beds & Burden of Emergency and
Injury Cases
Hospital Categories
% of Emergency and
injury cases
(One Year)
% of Emergency and
injury cases
(One Day)
% of Available
Emergency Beds
Medical Colleges13%17%3%
Govt. Hosp.
(>300 bed strength)
14%11%4%
Govt. Hosp.
(<300 bed strength)
15%11%4%
Pvt. Hosp.
(>300 bed strength)
9%10%4%
Pvt. Hosp.
(<300 bed strength)
12%30%5%
Different categories of hospitals have only 3-5% available emergency beds while the yearly burden
of patients’ ranges from 9 to 15%, which is much more than the available beds. It may be because
the resources available in the healthcare facilities are either underutilized or over-utilized. By the
above observation, it is clear that the optimum utilization of resources is missing in the hospitals.
The burden of emergency cases at medical college was high compared to both district hospitals
and private hospitals. It may be because people are not utilizing secondary care hospitals due to
lack of quality of care (lack of facilities present in district hospitals when compared to medical
colleges).
About 65.9% populations belongs to rural areas (according to the World Bank collection of
development indicators in 2018), most of the rural population cannot afford private hospitals
due to high expenses.
As per current MCI guidelines, 35 emergency beds should be available in 500 bedded medical
college i.e., 7% emergency beds. Table 8 A depicts the recommended number of beds per
category of healthcare facility
1. For MBBS & PG Programme: To start PG programme, 7% emergency beds (below table) are
sufficient, but to provide the quality emergency services this bed strength is less.
Table 7: Beds per centre as per MCI
No. Of UG
student
intake
Minimum
Total beds
ICU
beds
“Red”
category
beds/
Trolleys
“Yellow”
category Beds/
Trolleys
“Green”
category
beds/Trolleys
Triage beds/
Trolleys (other
than total beds/
trolley)
50 30 6 4 1553
100 35 7 5 1673
150 40 8 6 1884
200 45 9 7 2094
>200
50 or
above
10 8 22 10 5 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 46
2. For optimal care/services: To provide optimal emergency care services, we need to increase
the number of emergency beds to 12% of all beds with addition of 10% as buffer beds
based on footfall. Secondly, needs to be developed cashless for emergency care and thirdly,
to provide quality of care as per the existing and expected footfall we need to strengthen
district hospitals by-
Upgrading them to medical college
Developing residency programme in DNB: where in PG residents rotate regularly at
district hospitals
Initiate programme based in centivization of government hospitals
3. Upgradation of medical colleges and district hospitals to cater the existing and expected
footfall to provide quality service.
DNB (Diplomate of National Board) Emergency Medicine Criteria: The hospital should be
200 bedded with 50 patients per day in emergency (Assumption- By developing residency
programme, the footfall of patients will increase).
*Note: Emergency Beds: The beds assigned for emergency department.
Buffer Beds: The beds under department of emergency for addressing surge capacity including ICU facility and it should
have separate beds for disaster.
5. BURDEN OF MEDICO-LEGAL CASES
Table 8 summarizes the annual number of medico-legal cases attended in emergency of different
categories of hospitals with median [IQR] and min-max. The annual burden of medico-legal cases
attended at hospitals emergency was calculated by dividing the total number of medico-legal
cases attended at emergency with the total number of patients visiting in the emergency and the
median value of percentage is depicted. 47
Observations and Results with Suggestions
Table 8: Summary of Medico-legal cases attended at Emergency of different
Categories of Hospitals
Hospital Categories
Medico-legal Cases
% of MLC = Total MLC/
Total Emergency Pts.
n
Median [IQR]
Min-Max
Medical Colleges 13
15473 [16719]
216-91354
8.7%
Govt. Hosp.
(>300 bed strength)
18
2108 [4975]
87-23728
3%
Govt. Hosp.
(<300 bed strength)
15
1230 [1598]
236-10049
6.4%
Pvt. Hosp.
(>300 bed strength)
14
794 [1449]
257-2986
3.6%
Pvt. Hosp.
(<300 bed strength)
13
498 [927]
71-1500
2.5%
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range, MLC: Medico-legal cases
In medical colleges, maximum medico-legal cases in emergency were at Patna Medical College
& Hospital and minimum at New STNM Hospital, Sikkim.
In government hospital >300 beds, maximum medico-legal cases in emergency were at District
Hospital, Karim Nagar, Telangana and minimum at AIIMS, Patna.
In government hospital <300 beds, maximum medico-legal cases in emergency were at North
Goa District Hospital, Goa and minimum at District Hospital, Ganderbal.
In private hospital >300 beds, maximum medico-legal cases in emergency were at Dr Ram
Manohar Lohia Hospital, Lucknow and minimum at Cosmopolitan Hospitals Private Limited,
Kerala.
In private hospital <300 beds, maximum medico-legal cases in emergency were at Ruby General
Hospital, West Bengal and minimum at G G Hospital, Kerala.
Majority of district hospitals make more MLC’s when compared to medical college and private
hospitals. In district hospitals a dedicated CMO (Chief Medical Officer) is present, who makes
MLC cases. Preparation of MLC reports adds to the existing mandate of providing quality acute
care service by the emergency care provider.
Burden of Medico-legal cases on Emergency Department ranging between 2%-9%.
Suggestions for MLC:
These findings suggest higher burden of MLC’s at government hospitals. Amongst government
hospitals, the load is highest at medical colleges. Private hospital seems to have a disproportionally
lean load of MLC. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 48
Suggestions to improve MLC related services; the following are suggested:
1. Ensure equitable distribution for MLC related services among both government and
private sector.
2. Dedicated EMO (Emergency Medical Officer) / Senior Resident (Forensic Medicine) to
deal with MLC documentation and representation to court.
3. Develop cadre of Forensic Nursing and post them in the emergency for round the clock
frontline medico-legal service.
4. Station an in-house police post for mitigating plausible violence and protection of
emergency care provider. This would aid in better co-ordination of MLC documentation
and legal service.
6. BURDEN OF ADMISSIONS THROUGH EMERGENCY
In addition, table 9 summarizes the annual number of admissions through emergency at different
categories of hospitals.
The annual burden of admissions through hospital emergency department was calculated by
dividing the total number of admissions through ED with the total number of patients visiting in
emergency department.
Table 9: Summary of Admissions through Emergency Department at different
Categories of Hospitals
Hospital Categories
Admissions through Emergency
% of patients
admitted of those
visiting EDn
Median [IQR]
Min-Max
Medical Colleges14
31487 [23267]
552-80315
22.2%
Govt. Hosp.
(>300 bed strength)
15
6591 [13936]
373-55293
19.4%
Govt. Hosp.
(<300 bed strength)
12
1269 [4969]
147-227364
23.8%
Pvt. Hosp.
(>300 bed strength)
16
9877 [6749]
195-31899
31%
Pvt. Hosp.
(<300 bed strength)
14
4020 [4721]
1236-9834
39%
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range, ED: Emergency department
In medical college, maximum number of admissions through emergency was at Government
Medical College, Thiruvananthapuram and minimum at AIIMS, Bhopal.
In government hospital >300 beds, maximum admissions through emergency was at District
Hospital, Karim Nagar, Telangana and minimum at Deen Dayal Upadhyay Hospital, Himachal
Pradesh. 49
Observations and Results with Suggestions
In government hospital <300 beds, maximum admissions through emergency was at Puri District
Headquarter Hospital, Orissa and minimum at Morigaon Civil Hospital, Assam.
In private hospital >300 beds, maximum admissions through emergency was at Dr Ram Manohar
Lohia Hospital, Lucknow and minimum at Central referral Hospital, Sikkim.
In private hospital <300 beds, maximum admissions through emergency was at Jaipur Golden
Hospital, Delhi and minimum at Ruban Memorial Hospital, Bihar.
Admissions through emergency
Government Hospitals - 19% to 24%
Private Hospitals - 31% to 39%
Suggestions:
The number of admissions through emergency was high in district hospitals>300 beds than
medical colleges but they have less number of emergency beds to cater the existing footfall.
1. NABH Accreditation
2. District hospitals admits more patients in emergency than medical college, so
Upgrade them into medical college
Develop residency programme for emergency medicine
7. BURDEN OF DEATH OF TRAUMA PATIENTS
Table 10 depicts the annual number of death of trauma patients in emergency of different
categories of hospitals. It was compared with the total number of trauma patients (one day)
visited in emergency of all hospitals.
Table 10: Summary of Death of Trauma Cases in Emergency by Categories of Hospitals
Categories of Healthcare
Facilities
Death of Trauma Patients
(ONE YEAR)
Number of Trauma Patients visited in
Emergency (ONE DAY)
n
Median [IQR]
Min-Max
n
Total Pts
in one day
Median [IQR]
Min-Max
Medical Colleges
(>500 bed strength)
11 266 [1172]
40-8067
15 599 18 [25]
1-210
Govt. Hosp.
(>300 bed strength)
8 12 [35]
1-234
18 175 5 [11]
1-45
Govt. Hosp.
(<300 bed strength)
9 8 [23]
1-66
19 130 5 [6]
1-40
Pvt. Hosp.
(>300 bed strength)
9 14 [26]
2-206
18 143 3 [10]
1-35
Pvt. Hosp.
(<300 bed strength)
7 3 [37]
2-797
17 60 3 [4]
1-20
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 50
Death of trauma patients was high in medical college when compared to other categories of
hospitals. It may be assumed that the death of trauma patients was due to delay in definitive care
(beyond Golden Hour) and due to lack of trained human resources in emergency department.
Suggestion:
Develop a robust integrated emergency care system which includes injuries
8. BURDEN OF PATIENT’S DEATH DUE TO ROAD TRAFFIC INJURY
Table 11 depicts the annual number of patient’s death due to road traffic injury in emergency of
different hospital categories.
Table 11: Summary of Patient’s Death due to Road Traffic Injury by Categories of
Hospitals
Categories of Healthcare
Facilities
Patient’s Death due to Road Traffic Injury
n
Median [IQR]
Min-Max
Medical Colleges
(>500 bed strength)
8
171 [527]
1-1013
Govt. Hosp.
(>300 bed strength)
10
21 [81]
1-1042
Govt. Hosp.
(<300 bed strength)
5
11 [26]
11-37
Pvt. Hosp.
(>300 bed strength)
10
6 [19]
1-703
Pvt. Hosp.
(<300 bed strength)
7
6 [63]
2-324
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range
It may be assumed that the patients of road traffic injury died due to lack of pre-hospital care,
lack of injury prevention and may be they are non-salvageable.
9. BURDEN OF BROUGHT DEAD PATIENTS
Table 12 summarizes the annual number of brought dead patients in emergency of different
hospital categories with median [IQR] and min-max. 51
Observations and Results with Suggestions
Table 12: Summary of Brought Dead Patients in Emergency by
Different Category of Hospitals
Categories of Healthcare
Facilities
Brought Dead Patients
n
Median [IQR]
Min-Max
Medical Colleges
(>500 bed strength)
7
204 [137]
3-618
Govt. Hosp.
(>300 bed strength)
11
129 [170]
23-708
Govt. Hosp.
(<300 bed strength)
8
23 [24]
3-159
Pvt. Hosp.
(>300 bed strength)
11
70 [105]
5-733
Pvt. Hosp.
(<300 bed strength)
8
25 [91]
1-165
*n: total number of hospitals which shared data with assessor’s team, IQR: Interquartile range
It may be assumed that brought dead patients came to hospitals due to:
1. Failure to recognize, resuscitate and refer of sick patients either by bystander or
paramedic.
2. Probable non-salvageable patients.
Suggestions:
1. Develop and strengthen preventive emergency healthcare strategy such as National
Injury Prevention Programme
2. Develop a robust pre-hospital emergency care system including community
participation.
3. There should be installation of AED (Automated external Defibrillator) as a public access
device especially in mass gathering areas such as schools, shopping mall, railway station,
airport, religious gathering areas etc.
4. Implement good Samaritan law for all emergency conditions including injuries across
the country
10. BLOOD BANK SERVICES
Table 13 summarizes the hospital blood bank services for all categories of hospitals. As per the Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 52
assessment, 69 hospitals out of 100 had licensed in-house blood bank, out of which 66 hospitals
ran 24 X 7 services.
It was observed that 34 hospitals had a tie-up with an external blood bank facility, 57 hospitals
had separate component facility for packed cell (RBC), FFP, Platelet Cryoprecipitate, 57 hospitals
had availability of O- (Negative) blood in their hospitals (figure 10).
A. Hospital-wise comparison
It was observed that out of 20 medical colleges 18 had 24*7 blood bank service available in
hospital but one medical college (Tomo Riba Institute of Health & Medical Sciences, Papumpare)
did not have 24*7 blood bank facility while one medical college (B J Medical College & Sassoon
General Hospital, Pune) did not have in-house blood bank available but it had tie-up with other
blood bank.
Table 13: Summary of Hospital Blood Bank Services by Categories of Hospitals
Hospital Blood
Bank Services
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
FCPCNCFCPCNCFCPCNCFCPCNCFCPCNC
Licensed in-house
Blood Bank
181 1143 3 7 5 8170 2131 6
24*7 Blood Bank 181 1143 2 7 1 5170 2131 6
Tie up with
external blood
bank
7 1 2 6 4 1 6 3 4 6 0 5 9 3 3
Separate
Component
Facilities
161 2 6 6 6 6 2 8161 3131 6
O Negative Blood
Availability
172 1115 3 7 6 4153 2 7 4 9
ED Blood Storage4 1141 2175 3 9 4 1156 014
ED Blood
Transfusion
Protocol
6 0133 1153 213102 8101 9
Massive Blood
Transfusion
Protocol
7 0132 1164 1139 0118 012
**FC: Full Compliance, PC: Partial Compliance, NC: Non-Compliance, ED: Emergency department
Out of 100 hospitals, 11 hospitals (Christian Institute of Health Sciences & Research, Dimapur;
District Hospital, Ganderbal; District Hospital Bishnupur; Shija Hospital & Research Institute,
Imphal; Birla CK Hospital, Jaipur; Fortis Hospital, Jaipur; Civil Hospital, Sec-22, Chandigarh; Bhopal
Fracture Hospital, Bhopal; Sadar Hospital, Gaya; Paras HMRI Hospital, Bihar and Coronation
Hospital, Dehradun)were found which neither has in-house licensed blood bank nor has any
tie-up with external blood bank facility. 53
Observations and Results with Suggestions
Figure 10: Comparison of Hospital Blood Bank Services in Hospital Categories
The blood bank is under construction in Christian Institute of Health Sciences & Research,
Dimapur and District Hospital Bishnupur, while District Hospital, Ganderbal has only blood
storage. District Hospital, Dhamtari reported shortage of staff for blood bank.
**Blood Bank in the ED
It was observed that the majority of hospitals did not have facilities for storage of blood at ED.
Only 20 hospitals {10 government hospitals [6 district hospitals and 4 medical colleges], 10
private hospitals} had separate blood storage for ED.
Most of the hospitals did not have protocols for massive blood transfusion and ED blood transfusion
(Figure 10). Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 54
Best Practices for Blood Bank Services:
!In the 300-500 bedded government hospital category–District Hospital Baramulla,
Jammu & Kashmir had 24x7 blood bank availability and also had separate ED blood
storage with separate component facility.
!In the 100-300 bedded private hospital category- North Goa District Hospital had 24x7
blood bank availability and also had separate ED blood storage with separate component
facility.
6 district hospitals had separate blood storage
for ED:
District Hospital, Baramulla, J &K
District Hospital, Virajpet, Karnataka
Singtam District Hospital, Sikkim
District Hospital, King koti, Telangana
BDM District Hospital, Kotputli, Rajasthan
North Goa District Hospital, Goa
Only 4 medical colleges had separate blood
storage for ED:
B J Medical College, Pune
SMS Medical College & Hospital, Rajasthan
Patna Medical College & Hospital, Bihar
IPGMER & SSKM Hospital
Suggestions:
1. Blood bank services for 24*7 at all hospitals.
2. Blood storage facilities in the ED should be made mandatory for those medical college
and district hospitals (>300 beds) which deals with high volume major trauma cases,
emergency conditions requiring lifesaving blood transfusion services (e.g Massive upper/
lower gastrointestinal bleed, Massive hemoptysis, severe anaemia). 55
Observations and Results with Suggestions
B. Zone-wise comparison:
Table 14 and figure 11 summarizes the blood bank services for hospitals in different zones of India.
Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 56
Figure 11: Zone-wise Comparison of Hospital Blood Bank Services
It was observed that 5 hospitals in north zone neither had blood bank facility in hospital nor had
any tie-up with other blood bank. Similarly, 2 hospitals in east zone and 4 hospitals in north
east neither had blood bank facility in hospital nor had any tie-up with other blood bank. The
assessed hospitals of south zone and west zone had 24*7 available blood bank facilities either
in their hospital or had some tie-up with another blood bank facility.
Table 14: Zone-wise Summary of Hospital Blood Bank Services
Hospital Blood Bank
Services
North (n=30)South (n=21)East (n=11)West (n= 16)
North East
(n=22)
NCPCFCNCPCFCNCPCFCNCPCFCNCPCFC
Licensed in-house
Blood Bank
4323401642541114413
24*7 Blood Bank 3026311521622106313
Tie up with external
blood bank
6312416114033438
Separate Component
Facilities
831732153244298210
O-ve Blood
Availability
661822161534297410
ED Blood Storage 221713244239332002
ED Blood
Transfusion Protocol
1811010184247261813
Massive Blood
Transfusion Protocol
191911187038161903
**FC: Full Compliance, PC: Partial Compliance, NC: Non-Compliance, ED: Emergency Department 57
Observations and Results with Suggestions
11. DEFINITIVE CARE SERVICES
Definitive care is the care that is rendered conclusively to manage patient’s condition, encompassing
the full range of preventive, curative acute, convalescent, restorative, and rehabilitative medical
care.
In this study the following categories were assessed: emergency operative services, intensive care
unit services and specialized care services.
i. Emergency Operative Services:
It was observed that 53% hospitals had emergency operative services for trauma patients, 58%
hospitals had emergency operative services for non-trauma patients, 57% hospitals had emergency
operative services for obstetrics patients, 61% hospitals had emergency operative services for
orthopedic patients, and 47% hospitals had emergency operative services for neurosurgical
patients (table 15 and figure 12).
In addition, only 14 medical colleges had emergency operative services for trauma patients, 5
medical colleges showed partial compliance while one medical college (New STNM Hospital,
Sikkim) did not had emergency operative services for trauma patients. Also, 4 medical colleges
(Guru Nanak Dev Hospital, GMC, TRIHMS, New STNM Hospital and Patna Medical College)
did not have emergency operative services for neurosurgical patients.
Table 15: Overall Summary of Emergency Operative Services by Hospital Category
Emergency
Operative
Services
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt.hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
For Trauma
pts
14 5 17 9 31 8 1114 6 017 3 0
For Non-
Trauma pts
14 6 010 7 22 8 1014 6 018 2 0
For Obstetrics
pts
14 2 010 6 37 10 312 6 114 3 1
For
Orthopedic
pts
15 4 09 6 44 7 815 5 018 1 1
For
Neurosurgical
pts
13 2 44 3 100 3 1614 3 216 2 1
*n: total number of assessed hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 58
Figure 12: Comparison of Hospital Emergency Operative Services in Hospital Categories
ii. Critical Care Services
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit
(ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that
provides intensive treatment medicine.
Table 16: Overall Summary of Critical Care Services by Hospital Category
Definitive
Care Services
Medical
Colleges
(n=20)
Govt. Hospitals
(>300 bed
strength)
(n=20)
Govt. Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Common ICU 13 4 311 4 41 5 1416 3 117 3 0
Common
HDU
5 4 115 4 80 2 1814 3 214 2 3
Pediatric ICU14 1 34 5 90 2 1811 3 48 2 6
Neonatal ICU13 2 36 5 74 5 1112 3 312 3 2
Neurosurgical
ICU
8 3 74 1 110 0 1912 3 48 5 5
Cardiac ICU10 1 74 3 90 0 1915 2 215 1 2
*n: total number of hospitals, ICU: Intensive Care Unit, HDU: High Dependency Unit 59
Observations and Results with Suggestions
In this study, different types of ICUs were assessed. It was observed that majority of hospitals did
not had any common ICU as well as specialized types of ICU in their hospitals. A total of 58%
hospitals had common ICU, 38% had common HDU (High Dependency Unit), 37% hospitals
had pediatric ICU, 47% hospitals had neonatal ICU, only 32% hospitals had neurosurgery ICU,
and 44% hospitals had cardiac ICU were observed (table 16 and figure 13).
Figure 13: Comparison of Hospital Critical Care Services by Category of Hospital
It was observed that 20 out of 3 medical colleges (TRIHMS, Sher-i-kashmir Institute of medical
Sciences and Patna medical College) did not have common ICU. 3 medical colleges (Guru
Nanak Dev Hospital, GMC, TRIHMS, and New STNM Hospital) did not have pediatric ICU and
3 medical colleges (Sher-i-kashmir Institute of medical Sciences, New STNM Hospital and IGMC,
Shimla) did not have neonatal ICU.
iii. Specialized Care Services
Other than ICU, hospitals have some specialized care services, which were also assessed. It was
observed that 43% hospitals had cardiac cath lab, 28% hospitals had intervention radiology,
only 17% hospitals had intervention neuroradiology service with DSA, 26% hospitals had facility
for emergency CABG services, and only 18% hospitals had facility for radiofrequency ablation
services (table 17 and figure 14). Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 60
Figure 14: Comparison of Hospital Specialized Care Services by Category of Hospitals
Table 17: Overall Summary of Specialized Care Services by Hospital Category
Specialized Care
Services
Medical
Colleges
(n=20)
Govt.
Hospitals
(>300 bed
strength)
(n=20)
Govt.
Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Cardiac Cath Lab11 1 64 3 90 01914 3 214 22
Intervention
Radiology
9 2 71 4100 2178 4 610 44
Intervention
Neuro Radiology
with DSA
4 6 81 3110 0187 4 85 67
Facility for
Emergency
CABG Service
4 3112 3100 0189 5 511 43
Facility for
Radiofrequency
Ablation Service
5 0120 2120 0187 4 86 4 7
*n: total number of assessed hospitals 61
Observations and Results with Suggestions
Best Practices for Specialized Care Services at Hospitals
Cardiac Cath Lab:
1. Dr Shyam Prasad Mukharji Civil Hospital, Lucknow
2. Indira Gandhi General Hospital, Puducherry
3. Southern Railway Hospital, Chennai
4. District Hospital, Tenali*
Intervention Radiology*:
1. District Hospital, Baramulla
2. Puri District Hospital, Odisha
3. Indira Gandhi General Hospital, Puducherry
Intervention Neuroradiology service with DSA:
1. Indira Gandhi General Hospital, Puducherry*
Facility for Emergency CABG services:
1. District Hospital, Tenali
2. Southern Railway Hospital, Chennai
3. Indira Gandhi General Hospital, Puducherry*
*Facilities were present but not available for 24 hours due to lack of staff and equipments
Best Practices for Overall Definitive Care Services:
Overall the following hospitals had all compliance for defined definitive care
services, best practices were observed in Grant Medical Foundation Ruby Hall
Clinic, Shija Hospital & Research Institute, Manipal Hospital, Max Super Speciality
hospital, Ramakrishna Care Hospital and Primus Super Speciality hospital.
These hospitals had all types of emergency operative services, all types of ICU and
every specialized care services were observed in the above mentioned hospitals.
Suggestions:
1. Medical colleges should have all types of emergency operative, critical care and
specialized care services for 24*7.
2. District hospitals >300 beds should have trauma, non-trauma operative services, general
ICU (Intensive Care Unit), HDU (High Dependency Unit), NICU (Neonatal ICU) and
PICU (Pediatric ICU).
3. District hospitals <300 beds should have general operative services, general ICU
(Intensive Care Unit) / HDU (High Dependency Unit) and NICU (Neonatal ICU).
District hospitals may be upgraded into multi-speciality hospitals to improve the quality
of care. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 62
12. AMBULANCE SERVICES
12.1 Available ambulances in hospitals
A. Hospital-wise comparison:
A total of 378 ambulances were recorded in 100 hospitals, out of which 315 were functional,
31 were non-functional and the data of 32 ambulances were not known.
Out of the 315 functional ambulances, 148 ambulances were ALS (Advanced Life Support), 97
ambulances were BLS (Basic life Support), and 70 ambulances were neither ALS nor BLS (other
transport vehicles).
Table 18: Summary of available Ambulances by Hospital Category
Ambulance
Services
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
Total Ambulances 119 56 54 91 58
Functional 86 (72%) 37 (66%) 47 (87%) 91 (100%) 54 (93%)
ALS38 (44%) 21 (57%) 17 (36%) 40 (44%) 32 (59%)
BLS24 (28%) 6 (16%) 6 (13%) 45 (49%) 16 (30%)
Other Transport
Vehicles
24 (28%) 10 (27%) 24 (51%) 6 (7%) 6 (11%)
Non-Functional 16 (13%) 5 (9%) 7 (13%) 0 (0%) 3 (5%)
Data Not Known 17 (14%) 14 (25%) 0 (0%) 0 (0%) 1 (2%)
*n: number of assessed hospitals, ALS: Advanced Life Support, BLS: Basic Life Support
Figure 15: Representation of available Ambulances Status by Category of Hospitals 63
Observations and Results with Suggestions
Figure 16: Representation of types of Ambulances by Category of Hospitals
It was observed that ~48% of the ambulances were ALS of all the functional ambulances in
every category of hospital, and only 10% patients (red triaged patients) require ALS ambulances.
B. Zone-wise comparison
A total of 136 ambulances were found in north zone (n= 30), 82 ambulances were found in
south zone (n=21), 31 ambulances were found in east zone (n=11), 64 ambulances were found
in west zone (n=16), and 65 ambulances were found in north-east zone (n=22) of India (table
19 and figure 17, 18).
Table 19: Zone-wise Summary of available Ambulances in Hospitals
Hospital Ambulance
Services
North
(n=30)
South
(n=21)
East
(n=11)
West
(n=16)
North East
(n=22)
Total Ambulances 136 82 31 64 65
Functional103 (76%) 69 (84%) 29 (94%) 55 (86%) 59 (91%)
ALS33 (24%) 39 (48%) 17 (55%) 34 (53%) 25 (38%)
BLS35 (26%) 25 (30%) 8 (26%) 18 (28%) 11 (17%)
Other Transport
Vehicles
68 (50%) 18 (22%) 6 (19%) 12 (19%) 29 (45%)
Non-Functional6 (4%) 9 (13%) 2(7%) 9 (16%) 5 (8%)
Data Not Known27 (20%) 4 (5%) 0 (0%) 0 (0%) 1 (2%)
Good Practice by using Bike Ambulance
It was found that Max Super Speciality Hospital, Chandigarh has 2 functional bike ambulances
which were used for patient transport. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 64
Figure 17: Zone-wise Comparison of available Ambulances in Hospitals
Figure 18: Zone-wise Comparison of types of Ambulances in Hospitals
C. NABH Accreditation-wise comparison:
Table 20 and figure 19summarizes the number of ambulances on the basis of hospitals with
NABH accreditation and hospitals without NABH accreditation.
Figure 19: Comparison of available Ambulances with their types in NABH Accredited Hospitals and Non-NABH
Accredited Hospitals 65
Observations and Results with Suggestions
Table 20: Summary of available Ambulances in NABH accredited and non-NABH
Accredited Hospitals
Hospital Ambulance Services
NABH Accredited Hospitals
(n=28)
Non-NABH Accredited Hospitals
(n=72)
Total Ambulances121 32% 257 68%
Functional118 98% 197 77%
ALS59 49% 89 35%
BLS54 45% 43 17%
Other Transport Vehicles 87% 125 49%
Non-Functional32%28 11%
Data Not Known00%32 12%
*n: number of hospitals
Suggestions:
!As per MCI, number of in-hospital ambulances according to bed strength:
1. For > 300 beds, 1 ambulance should be present
2. For > 500 beds, 2 ambulances should be present
!The in-hospital ambulances should be optimally utilized in the common resource pool of
EMS (Emergency medical Service) of the region as per requirement.
!Regular maintenance of ambulances should be done.
!The ALS ambulances can be used for mobile stroke unit as well as for STEMI programme.
12.2 Hospital Ambulance Services
It was observed that out of 100 hospitals, 91 had in-house ambulances. Only 18% hospitals get
a pre-hospital notification of ambulance arrival at the hospital. Trained paramedics were available
in 34% hospitals.
Mobile stroke unit was available in only 4% hospitals and Tele stroke/STEMI (ST-segment elevation
myocardial infarction) was available in 19% hospitals. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 66
Figure 20: Comparison of Ambulance Services by Category of Hospitals
Table 21: Summary of Hospital Ambulance Services by Category of Hospitals
Ambulance
Services
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Ambulances in
Hospital
170 3170 1190 119 0 019 0 1
Pre Hospital
Notification
1 5130 3162 5139 4 66 6 8
Trained
Paramedics for
Ambulances
6 4100 7132 51312 4 314 2 4
Mobile Stroke
Unit
1 0190 1180 0201 0 182 1 16
Tele Medicine
Facility
7 1113 2152 1163 2 134 015
*n=number of hospitals 67
Observations and Results with Suggestions
12.3 Use of Ambulances by Hospitals
It was observed that mostly hospitals used the ambulances for inter-transfer of patients to other
hospitals,while a few number of ambulances used the ambulances to drop the patient (figure 21).
Figure 21: Overall representation of use of Ambulances by Hospitals
12.4 Patient transfer in absence of hospital ambulance:
It was found that in absence of hospital ambulance patient transfer takes place by private
ambulances in most hospitals, sometimes patient have to go by their own vehicles and sometimes
it takes place by 108 or 102 ambulances (figure 22).
Figure 22: Overall representation of Patient transfer in case hospital does not have ambulance services
It was observed that 6 hospitals (Christian Institute of Health Sciences & Research, Dimapur;
District Hospital, Baramulla, Jammu & Kashmir; Gauhati Medical College & Hospital; Government
General Hospital, Guntur; North Goa District Hospitaland IGMC, Shimla) does not have any
ambulances while 3 hospitals (Government Multispeciality Hospital, Sector 16, Chandigarh;
Apollo Hospitals, Chennaiand Deen Dayal Upadhyay Hospital, Shimla) did not share their
ambulance data with our assessor’s team. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 68
Best Practices for Hospital Ambulance Services:
!Primus Super Speciality Hospital is a private 138 bedded hospital and it have best hospital
ambulance services out of all 100 hospitals. It has mobile stroke unit as well as tele-
medicine facility.
!Hospitals have GVK centre which is a Centralized ambulance services in Goa.
!Mobile Stroke Unit was observed in Gauhati Medical College, Medeor Hospital, Sri
Ganga Ram Hospital, and Primus Super Speciality Hospital.
Note: It was found that some government hospitals did not have sufficient staff for ambulances
not even drivers. Jallianwala Bagh Matyr Memorial Hospital, Punjab and District Hospital,
Peroorkada, Kerala did not have manpower for ambulance.
North Goa District Hospital, Goa is running STEMI Programme by using tele-radiology. 6 hospitals
(Christian Institute of Health Sciences & Research, Dimapur; Synod Hospital, Aizawl, Mizoram;
Ramakrishna Mission Hospital, Arunachal Pradesh; District Hospital, Pasighat; Shija Hospital &
Research Institute, Imphal and Morigaon Civil Hospital, Assam) were found using tele-radiology
for various purpose such as for X-ray and CT scan.
Suggestions:
1. Create National Pre-hospital care guidelines.
2. Capacity building of existing paramedics by structured training program.
3. Creation of EMT (Emergency Medical Technician) course as a residency programme.
4. Dedicated job creation for EMT with performance based promotional ladder.
5. Establish Paramedic Council of India as regulatory body
13. ED PROTOCOL / SOP / GUIDELINES
A. Hospital-wise comparison:
In a healthcare facility, a protocol, also called a medical guideline, is a set of instructions which
describe a process to be followed to investigate a particular set of findings in a patient, or the
method which should be followed to control a certain disease.
It was observed that 41% hospitals had documented emergency manual, 30% hospitals had
documented policies and procedures for patient transfer in, 30% hospitals had documented
policies and procedures for patient transfer out, 57% hospitals gave discharge summary to patients,
58% hospitals had policy on handling cases of death, 44% hospitals had documented disaster
management plan, and only 41% hospitals had triage policy in ED. 69
Observations and Results with Suggestions
Table 22: Summary of ED Protocol / SOP / Guidelines by Category of Hospitals
ED Protocol
/ SOP /
Guidelines
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Emergency
Manual
1 3 154 7 93 3 1414 3 319 1 0
Policies and
procedures
for patient
transfer in
1 4 152 7 113 3 1413 0 711 6 3
Policies and
procedures
for patient
transfer out
1 5 141 9 102 6 1213 2 513 6 1
Discharge
Summary to
patients
7 7 58 5 76 6 816 4 020 0 0
Policy on
handling death
cases
9 6 510 5 58 7 414 3 317 3 0
Disaster
Management
Plan
6 2 125 5 105 3 1014 1 514 2 3
Triage Policy
in ED
5 0 143 2 155 0 1512 0 816 0 3
FIn medical college, only one hospital (IPGMER & SSKM Hospital) had emergency manual,
1 hospital (IPGMER & SSKM Hospital) had documented policies and procedures for patient
transfer in, 1 hospital (IPGMER & SSKM Hospital) had documented policies and procedures
for patient transfer out, 7 hospitals (Civil Hospital, Ahemdabad; Agartala Government Medical
College & G B Pant Hospital; Sher–I–Kashmir Institute of Medical Sciences, Srinagar, Government
General Hospital, Guntur; SMS Medical College & Hospital; AIIMS, Bhopal and IPGMER & SSKM
Hospital) gave discharge summary to patients, 9 hospitals had policy on handling cases of death,
6 hospitals had documented disaster management plan, and only 5 hospitals (AIIMS, Bhopal;
Rajiv Gandhi Government General Hospital, Madras Medical College; JIPMER, Pondicherry;
Government Medical College, Thiruvanananthapuram and IPGMER & SSKM Hospital) had triage
policy in ED (table 22 and figure 23).
It was observed that 7 district hospitals had documented emergency manual, 3 district hospitals had
documented policies and procedures for patient transfer in, 2 district hospitals had documented
policies and procedures for patient transfer out, 11 district hospitals gave discharge summary
to patients, 15 district hospitals had policy on handling cases of death, 9 district hospitals had
documented disaster management plan, and only 6 district hospitals (Jamanabai General Hospital,
Gujarat; Civil Hospital, Aizawl, Mizoram; District Hospital, Pasighat, Arunachal Pradesh; District
Hospital, Singtam, Sikkim; Southern Railways Hospital, Chennai and HNB Base Hospital,
Uttarakhand) had triage policy in ED. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 70
Figure 23: Comparison of ED Protocol / SOP / Guidelines by Hospital Categories 71
Observations and Results with Suggestions
B. Zone-wise comparison
Table 23: Zone-wise Summary of ED Protocol / SOP / Guidelines in Hospitals
ED Protocol / SOP
/ Guidelines
North (n=30)South (n=21) East (n=11)West (n= 16)
North East
(n=22)
NoPartialYesNoPartialYesNoPartialYesNoPartialYesNoPartialYes
Emergency Manual9 417113 55 2 47 4 5103 9
Policies and
procedures for
patient transfer in
13611114 45 0 64 6 6155 2
Policies and
procedures for
patient transfer out
126129 5 65 1 55 7 4118 3
Discharge Summary
to patients
5 5206 4 93 1 70 5117 7 8
Policy on handling
death cases
3 7204 3122 1 82 4106 9 6
Disaster
Management Plan
8 418101 75 2 45 4 7121 7
Triage Policy in ED151149 0 94 1 69 0 6170 5
*n=number of hospitals
Figure 24: Zone-wise Comparison of ED Protocol / SOP / Guidelines in hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 72
C. NABH Acrcreditation-wise comparison:
Figure 25: Overall Comparison of ED Protocol / SOP / Guidelines in NABH accredited and
non-NABH Accredited Hospitals
14. EMERGENCY CARE PROTOCOLS
A. Hospital-wise comparison
In Emergency Department, some emergency care protocols are present which have emergency
care protocol for different diseases. 38% hospitals had alert system for cardiac arrest, 16% had
alert system for trauma, 15% had alert system for chest pain, only 10% had for sepsis and 23%
had alert system for stroke (table 24 and figure 26).
Figure 26: Comparison of Emergency Care Protocols by Hospital Categories 73
Observations and Results with Suggestions
In medical college, 2 hospitals (Rajiv Gandhi Government General Hospital, Madras Medical
College and IPGMER & SSKM Hospital) have alert system for cardiac arrest and for trauma, only
1 hospital (IPGMER & SSKM Hospital) have alert system for chest pain, for sepsis and for stroke.
In government hospitals >300 beds, 4 hospitals (District Hospital, Baramulla, J&K; Government
District Hospital, Tenali; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow and Government
Multispeciality Hospital, Sector 16, Chandigarh) have alert system for cardiac arrest, 1 hospital
(District Hospital, Baramulla, J&K) have alert system for trauma, 1 hospital (District Hospital,
Baramulla, J&K) have alert system for chest pain, only 1 hospital (District Hospital, Karim Nagar)
have alert system for sepsis and 2 hospitals (District Hospital, Baramulla, J&K and Government
District Hospital, Tenali) have alert system for stroke.
In government hospitals <300 beds, only 1 hospital (Dr Jogalekar Hospital, Pune) have alert
system for cardiac arrest, for trauma, for chest pain for stroke.
Table 24: Overall Summary of Emergency Care protocols by Category of Hospitals
Emergency
Care
Protocols
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Blue:
Cardiac
Arrest
2 2 164 0 161 0 1914 1 417 0 3
Trauma 2 0 181 1 181 0 199 0 103 2 15
Chest Pain1 0 181 0 191 0 195 2 127 3 9
Sepsis 1 0 181 2 170 0 204 0 154 2 13
Stroke 1 0 182 0 181 0 1910 0 99 2 8
*n: number of hospitals
B. Zone-wise comparison:
Table 25 depicts the comparison of emergency care protocols at the assessed healthcare facilities.
Table 25: Zone-wise Summary of Emergency Care protocols in Hospitals
Emergency
Care
Protocols
North (n=30) South (n=21) East (n=11) West (n= 16)
North East
(n=22)
NoPartialYesNoPartialYesNoPartialYesNoPartialYesNoPartialYes
Cardiac
Arrest
12 0 1812 1 77 0 49 1 619 1 1
Trauma 24 1 515 0 58 1 212 1 321 0 0
Chest Pain 22 2 615 1 27 2 212 0 420 0 1
Sepsis 26 3 114 0 47 1 314 0 221 0 0
Stroke 20 1 912 0 67 1 312 0 420 0 1
*n=number of hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 74
Figure 27: Zone-wise Comparison of Emergency Care Protocols in Hospitals
C. NABH and non-NABH Accredited Hospitals comparison:
Figure 28 depicts the comparison of NABH and non-NABH accredited hospitals for the emergency
care protocols.
Figure 28: Overall Comparison of Emergency Care protocols in NABH accredited and non-NABH
Accredited Hospitals
Suggestions:
1. Develop standardized evidence based emergency care protocols (administrative and
clinical).
2. Development of academic residency programme.
3. Implementation of triage policy in each hospital. 75
Observations and Results with Suggestions
4. NABH Accreditation.
5. Increase the scope of Good Samaritan Law from road traffic injuries to other time
sensitive conditions.
15. MEASURES ENSURING SAFETY & SECURITY IN HOSPITALS
Several safety aspects were assessed for Emergency Department which is mentioned in the below
tables and figure. It was observed that majority of hospitals did not have periodic training of staff
and periodic mock drill was also not conducted regularly.
Nearly all private hospitals had periodic training programmes in their hospitals while most of
the government hospitals including medical colleges did not have regular periodic training of
staff. Similarly, mock drill conducted in most of the private hospitals while mostly government
hospitals did not conduct mock drill.
These aspects also assessed according to hospital bed strength
a. Category wise (table 26and figure 29)
b. 5 Zones of our country (zone wise) (table 27 and figure 30)
c. NABH accredited and non-NABH accredited hospitals (figure 31).
A. Hospital-wise comparison
Table 26: Overall Summary of measures ensuring Safety & Security by Category of Hospitals
Safety &
Security
measures
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Fire Safety 13 7 09 10 17 10 219 1 017 3 0
Building Safety12 3 49 7 48 6 515 3 117 2 1
Electrical
Safety
12 7 110 7 311 6 319 1 019 1 0
Patient and
Provider
Safety
12 7 08 9 38 6 517 3 020 0 0
Chemical
Safety
9 10 17 7 58 8 320 0 018 1 0
Periodic
Training of
Staff
7 5 84 9 73 13 416 3 118 2 0
Periodic Mock
Drill
6 5 94 7 93 11 616 3 117 3 0
Police Post
Available in
Premises
15 2 315 0 55 4 114 3 132 2 16
Alarm
Bell/Code
Announcement
in ED
3 7 94 2 132 2 1614 1 516 2 1
*n: number of hospitals, ED: Emergency Department Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 76
Figure 29: Comparison of measures ensuring Safety & Security by Hospital Categories 77
Observations and Results with Suggestions
B. Zone-wise comparison
Figure 30: Zone-wise comparison of measures ensuring Safety & Security in Hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 78
Table 27: Zone-wise measures ensuring Summary of Safety & Security in Hospitals
Safety &
Security
North (n=30)South (n=21) East (n=11) West (n= 16)
North East
(n=22)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Fire Safety 245 1108 28 3 012 3 010120
Building Safety224 4114 57 2 212 3 18 8 3
Electrical Safety235 2107 38 2 112 4 0165 1
Patient and
Provider Safety
227 1107 26 2 39 6 1164 1
Chemical Safety228 0105 48 2 110 5 0106 5
Periodic
Training of
Staff
187 59 3 83 7 110 6 08 8 6
Periodic Mock
Drill
186 67 2113 6 210 5 17 9 6
Police Post
Available in
Premises
126129 2 93 1 79 0 77 312
Alarm Bell/
Code
Announcement
in ED
164 96 3 94 1 67 4 54 216
*n=number of hospitals, ED=Emergency Department
C. NABH Accreditation comparison
Figure 31: Comparison of Safety & Security in NABH and Non-NABH Accredited Hospitals 79
Observations and Results with Suggestions
16. DISASTER MANAGEMENT
Hospital disaster management provides the opportunity to plan, prepare and when needed enables
a rational response in case of disasters/ mass casualty incidents (MCI). Disasters and mass casualties
can cause great confusion and inefficiency in the hospitals.
A. Hospital-wise comparison
The preparedness/readyness of hospitals for disaster management were analysed according to the
categories of hospitals as depicted in the below table and graph.
Figure 32: Comparison of preparedness/readyness for Disaster Management by Hospital Categories
It was observed that only 33 hospitals have documented disease outbreak management plan,
38 hospitals have surge capacity, only 14 hospitals (2 government hospitals: Government
Multispeciality hospital, Sector-16 and Dr Jogalekar Hospital) have separate decontamination
area for ED entrance, 35 hospitals have separate disease stock in ED, 32 hospitals conducted
drill and debriefing for disaster management, and 38 hospitals have system to redistribution of
patients to other hospitals during disaster. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 80
Table 28: Summary of preparedness/readyness for Disaster Management by
Category of Hospitals
Disaster
Management
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Disease
Management
Outbreak Plan
4 4127 4 92 71113 3 47 7 6
Surge Capacity 5 8 78 5 72 9 913 3 310 6 4
Separate
Decontamination
Area at ED entrance
0 2181 1181 2177 2105 510
Separate Disaster
Stock in ED
4 2147 1122 51311 2 711 5 4
Drill and Debriefing
for Disaster
Management
2 5135 4112 31513 3 410 5 5
Redistribution of pts
to other hospitals
4 2146 5 85 41114 2 49 8 3
*n: number of hospitals, ED: Emergency Department
B. Zone-wise comparison
Mostly healthcare facilities did not have separate decontamination area at ED entrance. Government
hospitals and medical colleges did not conducted drill and debriefing for disaster management.
The government healthcare facilities also lack the system for redistribution of patients to other
network hospitals during disaster (Zone wise-table 29 and figure 33).
Table 29: Zone-wise Summary of preparedness/readyness for Disaster Management in Hospitals
Disaster
Management
North (n=30)South (n=21)East (n=11)West (n= 16)
North East
(n=22)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Surge Capacity 189 37 4 83 5 38 3 52 812
Separate
Decontamination
Area at ED entrance
7 4191 2161 3 74 1111 219
Separate Disaster
Stock in ED
145118 2105 2 43 4 94 315
Drill and Debriefing
for Disaster
Management
147 98 1113 3 54 3 93 613
Redistribution of pts
to other hospitals
164 96 2124 3 48 5 33 712
*n: number of hospitals, ED: Emergency Department 81
Observations and Results with Suggestions
It was observed during analysis that north-east was the weakest zone in disaster management in
all the required aspects as mentioned in table 29 and figure 33.
Figure 33: Zone-wise Comparison of preparedness/readyness for Disaster Management in Hospitals
C. NABH Accreditation comparison
In addition, it was also observed that the hospitals which were NABH accredited had good disaster
management system when compared with non-NABH accredited hospitals (figure 34).
Best Practices for preparedness/readiness for Disaster
Management
Fortis Hospital, Punjab, Government Multispecialty Hospital, Sector 16, Apollo Hospital, Paras
HMRI Hospital, Ramakrishna Care Hospital, Medeor Hospital, and Sri Ganga Ram Hospital
had all the required stocks and requirements needed for disaster management. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 82
Figure 34: Overall Comparison of preparedness/readyness for Disaster Management in NABH
and Non-NABH Accredited Hospitals
Suggestions:
1. There should be standard protocols for implementation of in-hospital disaster management
plan
2. Implementation of hospitals preparedness for both external and internal disaster
management.
3. There should be separate decontamination area at entrance of emergency department.
4. Every hospital should have surge capacity with separate disaster stock in emergency
department.
5. There should be periodic drills and debriefing for disaster management.
6. Regular monitoring and evaluation of implementation of disaster management protocols
should be done by national disaster management authority.
17. CONTINUOUS QUALITY IMPROVEMENT
It is a process of creating an environment in which management and workers strive to create
constantly improving quality. The purpose of continuous quality improvement programs is to
improve health care by identifying problems, implementing and monitoring corrective action
and studying its effectiveness.
A. Hospital-wise comparison
It was observed that 40% hospitals had dedicated staff for identification and loop closure, 52%
hospitals undergo regular audits, 42% hospitals had continuous education and training programs,
42% hospitals had key indicators for quality monitored, only 22% hospitals had quality indicators
for urgent and interventional procedures monitored, 50% hospitals had death review committee,
and 42% hospitals had central empowered hospital committee for continuous quality improvement
for emergency services.
Most of the government hospitals and medical colleges do not run continuous quality improvement
programmes and training while on the other hand; private hospitals showed good performance
in continuous quality improvement (table 30 and figure 35). 83
Observations and Results with Suggestions
Table 30: Summary of Continuous Quality Improvement by Category of Hospitals
Continuous Quality
Improvement
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt.
hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Dedicated Staff for
gap identification &
loop closure
2 6115 5104 412145 1155 0
Regular audits in
hospital
7 7 66 4106 8 6154 1181 0
Continuous
Education and
Training programs
4 7 96 7 71 910144 2173 0
Key Indicators of
Quality Monitored
5 7 85 9 65132125 2155 0
Quality Indicators
for urgent and
interventional
procedures
monitored
1 4152 0172 2169 6 58 6 6
Death Review
Committee
6 6 86 4104 511162 2180 2
Central Empowered
Hospital Committee
4 3134 6105 411136 1163 1
*n: number of hospitals
Out of 20 medical colleges, 2 hospitals (Civil Hospital, Ahmedabad and JIPMER Pondicherry) had
dedicated staff for identification and loop closure, 7 hospitals undergo regular audits, 4 hospitals
(Regional Institute of Medical Sciences, Imphal; Rajiv Gandhi Government General Hospital,
Madras Medical College; JIPMER, Pondicherry and IPGMER & SSKM Hospital) had continuous
education and training programs, 5 hospitals had key indicators for quality monitored, only 1
hospital (Gauhati Medical College & Hospital) had quality indicators for urgent and interventional
procedures monitored, 6 hospitals had death review committee, and 4 hospitals (Civil Hospital,
Ahemdabad; Rajiv Gandhi Government General Hospital, Madras Medical College; JIPMER,
Pondicherry and IPGMER & SSKM Hospital) had central empowered hospital committee for
continuous quality improvement for emergency services. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 84
Figure 35: Comparison of Continuous Quality Improvement by Hospital Categories
Out of 20 government hospitals >300 beds, following were observed:
1. 5 hospitals had dedicated staff for identification and loop closure (Jallianwala Bagh
Matyr Memorial Hospital, Amritsar; District Hospital, Baramulla, J&K; Dr Shyam Prasad
Mukharji Civil Hospital, Lucknow; Government Multispeciality Hospital, Sector 16 and
Deen Dayal Upadhyay Hospital, H.P.)
2. 6 hospitals undergo regular audits (Jallianwala Bagh Matyr Memorial Hospital, Amritsar;
District Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow;
Government Multispeciality Hospital, Sector 16; HNB Base Hospital and Deen Dayal
Upadhyay Hospital, H.P.)
3. 6 hospitals had continuous education and training programs (Civil Hospital, Shillong; Dr
Shyam Prasad Mukharji Civil Hospital, Lucknow; Southern Railways Hospital, Chennai; 85
Observations and Results with Suggestions
District Hospital, Baramulla, J&K, AIIMS, Patna and Deen Dayal Upadhyay Hospital,
H.P.)
4. 5 hospitals had key indicators for quality monitored (Civil Hospital, Shillong; District
Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow; Southern
Railways Hospital, Chennai and Deen Dayal Upadhyay Hospital, H.P.)
5. 2 hospitals had quality indicators for urgent and interventional procedures monitored
(District Hospital, Baramulla, J&K and Government Multispeciality Hospital, Sector 16)
6. 6 hospitals had death review committee (Jallianwala Bagh Matyr Memorial Hospital,
Amritsar; District Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital,
Lucknow; Government Multispeciality Hospital, Sector 16; AIIMS, Patna and Deen
Dayal Upadhyay Hospital, H.P.)
7. 4 hospitals had central empowered hospital committee for continuous quality
improvement for emergency services (Jallianwala Bagh Matyr Memorial Hospital,
Amritsar; District Hospital, Baramulla, J&K; AIIMS, Bhubneshwar and Government
Multispeciality Hospital, Sector 16)
Out of 20 government hospitals <300 beds, following were observed:
1. 4 hospitals had dedicated staff for identification and loop closure (Civil Hospital, Aizawl,
Mizoram; District Hospital, Ganderbal; Dr Jogalekar Hospital, Pune and District Hospital,
Singtam)
2. 6 hospitals undergo regular audits (Civil Hospital, Aizawl, Mizoram; District Hospital,
Pasighat; District Hospital, Singtam; District Hospital, King Koti; Dr Jogalekar Hospital,
Pune and North Goa District Hospital)
3. Only 1 hospital had continuous education and training programs (Dr Jogalekar Hospital,
Pune)
4. 5 hospitals had key indicators for quality monitored (Civil Hospital, Aizawl, Mizoram;
District Hospital, Singtam; District Hospital, King Koti; Dr Jogalekar Hospital, Pune and
North Goa District Hospital)
5. 2 hospitals had quality indicators for urgent and interventional procedures monitored
(North Goa District Hospital and Dr Jogalekar Hospital, Pune)
6. 4 hospitals had death review committee (Civil Hospital, Aizawl, Mizoram; District
Hospital, Pasighat; District Hospital, Singtam and North Goa District Hospital)
7. 5 hospitals had central empowered hospital committee for continuous quality
improvement for emergency services (Civil Hospital, Aizawl, Mizoram; District Hospital,
Singtam; District Hospital, King Koti; Dr Jogalekar Hospital, Pune and North Goa District
Hospital)
B. Zone-wise comparison
It was observed that North zone performed best out of all 5 zones in continuous quality
improvement while the rest of the zones performed below average (table 31 and figure 36). Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 86
Table 31: Zone-wise Summary of Continuous Quality Improvement in Hospitals
Continuous Quality
Improvement
North
(n=30)
South (n=21)East (n=11)West (n=16)
North East
(n=22)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Dedicated Staff for gap
identification & loop
closure
19566862546376411
Regular audits in hospital22538474436641066
Continuous Education
and Training programs
15123839533655868
Key Indicators of Quality
Monitored
17936104452754895
Quality Indicators for
urgent and interventional
procedures monitored
1151333142454391318
Death Review Committee19299563265381048
Central Empowered
Hospital Committee
18487494526556313
*n: number of hospitals
Figure 36: Zone-wise Comparison of Continuous Quality Improvement in Hospitals 87
Observations and Results with Suggestions
C. NABH and non-NABH Accredited Hospitals comparison:
In addition, it was observed that NABH accredited hospitals had good performance in continuous
quality improvement when compared to non-NABH accredited (figure 37).
Figure 37: Overall Comparison of Continuous Quality Improvement in NABH and Non-NABH
Accredited Hospitals
NABH accredited healthcare facilities had regular audits in their facility, dedicated staff for
loop closure, runs training program cycles for skill development, had key indicators and quality
indicators for urgent and interventional procedures monitored. They had death review committee
to review the cause of patient’s death. Most of the NABH accredited hospitals followed the above
procedures for quality improvement.
Best Practices for Continuous Quality Management
Best practices for continuous quality management were observed in District Hospital,
Baramulla; Manipal Hospital; Fortis hospital, Jaipur; Max Super Speciality Hospital; Apollo
Hospital; Care Hospital; Yashoda Hospital, Malakpet; Paras HMRI Hospital; Ramakrishna Care
Hospital; Medeor Hospital and Artemis Hospital.
Suggestions:
1. There should be dedicated quality manager for gap identification and loop closure.
2. Develop a quality council among emergency care providers.
3. Mandatory Emerald certification under NABH.
4. Regular mortality and morbidity meeting.
5. Regular third-party audit of external agencies by using KPI and the funding of the
hospital should be linked with it.
6. Continuous training of quality council provider as well as manager.
18. COMPUTERIZED DATA MANAGEMENT SYSTEM
Healthcare data management is the process of storing, protecting, and analysing data pulled from
diverse sources. Managing the wealth of available healthcare data allows health systems to create
holistic views of patients, personalize treatments, improve communication, and enhance health
outcomes. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 88
A. Hospital-wise comparison:
Out of 100 studied hospitals 52 hospitals did not had any electronic health record (EHR) and
other hospitals had EHR system.
Table 32: Summary of Data Management System by Category of Hospitals
Computerized Data
Management System
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
EHR61137 6 75 6 9128 0182 0
Patient Registration
System
152 3170 3102 8200 0200 0
Patient Clinical
Examination Notes
2 1173 1160 1196 5 96 5 9
Patient Investigation Lab
Reports
103 77 4 94 313162 2181 1
Patient Radiological
Investigation Reports
123 5102 83 511182 0162 2
Trauma Registry 2 5133 5121 2176 3117 5 7
Injury Surveillance
System
0 2180 3172 0182 3144 411
ED Surveillance System1 3160 4161 1189 1107 3 9
Data Retrieval System3 4134 8 82 315122 6122 5
*n: number of hospitals, ED: Emergency Department, EHR: Electronic Health Record
In addition, it was also observed that 19 hospitals have trauma registry, only 8 hospitals have
injury surveillance system, 18 hospitals have emergency department surveillance system, and 33
hospitals have data retrieval system for quality improvement & research.
Out of 20 medical colleges, 6 hospitals had electronic health record (EHR), 15 hospitals had
computerized patient registration system, only 2 hospitals (AIIMS, Bhopal and IPGMER & SSKM
Hospital) had computerized patient clinical examination notes, 10 hospitals had computerized
patient investigation lab reports and 12 hospitals had computerized patient radiological
investigation reports.(Note: Though hospitals have answered yes for trauma registry but many of
them do not understood it’s meaning).
In addition, it was also observed that 2 hospitals (AIIMS, Bhopal and IPGMER & SSKM Hospital)
had trauma registry, none of them had injury surveillance system, 1 hospital (AIIMS, Bhopal) had
emergency department surveillance system, and 3 hospitals (Civil Hospital, Ahemdabad; AIIMS,
Bhopal and JIPMER, Pondicherry) had data retrieval system for quality improvement & research
(table 32 and figure 38). 89
Observations and Results with Suggestions
Figure 38: Comparison of Data Management System by Hospital Categories
Out of 20 government hospital >300 beds, 7 hospitals had electronic health record (EHR),
17 hospitals had computerized patient registration system, only 3 hospitals (Dr Shyam Prasad
Mukharji Civil Hospital, Lucknow; AIIMS, Patna and Jai Prakash Narayan District Hospital, Bhopal)
had computerized patient clinical examination notes, 7 hospitals had computerized patient
investigation lab reports and 10 hospitals had computerized patient radiological investigation
reports. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 90
In addition, it was also observed that 3 hospitals (AIIMS, Patna; Civil Hospital, Shillong and
HNB Base Hospital) had trauma registry, none of them had injury surveillance system and
emergency department surveillance system, and 4 hospitals (AIIMS, Bhubneshwar; District
Hospital, Baramulla, J&K; Dr Shyam Prasad Mukharji Civil Hospital, Lucknow and Deen Dayal
Upadhyay Hospital, H.P.) had data retrieval system for quality improvement & research.
Out of 20 government hospital <300 beds, 5 hospitals had electronic health record (EHR), 10
hospitals had computerized patient registration system, none of them had computerized patient
clinical examination notes, 4 hospitals had computerized patient investigation lab reports and 3
hospitals had computerized patient radiological investigation reports.
In addition, it was also observed that 1 hospital (Puri District Headquarter Hospital, Orissa)
had trauma registry, 2 hospitals (Puri District Headquarter Hospital, Orissa and Dr Jogalekar
Hospital, Pune) had injury surveillance system, 1 hospital (Dr Jogalekar Hospital, Pune) had
emergency department surveillance system, and 2 hospitals (Civil Hospital, Aizawl, Mizoram
and Dr Jogalekar Hospital, Pune) had data retrieval system for quality improvement & research.
Computerized data management system found weak in government sector
especially in government hospitals less than 300 bed strength.
Trauma registry, injury surveillance system, emergency department surveillance system, and data
retrieval system for quality improvement & research were found weak in all categories of the
healthcare facilities (table 32 and figure 38).
B. Zone-wise comparison
Table 33: Zone-wise Summary of Data Management System in Hospitals
Data Management
System
North (n=30)South (n=21)East (n=11)West (n=16)
North East
(n=22)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
EHR167 77 9 47 2 2114 16115
Patient Registration
System
250 5170 39 0 2141 1163 3
Patient Clinical
Examination Notes
4 4222 5134 2 55 2 91 120
Patient Investigation
Lab Reports
203 78 5 76 1 4112 39 112
Patient Radiological
Investigation Reports
15510122 67 1 3103 3134 4
Trauma Registry 510152 4146 1 44 2 91 219
Injury Surveillance
System
3 4230 3163 3 41 2120 022
ED Surveillance
System
7 4193 4123 3 54 0110 022
Data Retrieval
System
143135 7 75 2 46 4 52 317
*n: number of hospitals, ED: Emergency department, EHR: Electronic Health Record 91
Observations and Results with Suggestions
Figure 39: Zone-wise Comparison of Data Management System in Hospitals
Out of all five zones of India, north east was found weak in sector of computerized data
management system. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 92
C. NABH and non-NABH Accredited Hospitals comparison:
In addition, it was observed that data management is good in NABH Accredited Hospitals but
the data for research was found below average (figure 40).
Figure 40: Comparison of Data Management System in NABH and Non-NABH Accredited Hospitals
Best Practices for Data Management System was observed in Ruban Memorial Hospital, Asian
Hospital, and Primus Super Speciality Hospital (with 100% score).
Suggestions:
1. Develop National Emergency Department Information System (EDIS)
2. Implement and integrate the computerized care delivery template which will serve as
clinical notes, registry and surveillance
3. It will use the data for quality improvement initiative and research
4. Develop various emergency conditions registries such as cardiac arrest, poisoning, snake
bite including trauma registry
19. FINANCING
Availability of dedicated funds for emergency department assessed for all hospitals. Out of 60
government healthcare facilities, only 2hospitals received sufficient central government funds,
13 did not received sufficient central government funds and the rest did not received any fund
at all for ED services.
A. Hospital-wise comparison
It was observed that none of the hospitals received dedicated funds for emergency department
because of lack of dedicated emergency department in hospitals. Some hospitals received funds
from state such as funds for trauma. 93
Observations and Results with Suggestions
Table 34: Overall Summary of Financing by Category of Hospitals
Financing for
Emergency
Department
Medical
Colleges with ED
Academics (n=3)
Medical Colleges
with Emergency
Services (n=17)
Govt. hospitals
(<300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
SFNSFNF SFNSFNF SFNSFNF SFNSFNF
Central Govt Funds
for ED Services
0 1 1 2 3 12 0 4 15 0 4 14
State Govt Funds for
ED Services
2 0 1 3 7 7 5 7 7 3 7 8
(**SF: Sufficient Funds, NSF: Not Sufficient Funds, NF: No Funds, n: number of hospitals)
Figure 41: Comparison of Financing by Hospital Categories
Out of 3 medical colleges with academic emergency department, 2 had received sufficient funds
from state government- a) funds for trauma (JIPMER, Pondicherry) b) funds from Government of
Gujarat(Civil Hospital, Ahmedabad).
Out of 17 medical colleges without academic emergency department, 2 hospitals (Regional
Institute of Medical Sciences, Imphal and AIIMS, Bhopal) had sufficient funds, 3 hospitals
(Government General Hospital, Guntur; Government Medical College, Thiruvanananthapuram
and Patna Medical College & Hospital, Patna) had funds but not sufficient and 12 hospitals had
no funds from central government.
B. Zone-wise comparison
Out of 100 hospitals from five zones of country, it was observed that east zone was the weakest
zone for receiving funds from government either state or central.
Table 35: Zone-wise Summary of Financing in Hospitals
Financing for ED
North (n=15)South (n=15) East (n=5) West (n=10)
North East
(n=14)
SFNSFNFSFNSFNFSFNSFNFSFNSFNFSFNSFNF
Central Govt Funds
for ED Services
0 3121 5 9 0 3 2 1 0 6 1 211
State Govt Funds
for ED Services
2 7 6 4 3 8 0 3 2 3 1 3 3 7 4
(* n= number of government hospitals in respective zones, ED= Emergency Department)
(**SF: Sufficient Funds, NSF: Not Sufficient Funds, NF: No Funds) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 94
Figure 42: Zone-wise ccomparison of Financing in Hospitals
C. Status of funds
It was observed that some hospitals received funds on time others did not received on time and
in most of the hospital’s funds are not fully utilized as depicted in the below table and figure.
Table 36: Overall Summary of Financial Status by Category of Hospitals
Financial Status
Medical
Colleges
(n=19)
Govt. hospitals
(>300 bed
strength)
(n=15)
Govt. hospitals
(<300 bed
strength)
(n=17)
Pvt. hospitals
(>300 bed
strength)
(n=10)
Pvt. hospitals
(<300 bed
strength)
(n=16)
Yes No Yes No Yes No Yes No Yes No
Full Utilisation
of Funds
8 10 6 9 6 11 1 9 4 9
Delay in Release
of Funds
5 14 4 11 2 15 0 10 2 14
(* n= number of government hospitals in respective zones) 95
Observations and Results with Suggestions
Figure 43: Overall Comparison of Financial Status by Hospital Categories
D. Funding Schemes
The studied hospitals received funds from central and state government under several funding
schemes. Most of the funding schemes cover trauma care services and other hospital services.
From the entire studied funding schemes, one major funding scheme was Ayushman Bharat. Out
of 100 hospitals, 66 hospitals received funds from either state or central government.
Figure 44: Funding Schemes by Category of Hospitals
E. Ayushman Bharat (PMJAY)
Ayushman Bharat provides coverage for 35 hospitals in both government and private sector out of
100 hospitals. It covers 8 medical college, 9 government hospitals (>300 beds), 12 government
hospitals (<300 beds), 4 private hospitals (>300 beds), and 2 private hospitals (<300 beds) as
shown in figure 45.
Figure 45: Comparison of Ayushman Bharat Scheme by Category of Hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 96
Suggestions:
1. Protected funding for emergency and injury care services and for establishment of
residency programme in emergency medicine, emergency nursing and EMT (Emergency
Medical Technician) course.
2. Integration and aggregation of financial schemes for emergency and injury care.
3. Cashless scheme- Increase Ayushman Bharat scheme for all red-triaged patients in all
hospitals.
20. PHYSICAL INFRASTRUCTURE
In hospitals, patients seek medical treatment and staff members provide continuous support by
creating a healing environment with the support of appropriate physical aspects. A healthy hospital
environmental is found to have an impact on the quick recovery of diseases.
In this study, consensus based tool was developed which includes a checklist for physical
infrastructure of Emergency Department. The observations of physical infrastructure are given in
the table 37and figure 46.
Table 37: Summary of Physical Infrastructure by Hospital Categories
Hospital
Category
Medical
Colleges
(n=20)
Govt. Hosp.
(>300 bed
strength)
(n=20)
Govt. Hosp.
(<300 bed
strength)
(n=20)
Pvt. Hosp.
(>300 bed
strength)
(n=20)
Pvt. Hosp.
(<300 bed
strength)
(n=20)
Physical
Infrastructure
55.5% 56% 53.5% 76% 74.5%
*n=number of hospitals
Figure 46: Comparison of Physical Infrastructure for Emergency Department by Category of Hospitals 97
Observations and Results with Suggestions
Out of 10 critical checklist points assessed for emergency department for all the hospitals, the
overall compliance was as follows:
Separate access for ambulance services (45%)
Designated area for ambulances (58%)
Demarcated triage area (35%)
Emergency department with adequate space (48%)
Dedicated minor OT (63%)
Point of care lab (26%)
Police control room (44%)
Smooth entry area with wheel chair, etc (63%)
Adequate waiting area (63%)
Safe drinking water (63%)
Other Standard for physical infrastructure emergency mainly defines the access to ER, parking, staff
service at doorstep, clinical services provided, facilities available, information display and facility
upkeep. The hospitals conformed to the parameters of easy and direct access to ER, designated
parking for ambulance, staff and public, but 37% hospitals parked vehicle in front of ER and 25%
hospitals showed partial compliance to this objective.
The hospitals (48%) showed compliance, 26% however partial compliance to parameter of
smooth entry to emergency like ramp for stretchers, canopy and availability of staff at entrance
to help patient with wheelchair and stretchers.
The patient care assistant of most government hospitals was found to attend only critical
and unattended patients from ambulances. The information board displaying services
being provided was found missing from 13% hospitals and 24% hospitals partially fulfilled
the requirement by exhibiting only partial information.
Similarly display of names of doctors and staff on duty, important telephone numbers along
with relevant information were found missing from most of the government hospitals. 51%
hospitals have adequate waiting area. Mostly hospitals had functional male and female
toilets but only 38% hospitals have functional toilets with wheel chair. Police post was
available in 56% of hospitals.
Out of 100 hospitals, 48 hospitals had designated emergency rooms, 29 hospitals did not
have proper designated emergency room and 23 hospitals did not have any emergency
room. Only 34 hospitals had demarcated area for triage.
Only 23 hospitals had isolation room in emergency. Similarly the point of care lab
was found in only 26 hospitals (6 medical colleges, 3 government hospital >300 beds, 1
government hospital <300 beds, 10 private hospitals >300 beds and 6 private hospitals <300
beds).
Out of 100 hospitals, no separate room was present for sexual assault victim in 64 hospitals,
no availability of forensic evidence kit for them in 58 hospitals and no counselling service
for sexual assault / domestic violence cases in 57 hospitals. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 98
Suggestions:
1. Uniformity of name (Emergency/Emergency Medicine Department) in every hospital
for emergency / casualty / injury care etc.
2. The capacity and capability of ED should be standardizing based on the tier of facility,
footfall of patients and academic programme.
3. Availability of either point of care lab or hospital lab (24*7) for emergency services
4. Adequate space for ambulance drop zone.
5. There should be demarcated triage area.
6. There should be ICU in each hospital.
21. MANPOWER IN EMERGENCY DEPARTMENT
In Emergency Department, manpower plays a very crucial role in providing care to the patients.
It was observed that emergency department did not have adequate manpower that’s why the
quality of care is compromised in most of the government hospitals.
The manpower in emergency was recorded and it was observed that many government hospitals
had very less manpower in emergency. The percentage of manpower was calculated as per the
footfall of patients in emergency department as well as per emergency beds available in hospitals.
Table 38: Summary of Manpower in Emergency Department Category of Hospitals
Hospital
Categories
Medical
Colleges
(n=20)
Govt. Hosp.
(>300 bed
strength)
(n=20)
Govt. Hosp.
(<300 bed
strength)
(n=20)
Pvt. Hosp.
(>300 bed
strength)
(n=20)
Pvt. Hosp.
(<300 bed
strength)
(n=20)
Doctors37 15 12 50
Nurses234 10 11
Technicians 166 11 17
Support Staff 34 10 14 22 99
Observations and Results with Suggestions
Table 39: Detailed Summary of Manpower in Emergency Department by Category
of Hospitals
Overall
Manpower in
Emergency
Medical
Colleges
(n=20)
Govt. Hosp.
(>300 bed
strength)
(n=20)
Govt. Hosp.
(<300 bed
strength)
(n=20)
Pvt. Hosp.
(>300 bed
strength)
(n=20)
Pvt. Hosp.
(<300 bed
strength)
(n=20)
Median [IQR]
Min-Max
% Per footfall of
100 patients in ED
Median [IQR]
Min-Max
% Per footfall of
100 patients in ED
Median [IQR]
Min-Max
% Per footfall of
100 patients in ED
Median [IQR]
Min-Max
% Per footfall of
100 patients in ED
Median [IQR]
Min-Max
% Per footfall of
100 patients in ED
Faculty /
Consultant
3 [3]
1-8
0.19
6 [7.7]
1-39
2.53
2 [3.7]
1-33
6.41
2 [2]
1-138
1.19
2 [4]
1-80
9.44
Casualty
Medical
Officer
5.5
[3.5]
1-20
0.23
5 [6.5]
1-16
0.46
2 [4.2]
1-12
1.27
4 [2]
1-13
1.80
2 [5]
1-9
1.71
Senior
Resident
8 [8]
2-20
0.43
7 [2.5]
3-18
1.57 0 0
1.5
[13]
1-30
1.50
3 [3]
1-20
6.79
Junior
Resident
9.5
[6.2]
2-24
0.81
7 [9.5]
2-30
1.10
1 [0]
1-1
0.39
4 [7]
1-167
2.72
5 [9]
2-26
14.47
Medical
Officer
4 [4]
1-51
0.23
4 [3.5]
3-9
0.51
6 [4]
1-8
3.09
4 [7.2]
1-11
2.40
2 [5]
1-18
3.76
Intern
6.5
[3.7]
2-18
0.69
5 [6]
2-40
0.97
12 [8]
4-20
4.34
4 [85]
3-100
2.24
22 [0]
22-22
13.47
Nursing
officer
Incharge
3 [2]
1-33
0.19
2 [1]
1-18
0.30
1 [1.7]
1-10
0.61
2 [2]
1-4
0.75
1 [2]
1-4
0.85
Staff Nurse
/ Nursing
officer
21
[11.5]
4-70
2.25
12 [9]
3-165
3.25
7 [6.2]
1-31
3.09
17.5
[24.7]
3-50
8.94
15
[5.7]
3-35
10.24
Radiology
Technician
4 [4]
1-4
0.32
3 [2]
1-6
1.79
1 [2]
1-4
0.55
3 [6]
1-18
0.72
2 [2]
1-10
4.14
Lab
Technician
3 [2]
1-18
0.20
3 [4]
2-12
1.29
3 [3.7]
1-12
2.28
9 [12]
1-31
2.67
3 [3]
1-12
5.52
OT
Technician
3 [5.5]
1-10
0.39
2 [0]
1-2
0.87
2 [1]
1-3
2.73
10 [3]
6-12
4.79
2 [2]
1-14
3.78
H.A. / G.D. A.
6.5
[8.2]
1-19
0.92
4 [0]
4-4
1.30
1 [0.5]
1-2
2.46
4.5 [2]
3-10
4.60
4 [4]
1-12
8.05 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 100
Housekeeping
Staff
12
[20.2]
2-60
0.57
3 [3]
1-20
1.20
3 [1.5]
1-4
3.72
7 [3.5]
2-152
4.08
7.5
[8.5]
3-20
3.27
EMT
6 [6.5]
2-27
0.46
3 [1]
1-30
1.67
3 [0.5]
1-16
0.65
6
[15.2]
2-55
2.60
5 [3.5]
1-30
3.67
Security
8.5
[10.5]
2-83
1.03
4 [5]
1-30
0.97
3 [2.7]
1-6
1.07
4 [3]
2-25
2.25
4 [3]
1-10
3.24
Registration
Staff
3 [3.5]
1-19
0.26
3 [3.5]
1-35
0.50
2 [2.5]
1-5
0.88
4.5
[3.7]
1-22
2.04
3 [1]
1-10
2.49
Any Other
4 [0]
4-4
0.33
1.5
[0.5]
1-2
0.13
4 [0]
4-4
1.52
3 [0]
3-3
0.78
4 [2]
2-6
4.70
(*n-number of hospitals, GDA- General Duty Assistant, SA- Sanitary Attendant, HA- Housekeeping Attendant)
Note: A total of 357 staff members including doctors were recorded for Civil Hospital,
Ahemdabad (Medical College) in ED.
21.1 Other Specialist / Super Specialist Available in Hospital
In this study, the number of specialist and super specialist were also recorded for the whole
healthcare facility. It was observed that the hospitals were having adequate number of specialist
and super specialist in the hospital (Annexure VI) but the number of doctors in the emergency
department was not enough.
The median of consultants as well as residents was found high in medical colleges during OPD
hours. Emergency department is manned by junior doctors for caring of the sickest patients even
though the hospitals had adequate specialists.
21.2 Discussion for Manpower in Emergency
Table 40 depicts the gaps in manpower present in emergency or emergency department for the
existing annual footfall. There are several gaps like, less number of available emergency beds
and manpower, to manage patients in emergency department. 101
Observations and Results with Suggestions
Table 40: Comparison of Emergency Cases and Manpower in categories of Hospitals
Healthcare
Facilites
Bed
Strength
Emergency and Injury Care Patients% of
Emergency
and injury
care Patients
(One Year)
% of
Emergency
and injury
care Patients
(One Day)
% of
Available
Emergency
Beds
nMedian IQR Min-Max
Medical
colleges
<500 15119461140435
3560-
477845
13% 17% 3%
Government
Hospitals
>300 1743001118984
876-
3088834
14% 11% 4%
Government
Hospitals
<300 1618738 35139
1560-
227364
15% 11% 4%
Private
Hospitals
>300 1720161 22118
3676-
103524
9% 10% 4%
Private
Hospitals
<300 1113800 4908
4800-
8778
12% 30% 5%
Suggestions:
1. Round the clock physical posting of Consultants/Faculty in emergency department for
providing quality acute care.
2. Rotatory posting of doctors and nursing students from different disciplines including
interns for a defined period in emergency under the administrative control of ED.
3. Creation of dedicated post of doctors, nurses and paramedics for emergency department.
4. Establish academic emergency medicine, emergency nursing and EMT.
5. Capacity building of emergency care providers.
22. EQUIPMENT AND SUPPLIES IN ED
22.1 Biomedical Equipment
It assesses the availability of the equipment in accordance with the scope of service, inventory
maintenance and periodic inspection & calibration of equipment. It was observed that the
equipments are available according to the available services in 69 hospitals and the inventory
and log books are maintained properly in 67 hospitals. The records of periodically inspection
and calibration were found in 66 hospitals out of 100 (Table 41). Figure 47 illustrates the above-
mentioned points by category of hospitals.
Table 41: Summary of Biomedical Equipment by Category of Hospitals
Biomedical
Equipment
List of equipments
according to available
services
Medical equipment
inventory and log book
Periodically inspected &
calibrated equipment Record
Yes696766
Partial202318
No6511 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 102
Figure 47: Compliance of Biomedical Equipment by Hospital Categories
It was observed that the equipments and supplies for ED were mostly present in private hospitals
in comparison with the government hospitals as shown in the figure 48.
22.2 Compliance of critical available equipments
It was observed that most of the hospitals had all resuscitation/airway management equipments
but basic items like cervical collar, pelvic binder and bed-sheets, broselow tape, fluid warmer
were missing from most of the hospitals. It was also observed that only 59% hospitals had mobile
resuscitation beds, 39% hospitals had transport ventilators, 43% had Laryngeal Mask Airway, 50%
hospitals had vaginal speculum, and only 24% hospitals had capnography.
In addition, 28% hospitals had incubators, 28% hospitals had emergency cricothyroidotomy kit,
25% hospitals had emergency thoracotomy set, 23% hospitals had emergency decompressive
craniotomy set, only 17% hospitals had emergency thrombectomy sets, and 25% hospitals had
phototherapy unit (table 42). 103
Observations and Results with Suggestions
Figure 48: Comparison of Equipments and Supplies present in ED by Category of Hospitals i) on the basis of
Percentage range ii) Ranking on the basis of Overall Performance
Table 42: Overall Summary of Equipments and Supplies list in ED for 100
Healthcare Facilities by Category
Equipments&
Supplies in ED
Medical
Colleges
(n=20)
Govt.
Hospitals
(>300 bed
strength)
(n=20)
Govt.
Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Mobile bed for
resuscitation
10 2 810 4 64 21417 1 219 0 1
Crash cart 12 5 311 5 411 5 417 2 119 0 1
Hard cervical
collar
9 0115 3123 01616 0 416 1 3
Oxygen supply
by pipeline
15 2 315 0 54 11519 1 018 0 2
Oxygen cylinder18 1 119 1 019 0 119 1 020 0 0
Suction machine16 3 019 1 018 1 118 2 020 0 0
Multipara
monitor
1512 413 1 69 4 718 1 118 1 1
Simple/transport
monitor
10 3 712 1 77 31016 1 319 0 1
Defibrillator 13 5 213 2 58 6 618 1 118 1 1
All types of
forceps
11 3 610 5 49 5 617 3 018 2 0
Transport
ventilator
7 1124 1152 21614 2 413 2 5
AMBU bag 17 2 115 5 016 2 218 2 017 1 1 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 104
Suprapubic
cathetor
8 4 84 1152 11714 1 513 0 7
Light source 10 1 912 2 612 2 616 1 318 1 1
Stethoscopoe 14 3 318 0 119 1 018 1 119 0 0
Oropharyngeal
airway blades
14 3 314 4 210 4 620 0 019 0 1
LMA (Lanryngeal
Mask Airway)
9 0113 2152 11615 0 514 0 6
Tourniquet 12 1 712 2 69 01116 1 319 0 0
Pelvic binder &
bed-sheets with
clips
6 4102 3154 11512 0 813 0 7
Needle holder
and suture
material
15 3 217 1 113 6 119 1 020 0 0
Vaginal speculum8 3 96 3109 3 813 2 514 0 5
Ryles tubes 13 6 113 7 013 6 119 1 018 0 2
Foley’s catheter13 5 213 7 012 7 119 1 018 0 2
Laryngoscope 14 6 015 4 112 5 319 1 018 1 1
Endotracheal
tubes
14 6 016 4 010 6 418 2 019 0 1
Chest tubes with
water seal drain
11 5 47 4 83 31418 1 116 1 3
Blood pressure
monitor
17 2 117 2 117 3 019 1 020 0 0
ECG machine 17 3 017 2 117 1 220 0 020 0 0
Ultrasonic
nebulizer
12 3 510 4 57 21115 2 318 0 2
IV cannula and
IV infusion sets
16 2 215 5 019 1 019 1 019 1 0
Syringes and
disposable
needles
17 2 119 1 020 0 020 0 019 1 0
Broselow tape 1 2160 1182 11611 0 910 010
Protoscope 14 1 58 1118 21016 1 315 0 5
Fluid Warmer 3 2153 0172 4147 21110 010
Dressing sets 6 4 017 2 111 5 419 1 020 0 0
Personal
protecting
equipments
11 8 114 4 210 7 218 2 018 1 1
Central line of all
sizes
9 3 82 5122 21616 3 117 1 2
Capnography 5 3122 1161 2178 3 99 110 105
Observations and Results with Suggestions
Infusion pump
and syringe
drivers
10 2 87 1125 11418 2 019 0 1
Spine board with
sling & scotch
tape all sizes
5 2136 2121 11713 0 716 0 4
Splints for all
fractures
9 8 3510 53 71014 3 315 3 2
Non-invasive
and invasive
ventilators
10 2 83 4133 21516 3 115 1 4
Incubators 9 2 72 1171 2178 3 99 2 9
Emergency
Cricothyroidotomy
kit
7 1122 1171 2178 21011 1 8
Emergency
Thoracotomy set
7 0132 1161 0198 1118 210
Emergency
Decompressive
craniotomy sets
7 1112 1171 0196 3118 210
Emergency
Thrombectomy
sets
4 0150 2180 0207 1126 211
Phototherapy
unit
9 2 71 1173 2155 3128 210
*n-number of hospitals, AMBU- Artificial Manual Breathing Unit, ECG- Electrocardiography, IV- Intravenous, ED-Emergency
Department
All hospital emergency departments should ensure 100% availability of all these equipments:
1. Airway equipments:
Laryngeal Mask Airway (43%)
Endotracheal tubes (76%)
AMBU bag (84%)
Transport ventilator (39%)
Laryngoscope (77%)
Oropharyngeal airway blades (75%)
Capnography (24%)
Emergency Cricothyroidotomy kit (28%)
Peak Expiratory Flow (16%)
2. Breathing equipments:
Emergency Thoracotomy set (25%)
Chest tube with seal drain (53%)
Ultrasonic nebulizer (61%)
Oxygen cylinder (93%)
Oxygen supply by pipeline (70%)
Suction machine (90%)
Non-invasive and invasive ventilator (45%) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 106
All hospital emergency departments should
ensure 100% availability of all these
equipments:
1. Airway equipments:
Laryngeal Mask Airway (43%)
Endotracheal tubes (76%)
AMBU bag (84%)
Transport ventilator (39%)
Laryngoscope (77%)
Oropharyngeal airway blades
(75%)
Capnography (24%)
Emergency Cricothyroidotomy kit
(28%)
Peak Expiratory Flow (16%)
2. Breathing equipments:
Emergency Thoracotomy set (25%)
Chest tube with seal drain (53%)
Ultrasonic nebulizer (61%)
Oxygen cylinder (93%)
Oxygen supply by pipeline (70%)
Suction machine (90%)
Non-invasive and invasive ventilator
(45%)
3. Circulation equipments:
Multipara monitor (68%)
Transport monitor (39%)
Pelvic binder or bed-sheets with clips
(37%)
Fluid warmer (25%)
Portable Ultrasound machine (36%)
Central line of all sizes (44%)
Infusion pumps and syringe driver
(58%)
Defibrillator (68%)
4. General equipments:
Mobile bed for resuscitation (59%)
Crash cart (70%)
ED blood storage (18%)
Hard cervical collar (48%)
Spine board with slings (40%)
5. Pediatric equipments:
Broselow tape (24%)
Phototherapy Unit (25%)
Incubators (28%)
Suggestions:
1. All essential equipments and supplies should be present in emergency department of
every hospital.
2. There should be dedicated staff for maintenance of equipments in emergency.
3. There should be dedicated training of staff regarding the maintenance of equipments
(how to use and maintain).
4. Maintain checklist of supplies and equipments, they should be checked before end of
every shift and beginning of every shift
5. Maintain a checklist of non-functional equipments and consumed supplies and should
be communicated during handovers 107
Observations and Results with Suggestions
23. POINT OF CARE LAB
Point of care lab for ED was observed in only 18 hospitals out of all 100 hospitals. Most of the
hospitals performed these tests in emergency labs:
1. Random blood sugar (74%)
2. Pregnancy test (56%)
3. Urinary ketones (49%)
4. Hemogram (46%)
5. Electrolyte (44%)
6. Blood urea & serum creatinine (44%)
Point of care lab and hospital labs did not perform the entire listed test of annexure-4 of study
tool. D-dimer, Pro-BNP, plasma ketones, toxicology screening-urinary, serum osmolality, urine
osmolality, TEG and PEF also did not performed by most of the hospitals as shown in table 43,
44 and figure 49.
Figure 49: Overall Compliance of Point of Care Lab for ED & Hospital
Best Practices for Point of Care Lab in ED: It was observed that only 2 hospitals performed
all types of laboratory investigations for emergency department; Ramakrishna Care hospital
and Primus Super Speciality Hospital. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 108
Table 43: Summary of Point of Care Lab by Category of Hospitals
Point of care lab in
ED
Medical Colleges
(n=20)
Govt. Hospitals
(>300 bed
strength)
(n=20)
Govt. Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Hemogram- Hb,
Hct, TLC, DLC,
Platelet
100 88 0 89 0109 3 7100 7
Random blood Sugar160 3130 4141 4170 2140 3
Coagulation profile:
PT, APTT, INR
3 0115 1106 0137 2 9100 7
Electrolytes: Na, K,
Cl,Ca
9 0107 0 97 111112 6100 7
Blood Urea & Serum
Creatinine
110 86 0 98 0118 3 7100 7
Blood Gas Analysis6 2116 1 91 117132 4110 6
Cardiac enzymes,
Trop-I, Trop-T
7 3 94 1115 014114 3110 6
Serum Amylase 7 1115 0102 2155 310100 7
D-Dimer1 1162 0131 0186 2109 0 8
Pro-BNP0 1172 0131 0184 212100 7
Urinary ketones 9 1 99 0 87 111122 5120 5
Plasma Ketones 1 1162 0130 0194 2127 010
Toxicology
Screening-Urinary
0 0180 0150 0190 2164 013
Serum osmolality 1 0173 0120 0193 2138 0 9
Urine osmolality 1 0172 0130 0193 2139 0 8
Pregnancy test 102 79 0 7130 6131 4110 6
Thromboelastogram
(TEG)
0 0190 0140 0191 2162 114
Peak Expiratory
Flowmeter
0 0190 1140 0196 111100 7
Microscopy: Thin &
Thick Smear
3 1136 0108 0117 2 9100 7
Rapid Diagnostic
Test (Malaria)
6 0125 1108 0117 2 9100 7
CSF: Microscopy &
Gram staining
4 1123 1112 1166 2109 0 8
Portable USG 4 1123 1110 118151 4140 4
Echocardiography 7 0104 1112 017132 4131 4
Portable X ray 111 77 1 73 412171 2132 3
CT Scan 100 77 0 83 0148 3 8100 7
*n-number of hospitals, ED-Emergency Department, Hb- Hemoglobin , Hct- Hematocrit, TLC- Total Leukocyte Count,
DLC- Differential Leukocyte Count, PT- Prothrombin Time, APTT- Activated partial thromboplastin time, INR- International
Normalized Ratio, BNP- Brain Natriuretic Peptide, USG- Ultrasonography, CT- Computerized Tomography 109
Observations and Results with Suggestions
Table 44: Overall Summary of Hospital labs by Category of Hospitals
Hospital Labs
Medical Colleges
(n=20)
Govt. Hospitals
(>300 bed
strength)
(n=20)
Govt. Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
YesPartialNoYesPartialNoYesPartialNoYesPartialNoYesPartialNo
Hemogram- Hb,
Hct, TLC, DLC,
Platelet
190 1190 0190 0160 1150 0
Random blood Sugar170 2170 2180 1150 2140 1
Coagulation profile:
PT, APTT, INR
170 3132 4110 8180 0150 0
Electrolytes: Na, K,
Cl,Ca
170 2170 2150 4170 0150 0
Blood Urea & Serum
Creatinine
190 0181 0170 2170 0150 0
Blood Gas Analysis121 6101 81 117160 1140 1
Cardiac enzymes,
Trop-I, Trop-T
114 49 4 66 013170 1140 1
Serum Amylase 161 2121 56 112170 1150 0
D-Dimer 100104 0141 018151 2140 1
Pro-BNP8 0124 0141 018141 3140 1
Urinary ketones 142 3160 3141 4170 0140 1
Plasma Ketones 101 96 1112 017130 5110 4
Toxicology
Screening-Urinary
7 1122 0161 018111 66 1 9
Serum osmolality 8 1115 0131 018150 3140 1
Urine osmolality 8 2108 0101 117150 3150 0
Pregnancy test 180 1170 2180 1170 1140 1
Thromboelastogram
(TEG)
3 0161 0161 0189 0 84 011
Peak Expiratory
Flowmeter
4 1145 0132 017150 39 0 6
Microscopy: Thin &
Thick Smear
181 1181 0162 1180 0150 0
Rapid Diagnostic
Test (Malaria)
160 3181 0170 2180 0140 1
CSF: Microscopy &
Gram staining
142 4131 44 213180 0140 1
Portable USG 132 57 1102 116131 2120 3
Echocardiography 181 19 1 92 116161 0140 1
Portable X ray 142 2103 54 6 9150 1140 1
CT Scan 161 1100 86 011170 0130 2
*n-number of hospitals, ED-Emergency Department, Hb- Hemoglobin, Hct- Hematocrit, TLC- Total Leukocyte Count,
DLC- Differential Leukocyte Count, PT- Prothrombin Time, APTT- Activated partial thromboplastin time, INR- International
Normalized Ratio, BNP- Brain Natriuretic Peptide, USG- Ultrasonography, CT- Computerized Tomography Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 110
Figure 50: Comparison of Point of Care Lab for ED & for Hospital on % basis of compliance 111
Observations and Results with Suggestions
Suggestions:
All healthcare facilities should have either basic point of care lab in emergency department or
emergency lab in hospital for 24*7
24. ESSENTIAL MEDICINES FOR EMERGENCY
Out of 100 hospitals only 9 hospitals had all essential medicines required at emergency
department. In addition, it was found that only 11 hospitals had essential medicines used in
resuscitation out of all 100 hospitals.
Most of the hospitals did not have essential drugs used for emergency. The checklist contains
101 essential medicines required in emergency department. Out of these 101 medicines, 30
medicines are categorized as resuscitation medicines (medicines used in resuscitation).
We had calculated the percentages of all essential equipment and medicines. The availability of
essential medicines was calculated on three different scales: 50% or less (Score-0), 50% to 99%
(Score-1), and 100% (Score-2).
For resuscitation medicines, the scoring was based on two scales: the score was zero if even
one drug was missing from list (Score 0) and the score was two if all 30 medicines were present
(Score-2). Resuscitation drugs should be must in all hospitals.
Essential Medicines: The medicines that “satisfy the priority health care
needs of the population”. These are the medications to which people
should have access at all times in sufficient amounts. (WHO)
Resuscitation Medicines (n=30): The medicines
which are used during resuscitation process.
Resuscitation Medicine Package: It is a package
of 30 medicines. Even if one drug is deficient at
time of assessment, the score is zero.
Other essential
medicines (n=71):
The essential
medicines other
than resuscitation
medicines included in
this category
Only 2
medical
colleges have
complete
package of
resuscitation
medicines
None of the
government
hospitals have
complete
package of
resuscitation
medicines
9 private
hospitals have
complete
package of
resuscitation
medicines
9 private hospitals
have complete
package of
resuscitation
medicines
Figure 51: Chart of Essential medicines for Hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 112
Most of the hospitals did not have essential drugs used for emergency especially in government
hospitals when compared to the private ones. Not all private hospitals had all the enlisted drugs
for emergency as in annexure (figure 51).
Table 45: Overall Summary of Essential Medicines for Emergency:
Essential Medicines/
Drugs for Emergency
Medical
Colleges
(N=20)
Govt. Hosp.
(>300 bed
strength)
(N=20)
Govt. Hosp.
(<300 bed
strength)
(N=20)
Pvt. Hosp.
(>300 bed
strength)
(N=20)
Pvt. Hosp.
(<300 bed
strength)
(N=20)
Resuscitation Drugs 2 (10%) 0 (0%) 0 (0%) 3 (15%) 6 (30%)
Other Essential Drugs 72% 71% 63% 86% 87%
Only 2 medical colleges (Government Medical College, Thiruvanananthapuram and AIIMS, Bhopal)
had complete package of resuscitation drugs, other than these none of the government hospitals
had complete package of resuscitation drugs out of 60 hospitals.
For private hospitals >300 beds, 3 hospitals (Grant Medical Foundation Ruby Hall Clinic,
Pune; Kasturi Medical College & Hospital and Fortis Hospital, Jaipur) had complete package of
resuscitation drugs.
For private hospitals >300 beds, 6 hospitals (Bhailal Amin General Hospital; Birla CK Hospital,
Jaipur; Charak Hospital & Research Centre, Lucknow; Ruban Memorial Hospital; Ramakrishna
Care Hospital and Primus Super Speciality Hospital) had complete package of resuscitation drugs.
Figure 52: Comparison of Essential Medicines for Emergency by Category of Hospitals i) on the basis of Percentage
range ii) on the basis of Overall Performance/Compliance
Overall the small private hospitals performed best out of the 5 category of hospitals. Only 2
medical colleges have all essential medicines out of all 60 government hospitals. 113
Observations and Results with Suggestions
Suggestions:
1. Complete package of resuscitation medicines should be present in all hospitals for 24*7
2. Other essential medicines should also be present in all hospitals for 24*7
3. During third party audits, if any essential drug is missing from the resuscitation package
then the license of the hospital may be cancelled
Best Practices for Essential Medicines in ED
100% compliance was observed in following hospitals for essential medicines which
are required for emergency department:
Medical College: AIIMS, Bhopal, Government Medical College,
Thiruvanananthapuram
Private Hospital: Grant Medical Foundation Ruby Hall Clinic, Kasturi Medical
College & Hospital, Fortis Hospital, Jaipur, Birla CK Hospital, Ruban Memorial
Hospital, Ramakrishna Care Hospital, and Primus Super Speciality Hospital Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 114
II. LIVE OBSERVATION
1. DISPOSITION TIME
The time from entry of patient at emergency department to admission/transfer-out/discharge is
disposition time.
Ideally for time sensitive conditions (STEMI, stroke, trauma, cardiac arrest), patients should be
immediately seen after arrival in emergency department. For red triage, patient should be seen
within 10 min; for yellow triage, patient should be seen within 30 min and for green triage,
patient should be seen within 4 hours after arrival in emergency.
Ideal disposition time for red triage patients should be within 6 hours, for yellow triage patients
should be within 12 hours.
Table 46: Summary of Disposition Time of Patients Visited in Emergency Department
Disposition time
(in minutes)
Medical
Colleges
(n=20)
Govt. Hospitals
(>300 bed
strength)
(n=20)
Govt. Hospitals
(<300 bed
strength)
(n=20)
Pvt. Hospitals
(>300 bed
strength)
(n=20)
Pvt. Hospitals
(<300 bed
strength)
(n=20)
Red triaged
patients
90 [686]
7-4680
30 [44]
5-1440
17 [31]
5-60
45 [102]
6-240
15 [20]
5-48
Yellow triaged
patients
200 [307]
12-1440
90 [315]
10-3060
120 [121]
8-360
120 [210]
7-1920
30 [63]
10-225
Green triaged
patients
60 [214]
6-1450
45 [145]
1-720
46 [188]
10-900
75 [91]
4-575
32 [162]
7-420
*n-number of hospitals, Median [IQR] Min-Max
Figure 53: Chart of Disposition time of Patients by Hospitals Category 115
Observations and Results with Suggestions
The disposition time of red triaged patients was high in medical colleges with median of 90
minutes and low in private hospitals (<300 beds) with median of 15 minutes.
For yellow triaged patients the disposition time was high in medical college with median of 200
minutes and low in private hospitals (<300 beds) with median of 30 minutes.
Similarly, for green triaged patients it was high in private hospitals (>300 beds) with a median
of 75 minutes and low in private hospitals (<300 beds) with median of 32 minutes.
The disposition time of red triaged patients was high in medical college. It was due to various
factors observed as such:
1. Lack of emergency care provider
2. High patient load
3. Need of multi-speciality reviews
4. Multiple investigations being conducted
5. Lack of dedicated department leads todelayed decision making from definitive care/
disposal
6. Not availability of buffer beds for addressing surge capacity under emergency department
7. Mismatch between available emergency beds and patient load and manpower
8. Not availability of triage policy in most of the hospitals
Figure 54: Comparison of Disposal Time of Patients visited in Emergency by Hospital Category
Suggestions:
1. Implementation of triage policy in all hospitals (Prioritization of patient)
2. Adequate manpower should be present in hospitals as per footfall of patients and
emergency beds
3. Optimum utilization of resources
4. There should be a dedicated emergency nurse coordination (ENC) system
5. Empowered hospital committee comprising of members of emergency department and
allied medical and surgical speciality to address the issues and challenges pertaining to
emergency department Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 116
2. CHEST PAIN
A. Hospital-wise comparison:
In this study, a total of 201 patients of chest pain were observed by our assessor’s team from all
zones and categories of our country.
Percutaneous coronary intervention (PCI) is a non-surgical procedure used to treat narrowing
(stenosis) of the coronary arteries of the heart found in coronary artery disease. PCI is also used
in people after other forms of myocardial infarction or unstable angina where there is a high risk
of further events.
Firstly, 53% hospitals did not have triage. Secondly, ECG was not performed within 10 min in
30% hospitals. Some hospitals don’t even have ECG machine. Thirdly, Door to needle was not
performed 54% hospitals within 30 minutes. Lastly, Door to PCI was also absent in 68% hospitals.
Figure 55: Overall Comparison of Chest Pain Management by Category of Hospitals
*N=Number of red patients of chest pain, 65 patients were observed from 20 Medical Colleges, 33 patients were observed
from 20 Govt. Hosp. (>300 bed strength), 34 patients were observed from 20 Govt. Hosp. (<300 bed strength), 44 patients
were observed from 20 Pvt. Hosp. (>300 bed strength) and 25 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
The management of chest pain was observed best in the private hospitals (<300 beds) among
all the categories of healthcare facilities as shown in table 47 and figure 55. Overall door to PCI
was not done in most of the hospitals. 117
Observations and Results with Suggestions
Table 47: Summary of Chest Pain Management by Category of Hospitals: N (%)
Chest Pain
Management
Medical
Colleges
(N=65 Pts)
Govt. Hosp.
(>300 bed
strength)
(N=33 Pts)
Govt. Hosp.
(<300 bed
strength)
(N=34 Pts)
Pvt. Hosp.
(>300 bed
strength)
(N=44 Pts)
Pvt. Hosp.
(<300 bed
strength)
(N=25 Pts)
Yes No Yes No Yes No Yes No Yes No
Triage
22
(34)
43
(66)
14
(42)
19
(58)
7 (21)
27
(79)
28
(64)
16
(36)
24
(96)
1 (4)
Door to ECG
(<10 min)
37
(59)
26
(41)
23
(70)
10
(30)
16
(48)
17
(52)
39
(89)
5 (11)
24
(96)
1 (4)
Door to Needle
(<30 min)
17
(42)
23
(58)
8 (36)
14
(64)
1 (5)
20
(95)
16
(57)
12
(43)
18
(90)
2 (10)
Door to PCI
(<90 min)
6 (27)
16
(73)
5 (29)
12
(71)
0 (0)
16
(100)
11
(38)
18
(62)
10
(67)
5 (33)
*N=Number of red patients of chest pain, 65 patients were observed from 20 Medical Colleges, 33 patients were observed
from 20 Govt. Hosp. (>300 bed strength), 34 patients were observed from 20 Govt. Hosp. (<300 bed strength), 44 patients
were observed from 20 Pvt. Hosp. (>300 bed strength) and 25 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
Figure 56: Chart of Chest Pain Management of patients by Category of Hospitals
B. Zone-wise comparison
In addition, it was observed that the east zone performed best and the north zone performed
worst out of all zones.
In the east zone, 35 patients of chest pain had observed in 11 different hospitals and 17 patients
managed within the timeframe.
Similarly, 47 patients of chest pain had observed in 11 different hospitals of north zone and only
3 patients managed within the timeframe. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 118
Table 48: Zone-wise Summary of Chest Pain Management in Hospitals: N (%)
Chest Pain
Management
North (N=47
Pts.)
South (N=48
Pts.)
East (N=35
Pts.)
West (N=44
Pts.)
North East
(N=27 Pts.)
Yes No Yes No Yes No Yes No Yes No
Triage
16
(34)
31
(66)
17
(35)
31 (65)
25
(71)
10
(29)
27
(61)
17
(39)
10
(37)
17
(63)
Door to ECG
(<10 min)
34
(72)
13
(28)
26
(55)
21(45)
26
(76)
8 (24)
38
(88)
5 (12)
15
(56)
12
(44)
Door to
Needle (<30
min)
9 (32)
19
(68)
14
(33)
28 (67)
17
(74)
6 (26)
13
(57)
10
(43)
7 (47)8 (53)
Door to PCI
(<90 min)
3 (14)
18
(86)
8 (20)32 (80)
17
(74)
6 (26)3 (75)1 (25)1 (9)
10
(91)
*N=Number of red patients of chest pain, 47 patients were observed from 30 hospitals of north zone, 48 patients were
observed from 21 hospitals of south zone, 35 patients were observed from 11 hospitals of east zone, 44 patients were observed
from 16 hospitals of west zone and 27 patients were observed from 22 hospitals of north-east zone
Figure 57: Zone-wise Comparison of Chest Pain Management in Hospitals
*N=Number of red patients of chest pain, 47 patients were observed from 30 hospitals of north zone, 48 patients were
observed from 21 hospitals of south zone, 35 patients were observed from 11 hospitals of east zone, 44 patients were observed
from 16 hospitals of west zone and 27 patients were observed from 22 hospitals of north-east zone 119
Observations and Results with Suggestions
C. NABH Accreditation-wise comparison:
Also, it was observed that NABH accredited hospitals performed better than non-NABH accredited
hospitals for management of chest pain (table 49 and figure 58).
Table 49: Overall Summary of Chest Pain Management in NABH accredited and
non-NABH accredited hospitals: N (%)
Chest Pain Management
NABH Accredited Hospitals
(Pt.= 49)
Non-NABH Accredited Hospitals
(Pt.= 152)
YesNoYesNo
Triage38 (78) 11 (22) 57 (37) 95 (63)
Door to ECG (<10 min) 44 (90) 5 (10) 95 (64) 54 (36)
Door to Needle (<30 min) 22 (69) 10 (31) 38 (38) 61 (62)
Door to PCI (<90 min) 16 (52) 15 (48) 16 (24) 52 (76)
Figure 58: Overall Comparison of Chest Pain Management in NABH accredited and non-NABH accredited hospitals
Factors affecting Chest Pain Management:
1. Lack of manpower (such as ECG technician)
2. Lack of training
3. Lack of supplies (such as ECG machine)
4. Lack of infrastructure
5. Lack of policy
Suggestions for Management of Chest pain:
1. Upgrade them for thrombolysis.
2. Adequately trained emergency care provider.
3. All district hospitals must have ECG machine and technician.
4. Establish Tele-ECG and Tele-Medicine programme.
5. Resuscitate patient in district hospital and refer them to other higher government hospital.
6. Develop a STEMI Programme by Hub and Spoke Model (figure 59)
7. Develop PCI centres in multi-speciality hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 120
Figure 59: Hub and Spoke model for Thrombolysis near home – STEMI
Requirements for STEMI Hub and Spoke Model:
1. MOU (Memorandum of Understanding) with Local Government
2. Training
3. Supplies
4. Consent of patient
5. Governance
6. Budget Allocation
7. Cashless care in all hospitals for red triaged patients
Best practice in District Hospitals for Thrombolysis
1. District Hospital, Baramulla, J&K
2. North Goa District Hospital, Goa
3. Jai Prakash Narayan District Hospital, Bhopal
4. Southern Railway Hospital, Madras
3. STROKE
A stroke is a medical condition in which poor blood flow to the brain results in cell death. There
are two main types of stroke: ischemic, due to lack of blood flow, and haemorrhagic, due to
bleeding. Both result in parts of the brain not functioning properly. 121
Observations and Results with Suggestions
A. Hospital-wise comparison
The management of stroke was observed best in the small private hospitals and worst observed in
small government hospitals among all the categories of healthcare facilities due to lack of facilities
as shown in table 50 and figure 60.
Figure 60: Comparison of Stroke Management by Category of Hospitals
*N=Number of red patients of stroke, 50 patients were observed from 20 Medical Colleges, 17 patients were observed from
20 Govt. Hosp. (>300 bed strength), 14 patients were observed from 20 Govt. Hosp. (<300 bed strength), 25 patients were
observed from 20 Pvt. Hosp. (>300 bed strength) and 20 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
The management of stroke was also not observed well in district hospitals due to lack of
thrombolysis and CT scan machine.
Door to Doctor was achieved within 10 minutes in 79% hospitals. But Door to CT completion
was not performed within 25 minutes in 47% hospitals. Door to CT reading was not achieved
within 45 minutes in 52% hospitals. Door to thrombolysis was absent in 74% hospitals as shown
in figure 61. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 122
Table 50: Summary of Stroke Management by Category of Hospitals: N (%)
Stroke
Management
Medical
Colleges
(N=50 Pts)
Govt. hospitals
(>300 bed
strength)
(N=17 Pts)
Govt. hospitals
(<300 bed
strength)
(N=14 Pts)
Pvt. hospitals
(>300 bed
strength)
(N=25 Pts)
Pvt. hospitals
(<300 bed
strength)
(N=20 Pts)
Yes No Yes No Yes No Yes No Yes No
Door to Doctor
(<10 min)
38
(76)
12
(24)
15
(88)
2 (12)9 (64)5 (36)
20
(80)
5 (20)
18
(90)
2 (10)
Door to CT
Completion
(<25 min)
16
(34)
31
(66)
10
(63)
6 (37)1 (8)
12
(92)
19
(76)
6 (24)
17
(89)
2 (11)
Door to CT
reading
(<45 min)
15
(31)
33
(69)
10
(63)
6 (37)1 (8)
12
(92)
15
(60)
10
(40)
17
(94)
1 (6)
Door to
Thrombolytic
(<60 min)
6 (16)
32
(84)
6 (40)9 (60)0 (0)
9
(100)
7 (33)
14
(67)
6 (50)6 (50)
Door to First
Pass (<90 min)
6 (23)
20
(77)
6 (50)6 (50)1 (10)9 (90)5 (31)
11
(69)
8 (73)3 (27)
*N=Number of red patients of stroke, 50 patients were observed from 20 Medical Colleges, 17 patients were observed from
20 Govt. Hosp. (>300 bed strength), 14 patients were observed from 20 Govt. Hosp. (<300 bed strength), 25 patients were
observed from 20 Pvt. Hosp. (>300 bed strength) and 20 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
Figure 61: Chart of Stroke Management of patients by Hospital Category
B. Zone-wise comparison
In addition, it was observed that the east zone performed best and the north zone performed
worst out of all zones (table 51 and figure 62). 123
Observations and Results with Suggestions
Table 51: Zone-wise Summary of Stroke Management in Hospitals: N (%)
Stroke
Management
North (N=19
Pts.)
South (N=43
Pts.)
East (N=24
Pts.)
West (N=16
Pts.)
North East
(N=24 Pts.)
Yes No Yes No Yes No Yes No Yes No
Door to Doctor
(<10 min)
18
(95)
1 (5)
33
(77)
10
(23)
18
(75)
6 (25)
11
(69)
5 (31)
20
(83)
4 (17
Door to CT
Completion
(<25 min)
9 (47)
10
(53)
22
(51)
21
(49)
17
(71)
7 (29)6 (46)7 (54)9 (42)
12
(57)
Door to CT
reading (<45
min)
6 (33)
12
(67)
23
(53)
20
(47)
18
(75)
6 (25)6 (46)7 (54)5 (23)
17
(77)
Door to
Thrombolytic
(<60 min)
3 (27)8 (73)6 (15)
34
(85
16
(73)
6 (27)0 (0)
6
(100)
0 (0)
16
(100)
Door to First Pass
(<90 min)
3 (30)7 (70)7 (22)
25
(78)
15
(71)
6 (29)0 (0)
4
(100)
1 (13)7 (87)
*N=Number of red patients of stroke, 19 patients were observed from 30 hospitals of north zone, 43 patients were observed
from 21 hospitals of south zone, 24 patients were observed from 11 hospitals of east zone, 16 patients were observed from
16 hospitals of west zone and 24 patients were observed from 22 hospitals of north-east zone
Figure 62: Zone-wise Comparison of Stroke Management in Hospitals
*N=Number of red patients of stroke, 19 patients were observed from 30 hospitals of north zone, 43 patients were observed
from 21 hospitals of south zone, 24 patients were observed from 11 hospitals of east zone, 16 patients were observed from
16 hospitals of west zone and 24 patients were observed from 22 hospitals of north-east zone Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 124
C. NABH Accreditation-wise comparison
Also, it was observed that NABH accredited hospitals performed better than non-NABH accredited
hospitals for management of stroke (table 52 and figure 63).
Table 52: Overall Summary of Stroke Management in NABH accredited and non-
NABH accredited hospitals: N (%)
Stroke Management
NABH Accredited Hospitals (N=28)
(Pts.= 31)
Non-NABH Accredited Hospitals
(N=72) (Pts.= 95)
YesNoYesNo
Door to Doctor
(<10 min)
24 77% 7 23% 76 80% 19 20%
Door to CT Completion
(<25 min)
23 77% 7 23% 40 44% 50 56%
Door to CT reading
(<45 min)
23 79% 6 31% 35 38% 56 62%
Door to Thrombolytic
(<60 min)
10 43% 13 57% 15 21% 57 79%
Door to First Pass
(<90 min)
10 56% 8 44% 16 28% 41 72%
Figure 63: Overall Summary of Stroke Management in NABH accredited and non-NABH accredited hospitals
Factors affecting Stroke Management:
1. Lack of manpower
2. Lack of training
3. Lack of supplies (such as CT Scan machine)
4. Lack of infrastructure
5. Lack of policy
Best Practice for CT Scan in District Hospitals:
!District Hospital, Tenali
!Deen Dayal Upadhyay Hospital, Shimla
!Morigaon Civil Hospital, Assam 125
Observations and Results with Suggestions
Suggestions:
1. Thrombolysis near home – Hub and Spoke Model (figure 59)
2. Develop Tele-stroke programme
3. Stroke management by PPP (Public-Private Partnership) model in district hospitals
4. TRAUMA
A. Hospital-wise comparison
It was observed that trauma management was good in private hospitals when compared to the
government ones as shown in table 53and figure64, because the disposal of patients was delayed
in government hospitals.
Table 53: Summary of Trauma Management by Category of Hospitals: N (%)
Trauma Management
Medical
Colleges
(N=57 Pts)
Govt.
hospitals
(>300 bed
strength)
(N=30 Pts)
Govt.
hospitals
(<300 bed
strength)
(N=21 Pts)
Pvt. hospitals
(>300 bed
strength)
(N=24 Pts)
Pvt. hospitals
(<300 bed
strength)
(N=12 Pts)
Yes No Yes No Yes No Yes No Yes No
Door to Resuscitation time
(<15 min)
34
(60)
23
(40)
20
(67)
10
(33)
9 (43)
12
(57)
19
(73)
5 (21)
12
(100)
0 (0)
Door to CT Completion
time in Head Injury
(<45 min)
26
(50)
26
(50)
9 (31)
20
(69)
2 (11)
16
(89)
11
(69)
5 (31)
10
(83)
2 (17)
Disposal Time (in minutes)185 150 60 62 30
*N=Number of red patients of trauma, 57 patients were observed from 20 Medical Colleges, 30 patients were observed from
20 Govt. Hosp. (>300 bed strength), 21 patients were observed from 20 Govt. Hosp. (<300 bed strength), 24 patients were
observed from 20 Pvt. Hosp. (>300 bed strength) and 12 patients were observed from 20 Pvt. Hosp. (<300 bed strength)
Figure 64: Comparison of Trauma Management by Hospital Categories
*N=Number of red patients of trauma, 57 patients were observed from 20 Medical Colleges, 30 patients were observed from
20 Govt. Hosp. (>300 bed strength), 21 patients were observed from 20 Govt. Hosp. (<300 bed strength), 24 patients were
observed from 20 Pvt. Hosp. (>300 bed strength) and 12 patients were observed from 20 Pvt. Hosp. (<300 bed strength) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 126
B. Zone-wise comparison
Table 54: Zone-wise Summary of Trauma Management in Hospitals: N(%)
Trauma Management
North (N=43
Pts.)
South (N=42
Pts.)
East (N=16
Pts.)
West (N=26
Pts.)
North East
(N=17 Pts.)
Yes No Yes No Yes No Yes No Yes No
Door to Resuscitation
time (<15 min)
26
(60)
17
(40)
25
(60)
17
(40)
15
(94)
1 (6)
20
(77)
6
(23)
8
(47)
9 (53)
Door to CT
Completion time in
Head Injury (<45
min)
11
(30)
26
(70)
20
(49)
21
(51)
11
(79)
3
(21)
13
(62)
8
(38)
3
(21)
11
(79)
Disposal Time
(in minutes)
498 635 — 103 110
*N=Number of red patients of trauma, 43 patients were observed from 30 hospitals of north zone, 42 patients were observed
from 21 hospitals of south zone, 16 patients were observed from 11 hospitals of east zone, 26 patients were observed from 16
hospitals of west zone and 17 patients were observed from 22 hospitals of north-east zone.
Figure 65: Zone-wise Comparison of Trauma Management in Hospitals
*N=Number of red patients of trauma, 43 patients were observed from 30 hospitals of north zone, 42 patients were observed
from 21 hospitals of south zone, 16 patients were observed from 11 hospitals of east zone, 26 patients were observed from 16
hospitals of west zone and 17 patients were observed from 22 hospitals of north-east zone. 127
Observations and Results with Suggestions
C. NABH Accreditation comparison:
Table 55: Summary of Trauma Management in NABH accredited and non-NABH
accredited hospitals
Trauma Management
NABH Accredited Hospitals (N=28)
(Pt.= 37)
Non-NABH Accredited Hospitals
(N=72) (Pt.= 107)
YesNoYesNo
Door to Resuscitation time
(<15 min)
29 78% 8 22% 65 61% 42 39%
Door to CT Completion
time in Head Injury
(<45 min)
17 63% 1 37% 41 41% 59 59%
Disposal Time (in minutes)74395
Figure 66: Comparison of Trauma Management in NABH accredited and non-NABH accredited hospitals
Best Practice for CT Scan in District Hospitals:
1. District Hospital, Tenali
2. Deen Dayal Upadhyay Hospital, Shimla
3. HNB Base Hospital, Shimla
Factors affecting Trauma management:
1. Lack of staff
2. Lack of policy
3. Lack of training
4. Lack of resources (such as CT Scan machine)
Suggestions:
1. Adequate staff
2. Training
3. NABH Accreditation Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 128
5. INCIDENCE OF VIOLENCE
During assessment, incidence of violence was observed in the hospital and assessors noted the
observation in the given study tool. In the given table 56 and figure 67 the ratio of incidence of
violence is shown by category of hospitals.
Table 56: Summary of incidence of Violence by Hospital Categories: N (%)
Live
Observation
Medical
Colleges
(n=15)
Govt. hospitals
(>300 bed
strength)
(n=17)
Govt. hospitals
(<300 bed
strength)
(n=18)
Pvt. hospitals
(>300 bed
strength)
(n=18)
Pvt. hospitals
(<300 bed
strength)
(n=16)
Yes No Yes No Yes No Yes No Yes No
Incidence of
Violence
7 (47)8 (53)6 (35)
11
(65)
8 (44)
10
(56)
4 (22)
14
(78)
5 (31)11 (69)
Figure 67: Representation of Incidence of Violence Observed by Category of Hospitals
5.1 Reason of Violence
It was also observed during live observation about the reason of violence incident in hospitals.
The reason of violence was found either communication failure or care delay.
Figure 68: Representation of the reason of Violence by Category of Hospitals 129
Observations and Results with Suggestions
5.2 Mitigation measures
Mitigation measures were also recorded like availability of security guard in hospital, availability
of police in hospital and availability of anti-violence mitigation policy.
Table 57: Summary of Mitigation measures available by Category of Hospitals: N (%)
Mitigation
measures
Medical
Colleges
(N=20)
Govt. hospitals
(>300 bed
strength)
(N=20)
Govt. hospitals
(<300 bed
strength)
(N=20)
Pvt. hospitals
(>300 bed
strength)
(N=20)
Pvt. hospitals
(<300 bed
strength)
(N=20)
Yes No Yes No Yes No Yes No Yes No
Private security
guard
12
(86)
2 (14)8 (53)7 (47)
10
(63)
6 (37)
15
(94)
1 (6)
13
(87)
2 (13)
Private Security
Guard 24*7
10
(91)
1 (9)8 (80)2 (20)4 (43)3 (57)14 (0)
2
(100)
9 (18)2 (82)
Police Available
13
(93)
1 (7)9 (60)6 (40)7 (47)8 (53)4 (29)
10
(71)
7 (54)6 (46)
Police Available
Guard 24*7
11
(32)
1 (8)7 (78)2 (22)5 (63)3 (37)5 (56)4 (44)4 (50)4 (50)
Anti-violence
mitigation policy
available
6 (46)7 (54)1 (8)
11
(92)
2 (15)
11
(85)
7 (64)4 (36)9 (64)5 (36)
Figure 69: Representation of Mitigation measures available by Category of Hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 130
6. COMMUNICATION SKILLS IN EMERGENCY DEPARTMENT
During/after treatment of any patient, the health care provider/staff/nurses communicate with the
patient/patient attendant/relative to inform them about the condition of patient. It was observed
that sometimes the health care provider/staff/nurses did not communicate properly with the
patient/patient attendant/relative.
For knowing the way of communication, assessor’s team observed the communication between
hospital staff and patient during live observation and the summary of communication skills is
shown in table 58 and figure 70.
Table 58: Summary of Communication Skills in Emergency Department by
Category of Hospitals: N(%)
Communication Skills in ED
Medical
Colleges
(n=20)
Govt.
hospitals
(>300 bed
strength)
(n=20)
Govt.
hospitals
(<300 bed
strength)
(n=20)
Pvt.
hospitals
(>300 bed
strength)
(n=20)
Pvt.
hospitals
(<300 bed
strength)
(n=20)
Full content with empathy and
share decision making
7 (44) 9 (50) 8 (47) 16 (89) 13 (93)
Full content with empathy and
no share decision making
2 (13) 4 (22) 6 (35) 2 (11) 0 (0)
Full content with no empathy 3 (19) 5 (28) 1 (6) 0 (0) 1 (7)
Minimal Communication and
inappropriate behaviour
4 (25) 0 (0) 2 (12) 0 (0) 0 (0)
*n- number of hospitals
Figure 70: Representation of Communication Skills in Emergency Department of Hospital Category
Suggestions:
1. Create a cadre of emergency nurse coordinator (ENC) from the existing pool of nursing
officers with defined roles and responsibility.
2. Training of staff on communication skills from under-graduate level (for doctors, nurses
and paramedics).
3. Establish a concept of shared decision making. 131
Observations and Results with Suggestions
7. PATIENT SATISFACTION
During live observation by assessor’s team for 24 hours, 3-5 random patients from each triage
category (red, yellow and green) were asked few questions about the care (in terms of satisfaction)
provided in the hospital.
Table 59: Summary of Patient Satisfaction by Category of N(%) Hospitals N(%)
Patient
Satisfaction
Medical
Colleges (n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
Red
Triage
Yellow
Triage
Green
triage
Red
Triage
Yellow
Triage
Green
triage
Red
Triage
Yellow
Triage
Green
triage
Red
Triage
Yellow
Triage
Green
triage
Red
Triage
Yellow
Triage
Green
triage
Extremely
satisfied
1 (6)1 (7)0 (0)3 (21)2 (13)3 (20)1 (8)2 (15)5 (36)4 (24)5 (26)7 (39)2 (18)3 (23)4 (29)
Very
satisfied
6 (40)6 (40)5 (33)3 (22)6 (40)6 (40)3 (23)4 (31)4 (29)7 (41)9 (47)5 (28)7 (64)7 (54)6 (43)
Moderately
satisfied
4 (27)4 (27)5 (33)7 (50)7 (47)4 (27)5 (38)4 (31)3 (21)5 (29)3 (16)4 (22)2 (18)2 (15)3 (21)
Slightly
satisfied
3 (20)3 (20)4 (27)1 (7)0 (0)2 (13)4 (31)3 (23)2 (14)1 (6)2 (11)2 (11)0 (0)0 (0)1 (7)
Not at all
satisfied
1 (7)1 (6)1 (7)0 (0)0 (0)0 (0)0 (0)0 (0)0 (0)0 (0)0 (0)0 (0)0 (0)1 (8)0 (0)
*n- number of hospitals
Figure 71: Chart of Patient Satisfaction by Hospitals Categories
*Note: Patient satisfaction was individually observed and calculated for red, yellow and green triaged patients. The percentage
in brackets shows extremely satisfied and very satisfied patients/ patient attendant from the level of care provided by healthcare
facility Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 132
Figure 72: Representation of Triaged Patient Satisfaction for care provided by Hospital Categories 133
Observations and Results with Suggestions
Suggestions
1. Establish a suggestion box in the hospital, especially within the emergency department
premises.
2. Establish patient information display system.
3. Train emergency care providers on communication skills including grief counselling
and shared decision making.
8. REFERRAL OF THE PATIENT
During live observation, referral of patient was observed. Organization referral policy was checked.
It was also observed that the hospital provides proper arrangement to the patient or not and the
patient was assisted with any assistance or not from the hospital during referral.
It is clear from the table 60 and figure 73 that 55%hospitals have some referral policy, 53%
hospitals provide proper arrangement to patients and assistance was provided in only 49%
hospitals during referral.
Table 60: Summary of Referral of Patient by Hospital Categories: N (%)
Referral of
Patients
Medical
Colleges
(n=20)
Govt. hospitals
(>300 bed
strength)
(n=20)
Govt. hospitals
(<300 bed
strength)
(n=20)
Pvt. hospitals
(>300 bed
strength)
(n=20)
Pvt. hospitals
(<300 bed
strength)
(n=20)
Yes No Yes No Yes No Yes No Yes No
Any referral
policy
2 (15)
11
(85)
11
(61)
7 (39)
12
(71)
5 (29)
15
(83)
3 (17)
15
(94)
1 (6)
Any proper
arrangement
3 (23)
10
(77)
10
(56)
8 (44)9 (53)8 (47)
17
(94)
1 (6)
14
(93)
1 (7)
Any assistance
during referral
4 (31)9 (69)8 (44)
10
(56)
7 (41)
10
(59)
15
(88)
2 (12)
15
(94)
1 (6)
*n- number of hospitals Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 134
Figure 73: Graphically representation of Referral of Patient by Category of Hospitals
Suggestions:
1. Develop National Forward and Backward Referral Policy with safe transport integrated with
local EMS system
a. Hub and Spoke Model (figure 74)
b. Structured referral protocols
c. There should be informed transfer.
2. NABH Accreditation
There should be a Standard Referral back policy (Standard Forward & Backward Policy) and it
has to be in the form of hub and spoke model. In this policy, there should be a MOU of tertiary
care centres with mid-level government hospitals with multi-speciality district hospitals as well
as with private hospitals (cashless scheme).
In this policy, the referral should be on the basis of lack of facilities in secondary care. The tertiary
care should mandate to admit all red triaged patients as well as yellow triaged patients.
In case of fully utilized tertiary care centres, they need to admit patients through emergency then
they need to stabilize the patients and then they can transfer the stabilized yellow patient to other
middle level government hospital for further care to cater the load.
The red triaged patients need to admit through emergency in tertiary care then after stabilization
of patient transfer it either to ICU (who require ventilator) or HDU (who do not need ventilator).
It will vacant the red triaged beds in emergency and be available for other patients. 135
Observations and Results with Suggestions
Figure 74: Hub and Spoke Model for National Forward and Backward Referral Policy
Requirements:
1. MOU with Government and EMS
2. There should be trade-off between tertiary and secondary care system for management
of complex cases which are resource intensive in tertiary care with cases, which can
be stabilized in secondary care centres.
3. Optimal utilization of all tiers of healthcare system based on capacity and capabilities. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 136
III. LIVE OBSERVATION
(One Day Data of Emergency)
1. BURDEN OF PATIENTS (OPD AND EMERGENCY)
One day data (24 hours data either of previous day or same day) was collected by assessor’s team
from registration desk of the hospital containing information regarding total visits of patients in
hospital both OPD and emergency, admissions/transfer-out/discharge, death etc.
The burden of patients needing emergency came in 24 hours was 23% in medical colleges, 8%
in government hospitals more than 300 beds, 13% in government hospitals less than 300 beds,
6% in private hospitals more than 300 beds and 25% in private hospitals less than 300 beds as
shown in table 61.
The comparison of patients in OPD and emergency is represented in figure 75 for different
categories of hospitals.
In medical college, the burden of patients needing emergency for 24 hours was maximum at
SMS Medical College & Hospital and minimum at AIIMS, Bhopal.
In government hospitals >300 beds, the burden of patients in emergency was maximum at Indira
Gandhi Government General Hospital, Puducherry and minimum at District Hospital, Dhamtari
(for emergency) and Southern Railways Hospital, Chennai (for OPD).
In government hospitals <300 beds, the burden of patients in emergency was maximum at Puri
District Headquarter Hospital and minimum at Jamanabai General Hospital, Gujarat.
In private hospitals >300 beds, the burden of patients in emergency was maximum at Dr Ram
Manohar Lohia Hospital, Lucknow and minimum at Fortis Hospital, Rajasthan.
In private hospitals <300 beds, the burden of patients in emergency was maximum at Primus
Super Speciality Hospital, Delhi and minimum at Jaipur Golden Hospital, Delhi.
Table 61: Summary of number of patients at OPD and Emergency during Single day (24 hours)
Hospital Categories
Total Emergency and Injury
care Patients
OPD Patients other than
emergency cases
% of ED
Patients out
of all patients
visited in
hospital
n
Median [IQR]
Min-Max
n
Median [IQR]
Min-Max
Medical Colleges 16
446 [376]
55-7450
15
1942 [1374]
250-7545
17%
Govt. Hosp.
(>300 bed strength)
19
103 [92]
22-769
18
1223 [1095]
54-5164
11%
Govt. Hosp.
(<300 bed strength)
15
103 [103]
15-960
14
820 [1261]
40-2769
11%
Pvt. Hosp.
(>300 bed strength)
18
57 [87]
22-315
17
988 [1184]
27-3460
10%
Pvt. Hosp.
(<300 bed strength)
16
25 [24]
13-285
14 102 [332] 22-476 30%
*n: number of hospitals which shared data with assessor’s team, IQR: Interquartile range 137
Observations and Results with Suggestions
Figure 75: Comparison of Patients visited in OPD and Emergency in different Categories of Hospitals (ONE DAY)
*M. C.- Medical College, G. H.- Government Hospital, P. H.- Private Hospital, ED- Emergency department, OPD- Out patient
visit department
2. DISPOSITION SUMMARY
The disposition of patients in emergency department was also recorded by the team of assessors.
In this, number of admissions, LAMA (Leave against Medical Advice), discharge, Death in ED for
24 hours was recorded by the team. The summary of the patient disposal from ED is shown in
table 62 by categories of healthcare facilities. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 138
Table 62: Summary of Disposition of Patients at emergency department (24 hours)
by Category in the Healthcare Facilities: Median (% per total ED Visits)
Disposition of
Patients from ED
Medical
Colleges
Govt. Hosp.
(>300 bed
strength)
Govt. Hosp.
(<300 bed
strength)
Pvt. Hosp.
(>300 bed
strength)
Pvt. Hosp.
(<300 bed
strength)
n
Median
(% Out
of total
ED
visits)
n
Median
(% Out
of total
ED
visits)
n
Median
(% Out
of total
ED
visits)
n
Median
(% Out
of total
ED
visits)
n
Median
(% Out
of total
ED
visits)
Total Admissions 16
66
(15%)
16
24.5
(24%)
16
14
(13%)
1521(37%)15
13.5
(54%)
LAMA193.5 (1%)193 (3%)193.5 (3%)181 (2%)183 (12%)
Discharge 15
55
(12%)
15
50
(49%)
15
17
(17%)
15
22.5
(39%)
156.5 (26%)
Death 182 (0%)181.5 (1%)171 (1%)161 (2%)161 (4%)
Death due to Trauma
/ injury / Road traffic
accidents
152 (0%)141 (1%)163 (3%)130 (0%)13 1 (4%)
*n: Number of Hospitals, ED: Emergency department, LAMA: Leave against medical advice
3. SPECTRUM OF DISEASES
According to World Health Organization a state in which normal procedures are suspended and
extra-ordinary measures are taken is termed as emergency condition.
The spectrum of diseases present at ED were assessed for adult (10 diseases) and pediatric patients
(9 diseases) separately. Most of the hospitals maintained separate data for adult and pediatric,
while others did not have pediatric patient data.
3.1 Adult Patients
In table 63, the summary of adult diseases reported at the emergency department for all categories
of hospitals is depicted. 139
Observations and Results with Suggestions
Table 63: Summary of Spectrum of Diseases for Adults by Category of Hospitals
Spectrum
of Diseases
for Adults
Medical Colleges
(n=20)
Govt. Hosp.
(>300 bed
strength)
(n=20)
Govt. Hosp.
(<300 bed
strength)
(n=20)
Pvt. Hosp.
(>300 bed
strength)
(n=20)
Pvt. Hosp.
(<300 bed
strength)
(n=20)
N
Median [IQR]
Min-Max
(% Out of total
ED visits)
N
Median [IQR]
Min-Max
(% Out of total
ED visits)
N
Median [IQR]
Min-Max
(% Out of total
ED visits)
N
Median [IQR]
Min-Max
(% Out of total
ED visits)
N
Median [IQR]
Min-Max
(% Out of total
ED visits)
Chest Pain144
5.5
[10.2]
1-46
1.2385
3 [4.5]
1-28
2.9151
3 [4.2]
2-15
2.9184
4 [4.2]
1-13
7.0240
2 [2.5]
1-15
8
Stroke 75
5 [5]
1-42
1.1219
1 [1]
1-10
0.9725
3 [3]
1-9
2.9130
2 [1.5]
1-9
3.5114
1 [1.5]
1-5
4
Altered
Mental
Status
136
18 [25]
1-70
4.0459
3 [3]
1-17
2.9120
3 [1.5]
1-5
2.9127
2 [1]
1-6
3.5116
1 [1]
1-4
4
Trauma/
Road traffic
accident/
injuries
599
18 [25]
1-210
4.04175
5
[10.5]
1-45
4.85130
4.5 [6]
1-40
4.37143
3 [10]
1-35
5.2660
3 [4]
1-20
12
Respiratory
Distress
165
9 [21]
2-40
2.02144
6.5
[8.2]
1-38
6.3162
4 [9]
1-17
3.8883
6.5
[4.5]
2-22
11.4041
4 [4]
1-7
16
Pain in
Abdomen
232
13 [13]
2-72
2.91164
7 [7.5]
1-36
6.80161
15 [17]
1-27
14.56123
8 [5]
2-18
14.0448
3 [4]
1-11
12
Poisoning67
2.5
[6.7]
1-30
0.56115
2 [3.5]
1-79
1.946
1 [0.5]
1-3
0.9720
3 [4.7]
1-6
5.263
1 [0]
1-1
4
Snake Bite38
1 [4]
1-21
0.2224
4 [2]
2-10
3.884
1 [0.5]
1-2
0.9710
4 [2]
1-5
7.021
1 [0]
1-1
4
Fever 206
8 [24]
1-36
1.79262
11.5
[12.7]
1-72
11.17251
12 [15]
2-80
11.65148
6 [7]
1-42
10.5365
4 [7]
1-13
16
Pregnancy
related
200
26 [25]
1-140
5.8341
4.5 [3]
2-10
4.3715
2 [0.7]
1-5
1.9443
2 [2]
1-30
3.513
1.5
[0.5]
1-2
6
*n: number of hospitals, N: total number of patients recorded in 24 hours from district hospitals, IQR: Interquartile range
It was observed that the trauma care (1101 patients) accounted for the maximum number
of patients visiting in hospital emergency department followed by those with complaints
of fever (932 patients). Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 140
In medical colleges, the trauma care accounted for the maximum number of patients visiting in
hospital emergency department followed by those with complaints of pain in abdomen.
In government hospitals >300 beds, the maximum number of patients visiting in hospital
emergency department accounted for complaints of fever followed by those of trauma care
patients.
In government hospitals <300 beds, the maximum number of patients visiting in hospital
emergency department accounted for complaints of fever followed by those with complaints of
pain in abdomen.
In private hospitals (both >300 beds and <300 beds), the maximum number of patients visiting
in hospital emergency department accounted for complaints of fever followed by those of trauma
care patients.
3.2 Pediatric Patients
In table 64, the summary of pediatric diseases reported for all categories of hospitals is depicted.
Amongst pediatric patients, it was observed that the maximum number of patients visiting in
hospital emergency department accounted for complaints of fever (443 patients) followed by
those of diarrheal diseases (290 patients).
Table 64: Summary of Spectrum of Diseases for Pediatrics in all Categories of Hospitals
Spectrum
of Diseases
for
Pediatrics
Medical Colleges
(n=20)
Govt. Hosp.
(>300 bed
strength)
(n=20)
Govt. Hosp.
(<300 bed
strength)
(n=20)
Pvt. Hosp.
(>300 bed
strength)
(n=20)
Pvt. Hosp.
(<300 bed
strength)
(n=20)
N
Median (IQR)
Min-Max
(% Out of total
ED visits)
N
Median (IQR)
Min-Max
(% Out of total
ED visits)
N
Median (IQR)
Min-Max
(% Out of total
ED visits)
N
Median (IQR)
Min-Max
(% Out of total
ED visits)
N
Median (IQR)
Min-Max
(% Out of total
ED visits)
Respiratory
Distress
115
6
[11.5]
1-35
1.3547
4 [5.5]
1-21
3.8811
2 [1]
1-3
1.9428
1 [3.7]
1-18
1.7535
2
[14.5]
2-31
8
Diarrheal
Disease
86
3.5
[11.7]
1-25
0.7834
3 [2]
1-7
2.9135
3 [2]
2-9
2.9129
2 [2]
1-16
3.51106
2
[26.5]
1-101
8
Altered
Mental
Status
19
1.5
[1.5]
1-7
0.342
1 [0]
1-1
0.973
1.5
[0.5]
1-2
1.466
3 [2]
1-5
5.261
1 [0]
1-1
4
Trauma/
Road
traffic
accident/
injuries
43
6 [5]
1-10
1.3516
2 [2]
1-5
1.9434
4 [3]
1-17
3.8811
1 [1]
1-4
1.7518
3 [6.5]
1-14
12 141
Observations and Results with Suggestions
Seizure 29
2 [4]
1-10
0.4512
1.5 [1]
1-5
1.467
2 [0.2]
1-2
1.9410
1 [1]
1-5
1.753
1.5
[0.5]
1-2
6
Pain in
Abdomen
102
2 [4]
1-12
0.4533
2 [1]
1, 12
1.9420
3 [2.5]
1-5
2.9124
2 [1.2]
1-12
3.5115
15 [0]
15-15
60
Poisoning13
4 [0.5]
4-5
0.900 0 0.000 0 0.002
2 [0]
2-2
3.512
2 [0]
2-2
8
Snake Bite4
1 [0.5]
1-2
0.220 0 0.004
2 [1]
1-3
1.941
1 [0]
1-1
1.750 0 0
Fever 159
6
[23.5]
1-47
1.3570
3 [4]
1-26
2.9135
2 [2.5]
1-11
1.9467
5 [10]
1-21
8.77112
2 [2]
1-105
8
*n: number of hospitals, N: total number of patients recorded in 24 hours from district hospitals, IQR: Interquartile range
In medical colleges, the maximum number of patients visiting in hospital emergency department
accounted for complaints of fever followed by those with respiratory distress.
In government hospitals >300 beds, the maximum number of patients visiting in hospital
emergency department accounted for complaints of fever followed by those with respiratory
distress.
In government hospitals <300 beds, the maximum number of visiting in hospital emergency
department patients accounted for complaints of fever and diarrheal disease followed by those
of trauma patients.
In private hospitals (both >300 beds and <300 beds), the maximum number of patients visiting
in hospital emergency department accounted for complaints of fever followed by those with
diarrheal patients. Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 142
IV. COMPARISON OF EMERGENCY CARE IN VARIOUS SYSTEMS
1. HOSPITALS WITH ACADEMIC EMERGENCY MEDICINE (N=5)
In this study, 5 medical colleges were selected which have academic emergency medicine in
their Post-Graduation programme.
The following observations were obtained during assessment from these hospitals with
academic emergency medicines:
Strengths at Hospitals with Academic Emergency Medicine:
1. They have 24*7 blood bank facility available (figure 76)
2. Adequate manpower in emergency
3. Definitive care services were observed well with proper ICU facilities in hospitals
with academic emergency medicine (figure 77)
4. They have disaster management plan with surge capacity, also conduct drill and
debriefing (figure 78)
5. Majority of them have triage policy
6. They conduct continuous education and periodic training programs for staff to
improve quality (figure 79)
7. They have dedicated staff for gap identification and loop closure.
8. They have key indicators for quality monitored.
9. They have computerized data management system (figure 80)
10. They have good communication skills in ED with satisfaction of majority of patients
(figure 83)
11. They have referral policy due to tie-up with local EMS system (figure 84)
Need to improve:
1. Emergency care protocols were missing (figure 84)
2. Lack of separate decontamination area (figure 78)
Figure 76: Summary of Hospital Blood bank in hospitals with academic emergency medicine and without academic
emergency medicine 143
Observations and Results with Suggestions
Figure 77: Summary of Definitive Care Services in hospitals with academic emergency medicine and without
academic emergency medicine Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 144
Figure 78: Summary of Disaster Managementin hospitals with academic emergency medicine and without
academic emergency medicine
Figure 79: Summary of Continuous Quality Improvement in hospitals with academic emergency medicine and
without academic emergency medicine 145
Observations and Results with Suggestions
Figure 80: Summary of Computerized Data Management System in hospitals with academic emergency
medicine and without academic emergency medicine
Figure 81: Summary of Communication Skills in ED in hospitals with academic emergency medicine and without
academic emergency medicine
Figure 82: Summary of Referral Policy in hospitals with academic emergency medicine and without
academic emergency medicine Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 146
Figure 83: Summary of Emergency Care Protocols in hospitals with academic emergency medicine
and without academic emergency medicine
2. GOVT. SECONDARY CARE V/S TERTIARY CARE HOSPITALS
Out of 100 hospitals, 34 were district hospitals (secondary care centres) and 25 were government
tertiary care centres from various states of our country. The following observations were obtained
during assessment from district hospitals:
Strengths
50% have 24*7 blood bank facility available (figure 84)
Some of hospitals (6) have separate ED blood storage (figure 85)
25% have 24*7 emergency operative services (figure 86)
Compliance for ED protocol/SOP/guidelines were good, when compared to tertiary care
government hospitals (figure 87)
Some of them conducted periodic mock drill and training of staff (figure 88)
Regular audits conducted in mostly district hospitals
Communication in ED and patient satisfaction of district hospitals were good, when
compared to tertiary care government hospitals
Majority have good referral policy with assistance during referral (figure 89)
Figure 84: Summary of Hospital Blood Bank in Secondary Care Centres 147
Observations and Results with Suggestions
Figure 85: Summary of Hospital Blood protocols in Secondary Care Centres
Figure 86: Summary of Emergency Operative Services in Secondary Care Centres Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 148
Figure 87: Summary of ED Protocols / SOP / Guidelines in Secondary Care Centres
Figure 88: Summary of Continuous Quality Improvement in Secondary Care Centres 149
Observations and Results with Suggestions
Figure 89: Summary of Referral Policy in Secondary Care Centres
Need to improve:
Lack of blood transfusion protocols (figure 85)
Lack of common ICU with PICU and NICU (figure 90)
Lack of computerized data management system (figure 91)
Figure 90: Summary of Critical Care Services in Secondary Care Centres Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 150
Figure 91: Summary of Computerized Data Management System in Secondary Care Centres
**Note: Comparison of District Hospitals >300 beds and <300 beds has done as a separate study 151
Observations and Results with Suggestions
3. PRIVATE HOSPITALS VS GOVERNMENT HOSPITALS
In this study, 60 hospitals were government hospitals and 40 hospitals were private hospitals
out of 100 hospitals. The following observations were obtained during assessment from these
hospitals were as follows:
Key point of checklist
Government
hospitals (n=60)
Private hospitals
(n=40)
Figure
Blood bank facility availability65%75%10
ED and massive blood transfusion protocol 17%25%10
Emergency operative services37%77%12
Periodic mock drill15%57%29
Periodic training programs for staff 18%77%29
Regular audits32%82%35
Communication in ED40%72%71
Referral policy42%75%74
4. NABH ACCREDITED VS NON-NABH ACCREDITED HOSPITALS
In this study, 28 hospitals were NABH accredited out of 100 hospitals; all NABH accredited
hospitals were private. The following observations were obtained during assessment from these
hospitals having NABH Accreditation:
Strength
They have 24*7 blood bank facility available.
They have ED and massive blood transfusion protocols.
They have good definitive care services.
They have all types of ED protocols/SOP/guidelines with triage (figure 25).
These hospitals conduct continuous education and periodic training programs for staff
(figure 37).
Periodic mock drill also conducted in these hospitals (figure 31).
Majority have computerized data management system (figure 40).
Management of time sensitive conditions is good as compared to non-NABH accredited
hospitals (figure 58, 63, 67)
They also have referral policy Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 152
V. COMPLIANCE OF INDIVIDUAL HOSPITALS TO
THE CHECKLIST
A checklist encompasses the following parameters was checked for all the hospitals studied. The
details are attached as Annexure VII.
The hospitals which scored 75% or above were found satisfactory and marked green, the score
of 50% to 74% requiring improvement was marked yellow and score of less than 50% in an area
were marked red. The areas in red suggested the need for an intervention on priority.
DISCUSSION 153
Observations and Results with Suggestions
DISCUSSION07 155
Discussion
DISCUSSION07
This study is the first cross-sectional stratified multi stage comprehensive assessment of emergency
and trauma care facilities using consensus based study tool in India. We found significant gaps
in whole system at various levels.
According to Medical Council of India, each hospital must have 5% emergency beds. It was
observed that all hospitals have an average of 3%-5% emergency beds. On the other hand, the
annual burden of patients visited in emergency is 10-30%, which is much more than the available
emergency beds present in hospitals.
A major concern was that only a few facilities at any level of care had ED blood storage, protocols
for massive blood transfusion and ED blood transfusion. A major gap in definitive care services
was that nearly all government hospitals (<300 bed strength) do not have common ICU.
Another major concern was the lack of protocols/SOP/guidelines for emergency department.
Nearly all government hospitals and medical colleges do not have emergency care protocols
(alert system for different diseases) and most of the government hospitals and medical colleges
do not have alarm bell/code announcement in ED.
The major gaps in disaster management in the healthcare facilities assessed were lack of separate
decontamination area in ED, separate disaster stock in ED, absence of drill and debriefing for
disaster management and the system for redistribution of patients to other network hospitals
during disaster was present in few hospitals. The quality indicators for urgent and interventional
procedures monitored were found missing at most of the hospital at any levels of care.
Also, gaps were observed in data management systems: most of the government hospitals and
medical colleges do not have trauma registry systems; while ~40% private hospitals have trauma
registry system. Nearly all government hospitals and medical colleges do not have injury and ED
surveillance system and most of the private hospitals also do not have injury and ED surveillance
system.
A major concern was lack of-provision of allocated budget (Central/ State Government) to finance
emergency care systems were observed at nearly all facilities at all tiers. The available few
allocated budget at a few locations pertained specifically for delivery of goals related to trauma Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 156
care.
There were lack of optimal availability of human resource, essential medicines, critical care
equipments and supplies at various levels. Of these, the most critical gaps were scarcities related
to doctors, paramedics, adherence to essential drug list at ED and essential emergency care
equipments such as cervical collar, transport ventilator, resuscitation medicines, etc. Many of the
frequently absent equipment were inexpensive items, which would save lives in many emergency
conditions.
Amongst the issues related to human resource, it was found that most of the hospitals had adequate
number of general duty doctors and specialists; deficiencies still prevailed in the emergency
department. This was probably due to lack of importance given to the emergency care services as
a separate standalone independent unit/department. Further, most of the posted doctors at the ED
were the most junior doctors, with least experience, that too on a rotational basis-corroborating
further with the aforementioned facts. The recent MCI mandate to develop standalone EDs at all
Medical Colleges should at least partially address these issues. But a larger change in attitude of
administrators, policy makers and doctors is required to bring about significant changes.
Additionally, major gaps were found in physical infrastructure both within and in immediate outside
surrounding areas of emergency departments that could be easily rectified with minimal budget.
These gaps such as independent direct access to ambulance services from the ED and demarcated
area for triage amongst others would be able to save lives by improving efficiency of delivery of
care. Most of these could be achieved by minimally altering the prevailing infrastructures.
Of the prevailing gaps in the infrastructure, lack of availability of a separate 24*7 point of care lab
for ED was prevalent at most of the health facilities. This is a critical deficiency, since availability
of timely lab results is crucial for management of patients with medical emergency conditions,
wherein time is of paramount importance.
The strengths of this study were the fact that this was the first systematic study of prevailing facility
based emergency and trauma care services in the country. The study has been conducted in a
robust manner covering all zones of the country by assessors trained in pre-specified standardized
tools in an unbiased way. The health facilities assessed covered all possible strata and levels of
care.
There are a few limitations to the study. First, most of the information of the healthcare facilities
was obtained from the direct interviews with one or two administrative official per facility.
However, this was partially compensated by live observations by the assessors. Second, most of
the facilities did not have inherent electronic data systems to capture historic information and
these had to be culled from other sources and by Delphi methods.
CONCLUSIONS 157
Discussion
CONCLUSIONS08 159
Conclusions
CONCLUSIONS08
Facility-level physical infrastructure, human resource, equipment & supplies, point of care lab
and essential medicines gaps existed in the current emergency care system at different healthcare
levels in India. Gaps in financing, protocols, blood bank, etc also existed in the current emergency
care system different healthcare facilities.
Gaps also existed between pre-hospital care and definitive care services, proper linkage should
be there. A major gap is lack of academic emergency medicine department at different healthcare
levels in India. All these gaps are likely to compromise the provisions of quality emergency care.
These findings point towards the implementation of a comprehensive programme of emergency
care system reforms in the country of India.
KEY
SUGGESTIONS KEY SUGGESTIONS 161
Conclusions
KEY SUGGESTIONS09 163
Summary Of Key Suggestions Emerging from the Study
SUMMARY OF KEY
SUGGESTIONS
EMERGING FROM
THE STUDY09
HEADINGSUGGESTIONS
Huge Mismatch between
Emergency Beds & Burden
of Emergency and Injury
Cases
We need to increase the emergency beds (12% emergency beds +10%
buffer beds) as per the existing and expected footfall.
Develop Cashless emergency care scheme for all red triaged patients
because of out of pocket expenditure during emergency conditions
To provide quality of care as per the existing and expected footfall we
need to strengthen district hospitals by-
Upgrade them into medical college
Develop residency programme (DNB)
Initiate incentivization and decentivization according to the performance
of hospital
Burden of Medico-legal
Cases
Develop Forensic Nursing in nursing college / dedicated EMO (Emergency
Medical Officer) / Senior Resident (Forensic Medicine) to deal with MLC
documentation and representation to court
In-house or nearby police post for mitigating violence and protection
of emergency care provider and for better co-ordination of MLC
documentation and legal service
Hospital Blood Bank
Services
But for running acute care services, we need blood bank services for
24*7 in all hospitals.
Majority of district hospitals have blood bank however the round the
clock service is missing in many of them, due to lack of staff.
Emergency blood storage is mandatory for those medical college and
district hospitals (>300 beds) which deals with more trauma cases Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 164
HEADINGSUGGESTIONS
Hospital Definitive Care
Services
Medical colleges should have all types of emergency operative, critical
care as well as specialized care services for 24*7
District hospitals >300 beds should have trauma, non-trauma operative
services, general ICU (Intensive Care Unit), HDU (High Dependency
Unit), NICU (Neonatal ICU) and PICU (Pediatric ICU).
District hospitals <300 beds should have general operative services,
general ICU (Intensive Care Unit) / HDU (High Dependency Unit) and
NICU (Neonatal ICU).
District hospitals may be upgraded into multi-speciality hospitals to
improve the quality of care
Hospital Ambulance
Services
The in-hospital ambulances should be optimally utilized in the common
resource pool of EMS (Emergency medical Service) of the region as per
requirement.
Regular maintenance of ambulance should be done.
The ALS ambulances can be used for mobile stroke unit as well as for
STEMI programme.
Creation of EMT (Emergency Medical Technician) course as a residency
programme
Dedicating job creation
Paramedic Council
ED Protocols / SOP /
Guidelines
Development of academic residency programme
Implementation of triage policy in each hospital
NABH Accreditation
Increase the scope of Good Samaritan Law from road traffic injuries to
other time sensitive conditions
Disaster Management
There should be standard protocols for implementation of in-hospital
disaster management plan
Implementation of hospitals prepared for disaster management for both
external and internal
Establish academic emergency medicine
There should be separate decontamination area at entrance of emergency
Every hospital should have surge capacity with separate disaster stock in
emergency
There should be drill and debriefing for disaster management
Regular monitoring and evaluation of implementation of disaster
management should be done from NDMA
Continuous Quality
Improvement
There should be dedicated quality manager for gap identification and loop
closure
Develop a quality council among emergency care providers
Mandatory Emerald certification under NABH
Regular mortality and morbidity meeting
Regular third party audit of external agencies by using KPI and the
funding of the hospital should be linked with it
Continuous training of quality council provider as well as manager 165
Summary Of Key Suggestions Emerging from the Study
HEADINGSUGGESTIONS
Computerized Data
Management System
Develop National Emergency Department Information System (EDIS)
Implement and integrate the computerized care delivery template which
will serve as clinical notes, registry and surveillance
It will use the data for quality improvement initiative and research
Develop various emergency conditions registries such as cardiac arrest,
poisoning, snake bite including trauma registry
Financing
Protected funding for emergency and injury care services and for
establishment of residency programme in emergency medicine,
emergency nursing and EMT (Emergency Medical Technician) course
Integration and aggregation of financial schemes for emergency and injury
care
Cashless scheme- Increase Ayushman Bharat scheme for all red-triaged
patients in all hospitals to save out of pocket expenditure
Physical Infrastructure
Uniformity of name (Emergency/Emergency Medicine Department) in
every hospital for emergency / casualty / injury care etc.
The capacity and capability of ED should be standardize based on the tier
of facility, footfall of patients and academic programme
Availability of either point of care lab or hospital lab (24*7) for
emergency services
Adequate space for ambulance drop zone
There should be demarcated triage area
There should be small ICU in each hospital
Manpower in Emergency
Department
Rotator posting of doctors and nursing students from different disciplines
including interns for a defined period in emergency
Creation of dedicated post for emergency department of doctors, nurses
and paramedics
NABH Accreditation
Establish academic emergency medicine, emergency nursing and EMT
Equipments and Supplies
in ED
All essential equipments and supplies should be present in every hospital
to improve the quality of care
There should be dedicated staff for maintenance of equipments in
emergency
There should be dedicated training of staff regarding the maintenance of
equipments (how to use and maintain)
Maintain checklist of supplies and equipments, they should be checked
before end of every shift and beginning of every shift
Maintain a checklist of non-functional equipments and consumed supplies
and should be communicated during handovers
Point of Care Lab
All healthcare facilities should have either basic point of care lab or
emergency lab in hospital for 24*7 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 166
HEADINGSUGGESTIONS
Essential Medicines for
Emergency
Complete package of resuscitation medicines should be present in all
hospitals for 24*7
Other essential medicines should also be present in all hospitals for 24*7
During third party audits, if any essential drug is missing from the
resuscitation package then the license of the hospital may be cancelled
Entry to Admission/
Transfer-out/Discharge
Time of Patients Visited in
Emergency Department
It should be a sovereign department
Implementation of triage policy in all hospitals (Prioritization of patient)
Adequate manpower should be present in hospitals as per footfall of
patients and emergency beds
Optimum utilization of resources
There should be a dedicated emergency nurse coordination (ENC) system
Chest Pain Management
Upgrade them for thrombolysis
Adequate trained emergency care provider
All district hospitals must have ECG machine and technician
Use Tele-ECG and Tele-Medicine programme
Resuscitate patient in district hospital and refer them to other higher
government hospital
Develop a STEMI Programme by Hub and Spoke Model
Develop PCI centres in multi-speciality hospitals
Stroke Management
Thrombolysis near home – Hub and Spoke Model
Develop Tele-stroke programme
Stroke management by PPP (Public-Private Partnership) model in district
hospitals
Communication Skills in
Emergency Department
Dedicated emergency nurse coordinator (ENC)
Training of staff on communication skills from under-graduate level (for
doctors, nurses and paramedics)
Referral of the Patient
Develop National Forward and Backward Referral Policy with safe
transport integrated with local EMS system
Hub and Spoke Model
Structured referral protocols
There should be informed transfer
NABH Accreditation
Burden of Death of
Trauma Patients
Develop a robust integrated emergency care system which includes injuries
Burden of Brought Dead
Patients
Develop preventive emergency healthcare strategy such as National Injury
Prevention Programme
Developing a robust emergency injury care initiative
There should be installation of public access device of AED (Automated
external Defibrillator) as a national policy in mass gathering areas such as
schools, shopping mall, railway station, etc. 167
Summary Of Key Suggestions Emerging from the Study
KEY POLICY
RECOMMENDATIONS10 169
Suggested Key Policy Recommendations
SUGGESTED
KEY POLICY
RECOMMENDATIONS10
These findings were suggestive for the following suggestions:
1. Develop a robust integrated emergency care system including injuries: The current
policy focus (which is predominately trauma-centric) should be leveraged to deliver
comprehensive emergency and trauma care services in an integrated manner, without
losing the gains achieved in delivery of trauma care services through-out the Nation.
2. Standardize the Protocols / SOP and Guidelines including Triage: The policies, protocols
and guidelines for emergency department should be standardized across all EDs in the
country, irrespective of their levels of care. The key for achieving this is a availability of
standardized universal emergency-care manual at the point of care. This manual should
contain- information for management of all anticipated emergency medical conditions
with updated SOPs, protocols and flow charts. Specific focus should also be given for
critical issues such as triage, handling of critical equipments, norms for optimal care
delivery. If feasible, these should also be available in a ready-to-use handy app format,
which can be downloaded on a mobile phone.
3. Adequate Space allocation for Emergency and Injury Care: Adequate space should be
allotted for emergency department in each hospital as per the footfall. The critical needs
for establishment of such a department should be met at all hospitals.
4. Develop Standardize Emergency Department: There is a need to develop a blue print
for a standalone standardized department of emergency medicine for various levels of
care, for the Nation. These norms need to be adapted after a consensus is achieved.
5. Establish Academic Emergency Medicine departments: This is the need of the hour to
ensure continuous ongoing medical education and development of skills for doctors,
nurses and paramedics. Further, development of such departments will be the key to
enhance research to provide further policy directions.
6. Continuous Training and Skill Development of ED Staff: There should be capacity
building of doctors, nurses and paramedics. The emergency care providers should be
trained for life saving skills with structured courses such as: ACLS, BLS, PALS, ATLS or Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 170
NELS, Point of care emergency ultrasound; with periodic refresher courses, to ensure
continuous skilling of defined core competencies.
7. Accreditation of all Emergency and the health facility for providing quality care: There
should be accreditation of all EDs and health facility for delivering and improving the
quality care. Regular quality checks on a specified format should be ensured to enhance
the performance of emergency care.
8. Upgradation and maintenance of existed Emergency and Health facility: The ED is like
a mini-hospital and in itself requires separate wide variety of resources. The availability
of resources should be supported with optimum utilization for maximum output. The
management of staff for 24 hours in right number should be a policy and same should be
followed for equipments and medicines. An effort should be made to integrate the EMS
with pre-hospital notification, so that the patients could be transferred to appropriate
health facility based on the level care needed for the underlying disease condition.
9. Pooling of Ambulances (Integration and aggregation of ambulances): The in-hospital
ambulances should be optimally utilized as a common resource pool for providing EMS
services for the entire -local region, as per requirement.
10. Optimization of Resources (manpower, infrastructure, supplies and medicines): Since
many of the gaps in optimization of resources needed for optimal emergency care
services can be achieved with minimal budgetary requirements, it is recommended
that phasing of the needs be done, so as to achieve early low hanging fruits. Some of
these examples include reallocation of available human resources, minimal alteration
of existing infrastructure to provide access to ambulance vehicles and creation of a
demarcated area for triaging.
11. Protected Funding for Emergency and Injury Care as well as for developing academic
department / DNB Emergency Medicine: Separate budget head needs to be created
for emergency care services. One option is to augment the prevailing funds for trauma
care to encompass overall emergency care delivery.
12. Cashless care for all red triaged patients in all hospitals: Policy for caring of all
emergency conditions for all citizens of the Nation for the initial critical period to
ensure early clinical stabilization is a way forward to achieve Health for all and SDGs.
NOTE: To carry forward the above recommendations, it is suggested that in the first phase, these
may be implemented at 30 existing facilities which have a functional emergency department and
trauma care facility. The lessons learnt from this endeavour can act as template to give further
directions. 171
Suggested Key Policy Recommendations
PHASE-I SUGGESTED KEY POLICY RECOMMENDATIONS
Uniformity of name–Emergency or Emergency Medicine Department
Create an empowered Hospital Committee, which have composition of different
disciplines and headed by Hospital in-charge/Medical Superintendent. The member
secretary should be Head of the Emergency Department.
Reorganize of the existing emergency department for comprehensive management of all
emergency conditions, at all tiers of healthcare facilities depending on the anticipated
footfall of patients.
Initiate Quality Improvement (QI) programmes.
Implement triage policy.
Initiate processes to capture data related to emergency care at each hospital.
Ensure 24*7 availability of adequate dedicated emergency staff such as doctors, nurses
and paramedics.
Optimize infrastructure and supplies from within the available resources and create a
roadmap for futuristic needs with timelines.
Ensure on-going training and skilling of doctors, nurses and paramedics.
Develop standardized care delivery template for time sensitive conditions.
Develop a robust pre-hospital care system linked with facility based emergency care
services.
Create a separate protected fund/ budget to address the immediate concerns regarding
critical supplies and equipment’s needs of the Emergency Department. REFERENCES 173
Suggested Key Policy Recommendations
REFERENCES11 175
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33. Essien E, Ifenne D, Sabitu K, Musa A, Alti-Mu’azu M, Adidu V, et al. Community loan funds
and transport services for obstetric emergencies in northern Nigeria. International Journal of
Gynaecology and Obstetrics1997; 59Suppl 2:S237-44.
34. Shehu D, Ikeh AT, Kuna MJ. Mobilising transport for obstetric emergencies in north western
Nigeria. International Journal of Gynaecology and Obstetrics 1997; 59 Supp l2: S173-80. ANNEXURES 179
References
ANNEXURES12 181
Annexure-I: List of Hospitals
ANNEXURE-I:
LIST OF HOSPITALS12
Zone
S.
No.
State
Medical
College
Government
Hospital more
than 300 beds
Government
Hospital less
than 300
beds
Private
Hospital
more than
300 beds
Private
Hospital less
than 300 beds
NORTH
ZONE
1
Jammu &
Kashmir
Sher-i-Kashmir
Institute of
Medical
Sciences,
Srinagar
District
Hospital
Hospital,
Barahmulla
District
Hospital
Ganderbal,
Ganderbal
- -
2
Himachal
Pradesh
IGMC, Shimla
District
Hospital
(Deen Dayal
Upadhyay
Hospital),
Shimla
- - -
3Punjab
Guru Nanak
Dev Hospital
& Govt.
Medical
College,
Amritsar
Jallianwala
Bagh Martyr’s
Memorial
Civil Hospital,
Rambagh
-
Fortis
Hospital,
Mohali
Shivam
Hospital,
Multi Super
Speciality
Hospital,
Hoshiarpur
4Uttarakhand -
HNB Base
Hospital
Coronation
Hospital,
Dehradun
- -
5
Utttar
Pradesh
-
Civil Hospital-
Lucknow
-
RML
Hospital,
Lucknow
Charak
Hospital
Dubagga
6Chandigarh -
Government
Superspeciality
Hospital,
Sector-16
Civil
Hospital
Sector-22,
Chandigarh
-
Max
Superspeciality
Hospital,
Mohali Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 182
7Rajasthan
SMS Medical
College &
Hospital, Jaipur
Hari Baksh
Kanwatia
Hospital, Jaipur
Govt. BDM
Hospital,
Kotputli
Fortis
Hospital,
Jaipur
Birla Hospital-
CK Birla,
Jaipur
8Delhi- - -
Yashoda
hospital,
Kaushambi
Indian Spinal
Injuries Centre
Asian
Hospital
Medeor
Hospital,
Manesar
Sri Ganga
Ram Hospital
Jaipur Golden
Hospital
Artemis
Hospital
Primus Super
Speciality
Hospital
WEST
ZONE
1Gujarat
BJ Medical
College &
Civil Hospital,
Ahemdabad
GMERS
Medical
College &
Hospital, Gotri,
Vadodara
Jamanabai
Government
Hospital,
Mandvi
Parul
Sewasharam
Hospital,
Vadodara
Bhailal Amin
General
Hospital,
Vadodara
2Maharashtra
BJ Medical
College &
Sassoon
General
Hospital, Pune
-
Sri Seva
Medical
foundation
Dr Jogalekar
Hospital,
Shirwal,
Pune
Grant
Medical
Foundation
Ruby Hall
Clinic, Pune
-
3
Madhya
Pradesh
AIIMS, Bhopal
Jai Prakash
District
Hospital,
Shivaji Nagar,
Bhopal
- -
Bhopal
Fracture
Hospital,
Bhopal
4Chhattisgarh-
District
Hospital,
Dhamtari
District
Hospital,
Tikarpara,
Raipur
-
Ramkrishna
CARE
Hospital,
Pachpedhi
5Goa
Goa Medical
College, Panaji
-
North Goa
District
Hospital,
Mapusa
- -
EAST
ZONE
1Bihar PMCH, Patna AIIMS Patna
Sadar
Hospital,
Gaya
Paras HMRI
Hospital,
Patna
Ruban
Memorial
Hospital
Patliputra
3Orissa -
AIIMS,
Bhubneshwar
District
Headquarter
Hospital,
Puri
Capital
Hospital,
Bhubneshwar
Care Hospital,
Bhubneshwar
4West Bengal
IPGMER &
SSKM
- - -
Ruby General
Hospital 183
Annexure-I: List of Hospitals
NORTH
EAST
ZONE
1Sikkim
New STNM-
Govt- medical
college, Sikkim
-
Singtam
District
Hospital
Central
Referral
Hospital,
Gangtok
-
2
Arunachal
Pradesh
TomoRiba
Institute of
Health &
Medical
Sciences,
Papumpare
-
BakinPertin
General
Hospital,
Pasighat
-
Ramakrishna
Mission
Hospital,
Itanagar
3Assam
Gauhati
Medical
College and
Hospital,
Guwahati
-
Morigaon
Civil
Hospital
GNRC
Hospital,
Guwahati
Nemcare
Superspecialty
Hospital,
Guwahati
4Meghalaya -
Civil Hospital
Shillong
- - -
5Nagaland - -
District
Hospital,
Peren
-
Christian
Institute
of Health
Science and
Research
6Manipur RIMS, Imphal -
District
Hospital,
Bishnupur
-
Shija Hospital
& Research
Institute,
Lamphelpat,
Imphal
7Tripura
Agartala
Government
Medical
College & G B
Pant Hospital
-
Gomti
District
Hospital,
Udaipur
Tripura
medical
college&
BRAM
Teaching
Hospital,
Agartala
-
8Mizoram -
Zoram Medical
College
Civil
Hospital,
Aizawl
Synod
Hospital
(Presbyterian
Hospital)
- Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 184
SOUTH
ZONE
1Telangana -
District
Hospital,
Karim Nagar,
Hyderabad
District
Hospital,
King Koti,
Hyderabad
Yashoda
Hospital,
Malakpet,
Hyderabad
-
2Karnataka
Mysore
Medical
College
& Krishna
Rajendra
Hospital,
Mysuru
Victoria
Hospital,
Bengaluru
Government
Hospital,
Virajpet
Manipal
Hospital,
Bengaluru
-
3
Andhra
Pradesh
Guntur
Medical
college &
Government
General
Hospital
Government
District
Hospital,
Tenali
-
Kasturi
Medical
College &
Hospital
Lalitha Super
Specialty
Hospital,
Kothapet,
Guntur
4Kerala
Trivandrum
Govt Medical
College
District
Hospital,
Neyyattinkara
District
Hospital,
Peroorkada
Cosmopolitan
Hospitals Pvt
Ltd
G G Hospital
5Tamil Nadu
Madras
Medical
College
Madras
Railway
Hospital,
Madras
(Southern
Railway
Headquarters
Hospital)
-
Apollo
Hospital
-
6Pondicherry
JIPMER,
Pondicherry
Indira Gandhi
Government
General
Hospital,
Pondicherry
- - - 185
Annexure-II: Study Tool
ANNEXURE-II:
STUDY TOOL
Section A: Background Information of the Hospital:
Date of Inspection:
1.
Name of the
hospital:
Name of Inspection Team Member:
1.
2.
3.
2.
Address of the
hospital:
3.
Type of Health
Care Facility
Government/Non Govt. (Trust/society/
Corporate/…………………... Specify)
Large Tertiary( >500 Beds) /
Secondary (300-500 Beds) /
Secondary (100-300 Beds)
4.Total no of
Inpatient
Beds in the
hospital
Total no. of beds in Emergency care
area
Red (ESI:1-2)
Yellow (ESI: 3-4)
Green (ESI: 5)
5.Total number of patients visited in hospital outpatient
department (OPD ) (During 1st Jan 2018 to 31st Dec 2018)
Adult Pediatric
(Age - 0 to …..)
6.Total number of patients visited in emergency (During 1st
Jan 2018 to 31st Dec 2018)
Adult Pediatric
(Age - 0 to …..) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 186
7.Total number of death of trauma patients in emergency
department (During 1st Jan 2018 to 31st Dec 2018)
Adult Pediatric
(Age - 0 to …..)
8.Total number of patient’s death due to road traffic injury in
emergency department (During 1st Jan 2018 to 31st Dec
2018)
Adult Pediatric
(Age - 0 to …..)
9.Total number of patients which are brought dead to the
hospital (During 1st Jan 2018 to 31st Dec 2018)
Adult Pediatric
(Age - 0 to …..)
10.Total number of Medicolegal cases attended in Emergency
(During 1st Jan 2018 to 31st Dec 2018)
11.Total Number of admissions through Emergency (last 1yr)
Section-B: Hospital Services
1. BLOOD BANK(SCORE- 1: Full Compliance, 2: Partial Compliance, 3: Non
Compliance)
S.No. OBJECTIVE ELEMENTSCheck point SCORE
REMARKS
(If any)
1.
Does the facility have a licensed in-
house blood bank?
Admin Interview/
Facility Visit
SCORE
2.
If yes, does the blood bank available
for 24x7?
Admin Interview/
Facility Visit
SCORE
3.
If no, any tie up with external Blood
bank facility?
Admin Interview/
Facility Visit
SCORE
4.
Does the emergency have separate
component facility: Packed cell (RBC),
FFP, Platelet, Cryoprecipitate?
Admin Interview /
Blood bank Visit/
Stock Register
SCORE
5.
Does the facility have 0-Negative
Blood availability?
Blood bank Visit/
Stock Register
SCORE
6.ED Blood storage
Facility available in
ED
SCORE
7.ED Blood Transfusion Protocol Written protocol SCORE
8.Massive Blood Transfusion ProtocolWritten protocol SCORE 187
Annexure-II: Study Tool
Definitive Care Services (Score: 1-No, 2- Partial, 3- Yes)
*NOTE: Question no 12 to 16 is not applicable for district hospital
S.
No.
OBJECTIVE ELEMENTSCheck point SCORE
REMARKS
(If Any)
1.
Emergency operative services for
Trauma patients
Admin interview / 24 hours
available facility/OT Register
SCORE
2.
Emergency operative services
for Non-Trauma (Surgical,
Orthopedics etc.) patients
Admin interview / 24 hours
available facility/OT Register
SCORE
3.
Emergency operative services for
Obstetrics patients
Admin interview / 24 hours
available facility/OT Register
SCORE
4.
Elective Operative services for
Orthopedic patients
Admin interview / OT
facility/OT Register
SCORE
5.
Elective Operative services for
neurosurgical patients
Admin interview / OT
facility/OT Register
SCORE
6.
Common Intensive care services
(ICU)
Admin interview / facility/
Facility Register
SCORE
7.
Common High dependency Unit
(HDU)
Admin interview / facility/
Facility Register
SCORE
8.Pediatric ICU
Admin interview / facility/
Facility Register
SCORE
9.Neonatal ICU
Admin interview / facility/
Facility Register
SCORE
10.Neurosurgery ICU
Admin interview / facility/
Facility Register
SCORE
11.Cardiac Intensive care Unit
Admin interview / facility/
Facility Register
SCORE
12.Cardiac Cath lab*
Admin interview / facility/
Facility Register
SCORE
13.Intervention Radiology*
Admin interview / facility/
Facility Register
SCORE
14.
Intervention Neuroradiology
service with DSA*
Admin interview / facility/
Facility Register
SCORE
15.
Facility for Emergency CABG
services*
Admin interview / facility/
Facility Register
SCORE
16.
Facility for Radiofrequency
ablation services*
Admin interview / facility/
Facility Register
SCORE Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 188
Hospital Ambulance Services(Score: 1-No, 2- Partial, 3- Yes)
SN. OBJECTIVE ELEMENTS Check point SCORE
REMARKS
(if any)
1.
Do you have ambulances
in your hospital?
Admin interview /
Facility/Ambulance visit
SCORE
2.
If Yes, total number of
ambulances.
Admin interview /
Facility/Ambulance visit
NUMBERS
3.
Total Number of
Functional ambulances
and Non-Functional
ambulances.
Admin interview /
Facility/Ambulance visit
Functional-
Numbers
Non-functional-
Numbers
4.
Number of BLS/ALS
(Advance life support)
ambulances.
Admin interview/
Ambulance visit
ALS- (Numbers
only)
BLS- (Numbers
only)
5.
For what purpose, hospital
uses these ambulances?
Admin interview/
Ambulance driver
Pick up the patient/
Drop Patient /
Intra-transfer of
patient in hospital
/ Inter transfer of
patient to other
hospital
6.
If hospital doesn’t have
any ambulance, then how
you transfer patient from
your hospital to other
hospital?
Admin interview COMMENT
7.
Do you get Pre-Hospital
Notification (Prior
information about patient’s
condition is communicated
to ED)?
Admin interview /
Paramedic/Ambulance
driver/Patient Interview
SCORE
8.
Does the ambulance is
manned with appropriately
trained paramedics as per
the level of ambulance
services?
Admin interview /
Paramedic Interview
SCORE
9.
Do you have mobile stroke
unit?
Admin interview /
Mobile stroke unit visit
SCORE
10.
a) Do you have Tele-
Medicine facility?
b) If no, did you start this
facility in coming days?
c) If Yes, how are you
using it for patient care?
d) Does it have minimum
requirements?
Admin interview /
Tele-stroke facility
visit (whether the
facility is mentoring
the thrombolysis in at
district hospital via tele
technology platform)
a. YES/NO
b. SCORE
c. COMMENT
d. sSCORE 189
Annexure-II: Study Tool
Section-C: Ed Protocol/Sop and Guidelines (Score: 1-No, 2- Partial,
3- Yes)
SN. OBJECTIVE ELEMENTSCheck Point SCORE
Remarks
(If any)
1.
a. Do you have documented
Emergency Manual at the
point of care?
b. If yes, only documented/
implemented?
c. If implemented, off-on
implemented/regular?
d. If no, what is the protocol?
Protocol /SOP and
procedures for emergency
care are documented and
operations in ED must
be guided by them (e.g.
Clinical Protocol/Treatment
guidelines.)
SCORE
SCORE
SCORE
REMARKS
2.
e. Do you have documented
triage guidelines and
protocol?
f. If no, how you manage
patients in emergency
department?
Triage protocol /SOP and
procedures for emergency
care are documented and
operations in ED must be
guided by them
SCORE REMARKS
3.
g. Do you have documented
policies and procedures
which guide the transfer
of patients into the
organization?
h. If yes, only documented/
implemented?
i. If implemented, off-on
implemented/ regular?
j. If no, what is the protocol?
Outside patients are
admitted only after proper
referral by a doctor with
prior communication
depending on the services
provided and bed
availability.
SCORE
SCORE
SCORE
REMARKS
4.
k. Do you have documented
policies and procedures
which guide the transfer-out/
referral of stable and unstable
patients after stabilization to
another facility in appropriate
manner with documentation?
l. If yes, only documented/
implemented?
m. If implemented, off-on
implemented/ regular?
n. If no, what is the protocol?
Documentation of referrals,
advance communication,
written orders by treating
doctor and consent of the
attendant/patient taken.
SCORE
SCORE
SCORE
d) REMARKS
5.
a. Do you give discharge
summary to all patients?
b. If no, which procedure you
follow?
Discharge with regard
to LAMA, DAMA, MLC,
Abscond (Clearly mentions
the treatment given, name
of the treating doctor etc.)
SCORE b) REMARKS Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 190
6.
a. Do you have policy on
handling cases of death
(outside and inside hospital)
mentioned in manual?
b. If no, how you manage death
cases?
To make MLC, intimate
police, dead body hand
over etc.
SCORE b) REMARKS
7.
a. Do you have documented
disaster management plan?
b. If no, which procedure you
follow?
SCORE b) REMARKS
8.
Is there a triage policy/system at
your emergency department? If
Yes then:
a. Are you using triage?
b. Is there a dedicated triage
nurse?
c. Is there a colour triage band
available?
d. Is there any regular audit of
your triage system?
Verify written SOP &
Interview
YES/ NO
a) SCORE
b) SCORE
c) SCORE
d) SCORE
9.
Do you have alert system: code
Blue?
Verify written SOP &
Interview
SCORE
10.
Do you have alert system:
Trauma?
Verify written SOP &
Interview
SCORE
11.
Do you have alert system: Chest
Pain?
Verify written SOP &
Interview
SCORE
12.Do you have alert system: Sepsis?
Verify written SOP &
Interview
SCORE
13.Do you have alert system: Stroke?
Verify written SOP &
Interview
SCORE
Section-D: Safety & Security (Score: 1-No, 2- Partial, 3- Yes)
S. No. Objective ElementsCheck PointScore Remarks (If Any)
1.Do you have fire safety?
Admin interview/smoke detectors, fire
extinguishers (class A, B , C or ABC
type) Sign postings, Fire exits etc.
SCORE
2.
Do you have building
safety?
Admin InterviewSCORE
3.
Do you have electrical
safety?
Admin interview/UPS, Generators for
monitors and ventilators etc.
SCORE
4.
Do you have patient and
provider safety?
Side rails, window grills, etc. SCORE
5.
Do you have chemical
safety?
Regular sterilization, safety hazard
specially PEP, Pre-exposure
immunization such as swine flow, etc.
SCORE 191
Annexure-II: Study Tool
6.
a) Do you have periodic
training of staff? (Every 6
months )
b) Do you have periodic
mock drill? (Every 6
months )
Admin interview/Response time
measured and corrective measures
taken (Record maintained)
SCORE
5
Do you have police
post available within the
premises?
Admin interview/Facility visit SCORE
6
Do you have alarm bell
in Emergency/ Code
announcement available
for extra help?
Admin interview/ Facility visit/Security
system is in place in case of violence,
mass situation in ED
SCORE
Section-E: Disaster Management (Score: 1-No, 2- Partial, 3- Yes)
S.
No.
Objective ElementsCheck PointScore Remarks
1
Do you have disease outbreak
management plan?
Admin interview/ See Plan
document [e.g. for Dengue,
malaria etc. and other community
emergencies]
SCORE
2
Do you have surge capacity in
your hospital?
Admin interview/ Facility visit
[Triage area is marked, expansion
of care area, line of authority is
clear, internal communication
system]
SCORE
3
Do you have separate
decontamination area at ED
entrance?
Admin interview/ Facility visit
[Provision for flexible and
expandable facility]
YES/NO
4
Do you have separate disaster
stock in ED?
If yes, for how many patients
(e.g. 50, 100)?
Admin interview/ Facility visit
[Medical supplies, manpower,
medicines etc.]
SCORE
NUMBER
5
Does drill is conducted and
debriefing is done for disaster
management?
Admin interview/ See Plan
document [Role and responsibility
of staff in disaster is checked and
recorded]
SCORE
6
Do you have system to
redistribution of patients to
other network hospitals during
disaster?
Admin interview/ See Plan
document [Prior plan for increased
load of patients]
SCORE Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 192
Section-F: Continuous Quality Improvement (Score: 1-No,
2- Partial, 3- Yes)
S.No. Objective ElementsCheck Point Score
Remarks
(If Any)
1.
Do you have dedicated staff
for gap identification and loop
closure?
Admin interview
(Dedicated staff can be: Patient
safety nurse, Infection control nurse,
Emergency nurse coordinators,
Quality manager)
SCORE
2.
Do you have regular audits in
your hospital?
Admin interview
[Death audits and post event
analysis etc./
Clinical audit]
SCORE
3.
Do you have continuous
education and training
programs cycles for
professional development and
skill improvement?
Admin interview
(Trainings like- ACLS, BLS, ATLS,
etc.)
SCORE
4.
Do you have key indicators of
quality monitored?
Admin interview
[Key Indicators are Mortality rate,
Referral rate, Return to ER, LAMA,
Absconding rate]
SCORE
5.
Are quality indicators for
urgent and interventional
procedures monitored?
(% of patients receiving
interventions is documented,
at-least 50%)
Admin interview
[e.g. 1. MI- (Door to needle -30
mins thrombolysis, door to balloon
time 90 mins PCI) 2. Stroke: (door
to needle time 60 mins) 3. Trauma
resuscitation (30 min of arrival) ]
SCORE
6.
Do you have death review
committee?
Admin interviewSCORE
7.
Do you have Central
Empowered Hospital
committee for continuous
quality improvement of
Emergency services?
Admin interviewSCORE 193
Annexure-II: Study Tool
Section-G: Data Management System (Score: 1-No,
2- Partial, 3- Yes)
S.No.Objective ElementsCheck Point Score
Remarks
(If Any)
1.
Do you have Integrated Computerized EHR
(Registration, Clinical care, Lab, Radiology,
Others and Disposal)?
Admin interview SCORE
2.
Do you have Computerized Patient
Registration system?
Admin interview SCORE
3.
Do you have Computerized Patient clinical
examination notes?
Admin interview SCORE
4.
Do you have Computerized Patients
investigation Lab reports?
Admin interview SCORE
5.
Do you have Computerized Patients
radiological investigation reports?
Admin interview SCORE
6.Do you have Trauma registry?Admin interview SCORE
7.Do you have Injury Surveillance system? Admin interview SCORE
8.
Do you have Emergency Department
Surveillance system?
Admin interview SCORE
9.
Do you have data retrieval system for Quality
Improvement & Research?
Admin interview SCORE
Section-H: Financing (Score: 1-No Funds, 2-Not Sufficient,
3-Sufficient)
Sn. Objective ElementsCheck Point Score Remarks
1.
Do you have Central Govt. funds for
Emergency and Trauma services?
Admin interviewSCORE
2.
Do you have dedicated State Govt. funds
for Emergency and Trauma services?
Admin interviewSCORE
3.
If funds are available, which health
protection schemes are covering your
emergency care system?
Admin interview —
NAME THE
SCHEME
4.
Full Utilization of funds (Annual
utilization)?
Admin interviewSCORE
5.Is there any delay in release of funds?Admin interviewSCORE Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 194
ANNEXURE-1: PHYSICAL INFRASTRUCTURE
1. OUTSIDE EMERGENCY (SCORE: 1-NO, 2- PARTIAL, 3- YES)
S.N. Objective pointsCheck pointScore
1.
Does the hospital have easy and
direct access to the Emergency
Department?
Adequate Signage on the major road and
boundary of the Hospital, E.D Board is
prominently
displayed with illumination in night facility
Score
2.
Does the access road of hospital is
wide enough?
Can pass three ambulances at a time Score
3.
Does the vehicles parked on
the way /in front of emergency
department?
People are using as parking lotScore
4.
Does the hospital have separate
access for ambulance services?
Sufficient space for Ambulance offloading and
turn-around
Score
5.
Does the hospital have designated
parking area for Ambulance, Staff
and Public?
No vehicles parked on the way/in front of
emergency
parking, “No Parking Board” placed outside
emergency
Score
6.
Does the hospital have smooth entry
area with adequate wheel chair,
trolley and stretcher bay?
Entrance have a canopy, ramp for stretchers
and wheelchairs
with Demarcated space for trolleys and
wheelchair
Score
7.
Does the hospital have patient
attendant at the entrance of hospital
to help the patient with the wheel
chair, stretcher, etc.?
Staff Responds with a wheel chair, stretcher,
trolley promptly
Score
8.Seamless flow of the patient
Unidirectional flow, separate entrance, no
crisscross.
Score
9.
Does the services provided to
the patients are clearly defined,
displayed prominently?
signage/ boardsScore
10.
Does the names of the doctors and
nursing staff on shift/duty/call are
displayed and updated?
Score
11.
Is important Telephone numbers are
displayed in hospital?
numbers including emergency no, ambulance,
blood bank, police, referral centers etc.
displayed
Score
12.
Does all relevant information is
displayed for the patients and
visitors including user charges
wherever applicable at the time of
procedure/ investigation/admission?
Service charges/ User charges are displayed
on a board/printed on pamphlet/ personally
counseled, enquiry counter/Help desk/
registration counter / designated staff.
Score 195
Annexure-II: Study Tool
13.Do you have adequate waiting area?It has comfortable seating , information boardScore
14.
Do you have safe drinking water
facility?
24hrs drinking water facilityScore
15.
Do you have functional male toilets?
Do you have functional female
toilets?
Do you have functional toilets for
differently able person with wheel
chair?
Male toilet, Female toilet, Toilet for differently
able with ( at least 1 wheelchair accessible
W.C and wash basins present)
Score
16.
Do you have clean facility and is
that maintained adequately?
Building is painted, plastered, no cracks and
seepage visible and furniture fixtures clean and
intact with no junk around
Score
17.
Do you have Cafeteria facility for
the family members/ attendants?
Score
18.Do you have police control room?Score
19.
Do you have Emergency Registration
Counter?
Score
20.
Do you have ambulance driver’s
room?
Ambulance driversScore
Remarks (if any):
2. INSIDE EMERGENCY (SCORE: 1-NO, 2- PARTIAL, 3- YES)
SN Objective ElementsCheck PointScore
1.
Do you have emergency department
with adequate space as per patient load
(Circulation space and open space)?
Admin interview / 1000 m2 per 100patient
daily load (NQAS standards),Corridors are
broad enough (2-3m) for easy movement
of stretcher and Trolley
Score
2.
Does your department has proper layout
and demarcated areas as per Triage?
1.Resuscitation Area(Red)
2.Observation Area(Yellow)
3 Ambulatory Area (Green)
Score
3.
Do you have demarcated station for
doctors and nurses?
Preferably in the center from where all
beds are visible
Score
4.Do you have demarcated plaster room?Score
5.
Do you have dedicated Isolation rooms
(Emergency Infections)?
Negative pressure and separate AHUe.g.
Swine flu/Ebola pts.
Score
6.Do you have dedicated minor OT?Score
7.
Do you have provision for Emergency
OT?
Score Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 196
8.Do you have point of care lab? Designated lab area in emergency Score
9.
Do you have linkage to other facility on
the same floor?
Radiology department, OT, Lab etc.
Score
10.
Do you have separate room for
examination of rape / sexual assault
victim?
As per One stop Centre
Score
11.
Do you have availability of sexual assault
forensic evidence kit?
Kit has protocols and guidelines for
collection of forensic evidence.
Score
12.
Do you have counselling services for
Sexual assault / domestic violence cases?
Score
13.
Do you have demarcated area for
keeping dead bodies?
Score
14.
Do you have availability of clean utility
room?
Score
15.
Do you have availability of dirty utility
room?
Score
16.
Do you have store?Storage to refrigerate, keep equipment &
Emergency supplies
Score
17.
Do you have curtains/screens at point of
care?
Privacy and dignity of patients maintained.
Score
18.
Do you have demarcated duty room for
doctors?
Score
19.
Do you have demarcated duty room for
nursing staff?
Score 197
Annexure-II: Study Tool
ANNEXURE-2: MANPOWER IN EMERGENCY
S.N. Category
Private Govt. Hospitals Medical Colleges
Less than
300 beds
More
than 300
beds
Less than
300 beds
More
than 300
beds
Govt.
Medical
Private
Medical
1.Faculty/Consultant
2.CMO (casualty medical
officer)
3.SR ( Senior Residents )
4.JR ( Junior Residents)
5.MO (medical officer)
6.Intern
7.Nursing officer In charge /
Team leader
8.Staff Nurse/ Nursing Officer
9.Radiology technician/
Radiographer
10.Lab Technician
11.OT. Technician
12.H.A*/ GDA*/ Orderly
13.SA*/ Housekeeping staff
14.EMT
15.Security
16.Registration staff
17.Any other
*
GDA-General Duty Assistant, SA- Sanitary Attendant HA- Hospital Attendant
Other Specialist/ Super Specialist
S.N. Specialty Designation Timings
24x7 Physically
present
On-Call
Empanelled
(As and when
Required)
1.Medicine Consultant
Resident
2.General Surgery Consultant
Resident
3.Pediatrics Consultant
Resident Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 198
4.
Gynecology&
Obstetrics
Consultant
Resident
5.Orthopedics Consultant
Resident
6.Radiology Consultant
Resident
7.Anesthesia Consultant
Resident
8.Critical care Consultant
Resident
9.Ophthalmology Consultant
Resident
10.ENTConsultant
Resident
11.Psychiatry Consultant
Resident
12.Dermatology Consultant
Resident
13.
Forensic
Medicine
Consultant
Resident
14.Lab Medicine Consultant
Resident
15.
Transfusion
Medicine/ Blood
Bank
Consultant
Resident
16.Cardiology Consultant
Resident
17.
CTVS (Cardiac
Surgery)
Consultant
Resident
18.Neurology Consultant 199
Annexure-II: Study Tool
Resident
19.Neurosurgery Consultant
Resident
20.Plastic Surgery Consultant
Resident
21.
Maxillofacial
Surgery
Consultant
Resident
22.Gastroenterology Consultant
Resident
23.Nephrology Consultant
Resident
24.Urology Consultant
Resident
25.Neuro Radiology Consultant
Resident
26.Pediatric SurgeryConsultant
Resident
27.Neonatology Consultant
Resident
28.Hematology Consultant
Resident
29.Oncology Consultant
Resident Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 200
ANNEXURE-3: EQUIPMENTS & SUPPLIES IN ED
BIO MEDICAL EQUIPMENT (SCORE: 1-NO, 2- PARTIAL, 3- YES)
S.N.OBJECTIVE ELEMENTCheck points SCORE
1.
Do you have list of equipment in accordance with its
scope of services available?
SCORE
2.
Do you have medical equipment inventory and log
book?
Logs are maintained for
operational
and maintenance purposes
SCORE
3.
Do you have periodically inspected and calibrated
equipment record?
SCORE
EQUIPMENTS & SUPPLIES IN ED (SCORE: 1-NO, 2- PARTIAL, 3- YES)
S. No.24x7 availability of Score Remarks
1. Do you have mobile bed for Resuscitation?Score Remarks
2. Do you have crash cart (specialized cart for resuscitation)? Score Remarks
3. Do you have Hard Cervical collar?Score Remarks
4. Do you have Central Oxygen Supply through pipeline?Score Remarks
5. Do you have Oxygen cylinder?Score Remarks
6. Do you have suction machine?Score Remarks
7. Do you have Multipara Monitor (To monitor Heart rate, BP,
SPO2[Essential] ECG, Respiration Rate [Desirable] etc)?
Score Remarks
8. Do you have simple monitor/transport monitor?Score Remarks
9. Do you have defibrillator with external pacer?Score Remarks
10.Do you have Toothed Forceps, Kocher Forceps, Magill’s forceps,
Artery forceps?
Score Remarks
11.Do you have transport ventilator?Score Remarks
12.Do you have AMBU Bag for adult and Paediatric?Score Remarks
13.Do you have suprapubic catheter?Score Remarks
14.Do you have light source to ensure visibility (lamp and flash light)?Score Remarks
15.Do you have stethoscope?Score Remarks
16.Do you have oropharyngeal airway adult and pediatric blades? Score Remarks
17.Do you have LMA?Score Remarks
18.Do you have tourniquet?Score Remarks
19.Do you have pelvic binder or bed sheets with clips?Score Remarks
20.Do you have needle holder and suture material (absorbable and non
absorbable)?
Score Remarks 201
Annexure-II: Study Tool
21.Do you have vaginal speculum?Score Remarks
22.Do you have different sizes of Ryles tube?Score Remarks
23.Do you have different sizes of Foley’s catheter?Score Remarks
24.Do you have laryngoscope with all sized blades?Score Remarks
25.Do you have Endotracheal Tubes of all sizes?Score Remarks
26.Do you have Laryngeal Mask Airway (LMA)?Score Remarks
27.Do you have Chest Tubes with Water seal drain?Score Remarks
28.Do you have Blood Pressure monitor?Score Remarks
29.Do you have ECG machine?Score Remarks
30.Do you have ultrasonic nebulizer?Score Remarks
31.Do you have IV cannula and IV infusion sets?Score Remarks
32.Do you have syringes and disposable needles?Score Remarks
33.Do you have broselow tape?Score Remarks
34.Do you have proctoscope?Score Remarks
35.Do you have fluid warmer?Score Remarks
36.Do you have dressing sets (Alcohol based solution, Betadinesolution
gauze, roller, adhesive tape)?
Score Remarks
37.Do you have personal protecting equipment’s (Apron, glove, face
mask, eye protection)?
Score Remarks
38.Do you have central line of all sizes?Score Remarks
39.Do you have capnography?Score Remarks
40.Do you have Infusion pump and Syringe Drivers?Score Remarks
41.Do you have spine board with sling and scotch tapes all sizes? Score Remarks
42.Do you have splints for all types of fracture?Score Remarks
43.Do you have non-invasive and invasive ventilators?Score Remarks
44.Do you have incubators?Score Remarks
45.Do you have emergency cricothyroidotomy kit?Score Remarks
46.Do you have emergency thoracotomy set?Score Remarks
47.Do you have emergency decompressive craniotomy sets?Score Remarks
48.Do you have emergency thrombectomysets?Score Remarks
49.Do you have phototherapy unit?Score Remarks
Remarks (if any): Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 202
ANNEXURE-4: POINT OF CARE LAB
(SCORE: 1-NO, 2- PARTIAL, 3- YES)
S. No.Point of Care Lab In ED In HospitalRemarks
1.Hemogram- Hb, Hct, TLC, DLC, PlateletScore Score Remarks
2.Random Blood SugarScore Score Remarks
3.Coagulation Profile: PT, APTT, INRScore Score Remarks
4.Electrolytes: Na, K, Cl, CaScore Score Remarks
5.Blood Urea & Serum CreatinineScore Score Remarks
6.Blood Gas AnalysisScore Score Remarks
7.Cardiac enzymes, Trop-I, Trop-T, Score Score Remarks
8.Serum AmylaseScore Score Remarks
9.D-dimer, Score Score Remarks
10.Pro-BNPScore Score Remarks
11.Urinary KetonesScore Score Remarks
12.Plasma KetonesScore Score Remarks
13.Toxicology screening- UrinaryScore Score Remarks
14.Serum osmolalityScore Score Remarks
15.Urine osmolalityScore Score Remarks
16.Pregnancy testScore Score Remarks
17.Thromboelastogram (TEG)Score Score Remarks
18.Peak expiratory FlowmeterScore Score Remarks
19.Microscopy: Thick & Thin smear (For Malaria parasite &
Gram staining)
Score Score Remarks
20.Rapid diagnostic test for Malaria (Card test) Score Score Remarks
21.CSF: Microscopy & Gram stainingScore Score Remarks
22.Portable USG (Bed side/Point of Care) Score Score Remarks
23.EchocardiographyScore Score Remarks
24.Portable X-ray (Bed side/Point of Care)Score Score Remarks
25.CT scanScore Score Remarks
Remarks (if any): 203
Annexure-II: Study Tool
ANNEXURE-5: ESSENTIAL MEDICINES FOR EMERGENCY
(SCORE: 1-NO, 2- PARTIAL, 3- YES)
S. No. Drug Name ScoreS. No. Drug Name Score
1.Oxygen medicinal gas Score 27.PhenobarbitoneScore
2.Thiopentone sodiumScore 28.PhenytoinScore
3.
Lignocaine hydrochloride (Jelly
sterile)
Score 29.Amoxicillin + Clavulanic acidScore
4.Lignocaine hydrochloride (Inj.)Score 30.Ampicillin sodiumScore
5.AtropineScore 31.Benzathine penicillin Score
6.DiazepamScore 32.CefotaximeScore
7.DiclofenacScore 33 Ceftriaxone powder Score
8.IbuprofenScore 34.AmikacinScore
9.Paracetamol (Tablet) Score 35.CiprofloxacinScore
10.Paracetamol (Syrup) Score 36.Gentamycin sulphate Score
11.Paracetamol (Inj.)Score 37.MetronidazoleScore
12.Morphine sulphateScore 38.Heparin sodiumScore
13.Tramadol hydrochloride (Tablet)Score 39.EthamsylateScore
14.Tramadol hydrochloride (Inj.)Score 40.Vitamin KScore
15.CetrizineScore 41.Plasma volume exppander Score
16..Pheniramine maleate Score 42.DiltiazemScore
17.Dexamethasone disodium Score 43.Glycerinetrinitrate Score
18.Hydrocortisone sodium SuccinateScore 44.GlycerinetrinitratenitroglycerineScore
19.AdrenalineScore 45.Isosorbidemononitrate Score
20.Charcoal activatedScore 46.Isosorbidedinitrate Score
21.Antisnake venomScore 47.Adenosine phosphate Score
22.Calcium gluconateScore 48.DobutamineScore
23.Naloxone hydrochloride Score 49.Dopamine hydrochloride Score
24.Pralidoxime (PAM)Score 50.StreptokinaseScore
25.LorazepamScore 51.Potassium permanganate Score
26.Magnesium sulphateScore 52.Silver sulfadiazine Score
53.Calamine lotionScore 78.XylometazolineScore
54.Povidone iodine (Solution) Score 79.GlycerineScore
55.Povidone iodine (Ointment) Score 80.OxytocinScore
56.FurosemideScore 81.HaloperidolScore
57.MannitolScore 82.AlprazolamScore
58.RantidineScore 83.AminophyllineScore
59.Metoclopramide hydrochloride Score 84.Ipratropium bromide – aerosolScore Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 204
60.ProchlorperazineScore 85.Salbutamol sulphate Score
61.OndansetronScore 86.Etophylline + Theophylline Score
62.Promethazine hydrochloride Score 87.BudesonideScore
63.PromethazineScore 88.Glucose/dextroseScore
64.Hyiscine butyl bromide Score 89.
Glucose with sodium chloride/
saline
Score
65.Glycerine salineScore 90.Potassium chloride Score
66.Oral rehydration salts Score 91.Ringer lactateScore
67.Insulin (soluble)Score 92.Sodium bicarbonate Score
68.Intermediate-acting insulin (Lente)Score 93.Sodium chlorideScore
69.Anti-Rabies Immunoglobulin Score 94.Water for injection Score
70.Tetanus vaccineScore 95.ArtesunateScore
71.Anti-Rabies vaccine Score 96.ArtemetherScore
72.NeostigmineScore 97.Quinine (Dihydrochloride) Score
73.CiprofloxacinScore 98.Chloroquinine phosphate Score
74.Atropine sulphateScore 99.AmiodaroneScore
75.Tropicamide + Phenylepherine Score100.DigoxinScore
76.Sodium carboxymethyl celluloseScore101.PantoprazoleScore
77.SalineScore
Remarks (if any): 205
Annexure-II: Study Tool
LIVE OBSERVATION
1.Name of the hospital: Name of Inspection Team Member:
1.
2.
3.
2.Type of Health Care
Facility
District Hospital
Tertiary Care
Apex Tertiary CarDate of Inspection:
INITIAL ASSESSMENT AND REASSESSMENT
(Score: 1-No/Never, 2- Partial, 3- Yes (24X7 basis)
S.N.Objective ElementsCheck Point Score
1.Does the emergency department priorities initial
assessment of the patient?
Time: Red – 10 mins, Yellow- 30
mins, Green- 4 hours of arrival
SCORE
2.Does the hospital staff record all treatment,
assessment and reassessment details in patient
record sheet?
Direct Observation & Patient
records (Only few samples)
SCORE
3.Record the disposition time of patients from their
arrival to departure from hospital [in minutes].
Minimum number of patients to be recorded:
RedYellowGreenDisposal Time
(Emergency
Department)
= Arrival time
(Registration time)
to Admission/
discharge/ transfer
out time
>500 beds 5 5 10
300-500
beds
2 2 5
100-300
Beds
2 2 5
Red Yellow Green
P1:
Disposal
Time
P1:
Disposal
Time
P1:
Disposal
Time
P6:
Disposal
Time
P2:
Disposal
Time
P2:
Disposal
Time
P2:
Disposal
Time
P7:
Disposal
Time
P3:
Disposal
Time
P3:
Disposal
Time
P3:
Disposal
Time
P8:
Disposal
Time
P4:
Disposal
Time
P4:
Disposal
Time
P4:
Disposal
Time
P9:
Disposal
Time
P5:
Disposal
Time
P5:
Disposal
Time
P5:
Disposal
Time
P10:
Disposal
Time
1. CHEST PAIN
Instructions: Please, score YES/ NO below the objective elements (check points) in the table.
If No, than reason should be score for the categories provided below based on scale (1-5). The
scale score for each category will be as follows: Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 206
a. Manpower (Score 1-5) – 1: Minimal manpower, 2: Inadequate manpower in all shifts, 3:
Inadequate manpower in some shifts, 4: Adequate manpower with coverage5: Adequate
manpower available for 24*7
b. Training (Score 1-5) –1: None, 2: Only few are trained, 3:Only doctors are trained, 4: Mostly
staff are trained, 5: All are trained
c. Supply (Score 1-5)–1:No supply available, 2: Minimal Supply available, 3: Inadequate supply
available only in some shifts, 4: Inadequate supply available on 24*7 basis, 5: Adequate
supply available for 24*7
d. Infrastructure (Score 1-5)–1: No infrastructure and no tie up with other facilities, 2: Not
having any infrastructure but tie up with other facilities, 3: Infrastructure available but
not functioning at all, 4: Infrastructure available but functioning only for limited hours, 5:
Infrastructure available for 24*7
e. Policy (Score 1-5)–1: No policy available, 2: Some policy is available but not standard, 3:
Organizational policy in place but not in use, 4: Organizational policy in place but sometime
in use, 5: Organizational policy in place and in use
Objective ElementsPatient 1
Triage (Red)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to ECG (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door To
Needle(<30min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to PCI; wire
crossing (<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify 207
Annexure-II: Study Tool
Objective ElementsPatient 2
Triage (Red)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to ECG (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door To Needle(<30min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to PCI; wire crossing
(<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 3
Triage (Red)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to ECG (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door To Needle(<30min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 208
Door to PCI; wire crossing
(<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 4
Triage (Red)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to ECG (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door To Needle(<30min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to PCI; wire crossing
(<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 5
Triage (Red)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to ECG (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify 209
Annexure-II: Study Tool
Door To Needle(<30min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to PCI; wire crossing
(<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
2. STROKE
Instructions: Please, score YES/ NO below the objective elements (check points) in the table.
If No, than reason should be score for the categories provided below based on scale (1-5). The
scale score for each category will be as follows:
a. Manpower (Score 1-5) – 1: Minimal manpower, 2: Inadequate manpower in all shifts, 3:
Inadequate manpower in some shifts, 4: Adequate manpower with coverage5: Adequate
manpower available for 24*7
b. Training (Score 1-5) –1: None, 2: Only few are trained, 3:Only doctors are trained, 4: Mostly
staff are trained, 5: All are trained
c. Supply (Score 1-5)–1:No supply available, 2: Minimal Supply available, 3: Inadequate supply
available only in some shifts, 4: Inadequate supply available on 24*7 basis, 5: Adequate
supply available for 24*7
d. Infrastructure (Score 1-5)–1: No infrastructure and no tie up with other facilities, 2: Not
having any infrastructure but tie up with other facilities, 3: Infrastructure available but
not functioning at all, 4: Infrastructure available but functioning only for limited hours, 5:
Infrastructure available for 24*7
e. Policy (Score 1-5)–1: No policy available, 2: Some policy is available but not standard, 3:
Organizational policy in place but not in use, 4: Organizational policy in place but sometime
in use, 5: Organizational policy in place and in use Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 210
Objective ElementsPatient 1
Door to Doctor (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion
(<25min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT reading (<45
min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to Thrombolytic
(<60 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to first pass
(<90min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 2
Door to Doctor (<10min)YES/ NO
If No, than score the reasons
Manpower Training SuppliesInfrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion
(<25min)
YES/ NO
If No, than score the reasons
Manpower Training SuppliesInfrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify 211
Annexure-II: Study Tool
Door to CT reading (<45 min)YES/ NO
If No, than score the reasons
Manpower Training SuppliesInfrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to Thrombolytic (<60
min)
YES/ NO
If No, than score the reasons
Manpower Training SuppliesInfrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to first pass (<90min)YES/ NO
If No, than score the reasons
Manpower Training SuppliesInfrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 3
Door to Doctor (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion
(<25min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT reading
(<45 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to Thrombolytic
(<60 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 212
Door to first pass (<90min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 4
Door to Doctor (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion
(<25min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT reading
(<45 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to Thrombolytic
(<60 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to first pass (<90min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify 213
Annexure-II: Study Tool
Objective ElementsPatient 5
Door to Doctor (<10min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion
(<25min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to CT reading
(<45 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to Thrombolytic
(<60 min)
YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
Door to first pass (<90min)YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5)Score (1-5)
Any Other ReasonPlease Specify
3. TRAUMA (RED CATEGORY)
Instructions: Please, score YES/ NO below the objective elements (check points) in the table.
If No, than reason should be score for the categories provided below based on scale (1-5). The
scale score for each category will be as follows:
a. Manpower (Score 1-5) – 1: Minimal manpower, 2: Inadequate manpower in all shifts, 3:
Inadequate manpower in some shifts, 4: Adequate manpower with coverage5: Adequate
manpower available for 24*7 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 214
b. Training (Score 1-5) –1: None, 2: Only few are trained, 3:Only doctors are trained, 4: Mostly
staff are trained, 5: All are trained
c. Supply (Score 1-5)–1:No supply available, 2: Minimal Supply available, 3: Inadequate supply
available only in some shifts, 4: Inadequate supply available on 24*7 basis, 5: Adequate
supply available for 24*7
d. Infrastructure (Score 1-5)–1: No infrastructure and no tie up with other facilities, 2: Not
having any infrastructure but tie up with other facilities, 3: Infrastructure available but
not functioning at all, 4: Infrastructure available but functioning only for limited hours, 5:
Infrastructure available for 24*7
e. Policy (Score 1-5)–1: No policy available, 2: Some policy is available but not standard, 3:
Organizational policy in place but not in use, 4: Organizational policy in place but sometime
in use, 5: Organizational policy in place and in use
Objective ElementsPatient 1
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion time
in Head Injury (<45min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Disposal time (Arrival time
to Admission/Transfer out/
Death declaration time)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify 215
Annexure-II: Study Tool
Objective ElementsPatient 2
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion time
in Head Injury (<45min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Disposal time (Arrival time
to Admission/Transfer out/
Death declaration time)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 3
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion time
in Head Injury (<45min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Disposal time (Arrival time
to Admission/Transfer out/
Death declaration time)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 216
Objective ElementsPatient 4
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion time
in Head Injury (<45min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Disposal time (Arrival time
to Admission/Transfer out/
Death declaration time)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Objective ElementsPatient 5
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Door to CT completion time
in Head Injury (<45min)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify
Disposal time (Arrival time
to Admission/Transfer out/
Death declaration time)
YES/ NO
If No, than reason
Manpower TrainingSupplies Infrastructure
Policy or
Guidelines
Score (1-5)Score (1-5)Score (1-5)Score (1-5) Score (1-5)
Any Other ReasonPlease Specify 217
Annexure-II: Study Tool
Incidence of Violence
Is there any violence with patient or healthcare provider observed?
1.1. If yes, than violence observed (please tick) was: (1) Verbal (2) Physical (3) Both
1.2. Please tick the reason of the violence that was observed; (1) Communication Failure
(2) Care Delay (3) Inappropriate Care (4) Inappropriate Behavior of healthcare
professional
1.3. Mitigation measures available:
Private Security Guard Yes/No
If yes, Available for 24*7 basis Yes/No
Police Available Yes/No
If yes, Available for 24*7 basis Yes/No
Anti-violence mitigation policy available Yes/No
Communication in Emergency Department
Mention the type of communication followed by the healthcare providers/staff/nurses with the
patients in emergency department (Please tick below).
1. Full content with empathy and share decision making
2. Full content with empathy and no share decision making
3. Full content with no empathy
4. Minimal communication and inappropriate behaviour
5. No communication at all
Patient Satisfaction
Perform one interview with patient or relative of the patient and please ask the following questions:
1. For Patient in Red Triage;
1.1. Does the patient/relative is satisfied with the emergency department services?Yes/No
If yes, please ask the patient satisfaction level based on the scale:
Extremely
Satisfied
Very
Satisfied
Moderately
Satisfied
Slightly
Satisfied
Not at all
Satisfied
If not satisfied, reason ............................................
2. For Patient in Yellow Triage;
2.1 Does the patient/relative is satisfied with the emergency department services?Yes/No
If yes, please ask the patient satisfaction level based on the scale: Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 218
Extremely
Satisfied
Very
Satisfied
Moderately
Satisfied
Slightly
Satisfied
Not at all
Satisfied
If not satisfied, reason ............................................
3. For Patient in Green Triage;
3.1 Does the patient/relative is satisfied with the emergency department services?Yes/No
If yes, please ask the patient satisfaction level based on the scale:
Extremely
Satisfied
Very
Satisfied
Moderately
Satisfied
Slightly
Satisfied
Not at all
Satisfied
If not satisfied, reason ............................................
Referral of the Patient
What is the referral policy of patient in the organization? Please answer (Yes/No) the following
questions:
1. Is there any referral policy in the organization? Yes/No
2. Is there any proper arrangement of patient referral? Yes/No
3. Is there any assistance during the patient referral? Yes/No
3.1. If Yes, type of assistance
(1) Technician (2) Nurse (3) Doctor (4) Other
(If other, please specify ............................................)
Details of the patient to be filled by registration desk for last
24 Hours
Health Facility Name:Time:Date:
Total Patients visited in Hospital for last 24
Hours
Numbers
Adult- Pediatric-
(please write the cut off
age)
Total Number of Patients visited in Emergency
Department for last 24 Hours
Numbers
Adult- Pediatric-
(please write the cut off
age)
Total admissions in emergency department
Numbers
Adult- Pediatric-
(please write the cut off
age) 219
Annexure-II: Study Tool
Total Leaving Against Medical Advice (LAMA)
from emergency department
Numbers
Adult- Pediatric-
(please write the cut off
age)
Total discharge from emergency department
Numbers
Adult- Pediatric-
(please write the cut off
age)
Total Death in emergency department
Numbers
Adult- Pediatric-
(please write the cut off
age)
Total Death in emergency department-
Trauma/Injury/Road Traffic Accidents
Numbers
Adult- Pediatric-
(please write the cut off
age) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 220
Adult Patients
(Please tick one check box for one patient)
Pediatric Patients
(Please tick one check box for one patient)
1. Chest Pain Patients1. Respiratory distress
2. Stroke2. Diarrheal disease
3. Altered Mental status3. Altered Mental status 221
Annexure-II: Study Tool
Adult Patients
(Please tick one check box for one patient)
Pediatric Patients
(Please tick one check box for one patient)
4. Trauma/ Road Traffic Accidents/
Injuries
4. Trauma/ Road Traffic Accidents/
Injuries
5. Respiratory Distress5. Seizure
6. Pain abdomen6. Pain abdomen Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 222
Adult Patients
(Please tick one check box for one patient)
Pediatric Patients
(Please tick one check box for one patient)
7. Poisoning7. Poisoning
8. Snake Bite8. Snake Bite
9. Fever9. Fever 223
Annexure-II: Study Tool
Adult Patients
(Please tick one check box for one patient)
10. Pregnancy Related Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 224
ANNEXURE-III:
LIST OF SCIENTIFIC ADVISORY
COMMITTEE MEMBERS
S.
No.
Name of Member DesignationE-mail ID
1.
Dr. Prof. Anurag
Srivastava
Professor & Head of
Department of Surgical
Disciplines, AIIMS, New
Delhi
dr.anuragsrivastava@gmail.com
2.
Dr. Prof. Ashish
Bhalla
Professor, Department of
Internal Medicine, PGIMER,
Chandigarh
bhalla.chd@gmail.com
3.
Dr. Prof. Ashok
Deorari
Department of Neonatology,
AIIMS, New Delhi
ashokdeorari_56@hotmail.com
4.
Dr. Prof. D.
Prabhakaran
Vice President (Research&
Policy), Public Health
Foundation of India
Executive Director of Centre
for Chronic Disease Control
New Delhi
dprabhakaran@phfi.org
5.
Dr. Prof. Deepak
Agarwal
Professor, Department of
Neurosurgery, JPNATC,
New Delhi
drdeepak@gmail.com
6.
Dr. Gururaj
Gopalakrishnan
Department of Epidemiology
WHO Collabrating Centre
for Injury Prevention &
Safety Promotion Centre for
Public Health
epiguru@yahoo.com, guru@
nimhans.kar.nic.in 225
Annexure-III: List of Scientific Advisory Committee Members
S.
No.
Name of Member DesignationE-mail ID
7.
Dr. Jayaraj
Mymbilly
Balakrishnan
Professor & Head of
Department of Emergency
Medicine, KMC, Mangalore
jayarajmb2004@gmail.com
8.
Dr. Jayashree
Muralidharan
Department of Pediatrics,
Advanced Pediatrics Centre,
PGIMER, Chandigarh
mjshree@hotmail.com
9.
Dr. Prof.
Kameshwar
Prasad
Professor Ex- HOD,
Department of Neurology,
AIIMS, New Delhi, Chief
Neurosciences Centre,
AIIMS, New Delhi
drkameshwarprasad@gmail.com
10.
Dr. Mathew
Varghese
Orthopedist, Department of
Orthopedics, St. Stephen’s
Hospital
mathewvarghese.ms@gmail.com
11.
Dr Prof.
Narendra K.
Arora
Executive Director, INCLEN
Trust International
nkarora@inclentrust.org
12.Dr. Nobhojit Roy
Advisor, Public Health
Planning, NHSRC, MoHFW,
Government of India
nobsroy@gmail.com
13.
Dr. Patanjali Dev
Nair
Department of Non-
communicable Diseases and
Environment Health (NDE)
WHO Regional Officer for
South-East Asia,
I.P. Estate, New Delhi
nayarp@who.int
14.
Dr. Prof. Rajesh
Malhotra
Professor & Head of
Department of Orthopedics,
AIIMS, New Delhi Chief of
JPNATC, New Delhi
chiefoffice06@gmail.com
15.
Dr. Prof. Shakti
Gupta
Professor, Department of
Hospital Administration,
AIIMS, New Delhi
shakti810505@gmail.com
16.
Dr. Prof. Vivek
Trikha
Professor, Department of
Orthopedics, JPNATC,
AIIMS, New Delhi
vivektrikha@gmail.com
17.Dr. Yogesh Suri
Senior Advisor, NITI Aayog,
New Delhi
yogesh.suri@nic.in Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 226
ANNEXURE-IV:
PATIENT INFORMATION
SHEET
Study Title: “A country-level Gap Analysis of the current status of emergency and injury care
at secondary and tertiary care centres in India”
SUBJECT INFORMATION SHEET & INFORMED CONSENT
DOCUMENT
Purpose of the study: This study is being conducted as a country level assessment of emergency
and injury current status of facility based Emergency and Injury care in prefixed 50 government
medical colleges (75%), large private hospitals (25%) and 50 district hospitals in India. Department
of Emergency Medicine JPN Apex Trauma Centre, AIIMS, New Delhi is conducting this national
level assessment in collaboration with NITI Aayog and Ministry of Health and Family Welfare,
New Delhi. This project is introduction of current status of emergency and injury care at tertiary
care (both public and private) and district hospitals through gap analysis in India. This project is
documenting the current status of emergency and injury care in the tertiary care and district health
care facilities through collection of data sets from the hospitals including live data recording of
de-identified clinical cases for 24 hours.
Participation: For the study, we have received the administrative approval from state and district
authorities. As the concerned health staff of the health facility, we wish to obtain your feedback on
few aspects of emergency and injury care. Thus, we are inviting you to participate in the project.
Study Procedures:
For the participation, you will be asked to sign a consent form and one copy of the
signed consent form will be given to you.
Then the assessor shall discuss with you on few issues related to the emergency and
injury care.
The information and opinion shared by you shall be treated as confidential. Your
identifiers shall not be collected. 227
Annexure-IV: Patient Information Sheet
Duration of participation: Your participation for this study is limited to one time contact only
and shall end with end of the interaction. No further contact shall be required.
Data collection during contact: The assessors shall collect the practices followed and opinions
related to emergency and injury care at your facility. The assessors shall use a guide to collect
the information and the process is expected to take about 2 days.
Risks and Benefit: Your identification shall not be collected and used in analysis. The information
shared by you shall be treated as confidential and shall not be shared with any identifier with the
administration or any other person. There is no financial benefit to you. But your participation shall
assist understanding the current gaps for strengthening and expanding the linkages of emergency
and injuries care at national level.
Confidentiality: Your identification and information shared by you will be treated as confidential.
All information collected will be labeled with a unique ID and not with your name or any other
identifying information. All project documents and records will be kept under lock and key or
computers with passwords under supervision of the Investigators. This information may be looked
at ethics committee members reviewing the study.
Compensation for participation: There will be no monetary compensation provided for
participation in this study.
Contact details: If you have a concern about any aspect of participation, contact the investigator(s)
from the hospital or related to the project. Their telephone numbers and address are listed below.
Name and address of responsible persons:
Dr Sanjeev Kumar Bhoi
Principal Investigator
Professor
Department of Emergency
Medicine JPN Apex Trauma
Centre, AIIMS, New Delhi
Email:sanjeevbhoi@gmail.com
Dr. Tej Prakash Sinha
Co-Investigator
Associate Professor
Department of Emergency
Medicine JPN Apex Trauma
Centre, AIIMS, New Delhi
Email:drsinha1234@gmail.com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 228
ANNEXURE-V:
CONFIDENTIALITY /
CONFLICT OF INTEREST
AGREEMENT FORM FOR
NATIONAL ASSESSOR
In recognition of the fact, that I…………………. (Name and Designation),and his/her
affiliation……………herein referred to as the “Undersigned”, has been engaged as a National
Assessor of the AIIMS, has been asked to assess a national project titled “A country level assessment
of current status of emergency and injury care at secondary and tertiary level centers in India”
to be conduct by Department of Emergency Medicine JPN Apex Trauma Centre, AIIMS, New
Delhi funded by the NITI Aayog.
This Agreement thus encompasses any information deemed Confidential or Proprietary provided
to the Undersigned in conjunction with the duties as a National Assessor. Any written information
provided to the Undersigned that is of a Confidential, Proprietary, or Privileged nature shall be
identified accordingly.
As such, the Undersigned agrees to hold all Confidential or Proprietary trade secrets (“information”)
in trust or confidence and agrees that it shall be used only for contemplated purposes, shall not
be used for any other purpose or disclosed to any third party. Written Confidential information
provided shall not be copied or retained. All Confidential information (and any copies and notes
thereof) shall remain the sole property of the Department of Emergency Medicine JPN Apex
Trauma Centre, AIIMS, New Delhi.
The Undersigned agrees not to disclose or utilize, directly or indirectly, any Confidential or
Proprietary information belonging to a third party in fulfilling this agreement. Furthermore, the
Undersigned confirms that his/her performance of this agreement is consistent with the institute’s
policies and any contractual obligations they may have to third parties.
The Undersigned will immediately disclose to the Principal Investigator of project, any actual or
potential conflict of interest that he/she may have in relation to any particular and to abstain from
any participation in the project.
When a National Assessor has a conflict of interest, the assessor should notify the Principal
Investigator and except to provide information requested by the Principal Investigator. 229
Annexure-V: Confidentiality / Conflict of Interest Agreement Form for National Assessor
AGREEMENT ON CONFIDENTIALITY AND CONFLICT OF INTEREST
Please sign and date this Agreement, if the Undersigned agrees with the terms and conditions
set forth above. The original (signed and dated Agreement) will be kept on file in the custody
of the JPNATC, Department of Emergency (WHO collaborated Centre) AIIMS. A copy will be
given to you for your records.
In the course of my activities as a National Assessor for this countrywide project for onsite
assessments, I may be provided with confidential information and documentation (which we
will refer to as the “Confidential Information”). I agree to take reasonable measures to protect the
Confidential Information; subject to applicable legislation, including the Access to Information Act,
not to disclose the Confidential Information to any person; not to use the Confidential Information
for any purpose outside the mandate, and in particular, in a manner which would result in a
benefit to myself or any third party; and to return all Confidential Information (including any
minutes or notes I have made as part of my duties) to the Principal Investigator upon termination
of my functions as a National Assessor.
Whenever I have a conflict of interest, I shall immediately inform the Principal Investigator not
to count me toward a quorum for candidate.
Upon signing this agreement, I agree to take reasonable measures and full responsibility to keep
the information as confidential.
I, …………………………………., have read and accept the aforementioned terms and conditions
as explained in this Agreement.
_____________________ _____________________
Undersigned Principal Investigator
(National Assessor)
_____________________ _____________________
Date & Place Date &Place Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 230
ANNEXURE-VI:
OVERALL SUMMARY OF OTHER
SPECIALIST / SUPER SPECIALIST
AVAILABLE IN HOSPITAL
{MEDIAN [IQR] MIN-MAX} BY
CATEGORY OF HOSPITALS
DepartmentDesignation
Timings
Medical
Colleges
(N=20)
Govt.
Hosp.
(>300 bed
strength)
(N=20)
Govt. Hosp.
(<300 bed
strength)
(N=20)
Pvt. Hosp.
(>300 bed
strength)
(N=20)
Pvt. Hosp.
(<300 bed
strength)
(N=20)
Medicine
Consultant
During OPD Hours
only
12 [7] 2-214 [2] 1-72 [2] 1-84.5 [4] 2-114 [2] 2-6
24 x 7 Physically
Present
3 [1] 1-33 [0] 1-32 [1] 1-3 3 [0] 3-5 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 1-33 [0] 3-4 3 [0] 3-3 3 [0] 2-3
Empanelled / As and
when required
0 3 [0] 3-3 0 5 [0] 5-5 0
Resident
During OPD Hours
only
14 [18]
4-64
5 [5] 2-153 [1] 2-4
10.5 [10.2]
1-15
4.5 [3.5] 1-6
24 x 7 Physically
Present
3 [0] 2-33 [1] 1-32.5 [0.5] 2-33 [0] 3-5 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 3-33 [0] 3-3 3 [0] 3-3 0
Empanelled / As and
when required
0 5 [0] 5-5 0 0 0
General Surgery
Consultant
During OPD Hours
only
12 [8] 2-246 [3] 1-92 [2] 1-6
6.5 [5.7]
2-11
3 [2.5] 1-4
24 x 7 Physically
Present
3 [1] 1-33 [1] 2-43 [0.5] 2-33 [0] 3-7 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 1-33 [0] 3-3 3 [0] 3-33 [0.7] 1-3
Empanelled / As and
when required
0 3 [0] 3-3 0 3 [0] 3-3 0 231
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
General Surgery
Resident
During OPD Hours
only
20 [22]
2-53
4 [7] 2-142 [2.5] 1-6
14 [5.5]
4-15
3 [1] 2-6
24 x 7 Physically
Present
3 [0] 3-33 [1] 1-31 [0] 1-1 3 [0] 3-6 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Pediatrics
Consultant
During OPD Hours
only
6 [1] 2-103 [4] 1-92 [1] 1-63 [2.5] 1-73 [1] 1-5
24 x 7 Physically
Present
2 [1] 1-32 [2] 1-32 [0] 2-2 3 [0] 3-7 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [1] 1-33 [0] 3-3 3 [0] 3-33 [0.5] 1-3
Empanelled / As and
when required
0 3 [0] 3-3 0 2 [0] 2-2 3 [0] 3-3
Resident
During OPD Hours
only
7 [6] 2-206 [2.5] 4-94 [1.5] 1-48.5 [0.5] 8-93.5 [0.5] 3-4
24 x 7 Physically
Present
3 [0] 3-33 [0.5] 1-32 [1] 1-3 3 [0] 3-8 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Gynaecology & Obstetrics
Consultant
During OPD Hours
only
8 [10.7]
1-16
3 [2.5] 1-72 [1] 1-105 [2.7] 1-183 [0.7] 3-6
24 x 7 Physically
Present
2 [1] 1-33 [0.2] 2-33 [0.2] 2-33 [0] 3-7 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [1] 1-33 [0] 3-7 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 10 [0] 10-103 [0] 3-3
Resident
During OPD Hours
only
9 [9.5]
1-33
5 [1.5] 2-84 [1] 1-5
10 [4.5]
2-11
3.5 [0.5] 3-4
24 x 7 Physically
Present
3 [0] 3-43 [0.5] 2-33 [0.5] 2-33 [0] 3-103 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-3
1.5 [0.5]
1-2
3 [0] 3-3 3 [0] 3-3 0
Empanelled / As and
when required
0 0 0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 232
Orthopedics
Consultant
During OPD Hours
only
6.5 [6.2]
2-14
3 [4] 1-61 [2] 1-54.5 [4.2] 1-82 [1.5] 1-4
24 x 7 Physically
Present
3 [1] 1-33 [0.2] 2-32 [1] 1-3 3 [0] 3-9 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [1] 1-33 [0] 2-3 3 [0] 3-3 3 [0] 2-3
Empanelled / As and
when required
0 3 [0] 3-3 0 4 [0] 4-4 0
Resident
During OPD Hours
only
3 [11] 1-386 [2] 5-9 0 7.5 [1.5] 6-92 [1] 1-3
24 x 7 Physically
Present
3 [0] 3-43 [1.5] 1-31 [0] 1-1 3 [0] 3-5 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-3 0 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Radiology
Consultant
During OPD Hours
only
5 [5.2]
1-16
1.5 [1] 1-41 [1.5] 1-43 [1.5] 1-41.5 [1.7] 1-5
24 x 7 Physically
Present
3 [0] 3-32 [1] 1-33 [0] 3-3 3 [0] 3-4 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0.5] 1-32 [1] 1-3 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0
Resident
During OPD Hours
only
7 [9.7]
1-16
2 [0] 2-21 [0] 1-1 4 [1] 3-5
6.5 [3.5]
3-10
24 x 7 Physically
Present
3 [0] 3-52 [2] 1-31 [0] 1-1 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-3 0 0 3 [0] 3-3 0
Empanelled / As and
when required
0 0 0 0 0
AnesthesiaConsultant
During OPD Hours
only
11 [9.5]
2-39
4 [5.5] 1-102 [2.2] 1-7
7.5 [5.2]
3-23
3 [4.5] 1-11
24 x 7 Physically
Present
3 [0] 3-33 [0] 1-43 [1] 1-3 3 [0] 3-5 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0.5] 1-33 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0 233
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
Anesthesia
Resident
During OPD Hours
only
10 [22.7]
1-45
6.5 [5.5]
2-9
2 [1.5] 1-46 [2] 6-10
6.5 [3.5]
3-10
24 x 7 Physically
Present
3 [0] 3-43 [1] 1-42 [1] 1-3 3 [0] 3-8 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Critical Care
Consultant
During OPD Hours
only
3 [2.5] 1-6
2.5 [1.5]
1-4
4 [4] 1-7 3 [0] 1-43 [3] 1-13
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-33 [0] 3-3 3 [0] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Resident
During OPD Hours
only
3.5 [2.5]
1-6
0 2 [0] 2-24.5 [1.5] 3-64 [1] 3-5
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Ophthalmology
Consultant
During OPD Hours
only
3 [3] 1-102 [1] 1-51 [2.2] 1-53 [2.5] 1-52 [1.5] 1-6
24 x 7 Physically
Present
3 [0] 3-32 [2] 1-32.5 [0.5] 2-32 [1] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 3-33 [0] 3-6 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 4 [0] 4-4 0
Resident
During OPD Hours
only
1 [5.2]
1-22
5 [2] 1-5 0 2 [0] 2-2 2 [0] 2-2
24 x 7 Physically
Present
3 [0] 3-33 [0.5] 1-31 [0] 1-1 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0.2] 2-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 234
ENT
Consultant
During OPD Hours
only
5 [4.2]
1-10
2 [1.5] 1-41 [1.5] 1-63 [2] 1-62 [0.5] 1-3
24 x 7 Physically
Present
3 [0] 3-31 [1] 1-32 [0] 2-23.5 [0.5] 3-43 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 1-33 [0] 3-3 3 [0] 3-3 3 [0] 2-3
Empanelled / As and
when required
0 0 0 1 [0] 1-1 0
Resident
During OPD Hours
only
4 [7] 1-232 [1.5] 1-4 0 4 [2] 2-6 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 1-32 [0] 2-2 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0.2] 2-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Psychiatry
Consultant
During OPD Hours
only
2.5 [3.2]
1-5
2 [0.5] 1-31 [0] 1-43 (1.5] 1-52 [2] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 2 [1] 1, 3 0
On Call during
Non-OPD Hours
3 [0] 1-33 [0] 1-33 [0] 1-3 3 [0] 3-3 3 [0] 1-3
Empanelled / As and
when required
0 0 0 0 3 [0] 3-3
Resident
During OPD Hours
only
2.5 [3]
1-10
2.5 [0.5]
2-3
0 4.5 [2.5] 2-7 0
24 x 7 Physically
Present
3 [0] 3-33 [0.5] 1-3 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0.5] 1-3
2.5 [0.5]
2-3
0 3 [0] 3-3 0
Empanelled / As and
when required
0 0 0 0 0
Dermatology
Consultant
During OPD Hours
only
3 [5.5] 1-72 [1.5] 1-41 [0.2] 1-42 [0.7] 2-33 [1] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [1] 1-3 0 2.5 [0.5] 2-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0] 1-33 [0.5] 1-33 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 5 [0] 5-5 0 235
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
Dermatology
Resident
During OPD Hours
only
6 [6] 2-14
3.5 [0.5]
3-4
0 2.5 [0.5] 2-3 0
24 x 7 Physically
Present
3 [0] 3-33 [1] 1-31 [0] 1-1 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0.5] 1-3
2.5 [0.5]
2-3
0 0 0
Empanelled / As and
when required
0 0 0 0 0
Forensic Medicine
Consultant
During OPD Hours
only
2 [9] 1-101 [2] 1-61 [0] 1-1 3 [2] 1-4 0
24 x 7 Physically
Present
3 [0] 3-33 [1] 1-3 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 1-33 [0] 1-33 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0
Resident
During OPD Hours
only
3.5 [2.5]
1-6
1 [0] 1-1 0 1 [0] 1-1 0
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [1] 1-3
2.5 [0.5]
2-3
0 0 0
Empanelled / As and
when required
0 0 0 0 0
Lab Medicine
Consultant
During OPD Hours
only
2 [0] 2-24 [5.5] 3-252 [1] 1-5
3.5 [1.7]
1-11
2 [0] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 3-33 [0.5] 3-43 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0
Resident
During OPD Hours
only
1 [0] 1-1 0 1 [0] 1-1 0 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-33 [0] 3-3 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
0 0 0 0 0
Empanelled / As and
when required
0 0 0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 236
Transfusion Medicine / Blood Bank
Consultant
During OPD Hours
only
2 [2.2] 1-41 [2] 1-41 [0.5] 1-51 [1.5] 1-41 [1] 1-4
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [1.5] 1-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 3-33 [0] 3-3 3 [0] 1-3 0
Empanelled / As and
when required
0 0 0 0 0
Resident
During OPD Hours
only
2.5 [1.5]
1-4
0 1 [0] 1-1 0 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-3 0 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Cardiology
Consultant
During OPD Hours
only
2 [3] 1-64 [2] 2-63 [1] 2-43 [2] 1-111 [1.5] 1-4
24 x 7 Physically
Present
0 0 0 0 0
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-3 0 3 [0] 3-3 3 [0] 1-3
Empanelled / As and
when required
0 3 [0] 3-3 0 1 [0] 1-1 0
Resident
During OPD Hours
only
6 [0] 6-6 0 0 4 [0] 4-4 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [1] 1-3
2.5 [0.5]
2-3
0 0 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
CTVS (Cardiac Surgery)
Consultant
During OPD Hours
only
2.5 [1.7]
1-5
1 [0] 1-11 [0] 1-1 3 [2] 1-61.5 [1.2] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-33 [0.5] 1-31 [0] 1-1 3 [0] 1-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0 237
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
CTVS (Cardiac Surgery)
Resident
During OPD Hours
only
6 [0] 6-61 [0] 1-1 0 3 [0] 3-3 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [1] 1-3 0 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Neurology
Consultant
During OPD Hours
only
2.5 [1.5]
1-4
0 1 [0] 1-1 3 [0] 2-32 [0.5] 2-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0.2] 3-43 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-31 [0] 1-1 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 1 [0] 1-1 3 [0] 3-3
Resident
During OPD Hours
only
3.5 [2.5]
1-6
0 0 4 [0] 4-4 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [1] 1-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Neurosurgery
Consultant
During OPD Hours
only
3 [2.2] 2-51 [0] 1-12 [0] 2-2 3 [1] 2-4 2 [2] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [1] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-31 [0] 1-1 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0
Resident
During OPD Hours
only
2.5 [1.2]
1-3
1 [0] 1-1 0 4 [0] 4-4 0
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 238
Plastic Surgery
Consultant
During OPD Hours
only
3 [2.7] 1-51 [0] 1-11 [0] 1-1 1 [1] 1-3 2 [1] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 2.5 [0.5] 2-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-31 [0] 1-1 3 [0] 3-3 3 [0] 1-3
Empanelled / As and
when required
0 3 [0] 3-3 0 2 [0] 2-2 0
Resident
During OPD Hours
only
2.5 [3] 1-41 [0] 1-1 0 0 2.5 [1.5] 1-4
24 x 7 Physically
Present
3 [0] 2-33 [0] 3-3 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Maxillofacial Surgery
Consultant
During OPD Hours
only
1.5 [0.5]
1-2
2 [0] 2-21 [0] 1-11 [0.5] 1-31 [0.2] 1-2
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-31 [0] 1-1 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-32 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Resident
During OPD Hours
only
0 2 [0] 2-2 0 0 0
24 x 7 Physically
Present
3 [0] 3-31 [0] 1-1 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
2 [1] 1-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Gastroenterology
Consultant
During OPD Hours
only
1.5 [1.7]
1-5
2 [0] 2-22 [0] 2-2 1 [2] 1-4 1 [2] 1-5
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0.5] 3-43 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-3 3 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 4 [0] 4-4 0 239
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
Gastroenterology
Resident
During OPD Hours
only
10 [0] 10-
10
2 [0] 2-2 0 1 [0] 1-1 3 [0] 3-3
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Nephrology
Consultant
During OPD Hours
only
1 [1] 1-32 [0] 2-21 [0] 1-1 2 [2] 1-42 [2.5] 1-5
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0.2] 2-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0] 1-31 [0] 1-1 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 1 [0] 1-1 0
Resident
During OPD Hours
only
3 [1] 2-41 [0] 1-1 0 0 0
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-21 [0] 1-1 0 2 [1] 1-3
Empanelled / As and
when required
0 0 0 0 0
Urology
Consultant
During OPD Hours
only
3 [2.5] 1-41 [0] 1-11 [0] 1-13 [0.7] 1-31 [1] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-33 [0] 3-3 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 1 [0] 1-1 0
Resident
During OPD Hours
only
3 [3.2] 1-81 [0] 1-1 0 0 0
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-33 [0] 3-3 0 0 0
Empanelled / As and
when required
0
2.5 [0.5]
2-3
0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 240
Neuro Radiology
Consultant
During OPD Hours
only
0 0 0 2 [1] 1-3 0
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
2 [1] 1-31 [0] 1-1 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 3 [0] 3-3 0 0 0
Resident
During OPD Hours
only
0 0 0 0 0
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
0 0 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Pediatric Surgery
Consultant
During OPD Hours
only
2 [2.2] 1-41 [0] 1-1 0 1 [1] 1-3 1 [1] 1, 3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-3 0 3 [0] 3-3 3 [0] 2-3
Empanelled / As and
when required
0 0 0 1 [0] 1-1 0
Resident
During OPD Hours
only
4.5 [3.5]
1-8
1 [0] 1-1 0 0 0
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-3
2.5 [0.5]
2-3
0 0 0
Empanelled / As and
when required
0 0 0 0 0
Neonatology
Consultant
During OPD Hours
only
1.5 [0.5]
1-2
1 [0] 1-1 0 3.5 [1.2] 2-41 [0.5] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0.5] 1-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [1] 1-33 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0 241
Annexure-VI: Overall Summary of Other Specialist / Super Specialist Available in Hospital
Neonatology
Resident
During OPD Hours
only
2 [0] 2-2 0 0 0 0
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
3 [0] 3-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0
Hematology
Consultant
During OPD Hours
only
3 [0] 3-3
1.5 [0.5]
1-2
0 2.5 [1.7] 1-52 [1] 1-3
24 x 7 Physically
Present
3 [0] 3-33 [0.5] 2-3 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 3-32 [1] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Resident
During OPD Hours
only
4 [0] 4-41 [0] 1-1 0 0 0
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 0
On Call during
Non-OPD Hours
0 2 [0] 2-2 0 0 3 [0] 3-3
Empanelled / As and
when required
0 0 0 0 0
Oncology
Consultant
During OPD Hours
only
1 [0.5] 1-2 0 1 [0] 1-12 [2.2] 1-41 [3.5] 1-8
24 x 7 Physically
Present
3 [0] 3-33 [0] 3-3 0 3 [0.5] 1-33 [0] 3-3
On Call during
Non-OPD Hours
3 [0] 1-33 [0.5] 1-3 0 3 [0] 3-3 3 [0] 3-3
Empanelled / As and
when required
0 0 0 5 [0] 5-5 0
Resident
During OPD Hours
only
6 [0] 6-6 0 0 0 2 (0) 2, 2
24 x 7 Physically
Present
3 [0] 3-3 0 0 3 [0] 3-3 3 [0] 3-3
On Call during
Non-OPD Hours
2 [1] 1-32 [0] 2-2 0 0 0
Empanelled / As and
when required
0 0 0 0 0 Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 242
Annexure-VII:
List of National
Assessors
S.N. NameDesignation StateEmail
1 Dr Adarsh S B
Senior Resident , Dept of
Emergency Medicine, JSS
Medical College, JSS Academy
of Higher Education, Mysuru,
Karnataka
Karnatakaadarshashu6789@gmail.com
2 Dr Ajay
MD, Emergency Medicine,
JIPMER, Puducherry
Puducherryaj.ai.inn@gmail.com
3 Dr Ajit Baviskar
Professor, Dept of Emergency
Medicine, DY Patil Medical
college
Maharashtradrbaviskar@hotmail.com
4
Dr Ajith
Venugopalan
HOD, Dept of Emergency
Medicine, MOSC kolenchery,
Ernakulam
Kerala ajith.v123@gmail.com
5
Dr Akilan
Elangovan
Assistant Professor, Department
of Emergency Medicine
Tamil Naduakey6986@gmail.com
6
Dr Amit Kumar
Singh
Junior Resident, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi dr.aks2888@gmail.com
7 Dr Anil Kumar
Associate Professor and
HOD, Dept of Trauma and
Emergency Medicine, AIIMS
Patna
Patna dranil4@gmail.com
8 Dr Ankit Sharma
Junior Resident, Dept of
Trauma and Emergency
Medicine, AIIMS Bhubaneswar
Orissa
chetan91_sharma@rediffmail.
com
9
Dr Apoorva
Gomber
Junior Resident, Dept of
Pathology, RML Hospital, New
Delhi
Delhi
drapoorvagomber@gmail.
com 243
Annexure-VII: List of National Assessors
10Dr Arun Prasad
Associate Professor, Dept
of Trauma and Emergency
Medicine, AIIMS Patna
Patna drarunpd@gmail.com
11Dr Arushi Ghai
MD, Community Medicine,
AIIMS, New Delhi
Delhi ritin.mohindra@gmail.com
12Dr Ashok Kumar
Associate Professor/ CNO
AIIMS, Jodhpur
Rajasthanashokbishnoi11@gmail.com
13
Dr Awaneesh
Katiyar
Dept of Trauma and
Emergency Medicine, AIIMS
Rishikesh
Uttarakhand-
14
Dr Bharat
Bhushan
Bhardwaj
Assistant Professor, Dept
of Trauma and Emergency
Medicine, AIIMS Rishikesh
Uttarakhandbharatbbhardwaj@gmail.com
15
Dr Bharat
Choudhary
Assistant Professor, Dept
of Trauma & Emergency
(Pediatrics), AIIMS, Jodhpur
Rajasthandrbharatpaeder@gmail.com
16Dr Bharath G
Junior Resident, JPNATC,
AIIMS, New Delhi
Delhi bharathg531@gmail.com
17Dr Brunda R L
Junior Resident, JPNATC,
AIIMS, New Delhi
Delhi bru1471992@gmail.com
18
Dr Chandra
Prakash
Senior Resident, Dept of
Emergency Medicine, AIIMS
New Delhi
Delhi
chandraprakashpatlauni@
gmail.com
19
Dr Cyril G
Cherian
Emergency department, District
Hospital, Aluva, Ernakulum
Kerala cyrilgc@gmail.com
20Dr D Srikanth
Consultant Surgeon & Nodal
Officer for Trauma Care
Emergency, Trivandrum District
Hospital
Kerala drdsrikanth@gmail.com
21
Dr Debayan Sinha
Roy
Junior Resident, SSKM
Hospital, Calcutta
West Bengaldebayansinharoy@gmail.com
22Dr Deepti
Junior Resident, AIIMS, New
Delhi
Delhi ritin.mohindra@gmail.com
23
Dr Dipak Kumar
Sharma
Professor of Surgery & HOD
of Emergency Medicine, Govt.
Medical college, Guwahati
Assam
dipakkumarsarma@hotmail.
com
24Dr Gaurav Kumar
Senior Resident, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi gauravmuvalia07@gmail.com
25
Dr Ghanashyam
Timilsina
Junior Resident, Dept. of
Emergency Medicines,
JPNATC, AIIMS, New Delhi
Delhi
ghanashyam.timilsina@gmail.
com
26
Dr Gummadidala
Manoj kumar
Senior Resident, Dept of
Emergency Medicine, AIIMS,
New Delhi
Delhi drmanoj2k8@gmail.com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 244
27
Dr Harshad
Dongare
Associate Professor, Dept
of Anaesthesia, Incharge of
Emergency Dept, SSMF Dr
Jogalekar Hospital Shirwal
Maharashtraharshaddoc@gmail.com
28Dr Kalyan Bora
1st Year, PGT, GMCH,
Guwahati
Assam
kalyanborah1987@gmail.
com
29Dr Kishen Goel
Senior Resident, Dept
of Critical Care, AIIMS
Bhubaneswar
Orissa goelkishen@gmail.com
30Dr Linu Sekhar
Assistant Professor and
Incharge, Sree Gokulam
Medical college, Trivandrum
Kerala linu24886@gmail.com
31Dr M Sukumar
Senior Resident, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi mrsuku@gmail.com
32
Dr Madhu
Srinivasarangan
Assistant Professor, Dept of
Emergency Medicine, JSS
Medical College, JSS Academy
of Higher Education, Mysuru,
Karnataka
Karnatakamadhu@jssuni.edu.in
33
Dr Mahaveer
Singh Rodha
Associate Professor, Dept of
Trauma & Emergency, AIIMS,
Jodhpur
Rajasthanmsrodha@gmail.com
34Dr Manoj Nagar
Assistant Professor, Dept
of Trauma and Emergency
Medicine, AIIMS Bhopal
MP
manoj.ortho@aiimsbhopal.
edu.in
35
Dr Manzoor
Ahmed Rather
Consultant Anaesthesia in
Critical Care, Directorate of
Health Services, Jammu &
Kashmir
Kashmir drmanzoor22@gmail.com
36Dr Mayuri Mhatre
Senior Resident, Dept. of
Emergency Medicine, MGM
Medical College, Navi Mumbai
Maharashtradr_mayuri@hotmail.com
37
Dr Md Sabah
Siddiqui
Associate Professor, Dept
of Internal Medicine, AIIMS
Raipur
Chhattisgarhdr.sabahsiddiqui@gmail.com
38
Dr Md Sharjeel
Khan
Junior Resident, SSKM
Hospital, Calcutta
West Bengalmdsharjeelkhan@gmail.com
39
Dr Meenaloshni
Jayaseelan
Junior ResidentDelhi sinna.loshi@gmail.com
40
Dr Megha
Yashwant
Solasakar
Register, ICU, Joglekar
Hospital, Shirwal
Maharashtra
dr.meghasolasakar@gmail.
com
41
Dr Midhun
Mohan N
Provisional Assistant Professor,
Govt Medical College,
Kozhikode
Kerala midhun6486@gmail.com 245
Annexure-VII: List of National Assessors
42
Dr Mohameed
Haneef M
HOD and Consultant, Dept of
Emergency Medicine, Medical
Trust Hospital, Ernakulam
Kerala
haneef_farook@rediffmail.
com
43
Dr Monesh
Bhandari
Medical Officer (Academics),
Symbiosis Institute of Health
Sciences
Maharashtramoneshbhandari@gmail.com
44Dr Nazrul Islam
3rd Year, PGT, GMCH,
Guwahati
Assam nazrulislam3009@gmail.com
45Dr Nidhi Kaeley
Assistant Professor, Dept of
Emergency Medicine, AIIMS
Rishikesh
Uttarakhanddrnidhi_kaeley@yahoo.com
46Dr Nipin Kalal
Assistant Professor/ ANS AIIMS,
Jodhpur
Rajasthankalalnipin@gmail.com
47Dr Nirjala DeviJunior Resident, JNIMS, ImphalManipur nirjalawayenbam@gmail.com
48Dr Nisarg S
Senior Resident , Dept of
Emergency Medicine, JSS
Medical College, JSS Academy
of Higher Education, Mysuru,
Karnataka
KarnatakaSnisarg84@gmail.com
49Dr Nitin Borker
Associate Professor, Dept of
Pediatric Surgery, AIIMS Raipur
Chhattisgarhdrnitinborkar25@gmail.com
50Dr Nitin Kashyap
Associate Professor, Dept of
CTVS, AIIMS Raipur
Chhattisgarhnitinkashyap1@yahoo.com
51
Dr Paresh
Mahabal
Medical Officer, Goa Goa ritin.mohindra@gmail.com
52Dr Prabin
Medical Officer, UPHC,
Kakching, Imphal
Manipur prabinkh@gmail.com
53Dr Prawal Shrimal
Junior Resident, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi prawalaiimspulse@gmail.com
54Dr R. Surendar
Senior Resident, Emergency
Medicine, JIPMER, Puducherry
Puducherrydrsurendar18@gmail.com
55Dr Rachana
Assistant Professor, Dept of
Emergency Medicine, KMC
Mangalore
Karnatakarachana2806@gmail.com
56
Dr Rajeshwari
Vhora
Consultant, Emergency and
Critical Care, Global Hospital
Maharashtra
drrajeshwarivhora@gmail.
com
57
Dr Ramkaran
Chaudhary
Associate Professor, Dept of
surgery, AIIMS, Jodhpur
Rajasthanrkmoond@gmail.com
58
Dr Ravindra
Vishwakarma
Register, ICU, Vishwaraj
Hospital, Pune
Maharashtraramashrayv@gmail.com
59Dr Rina Parikh
Assistant Professor, Dept of
Emergency Medicine, SSG
Hospital and Medical college,
Baroda
Gujaratdrrinaparikh77@gmail.com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 246
60Dr Ritin Mohindra
Assistant Professor, Dept of
Emergency Medicine, AIIMS
New Delhi
Delhi ritin.mohindra@gmail.com
61Dr Sakshi Yadav
MD, Emergency Medicine,
AIIMS, New Delhi
Delhi sakshiyadav788@gmail.com
62
Dr Sangeeta
Sahoo
Assistant Professor, Dept
of Trauma and Emergency
Medicine, AIIMS Bhubaneswar
Orissa drsangeeta.asth@gmail.com
63Dr Saurabh Saigal
Associate Professor, Dept of
Anesthesia and Critical Care,
AIIMS Bhopal
MP
saurabh.criticalcare@
aiimsbhopal.edu.in
64
Dr Shandeep
Singh
Medical Officer, Medical
Directorate, Lamchel, Imphal
Manipur shaninsunville@gmail.com
65
Dr Shivasheesh
Rath
Junior Resident, Dept of
Trauma and Emergency
Medicine, AIIMS Bhubaneswar
Orissa drsrath8@gmail.com
66Dr Shreyas Patel
Assistant Professor, Dept of
Emergency Medicine, SSG
Hospital and Medical college,
Baroda
Gujaratshreyas384@gmail.com
67
Dr Subhankar
Paul
Senior Resident, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi subhankargmch@gmail.com
68
Dr Sudhanshu
Agarwal
Senior Resident, Emergency,
AIIMS, Bhopal
MP
sudhanshu.mgmc@gmail.
com
69Dr Suprith C
Senior Resident, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi c.suprith@gmail.com
70
Dr Suvan Kanti
Chowdhury
Senior Resident, Dept. of
Emergency Medicine, GMCH,
Guwahati
Assam suvanchowdhary@gmail.com
71Dr Tanmay Dutta
Associate Professor, Dept of
Orthopedics, SSKM Hospital,
Calcutta
West Bengaltanmayortho@yahoo.com
72
Dr Vignan
Kappagantu
Junior Resident, Department of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi vignan_1504@yahoo.co.in
73Dr Y. Tato
Assistant Professor and Surgical
Specialist, TRIHMS Hospital
Naharlagun
Arunachal
Pradesh
yijum@yahoo.com
74
Dr. Bansi Dilip
bhai Trambadia
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratbansitrambadia@yahoo.co.in
75
Dr.Bhumiben
Mukeshbhai Patel
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratpatelbhumi0703@gmail.com 247
Annexure-VII: List of National Assessors
76
Dr. Himanshu
Rameshchandra
Patel
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujarat
Himanshupatel9061@gmail.
com
77
Dr. Hiren
Dahyabhai
Vaghela
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujarathirenvaghela28@gmail.com
78
Dr. Krunal Kumar
Pancholi
Assistant Professor, Dept of
Emergency Medicine, SSG
Hospital and Medical college,
Baroda
Gujarat
krunalpancholi90@gmail.
com
79
Dr. Madhur
Uniyal
Assistant Professor, Dept.
of Trauma Surgery, AIIMS,
Rishikesh
Uttarakhanddrmadhuruniyal@gmail.com
80
Dr. Malay
Mukeshbhai
Rathod
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratmalayrathod22@gmail.com
81
Dr. Mihir Haresh
kumar Patel
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratmihirpatel1265@gmail.com
82Dr. Shivani Patel
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratshivanip4796@gmail.com
83
Dr. Shreya Rajiv
Dholakia
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratshreya.d125@gmail.com
84
Dr.Sojitra Amit
kumar Ramnik
bhai
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratamit.sojitra42@gmail.com
85
Dr.Tapan Jitendra
kumar Patel
Intern Doctor, SSG Hospital
and Medical college, Baroda
Gujaratpateltapan2404@gmail.com
86Mr A. Ahamed
Tutor, Emergency & Trauma
care Technology, SRM Medical
College Hospital & Research
Centre, Kattankulathur
Tamil Naduahamedkhan108@gmail.com
87
Mr Arun kumar
T A
Nursing officer, Dept of
Trauma & Emergency, AIIMS
Raipur
Chhattisgarh
arunthekkumkovil@gmail.
com
88Mr Aswin S Pillai
Nursing officer, Dept of
Trauma & Emergency, AIIMS
Raipur
Chhattisgarhaswinspillai009@gmail.com
89
Mr Bhanwar Lal
Dewna
Senior Nursing Officer,
Department of Emergency
Medicine, AIIMS, Jodhpur
Rajasthanbldewna@gmail.com
90
Mr Dheeneshbabu
Lakshminarayanan
Nursing Officer, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi dheeneshbabu@gmail.com
91Mr Dinesh Sridhar
Nursing Officer, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi
dinodinesh.s1991@gmail.
com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 248
92Mr J Jayamurugan
Manager-Clinical Operations,
SRM University Hospital,
Potheri, Chennai
Tamil Nadujay202398@gmail.com
93
Mr Prakash
Mahala
Senior Nursing Officer,
Incharge Emergency Medicine,
AIIMS, Rishikesh
Uttarakhand
prakashjpmmahala@gmail.
com
94Mr Rashad
Nursing Officer, WHO CC for
Emergency & Trauma Care,
SEAR, JPNATC, AIIMS, New
Delhi
Delhi—
95
Mr Sreekanth
Vijayan
Nursing officer, Dept of
Trauma & Emergency, AIIMS
Raipur
Chhattisgarh
Sreekanthvijayan4@gmail.
com
96Mr Srinivas SHRI
Nursing Officer, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi mrsuku@gmail.com
97Mr Suneesh S
Staff Nurse, General Hospital,
Neyyattinkara
Kerala
Email_suneeshbadari@gmail.
com
98
Mr Vikas
Choudhary
Nursing Tutor/ ANS, AIIMS,
Jodhpur
Rajasthanvikasss.1988@gmail.com
99Mrs Jincy Jose
Nursing officer, Dept of
Trauma & Emergency, AIIMS
Raipur
ChhattisgarhJinjose06@gmail.com
100Mrs Pratibha S L
Staff Nurse, Gr1, General
Hospital, Neyyattinkara
Kerala prathibhantanta@gmail.com
101Ms Isha Kaushik
Nursing Officer, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi ishukaushik28@gmail.com
102Ms Nirmal Thakur
Public Relation Officer,
Department of Emergency
Medicine, AIIMS, New Delhi
Delhi Neeru.rjpt.2007@gmail.com
103
Ms Ramandeep
kaur
Nursing Officer, Department of
Emergency Medicine, AIIMS,
New Delhi
Delhi bhangoo0073@gmail.com
104Ms Roopa Rawat
Nursing Officer, WHO CC for
Emergency & Trauma Care,
SEAR, JPNATC, AIIMS, New
Delhi
Delhi rooparawat84@gmail.com
105
Ms Stephy
Kennady
Nursing Officer, Dept. of
Emergency Medicines,
JPNATC, AIIMS, New Delhi
Delhi
stephykennady95@gmail.
com
106Ms. Varsha Devi
Nursing Officer, Department of
pediatrics, AIIMS, New Delhi
Delhi varshaniepgi@gmail.com
107
Pulimela Aswan
Kumar
Nursing Officer, AIIMS, RaipurChhattisgarhaswansunny239@gmail.com 249
Annexure-VIII: Contact Details of Hospitals
ANNEXURE-VIII:
CONTACT DETAILS OF
HOSPITALS
S. No. State Hospital Name Contact Person Email ID
1.
Jammu &
Kashmir
Sher-i-Kashmir Institute
of Medical Sciences,
Srinagar
-contactus@skims.ac.in
District Hospital,
Barahmulla
Dr B.A.Chalkoo
Dr Syed Masood
cmobaramulla123@gmail.
com
drmasood3788@gmail.com
District Hospital,
Ganderbal
-msdhganderbal@gmail.com
2.
Himachal
Pradesh
IGMC, Shimla
Dr Mukand Lal
(Principal)
principal-igmc-hp@gov.in
District Hospital, ShimlaDr Ganga Sharma
dirhealthdhs@gmail.
com(DHS)
dr.ravicsharma@gmail.com
(DME)
3. Punjab
Govt. Medical College,
Amritsar
Dr Shiv Charan
sgtbasr@gmail.com,
drsharma1947@yahoo.com
Jallianwala Bagh Martyr’s
Memorial Civil Hospital,
Rambagh, Amritsar
Dr Varun Joshi
(Admin)
-
Fortis Hospital, MohaliDr Sunil
bhavna.ahuja@
fortishealthcare.com
Shivam Multi Super
Speciality Hospital,
Hoshiarpur
Navtej Bassa
navtej.bassan@gmail.com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 250
4. Uttarakhand
HNB Base Hospital
01346 244706
Sandeep (AO)
medicalsuprintendent@
gmail.com
principalvcsg@gmail.com
Coronation Hospital,
Dehradun
Dr S K Gupta
(CMO)
Dr Ramola (CMS)
cmodehradun@gmail.com
coronationhosp@gmail.com
5. Uttar Pradesh
Civil Hospital, Lucknow
Dr Ashok Kumar
Singh (CMO)
-
RML Hospital, Lucknow
Dr A S Tripathi
(Q/A)
Admin Block
director@drrmlims.ac.in,
directordrrmlims@gmail.com
Charak Hospital,
Lucknow
Manik Kumar
Saxena
-
6. Chandigarh
Government
Superspeciality Hospital
Dr Satbir -
Civil Hospital, Sec-22Dr Mandeep -
Max Superspeciality
Hospital
Lalit Kumar Sharma
-
7. Rajasthan
SMS Medical College &
Hospital
Dr Sudhir Bhandari
(Principal)
Dr D S Meena
(MS)
principalsmsmc@rajasthan.
gov.in
Hari Baksh Kanwatia
Hospital, Jaipur
Dr Harashwardhan
(MS)
sahai.dr@gmail.com
District Hospital,
Kothputli
Dr. Rati Ram
Yadav (PMO)
bdm.hospitalkotputli@gmail.
com
Fortis Hospital, Jaipur
Dr. Shri Kant
Swami (MS)
shrikant.swami@
fortishealthcare.com
Birla Hospital- CK Birla,
Jaipur
Dr. Ajeet Singh
(Senior Consultant
in EM)
ajeet.singh@rbhri.in 251
Annexure-VIII: Contact Details of Hospitals
8. Gujarat
B J Medical College,
Vadodara
-
dean-bjmc-ahm@gujarat.
gov.in
dean.bjmc@hotmail.com
drmmprabhakar@gmail.com
GMERS Medical College
and Hospital, Gotri
-
deanmcgv@gmail.com
dean@gmersmcgv.ac.in
Jamanabai Hospital-
cdmo.health.jamnabai@
gmail.com
ParulSevashram Hospital,
Vadodara
-
psh@paruluniversity.ac.in
parulsevashram@gmail.com
medical@paruluniversity.
ac.in
Bhailal Amin General
Hospital, Vadodara
- contact@baghospital.com
9. Maharashtra
BJ Medical College, Pune
Dr. Satyanarayan-
(MS)
drajaytaware@yahoo.com
sbpunpale@gmail.com
Sri Seva Medical
foundation Dr Jogalekar
Hospital, Shirwal, Pune
- drom2002@gmail.com
Grant Medical
Foundation Ruby Hall
Clinic, Pune
- drspathare@rubyhall.com
10.
Madhya
Pradesh
AIIMS, Bhopal- -
Jai Prakash District
Hospital, Bhopal
- cmhobho@nic.in
Bhopal fracture hospital,
Bhopal
-
rabbina.tamu@gmail.com
kamleshvarma@hotmail.com
11.Chhattisgarh
District Hospital,
Tikarpara, Raipur
Dr. Ravi Tiwari -
District Hospital,
Dhamtari
Dr. P.C. Thakur csdhamtari2012@gmail.com
Ramkrishna CARE
Hospital, Pachpedhi
Dr. Sujoy Das
Thakur (HOD)
dr.tanushree.sidharth@
carehospitals.com
12.Goa
Goa Medical College,
Panaji
Dr Rajesh Patil
Dr. S M Bandekar
(Dean)
dean_gmc.goa@nic.in
msgmcgoa@gmail.com
North Goa District
Hospital, Mapusa
Shailendra Munz
Dr. Geeta
Kakodkar (MS)
- Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 252
13.Bihar
PMCH, Patna -
principalsoffice@rediffmail.
com
info@patnamedicalcollege.
com
AIIMS, Patna -admin@aiimspatna.org
Sadar Hospital, Gaya --
Paras HMRI Hospital,
Patna
-infopat@parashospitals.com
Ruban Memorial
Hospital, Patliputra
14.Orissa
AIIMS, Bhubneshwar
info@aiimsbhubaneswar.
edu.in
District Headquarter
Hospital, Puri
Dr. Narahari
Moharana (CMO)
-
Capital Hospital,
Bhubneshwar
Dr Ashok K
Pattnaik (Director)
Dr Narayan Sethi-
(MS)
info@capitalhospital.in
Care Hospital,
Bhubneshwar
-
leads.BBSR@carehospitals.
com
15.West Bengal
IPGMER, SSKM Hospital,
Kolkata
Dr Manimoy
Bandopadhyay
(Director)
director.ipgmer@gmail.com
Ruby General Hospital,
Kolkata
Dr Sujoy Ranjan ruby@rubyhospital.com
16.Sikkim
New STNM, Arithang,
Gangtok, Sikkim
Dr N Senga -
Singtam District Hospital,
Sikkim
--
Central Referral Hospital,
Gangtok
Bunty Agarwal
(Admin)
-
17.
Arunachal
Pradesh
TRIHMS, Papumparetrihmsap@gmail.com
Bakin Pertin General
Hospital, Pasighat
Dr Y Darang -
Ramakrishanan Mission
Hospital, Itanagar
-
rkmitanagar@gmail.com
itanagar@rkmm.org 253
Annexure-VIII: Contact Details of Hospitals
18.Assam
Gauhati Medical College
and Hospital, Guwahati
-
superintendentgmch@gmail.
com
Morigaon Civil hospital,
Guwahati
-
jtdhsmorigaon2017@gmail.
com
GNRC Hospital,
Guwahati
-info@gnrchospitals.com
Nemcare Superspecialty
Hospital, Guwahati
-info@nemcarehospital.in
19.Meghalaya
Civil Hospital Shillong,
Meghalaya
-dc-ekh-meg@nic.in
20.Nagaland
District Hospital, Peren,
Nagaland
Dr Hatlhing
Hangsing
-
Christian Institute of
Health Science and
Research
Dr Clement -
21.Manipur
RIMS, Imphal -
dean@rims.edu.in
drsanta@rediffmail.com
District Hospital,
Bishnupur
--
Shija Hospital &
Research Institute, Meitei
longol, Imphal
-contact@shijahospitals.com
22.Tripura
Agartala Government
Medical College
Dr Sukomal Sarkar
agmc@rediffmail.com
principalagmc@gmail.com
msagmcgbph@gmail.com
Gomti District Hospital,
Udaipur
--
Tripura medical college&
BRAM Teaching
Hospital, Agartala
Dr Anarsh tmc.agt@gmail.com
23.Mizoram
Zoram Medical CollegeDr Debbie
director@mimerfalkawn.
edu.in
Civil Hospital, Aizawl
Dr John
Zohmingthanga
-
Synod Hospital
(Presbyterian Hospital)
Dr Zothua
preshospital_durtlang@
rediffmail.com
presdrt05@bsnl.in
24.Telangana
District Hospital, Karim
Nagar
-
disthospitalkarimnagar@
gmail.com
District Hospital, King
Koti, Hyderabad
--
Yashoda Hospital,
Malakpet, Hyderabad
Dr Ajith Singh
(Medical Admin)
dr.ajithsingh@yashodamail.
com Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 254
25.Karnataka
Mysore Medical College,
Mysore
--
Victoria Hospital,
Bengaluru
-
victoriahospitalbangalore@
ymail.com
msvh1900@gmail.com
Govt. Taluk Hospital,
Virajapet
-amovirajpetgh@gmail.com
Manipal Hospital -info@manipalhospitals.com
26.
Andhra
Pradesh
Guntur Medical College,
Guntur
-gmc_gtr@ap.nic.in
District Hospital Tenali--
Kasturi Medical College
& Hospital
-kmchgnt@gmail.com
Lalitha Super Specialty
Hospital, Kothapet,
Guntur
-
lalithahospitals@gmail.com
27.Kerala
Trivandrum medical
college
Dr Thomas
Mathew (Principal)
Dr Sharmath (MS)
principalmct@gmail.com,
supdt.mcht@gmail.com
Neyyatinkara General
Hospital
-dhneyyattinkara@gmail.com
District Model
Hopital, Perooraada,
Trivantapuram
-
dmhperoorkkada@gmail.
com
dhskerala.hlth@kerala.gov.
in(DHS)
Cosmopolitan Hospital,
Trivandrum
Ashok P Menon
(CEO)
ceo@cosmopolitanhospitals.
in
coo@cosmopolitanhospitals.
in
G G Hospital,
Trivandrum
-phkplgghospital@gmail.com
28.Tamil Nadu
Madras Medical college
Dr R Jayanthi
(Dean)
Dr Narayanasamy-
(MS)
deanmmc@tn.gov.in ,
gghdean@gmail.com
Southern Railway
Headquarters Hospital
Dr Nirmala
(Medical Director)
nirmala.deviv1959@gmail.
com
mdrhper@sr.railnet.gov
Apollo Hospital, Greams
Road, Chennai
-info@apollohospitals.com 255
Annexure-VIII: Contact Details of Hospitals
29.Pondicherry
JIPMER Pondicherry
Dr Rakesh
Aggarwal (Director)
director@jipmer.edu.in,
ashok1956badhe@gmail.
com
Indira Gandhi
Government General
Hospital, Pondicherry
Vizeacoumary
(Deputy Director)
Dr Simon (HOD)
vizeacoumary@gmail.com
30.Delhi
Primus Super Speciality
Hospital, Chanakyapuri
Dr Subrata Gorai
(MS)
casualty@primushospital.
com
ms@primushospital.com
Medeor Hospital,
Manesar
Mr Shastry vgr.shastry@medeor.in
Yashoda Hospital,
Kaushambi
Dr Anuj (MS)
dranujagarwal@rediffmail.
com
Indian Spinal Injury
Centre
Dr H S Chhabra
(Medical Director)
cma@isiconline.org
drhschhabra@isiconline.org
Asian Hospital
Dr Hilal Ahmed
(Director)
hilal.ahmed@aimsindia.com
Sri Ganga Ram Hospital
Dr Reena Kumar
(Addl Director
Medical)
Dr Sucheta (ED
Head)
dr.reena.kr@gmail.com
Artemis Hospital
Dr Sumit Ray
(Chief of Medical
Services)
sumit.ray@artemishospitals.
com
Jaipur Golden Hospital-drnishithmittal@yahoo.co.in Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 256
ANNEXURE-IX: COMPARATIVE
COMPLIANCE OF HOSPITALS
AMONG CATEGORIES 257
Annexure-IX: Comparative compliance of Hospitals among categories
COMPARATIVE OF COMPLIANCE AMONG MEDICAL COLLEGE
S.
No.
Name of Hospitals
Hospital Services
ED Protocol/
SOP/
Guidelines
Safety & Security
Disaster
management
Continuous
Quality
Management
Data
Management
System
Financing
Physical
Infrastructure
Equipment & Supplies
in ED
Essential medicine
in ED
Overall
Compliance
1
Civil Hospital, Ahemdabad
66%
21%
94%
67%
71%
50%
75%
56%
92%
88%
68%
2
Agartala Government Medical College & G B Pant Hospital
41%
17%
39%
0%
21%
39%
38%
76%
23%
67%
36%
3
Guru Nanak Dev Hospital, GMC, Amritsar, Punjab
45%
13%
28%
0%
7%
0%
38%
78%
30%
16%
26%
4
Tomo Riba Institute if Health & Medical Sciences, Papumpare
22%
0%
56%
0%
14%
17%
38%
56%
36%
35%
27%
5
B J Medical College & Sassoon General Hospital, Pune
57%
13%
72%
0%
7%
28%
50%
88%
56%
63%
43%
6
Sher - I - Kashmir Institute of Medical Sciences, Srinagar
57%
21%
56%
42%
50%
22%
38%
61%
63%
51%
46%
7
Regional Institute of Medical Sciences, Imphal
48%
13%
83%
25%
29%
28%
63%
92%
35%
43%
46%
8
Gauhati medical College & Hospital
62%
29%
50%
33%
43%
50%
38%
78%
60%
62%
51%
9
Mysore Medical College & Krishna Rajendra Hospital
40%
0%
33%
0%
7%
39%
0%
51%
34%
58%
26% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 258
10
New STNM Hospital
36%
0%
50%
0%
29%
44%
38%
47%
55%
77%
38%
11
Government General Hospital, Guntur
52%
17%
44%
0%
14%
33%
13%
58%
55%
77%
36%
12
SMS Medical College & Hospital
74%
13%
50%
42%
0%
39%
38%
69%
88%
91%
50%
13
Goa Medical College
72%
25%
83%
17%
57%
44%
25%
81%
49%
78%
53%
14
AIIMS, Bhopal
53%
25%
89%
17%
7%
89%
50%
44%
100%
100%
57%
15
Rajiv Gandhi Government General Hospital, Madras Medical College
69%
46%
100%
75%
79%
44%
75%
93%
82%
95%
76%
16
JIPMER, Pondicherry
72%
33%
89%
67%
86%
78%
25%
69%
70%
83%
67%
17
Government Medical College, Thiruvanananthapuram
57%
33%
78%
42%
43%
17%
75%
67%
80%
100%
59%
18
Patna Medical College & Hospital
36%
8%
22%
8%
29%
6%
38%
92%
59%
89%
39%
19
IPGMER & SSKM Hospital
91%
100%
89%
67%
86%
83%
38%
81%
92%
98%
83%
20
IGMC, Shimla
60%
4%
78%
8%
21%
6%
38%
71%
72%
87%
45%
0 to 49%
50 to 74%
75 to 100%
259
Annexure-IX: Comparative compliance of Hospitals among categories
COMPARATIVE OF COMPLIANCE AMONG GOVERNMENT HOSPITALS MORE THAN 300 BEDS
S.
No.
Name of Hospitals
Hospital Services
ED
Protocol/
SOP/
Guidelines
Safety
&
Security
Disaster
management
Continuous
Quality
Management
Data
Management
System
Financing
Physical
Infrastructure
Equipment & Supplies
in ED
Essential medicine
in ED
Overall
Compliance
1
GMERS Medical College & Hospital
48%
29%
56%
50%
14%
33%
0%
88%
72%
79%
47%
2
Civil Hospital, Shillong
21%
50%
78%
67%
29%
22%
0%
72%
58%
26%
42%
3
Jallianwala Bagh Matyr Memorial Hospital, Amritsar
31%
29%
78%
42%
79%
0%
38%
57%
41%
53%
45%
4
Zoram Medical College
21%
4%
22%
0%
0%
0%
13%
55%
52%
53%
22%
5
District Hospital, Baramulla, Jammu & Kashmir
47%
71%
100%
92%
100%
72%
38%
74%
53%
74%
72%
6
Victoria Hospital, Bangalore
66%
4%
33%
8%
29%
39%
25%
76%
44%
59%
38%
7
District Hospital, Karim Nagar
43%
21%
0%
0%
0%
0%
63%
67%
27%
56%
28%
8
Government District Hospital, Tenali
50%
50%
56%
17%
21%
39%
63%
85%
48%
80%
51%
9
Hari Baksh Kanwatia Hospital
19%
0%
28%
8%
7%
17%
50%
68%
34%
67%
30%
10
Dr Shyam Prasad Mukharji Civil Hospital, Lucknow
38%
29%
72%
50%
71%
50%
25%
64%
33%
78%
51% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 260
11
Government Multispeciality Hospital, Sector 16
28%
58%
100%
100%
93%
50%
25%
82%
49%
61%
65%
12
Jai Prakash Narayan District Hospital, Bhopal
26%
29%
72%
67%
7%
56%
75%
65%
60%
87%
54%
13
Southern Railways Hospital, Chennai
52%
38%
61%
83%
21%
61%
38%
60%
58%
69%
54%
14
AIIMS, Bhubneswar
41%
33%
67%
0%
36%
50%
75%
90%
71%
61%
52%
15
Indira Gandhi Government General Hospital, Pondicherry
48%
0%
33%
17%
21%
33%
50%
65%
49%
88%
40%
16
AIIMS, Patna
62%
25%
67%
17%
57%
83%
0%
66%
94%
94%
57%
17
General Hospital, Neyyatinkara
19%
8%
22%
17%
29%
11%
38%
72%
45%
65%
33%
18
District Hospital, Dhamtari
26%
21%
39%
17%
7%
28%
0%
67%
40%
60%
31%
19
HNB Base Hospital
33%
21%
39%
42%
36%
44%
0%
75%
76%
73%
44%
20
Deen Dayal Upadhyay Hospital
17%
8%
78%
42%
79%
61%
25%
66%
58%
79%
51%
0 to 49%
50 to 74%
75 to 100% 261
Annexure-IX: Comparative compliance of Hospitals among categories
COMPARATIVE OF COMPLIANCE AMONG GOVERNMENT HOSPITALS LESS THAN 300 BEDS
S.
No
Name of Hospitals
Hospital Services
ED
Protocol/
SOP/
Guidelines
Safety & Security
Disaster
management
Continuous
Quality
Management
Data
Management
System
Financing
Physical
Infrastructure
Equipment & Supplies
in ED
Essential medicine
in ED
Overall
Compliance
1
Jamanabai General Hospital
21%
38%
44%
0%
36%
28%
63%
81%
37%
72%
42%
2
Gomti District Hospital
26%
8%
61%
8%
14%
28%
50%
60%
32%
62%
35%
3
District Hospital, Peren, Nagaland
7%
17%
28%
0%
14%
0%
50%
83%
27%
16%
24%
4
Civil Hospital, Aizawl, Mizoram
28%
54%
83%
67%
86%
39%
75%
61%
57%
62%
61%
5
District Hospital, Pasighat
33%
21%
56%
8%
43%
17%
38%
53%
31%
56%
36%
6
Dr Jogalekar Hospital
38%
83%
67%
83%
86%
78%
0%
86%
94%
50%
67%
7
District Hospital, Ganderbal
17%
25%
67%
33%
36%
28%
38%
85%
55%
82%
47%
8
District Hospital, Bishnupur, Manipur
10%
8%
22%
25%
21%
11%
63%
63%
24%
50%
30%
9
Morigaon Civil Hospital, Assam
14%
8%
33%
25%
0%
39%
0%
69%
33%
63%
28%
10
Government Hospital Virajpet
33%
4%
28%
8%
29%
0%
25%
57%
43%
70%
30%
11
District Hospital, Singtam
28%
21%
56%
17%
71%
0%
25%
76%
53%
66%
41% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 262
12
District Hospital, King Koti
41%
13%
50%
0%
43%
44%
0%
73%
70%
57%
39%
13
Govt. BDM Hospital, Kotputli
28%
17%
22%
8%
21%
0%
38%
74%
37%
29%
27%
14
North Goa District Hospital
31%
21%
83%
8%
79%
33%
0%
60%
51%
83%
45%
15
Civil Hospital, Sector 22
7%
13%
67%
50%
21%
0%
38%
81%
53%
49%
38%
16
Puri District Headquarter Hospital, Orissa
34%
0%
72%
50%
43%
56%
63%
69%
61%
55%
50%
17
Sadar Hospital, Gaya
9%
0%
17%
0%
14%
0%
0%
44%
27%
40%
15%
18
District Hospital, Peroorkada
21%
8%
28%
0%
21%
33%
0%
73%
42%
53%
28%
19
District Hospital, Raipur
21%
38%
72%
33%
21%
0%
0%
76%
41%
59%
36%
20
Coronation Hospital, Dehradun
14%
21%
22%
58%
7%
6%
63%
58%
31%
68%
35%
0 to 49%
50 to 74%
75 to 100%
263
Annexure-IX: Comparative compliance of Hospitals among categories
COMPARATIVE OF COMPLIANCE AMONG PRIVATE HOSPITALS MORE THAN 300 BEDS
S.
No
Name of Hospitals
Hospital Services
ED Protocol/
SOP/
Guidelines
Safety & Security
Disaster
management
Continuous
Quality
Management
Data
Management
System
Financing
Physical
Infrastructure
Equipment & Supplies
in ED
Essential medicine
in ED
Overall
Compliance
1
Parul Sewasharam Hospital
52%
13%
78%
42%
50%
44%
0%
87%
90%
92%
55%
2
Tripura Medical College & BRAM Teaching Hospital
52%
21%
78%
50%
79%
39%
25%
76%
37%
76%
53%
3
Synod Hospital, Aizawl, Mizoram
38%
13%
50%
0%
7%
33%
0%
91%
88%
83%
40%
4
Grant Medical Foundation Ruby Hall Clinic
91%
100%
89%
92%
93%
89%
0%
89%
90%
100%
83%
5
GNRC, Guwahati, Assam
40%
21%
61%
50%
57%
33%
0%
91%
42%
54%
45%
6
Manipal Hospital, Bangaluru
86%
83%
89%
67%
100%
56%
0%
96%
88%
70%
74%
7
Central Referral Hospital, Sikkim
62%
8%
67%
8%
71%
44%
13%
87%
72%
94%
53%
8
Kasturi Medical College & Hospital
59%
38%
78%
17%
57%
44%
0%
89%
66%
100%
55%
9
Fortis Hospital, Jaipur
33%
92%
100%
83%
100%
94%
0%
84%
100%
100%
79%
10
Dr Ram Manohar Lohia Hospital
45%
38%
100%
67%
86%
44%
25%
63%
58%
67%
59%
11
Fortis Hospital, Punjab
86%
92%
89%
100%
86%
50%
0%
70%
76%
98%
75% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 264
12
Apollo Hospitals, Chennai
76%
96%
94%
100%
100%
94%
0%
72%
85%
87%
80%
13
Capital Hospital, Orissa
52%
54%
72%
92%
43%
83%
38%
94%
65%
80%
67%
14
Yashoda Hospital, Malakpet
83%
83%
89%
67%
100%
83%
0%
79%
100%
89%
77%
15
Paras HMRI Hospital
41%
96%
89%
100%
100%
67%
0%
93%
92%
97%
78%
16
Cosmopolitan Hospitals Privatre Limited
76%
38%
78%
25%
79%
56%
0%
85%
89%
91%
62%
17
Yashoda Hospital, Kaushambi
66%
75%
83%
75%
64%
67%
0%
76%
79%
91%
68%
18
Asian Hospital
88%
67%
94%
92%
93%
100%
0%
87%
96%
84%
80%
19
Sri Ganga Ram Hospital
84%
100%
89%
100%
93%
67%
0%
93%
94%
81%
80%
20
Artemis Hospital
84%
92%
89%
83%
100%
78%
0%
75%
94%
92%
79%
0 to 49%
50 to 74%
75 to 100%
265
Annexure-IX: Comparative compliance of Hospitals among categories
COMPARATIVE OF COMPLIANCE AMONG PRIVATE HOSPITALS LESS THAN 300 BEDS
S.
No
Name of Hospitals
Hospital Services
ED Protocol/
SOP/
Guidelines
Safety
&
Security
Disaster
management
Continuous
Quality
Management
Data
Management
System
Financing
Physical
Infrastructure
Equipment & Supplies
in ED
Essential medicine
in ED
Overall
Compliance
1
Bhailal Amin General Hospital
74%
63%
89%
83%
93%
72%
0%
92%
78%
98%
74%
2
Christian Institute of Health Sciences & Research, Dimapur
21%
33%
61%
25%
93%
56%
0%
84%
67%
77%
52%
3
Shivam Hospital, Hoshiarpur, Punjab
50%
38%
83%
17%
93%
44%
13%
86%
61%
66%
55%
4
Ramakrishna Mission Hospital, Arunachal Pradesh
43%
46%
78%
42%
86%
44%
0%
84%
78%
97%
60%
5
Shija Hospital & Research Institute, Meitei longol, Imphal
62%
42%
72%
33%
79%
33%
25%
85%
22%
71%
52%
6
Nemcare Superspeciality Hospital, Assam
79%
67%
89%
50%
36%
56%
50%
89%
80%
85%
68%
7
Lalitha Super Speciality Private Hospital
55%
75%
83%
25%
86%
89%
25%
88%
67%
94%
69%
8
Birla CK Hospital, Jaipur
41%
75%
78%
58%
79%
78%
0%
84%
100%
100%
69% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 266
9
Charak Hospital & Research Centre, Lucknow
59%
67%
94%
83%
93%
50%
0%
73%
98%
98%
72%
10
Max Super Speciality Hospital
86%
75%
89%
50%
100%
56%
13%
84%
92%
96%
74%
11
Bhopal Fracture Hospital, Bhopal
26%
67%
78%
17%
57%
67%
38%
97%
96%
68%
61%
12
Care Hospital, Orissa
69%
79%
89%
75%
100%
78%
0%
82%
73%
93%
74%
13
G G Hospital
62%
83%
89%
67%
79%
67%
0%
77%
82%
93%
70%
14
Ruban Memorial Hospital
57%
88%
89%
50%
79%
100%
0%
77%
99%
100%
74%
15
Ramakrishna Care Hospital
93%
75%
89%
100%
100%
94%
100%
80%
100%
100%
93%
16
Ruby General Hospital
53%
63%
78%
42%
79%
72%
25%
92%
76%
83%
66%
17
Indian Spinal Injuries Centre
62%
67%
89%
83%
93%
72%
0%
78%
90%
86%
72%
18
Medeor Hospital
76%
92%
89%
100%
100%
56%
0%
67%
88%
74%
74%
19
Jaipur Golden Hospital
74%
71%
83%
92%
86%
50%
0%
84%
83%
79%
70%
20
Primus Super Speciality Hospital
100%
100%
100%
75%
86%
100%
100%
72%
92%
100%
93%
0 to 49%
50 to 74%
75 to 100%
267
Annexure-IX: Comparative compliance of Hospitals among categories
MASTER SHEET DEPICTING COMPLIANCE AMONG HOSPITAL CATEGORIES
S.No.
Area of Concern
Medical College
Government
Hospitals more than
300 beds
Government
Hospitals less than
300 beds
Private Hospitals
more than 300
beds
Private Hospitals
less than 300 beds
Overall
Compliance
1
Hospital Services
56%
37%
23%
65%
62%
49%
2
ED Protocol/ SOP/ Guidelines
22%
26%
21%
61%
68%
40%
3
Safety & Security
64%
55%
49%
83%
84%
67%
4
Disaster management
26%
37%
24%
66%
58%
42%
5
Continuous Quality Management
35%
37%
35%
78%
85%
54%
6
Data Management System
38%
37%
22%
63%
67%
45%
7
Financing
42%
32%
31%
5%
19%
26%
8
Physical Infrastructure
70%
71%
69%
84%
83%
75%
9
Equipment & Supplies in ED
62%
53%
45%
80%
81%
64%
10
Essential medicine in ED
73%
68%
57%
86%
88%
74%
0 to 49%
50 to 74%
75 to 100% Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 268
MASTER SHEET DEPICTING OVERALL COMPLIANCE OF INDIVIDUAL HOSPITAL AMONG ALL CATEGORIES
Zone
S.
No.
State
Medical College
Government Hospital (more
than 300 beds)
Government Hospital
(less than 300 beds)
Private Hospital
(more than 300 beds)
Private Hospital (less
than 300 beds)
NORTH
ZONE
1
Jammu & Kashmir
Sher-i-Kashmir Institute of Medical Sciences, Srinagar (46%)
District Hospital Hospital, Barahmulla, Jammu & Kashmir(72%)
District Hospital Ganderbal, Ganderbal(47%)
-
-
2
Himachal Pradesh
IGMC, Shimla
(45%)
District Hospital,Shimla (Deen Dayal Upadhyay Hospital)(51%)
-
-
-
3
Punjab
Guru Nanak Dev Hospital & Govt. Medical College, Amritsar (26%)
Jallianwala Bagh Martyr’s Memorial Civil Hospital, Rambagh, Amritsar(45%)
-
Fortis Hospital, Mohali (75%)
Shivam Multi Super Speciality Hospital, Hoshiarpur (55%)
4
Haryana
-
-
-
-
-
5
Uttarakhand
-
HNB Base Hospital(44%)
Coronation Hospital, Dehradun (35%)
-
-
6
Utttar Pradesh
-
Civil Hospital- Lucknow(51%)
-
RML Hospital, Lucknow (59%)
Charak Hospital Hardoi road, near Safed Masjid, Dubagga
(72%)
7
Chandigarh
-
Government Superspeciality Hospital, Sector-16(65%)
Civil Hospital Sector-22, Chandigarh(38%)
-
Max Superspeciality Hospital, Mohali(74%) 269
Annexure-IX: Comparative compliance of Hospitals among categories
8
Rajasthan
SMS Medical College & Hospital, Jaipur (50%)
Hari Baksh Kanwatia Hospital, Shastri Nagar, Jaipur(30%)
Govt. BDM Hospital, Kotputli, Rajasthan(27%)
Fortis Hospital, Jaipur(79%)
Birla Hospital- CK Birla, Shanthi Nagar, Jaipur (69%)
9
Delhi
-
-
-
Yashoda Hospital, Kaushambi (68%)
Indian Spinal Injuries Centre (72%)
Asian Hospital(80%)
Medeor Hospital, Manesar (74%)
Sri Ganga Ram Hospital (80%)
Jaipur Golden Hospital (70%)
Artemis Hospital(79%)
Primus Super Speciality Hospital(93%)
WEST ZONE
1
Gujarat
BJ Medical College & Civil Hospital, Ahemdabad
(68%)
GMERS Medical College & Hospital, Gotri, Vadodara(47%)
Jamanabai Government Hospital, Mandvi(42%)
Parul Sewasharam Hospital, Vadodara(55%)
Bhailal Amin General Hospital, Vadodara(74%)
2
Maharashtra
BJ Medical College & Sassoon General Hospital, Pune (43%)
-
Sri Seva Medical foundation Dr Jogalekar Hospital, Shirwal, Pune (67%)
Grant Medical Foundation Ruby Hall Clinic, Pune(83%)
-
3
Madhya Pradesh
AIIMS, Bhopal (57%)
Jai Prakash District Hospital, Shivaji Nagar, Bhopal (54%)
-
-
Bhopal Fracture Hospital, Bhopal(61%) Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 270
4
Chhattisgarh
-
District Hospital, Dhamtari, Chhattisgarh(31%)
District Hospital, Tikarpara, Raipur, Chhattisgarh(36%)
-
Ramkrishna CARE Hospital (93%)
5
Goa
Goa Medical College, Panaji (53%)
-
North Goa District Hospital, Mapusa(45%)
-
-
EAST
ZONE
1
Bihar
PMCH, Patna(39%)
AIIMS Patna(57%)
Sadar Hospital, Gaya(15%)
Paras HMRI Hospital, Patna (78%)
Ruban Memorial hospital patliputra(74%)
3
Orissa
-
AIIMS, Bhubneshwar(52%)
District Headquarter Hospital, Puri(50%)
Capital Hospital, Bhubneshwar(67%)
Care Hospital, Bhubneshwar(74%)
4
West Bengal
IPGMER & SSKM(83%)
-
-
-
Ruby General Hospital (66%)
NORTH
EAST
ZONE
1
Sikkim
New STNM- Govt- medical college, Sikkim (38%)
-
Singtam District Hospital (41%)
Central Referral hospital, Gangtok (53%)
-
2
Arunachal Pradesh
Tomo Riba Institute of Health & Medical Sciences, Papumpare(27%)
-
Bakin Pertin General Hospital, Medog, Pasighat (36%)
-
Ramakrishna Mission Hospital, Itanagar(60%)
3
Assam
Gauhati Medical College and Hospital, Guwahati
(51%)
-
Morigaon Civil Hospital(28%)
GNRC Hospital, Guwahati (45%)
Nemcare Superspecialty Hospital, Guwahati(68%) 271
Annexure-IX: Comparative compliance of Hospitals among categories
4
Meghalaya
-
Civil Hospital Shillong, Meghalaya (42%)
-
-
-
5
Nagaland
-
-
-
District Hospital, Peren, Nagaland (24%)
-
-
Christian Institute of Health Science and Research (52%)
6
Manipur
RIMS, Imphal(46%)
-
-
District Hospital, Bishnupur (30%)
-
Shija Hospital & Research Institute, Imphal (52%)
7
Tripura
Agartala Government Medical College & G B Pant Hospital(36%)
-
-
Gomti District Hospital, Udaipur (35%)
Tripura medical college& BRAM Teaching Hospital, Agartala (53%)
-
8
Mizoram
-
Zoram Medical College(22%)
Civil Hospital, Aizawl(61%)
Synod Hospital(40%)
-
SOUTH
ZONE
1
Telangana
-
District Hospital, Karim Nagar, Hyderabad (28%)
District Hospital, King Koti, Hyderabad(39%)
Yashoda Hospital, Malakpet, Hyderabad(77%)
-
2
Karnataka
Mysore Medical College & Krishna Rajendra Hospital, Mysuru (26%)
Victoria Hospital, Bengaluru(38%)
Government Hospital, Virajpet (30%)
Manipal Hospital, Bengaluru (74%)
- Emergency and Injury Care at Secondary
and Tertiary Level Centres in India 272
3
Andhra Pradesh
Guntur Medical college & Government General Hospital(36%)
Government District Hospital, Tenali (51%)
-
Kasturi Medical College & Hospital(55%)
Lalitha Super Specialty Hospital, Kothapet, Guntur (69%)
4
Kerala
Trivandrum Govt Mediacl College(59%)
District Hospital, Neyyattinkara(33%)
District Hospital, Peroorkada (28%)
Cosmopolitan Hospitals Pvt Ltd(62%)
G G Hospital(70%)
5
Tamil Nadu
Madras Medical College
(76%)
Madras Railway Hospital, Madras (Southern Railway Headquarters Hospital)(54%)
-
Apollo Hospital(80%)
-
6
Pondicherry
JIPMER, Pondicherry (67%)
Indira Gandhi Government General Hospital, Pondicherry(40%)
-
-
-
0 to 49%
50 to 74%
75 to 100%
Emergency and Injury Care
at Secondary and Tertiary
Level Centres in India
A Report of Current Status on
Country Level Assessment
Emergency and Injury Care at Secondary and Tertiary Level Centres in India
A Report of Current Status on Country Level Assessment Phone Number: 011-26731068
Email: Office@whoccemcare.org
Office: Room No. 117, First Floor, Department of
Emergency Medicine, JPNATC, AIIMS, Ring Rd.,
Raj Nagar, New Delhi-110029