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A COUNTRY LEVEL ASSESSMENT OF CURRENT
STATUS OF EMERGENCY AND INJURY CARE AT
SECONDARY AND TERTIARY LEVEL CENTRES IN
INDIA
Project Report
Submitted to
NITI Aayog, New Delhi
This study was carried out with the financial support of NITI Aayog, Government of India,
and conducted by Department of Emergency Medicine, JPNATC, AIIMS.
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.
DISCLAIMER
No Name Designation Organization
PRINCIPAL INVESTIGATOR
1 Dr Sanjeev Kumar Bhoi Professor Department of
Emergency Medicine,
JPNATC, AIIMS,
New Delhi
CO-INVESTIGATORS
2 Dr Praveen Aggrawal Professor & HOD Department of
Emergency Medicine,
JPNATC, AIIMS,
New Delhi
3 Dr Tej Prakash Sinha Associate Professor
CONTRIBUTORS
4 Dr Tanu Jain Assistant Director
General
Directorate General of
Health Services,
Nirman Bhawan, New
Delhi
5 Dr S Rajesh Former Director
(Health)
NITI Aayog
6 Dr K Venkatnarayan Officer on Special
Duty
LIST OF INVESTIGATORS AND CONTRIBUTORS
We would like thanks to all those who are involved in this endeavour for their kind
cooperation for its successful completion. At the outset, we wish to express our sincere
gratitude to all those people who helped us to complete this project in an efficient manner.
This study was carried out with the financial support of NITI Aayog, Government of India,
and conducted by Department of Emergency Medicine, JPNATC, AIIMS.
We sincerely acknowledge God almighty, from whom all blessings and knowledge flowed in
achieving this study to a completion successfully.
We would like to thanks to Dr V K Paul, Member, National Institution for Transforming
India to help in conceive the study, guided through the processes.
We would like to thanks to Dr Madan Gopal, Sr. Consultant, NITI Aayog for his kind
support and co-operation, during this study.
We would like to thanks to all our research staff and team of national assessors for their kind
support and help to conduct this study in short duration of time.
We would like to say thanks to all selected healthcare facilities for their kind cooperation to
conduct this study in their hospitals. We would also thanks to all the nodal persons and
assessors, who gave their time and expertise in assessment of all the selected healthcare
facilities.
Also, we must extend our sincere thanks to all the stakeholders who agreed and provide their
support during this study.
ACKNOWLEDGEMENT
1. EXECUTIVE SUMMARY 1
2. INTRODUCTION 8
3.
REVIEW OF LITERATURE
1. Burden of Emergency Conditions in the South-East Asian Region
2. Burden in India
3. Current Status of Emergency Care in the India
4. WHO Emergency Care System Framework
5. Hospital Based Emergency Care in the Government Sector in
India
6. Training
7. Academic Emergency Medicine
8. Gaps
8.1. Research and Development for Emergency Services
8.2. Organization and financing
10
4. AIMS AND OBJEVTIVES 21
5. METHODOLOGY
1. Identification of potential healthcare facilities
2. Finalization of the sites
3. Development of study tools, standard operating procedures
4. Establishment of governance structure and a project
implementation
5. Training of assessors
6. Data Collection
7. Definition and process of Live Data Recording
8. Data Analysis
23
6. OBSERVATIONS AND RESULTS WITH RESULTS
I. FIELD VISIT (Administrative Interview/One year Data Collection)
1. Background Information of the Hospitals
2. Available Beds at Assessed Facilities
29
30
TABLE OF CONTENTS 3. Burden of Patients (OPD and Emergency)
4. Huge Mismatch between Emergency Beds & Burden of
Emergency and Injury Cases
5. Burden of Medico-legal Cases
6. Burden of Admissions through Emergency
7. Burden of Death of Trauma Patients
8. Burden of Patient‘s Death due to Road Traffic Injury
9. Burden of Brought Dead Patients
10. Blood Bank Services
11. Definitive Care Services
12. Ambulance services
12.1. Available ambulances in hospitals
12.2. Hospital Ambulance Services
12.3. Use of Ambulances by Hospitals
12.4. Patient transfer in absence of hospital ambulance
13. ED Protocol/SOP/Guidelines
14. Emergency Care Protocol
15. Measures ensuring Safety & Security in Hospitals
16. Disaster Management
17. Continuous Quality Improvement
18. Computerized Data management System
19. Financing
20. Physical Infrastructure
21. Manpower in Emergency Department
21.1. Other Specialist/Super Specialist Available in Hospital
21.2. Discussion for manpower in Emergency
22. Equipment and Supplies in ED
22.1. Biomedical Equipment
22.2. Compliance of critical available equipments
23. Point of Care Lab
24. Essential Medicines for Emergency
II. LIVE OBSERVATION (Onsite Live Observations)
1. Disposition Time
108
2. Chest Pain
3. Stroke
4. Trauma
5. Incidence of Violence
5.1. Reason of Violence
5.2. Mitigation Measures
6. Communication Skills in Emergency Department
7. Patient Satisfaction
8. Referral of the Patient
III. LIVE OBSERVATION (One day data of Emergency Department)
1. Burden of Patients (OPD and Emergency)
2. Disposition Summary
3. Spectrum of Diseases
3.1. Adult Patients
3.2. Pediatric Patients
IV. Comparison of Emergency care Services in various Systems
1. Hospitals with Academic Emergency Medicine
2. Govt. Secondary care v/s tertiary care Hospitals
3. Private Hospitals vs Government Hospitals
4. NABH accredited vs non-NABH accredited Hospitals
V. Compliance of individual hospitals to the checklist
133
140
152
7. DISCUSSION 153
8. CONCLUSIONS 156
9.
SUMMARY OF KEY SUGGESTIONS EMERGING FROM THE
STUDY
158
10. SUGGESTED KEY POLICY RECOMMENDATIONS 164
11. REFERENCES 168
12. ANNEXURES
I. List of Hospitals
II. Study Tool
III. List of Scientific Advisory Committee Members
IV. Patient Information Sheet
V. Conflict of Interest Agreement Form for National Assessor
VI. Overall Summary of Other Specialist / Super Specialist available
173 in Hospital {Median [IQR]Min-Max} by Category of Hospitals
VII. List of other participants in study
VIII. Contact Details of Hospitals
IX. Comparative compliance of Hospitals among categories
ACLS Advanced Cardiac Life Support
AIIMS All India Institute of Medical Sciences
ALS Advanced Life Support
AMBU Artificial Manual Breathing Unit
APTT Activated Partial Thromboplastin Time
ATLS Advanced Trauma Life Support
BLS Basic Life Support
Ca Calcium
CABG Coronary Artery Bypass Grafting
CCU Critical Care Unit
CD Communicable Disease
Cl Chlorine
CMO Chief medical officer
CT Computerized Tomography
DALYs Disability-Adjusted Life Years
DLC Differential Leucocyte Count
DNB Diplomat of National Board
DSA Digital Subtraction Angiography
ECG Electrocardiogram
ECS Emergency Care System
ED Emergency Department
EHR Electronic Health Record
EM Emergency Medicine
EMS Emergency Medical Services
EMT Emergency Medical Technician
ER Emergency Room
ETAT Emergency Triage Assessment and Treatment
FFP Fresh Frozen Plasma
GDA General Duty Attendant
GDP Gross Domestic Product
GHE Global Health Estimates
HA Hospital Attendant
Hb Hemoglobin
Hct Hematocrit
HDU High Dependency Unit
HMRI Hai Medicare and Research Institute
ICU Intensive Care Unit
INDUSEM INDO-US Emergency Medicine
INR International Normalized ratio
IPD In-Patient Department
IPGMER Institute of Post-Graduate Medical Education and Research
ITU Intensive Treatment Unit
ABBREVIATIONS IV Intra-venous
JPNATC Jai Prakash Narayan AIIMS Trauma Centre
JR Junior Residents
K Potassium
LAMA Left Against medical Advice
LMA Laryngeal Mask Airway
LMICs Lower Middle Income Countries
MCI Medical Council of India
MLC Medico legal Cases
MO Medical Officer
Na Sodium
NABH National Accreditation Board for Hospitals & healthcare Providers
NCD Non-Communicable Disease
NITI Aayog National Institution for Transforming India
OPD Out Patient Department
OT Operation Theatre
PALS Pediatric Advanced life Support
PCI Percutaneous Coronary Intervention
PEF Peak Expiratory Flowmeter
Pro-BNP N-terminal B-type Natriuretic Peptide
PT Platelet Transfusion
RBC Red blood Corpuscles
RTI Road Traffic Injury
SA Sanitary Attendant
SAC Scientific Advisory Committee
SD Standard Deviation
SEAR South East Asian Regions
SOP Standard Operating Procedures
SPSS Statistical Package for the Social Sciences
SR Senior Residents
SSG Sir Sayaji General
SSKM Seth SukhlalKarnani Memorial
STNM Sir ThutobNamgyal Memorial
TEG Thromboelastogram
TLC Total Leucocyte Count
Trop-I Troponin I
Trop-T Troponin T
U.S. United States
USG Ultrasound/Sonography
WHO World Health Organization
1
EXECUTIVE
SUMMARY
2
EXECUTIVE SUMMARY
Medical emergencies including Road Traffic Injuries are one of the majorleading 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.
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.
3
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:
o 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%)
o 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.
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.
4
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.
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
5
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.
Most of the hospitals across the spectrum lacked trauma registry and systems for
surveillance of trauma and Emergency Care.
6
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
andtimely delivery of care, translating into higher patient satisfaction levels.
7
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 effortsmade 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.
8
INTRODUCTION
9
INTRODU CTION
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.
10
REVIEW OF
LITERATURE
11
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 healthcoverage.
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 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 AsianRegion
Despite tremendous improvement in health care delivery in the SEAR over recent decades,
12
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)
Table 1: Projections of mortality by cause for 2015 and 2030
(4)
Deaths (thousands) by cause projected to 2015 and 2030 in SEAR
Year 2015 2030
Population (thousands) 1920761 2205146
GHE 2012 cause category
Deaths
%
Total
Deaths % Total
All Causes 14851 100 18595 100
I. Communicable, maternal,
perinatal and nutritional
conditions
3748 25.2 2998 16.1
13
II. Non-communicable diseases 9428 63.5 13472 72.5
A. Cardiovascular diseases 4159 28.0 5872 31.6
B. Respiratory diseases 1712 11.5 2561 13.8
C. Malignant neoplasms 1412 9.5 2310 12.4
D. Diabetes mellitus 434 2.9 690 3.7
III. Injuries 1676 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
injuriesare 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)
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
14
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)
Year 2016
Population (thousands) 1324200
GHE 2012 cause category %
Total
All Causes 100
I. Communicable, maternal,
perinatal and nutritional
conditions
27.5
II. Non-communicable diseases 61.8
A. Cardiovascular diseases 28.1
B. Respiratory diseases 10.9
C. Malignant neoplasms 8.3
D. Diabetes mellitus 6.5
III. Injuries 10.7
Data are % (95% uncertainty interval).
**Source: Reference (6)
Figure 3: Percent of total DALYs by age groups in India, 2016
(6)
**Source: Reference (6)
15
The higher proportion of the total DALY burden relative to their proportion of the population
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 diseaseswas 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 andtrauma.
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 emergencyconditions.
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
16
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)
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 buildingblocks).
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 patientsandproviders.
Figure 4a: WHO Emergency Care System Framework
(13)
**Source: WHO info-graphics
17
Patients may access any
level of care directly
Figure 4b: WHO Emergency Care System Framework
(13)
**Source: WHO info-graphics
Figure 5: Integrated Model: The roots feeding the Emergency Care System
18
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
19
was found to contribute towards reducing maternal deaths in Kebbistate, Nigeria, and in other
sites where the intervention was implemented
(22,23)
.
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 medicalservices.
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)
20
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 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 requirementsfor emergencies,
especially for obstetrics, have been used in various setting, especially in Africa.
(33, 34)
21
AIMS &
OBJECTIVES
22
AIMS 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
23
METHODOLOGY
24
METHOD OLOGY
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) andPrivate
hospitals less than 300-bed strength (20).
Figure 6: Map showing hospitals (tagged red) selected for this study from different
states and different zones
25
Figure 7a: Flow chart of Methodology
**where applicable
Selection of Healthcare Facilities
Finalization of Healthcare Facilities
Team formation of National Assessors
Development of Study Tool
Finalization of Study Tool through
Scientific Advisory Committee
Training of Assessors by tele /
video-conference
Field visit across country for
DATA COLLECTION
One year data collection
Based on administrative interview
Based on facility visit
Live data collection for 24 hours
Based on live observation
Data collection of Specific
Diseases
Data Analysis
Draft Report
Categorization **:
A) Hospital-wise
B) Zone-wise
C) NABH Accreditation-wise
26
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:
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
27
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.
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
Triage
Resuscitation
Relevant
Investigation
Relevant Consultation
(With definitive care
specialists)
Final Disposal
(Discharge/ referral/ admission
to general ward/ to ICU/
to OT/ to Cathlab)
Disposal
Decision
28
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).
Figure 7b: Overall representation of strategy and procedures of Data Collection
29
OBSERVATIONS
AND RESULTS
WITH
SUGGESTIONS
30
FIELD VISIT
(ADMINISTRATIVE
INTERVIEW/ONE YEAR DATA
COLLECTION)
31
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.
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
32
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).
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.
33
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.
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.
34
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.
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.
35
In table 5, separate adult and pediatric patient‘s data for OPD and emergency is reported with
median [IQR] and min-max.
Table 5: Summary of Patients visited in OPD and Emergency (Adult and Pediatric) 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
Adult Pediatric Adult Pediatric
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.
36
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.
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 Colleges
13%
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.
37
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 15 5 3
100 35 7 5 16 7 3
150 40 8 6 18 8 4
200 45 9 7 20 9 4
>200
50 or
above
10 8 22 10 5
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-
o Upgrading them to medical college
o Developing residency programme in DNB: where in PG residents rotate
regularly at district hospitals
o 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.
38
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.
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.
39
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.
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.
40
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 ED n
Median [IQR]
Min-Max
Medical Colleges 14
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.
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.
41
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
42
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
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
43
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.
44
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.
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
45
10. Blood Bank Services:
Table 13 summarizes the hospital blood bank services for all categories of hospitals. As per
the 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)
FC PC NC FC PC NC FC PC NC FC PC NC FC PC NC
Licensed in-house
Blood Bank
18 1 1 14 3 3 7 5 8 17 0 2 13 1 6
24*7 Blood Bank 18 1 1 14 3 2 7 1 5 17 0 2 13 1 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
16 1 2 6 6 6 6 2 8 16 1 3 13 1 6
O Negative Blood
Availability
17 2 1 11 5 3 7 6 4 15 3 2 7 4 9
ED Blood Storage 4 1 14 1 2 17 5 3 9 4 1 15 6 0 14
ED Blood
Transfusion Protocol
6 0 13 3 1 15 3 2 13 10 2 8 10 1 9
Massive Blood
Transfusion Protocol
7 0 13 2 1 16 4 1 13 9 0 11 8 0 12
**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.
46
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.
47
Most of the hospitals did not have protocols for massive blood transfusion and ED blood
transfusion (Figure 10).
6district 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).
B) Zone-wise comparison:
Table 14and figure 11 summarizes the blood bank services for hospitals in different zones of
India.
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.
48
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
49
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)
NC PC FC NC PC FC NC PC FC NC PC FC NC PC FC
Licensed in-house
Blood Bank
4 3 23 4 0 16 4 2 5 4 1 11 4 4 13
24*7 Blood Bank 3 0 26 3 1 15 2 1 6 2 2 10 6 3 13
Tie up with external
blood bank
6 3 12 4 1 6 1 1 4 0 3 3 4 3 8
Separate
Component
Facilities
8 3 17 3 2 15 3 2 4 4 2 9 8 2 10
O-ve Blood
Availability
6 6 18 2 2 16 1 5 3 4 2 9 7 4 10
ED Blood Storage 22 1 7 13 2 4 4 2 3 9 3 3 20 0 2
ED Blood
Transfusion
Protocol
18 1 10 10 1 8 4 2 4 7 2 6 18 1 3
Massive Blood
Transfusion
Protocol
19 1 9 11 1 8 7 0 3 8 1 6 19 0 3
**FC: Full Compliance, PC: Partial Compliance, NC: Non-Compliance, ED: Emergency Department
50
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
For Trauma pts 14 5 1 7 9 3 1 8 11 14 6 0 17 3 0
For Non-Trauma
pts
14 6 0 10 7 2 2 8 10 14 6 0 18 2 0
For Obstetrics pts 14 2 0 10 6 3 7 10 3 12 6 1 14 3 1
For Orthopedic
pts
15 4 0 9 6 4 4 7 8 15 5 0 18 1 1
For Neurosurgical
pts
13 2 4 4 3 10 0 3 16 14 3 2 16 2 1
*n: total number of assessed hospitals
Figure 12: Comparison of Hospital Emergency Operative Services in Hospital Categories
51
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.
Table16: 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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Common ICU 13 4 3 11 4 4 1 5 14 16 3 1 17 3 0
Common HDU 5 4 11 5 4 8 0 2 18 14 3 2 14 2 3
Pediatric ICU 14 1 3 4 5 9 0 2 18 11 3 4 8 2 6
Neonatal ICU 13 2 3 6 5 7 4 5 11 12 3 3 12 3 2
Neurosurgical
ICU
8 3 7 4 1 11 0 0 19 12 3 4 8 5 5
Cardiac ICU 10 1 7 4 3 9 0 0 19 15 2 2 15 1 2
*n: total number of hospitals, ICU: Intensive Care Unit, HDU: High Dependency Unit
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).
52
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).
53
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Cardiac Cath Lab 11 1 6 4 3 9 0 0 19 14 3 2 14 2 2
Intervention
Radiology
9 2 7 1 4 10 0 2 17 8 4 6 10 4 4
Intervention Neuro
Radiology with
DSA
4 6 8 1 3 11 0 0 18 7 4 8 5 6 7
Facility for
Emergency CABG
Service
4 3 11 2 3 10 0 0 18 9 5 5 11 4 3
Facility for
Radiofrequency
Ablation Service
5 0 12 0 2 12 0 0 18 7 4 8 6 4 7
*n: total number of assessed hospitals
54
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.
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.
55
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).
Table18: 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%)
ALS 38 (44%) 21 (57%) 17 (36%) 40 (44%) 32 (59%)
BLS 24 (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
56
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
Functional 103 (76%) 69 (84%) 29 (94%) 55 (86%) 59 (91%)
ALS 33 (24%) 39 (48%) 17 (55%) 34 (53%) 25 (38%)
BLS 35 (26%) 25 (30%) 8 (26%) 18 (28%) 11 (17%)
Other Transport
Vehicles
68 (50%) 18 (22%) 6 (19%) 12 (19%) 29 (45%)
Non-Functional 6 (4%) 9 (13%) 2(7%) 9 (16%) 5 (8%)
Data Not Known 27 (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.
57
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
58
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 Ambulances 121 32% 257 68%
Functional 118 98% 197 77%
ALS 59 49% 89 35%
BLS 54 45% 43 17%
Other Transport
Vehicles
8 7% 125 49%
Non-Functional 3 2% 28 11%
Data Not Known 0 0% 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
poolof 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 availabe in only 4% hospitals and Tele stroke/STEMI (ST-segment
elevation myocardial infarction) was availabe in 19% hospitals.
59
Figure20: 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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Ambulances in
Hospital
17 0 3 17 0 1 19 0 1 19 0 0 19 0 1
Pre Hospital
Notification
1 5 13 0 3 16 2 5 13 9 4 6 6 6 8
Trained
Paramedics for
Ambulances
6 4 10 0 7 13 2 5 13 12 4 3 14 2 4
Mobile Stroke
Unit
1 0 19 0 1 18 0 0 20 1 0 18 2 1 16
Tele Medicine
Facility
7 1 11 3 2 15 2 1 16 3 2 13 4 0 15
*n=number of hospitals
60
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.
61
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
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.
62
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.
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Emergency
Manual
1 3 15 4 7 9 3 3 14 14 3 3 19 1 0
Policies and
procedures for
patient transfer
in
1 4 15 2 7 11 3 3 14 13 0 7 11 6 3
Policies and
procedures for
patient transfer
out
1 5 14 1 9 10 2 6 12 13 2 5 13 6 1
Discharge
Summary to
patients
7 7 5 8 5 7 6 6 8 16 4 0 20 0 0
Policy on
handling death
cases
9 6 5 10 5 5 8 7 4 14 3 3 17 3 0
Disaster
Management
Plan
6 2 12 5 5 10 5 3 10 14 1 5 14 2 3
Triage Policy in
ED
5 0 14 3 2 15 5 0 15 12 0 8 16 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
63
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.
Figure 23: Comparison of ED Protocol / SOP / Guidelines by Hospital Categories
64
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)
No Partial Yes No Partial Yes No Partial Yes No Partial Yes No Partial Yes
Emergency
Manual
9 4 17 11 3 5 5 2 4 7 4 5 10 3 9
Policies and
procedures for
patient transfer in
13 6 11 11 4 4 5 0 6 4 6 6 15 5 2
Policies and
procedures for
patient transfer out
12 6 12 9 5 6 5 1 5 5 7 4 11 8 3
Discharge
Summary to
patients
5 5 20 6 4 9 3 1 7 0 5 11 7 7 8
Policy on handling
death cases
3 7 20 4 3 12 2 1 8 2 4 10 6 9 6
Disaster
Management Plan
8 4 18 10 1 7 5 2 4 5 4 7 12 1 7
Triage Policy in
ED
15 1 14 9 0 9 4 1 6 9 0 6 17 0 5
*n=number of hospitals
Figure 24: Zone-wise Comparison of ED Protocol / SOP / Guidelines in hospitals
65
C) NABH Acrcreditation-wise comparison:
Figure 25: Overall Comparison of ED Protocol / SOP / Guidelines in NABH accredited
and non-NABH Accredited Hospitals
66
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).
Figure26: Comparison of Emergency Care Protocols by Hospital Categories
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)
67
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Blue: Cardiac
Arrest
2 2 16 4 0 16 1 0 19 14 1 4 17 0 3
Trauma 2 0 18 1 1 18 1 0 19 9 0 10 3 2 15
Chest Pain 1 0 18 1 0 19 1 0 19 5 2 12 7 3 9
Sepsis 1 0 18 1 2 17 0 0 20 4 0 15 4 2 13
Stroke 1 0 18 2 0 18 1 0 19 10 0 9 9 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)
No Partial Yes No Partial Yes No Partial Yes No Partial Yes No Partial Yes
Cardiac
Arrest
12 0 18 12 1 7 7 0 4 9 1 6 19 1 1
Trauma 24 1 5 15 0 5 8 1 2 12 1 3 21 0 0
Chest Pain 22 2 6 15 1 2 7 2 2 12 0 4 20 0 1
Sepsis 26 3 1 14 0 4 7 1 3 14 0 2 21 0 0
Stroke 20 1 9 12 0 6 7 1 3 12 0 4 20 0 1
*n=number of hospitals
Figure 27: Zone-wise Comparison of Emergency Care Protocols in Hospitals
68
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.
4. NABH Accreditation.
5. Increase the scope of Good Samaritan Law from road traffic injuries to other time
sensitive conditions.
69
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Fire Safety 13 7 0 9 10 1 7 10 2 19 1 0 17 3 0
Building Safety 12 3 4 9 7 4 8 6 5 15 3 1 17 2 1
Electrical Safety 12 7 1 10 7 3 11 6 3 19 1 0 19 1 0
Patient and
Provider Safety
12 7 0 8 9 3 8 6 5 17 3 0 20 0 0
Chemical Safety 9 10 1 7 7 5 8 8 3 20 0 0 18 1 0
Periodic Training
of Staff
7 5 8 4 9 7 3 13 4 16 3 1 18 2 0
Periodic Mock
Drill
6 5 9 4 7 9 3 11 6 16 3 1 17 3 0
Police Post
Available in
Premises
15 2 3 15 0 5 5 4 11 4 3 13 2 2 16
Alarm Bell/Code
Announcement in
ED
3 7 9 4 2 13 2 2 16 14 1 5 16 2 1
*n: number of hospitals, ED: Emergency Department
70
Figure 29: Comparison of measures ensuring Safety & Security by Hospital Categories
71
B) Zone-wise comparison:
Figure 30: Zone-wise Comparison of measures ensuring Safety & Security in Hospitals
72
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Fire Safety
24 5 1 10 8 2 8 3 0 12 3 0 10 12 0
Building Safety
22 4 4 11 4 5 7 2 2 12 3 1 8 8 3
Electrical Safety
23 5 2 10 7 3 8 2 1 12 4 0 16 5 1
Patient and
Provider Safety
22 7 1 10 7 2 6 2 3 9 6 1 16 4 1
Chemical Safety
22 8 0 10 5 4 8 2 1 10 5 0 10 6 5
Periodic Training
of Staff
18 7 5 9 3 8 3 7 1 10 6 0 8 8 6
Periodic Mock Drill 18 6 6 7 2 11 3 6 2 10 5 1 7 9 6
Police Post
Available in
Premises
12 6 12 9 2 9 3 1 7 9 0 7 7 3 12
Alarm Bell/Code
Announcement in
ED
16 4 9 6 3 9 4 1 6 7 4 5 4 2 16
*n=number of hospitals, ED=Emergency Department
C) NABH Accreditation comparison:
Figure 31: Comparison of Safety & Security in NABH and Non-NABH Accredited
Hospitals
73
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
74
drill and debriefing for disaster management, and 38 hospitals have system to redistribution
of patients to other hospitals during disaster.
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Disease Management
Outbreak Plan
4 4 12 7 4 9 2 7 11 13 3 4 7 7 6
Surge Capacity 5 8 7 8 5 7 2 9 9 13 3 3 10 6 4
Separate
Decontamination Area
at ED entrance
0
2
18
1
1
18
1
2
17
7
2
10
5
5
10
Separate Disaster Stock
in ED
4 2 14 7 1 12 2 5 13 11 2 7 11 5 4
Drill and Debriefing for
Disaster Management
2 5 13 5 4 11 2 3 15 13 3 4 10 5 5
Redistribution of pts to
other hospitals
4 2 14 6 5 8 5 4 11 14 2 4 9 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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Surge Capacity 18 9 3 7 4 8 3 5 3 8 3 5 2 8 12
Separate
Decontamination Area
at ED entrance
7 4 19 1 2 16 1 3 7 4 1 11 1 2 19
Separate Disaster
Stock in ED
14 5 11 8 2 10 5 2 4 3 4 9 4 3 15
Drill and Debriefing
for Disaster
Management
14 7 9 8 1 11 3 3 5 4 3 9 3 6 13
Redistribution of pts
to other hospitals
16 4 9 6 2 12 4 3 4 8 5 3 3 7 12
*n: number of hospitals, ED: Emergency Department
75
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.
76
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.
77
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).
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Dedicated Staff for gap
identification & loop
closure
2 6 11 5 5 10 4 4 12 14 5 1 15 5 0
Regular audits in hospital 7 7 6 6 4 10 6 8 6 15 4 1 18 1 0
Continuous Education and
Training programs 4 7 9 6 7 7 1 9 10 14 4 2 17 3 0
Key Indicators of Quality
Monitored 5 7 8 5 9 6 5 13 2 12 5 2 15 5 0
Quality Indicators for
urgent and interventional
procedures monitored
1 4 15 2 0 17 2 2 16 9 6 5 8 6 6
Death Review Committee 6 6 8 6 4 10 4 5 11 16 2 2 18 0 2
Central Empowered
Hospital Committee
4 3 13 4 6 10 5 4 11 13 6 1 16 3 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
78
IPGMER & SSKM Hospital) had central empowered hospital committee for continuous quality
improvement for emergency services.
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
79
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;
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).
80
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Dedicated Staff for gap
identification & loop
closure
19 5 6 6 8 6 2 5 4 6 3 7 6 4 11
Regular audits in hospital 22 5 3 8 4 7 4 4 3 6 6 4 10 6 6
Continuous Education and
Training programs
15 12 3 8 3 9 5 3 3 6 5 5 8 6 8
Key Indicators of Quality
Monitored
17 9 3 6 10 4 4 5 2 7 5 4 8 9 5
Quality Indicators for
urgent and interventional
procedures monitored
11 5 13 3 3 14 2 4 5 4 3 9 1 3 18
Death Review Committee 19 2 9 9 5 6 3 2 6 5 3 8 10 4 8
Central Empowered
Hospital Committee
18 4 8 7 4 9 4 5 2 6 5 5 6 3 13
*n: number of hospitals
Figure 36: Zone-wise Comparison of Continuous Quality Improvement in Hospitals
81
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.
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.
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.
82
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.
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
EHR 6 11 3 7 6 7 5 6 9 12 8 0 18 2 0
Patient Registration
System
15 2 3 17 0 3 10 2 8 20 0 0 20 0 0
Patient Clinical
Examination Notes
2 1 17 3 1 16 0 1 19 6 5 9 6 5 9
Patient Investigation Lab
Reports
10 3 7 7 4 9 4 3 13 16 2 2 18 1 1
Patient Radiological
Investigation Reports
12 3 5 10 2 8 3 5 11 18 2 0 16 2 2
Trauma Registry 2 5 13 3 5 12 1 2 17 6 3 11 7 5 7
Injury Surveillance
System
0 2 18 0 3 17 2 0 18 2 3 14 4 4 11
ED Surveillance System 1 3 16 0 4 16 1 1 18 9 1 10 7 3 9
Data Retrieval System 3 4 13 4 8 8 2 3 15 12 2 6 12 2 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).
83
Figure38: Comparison of Data Management System by Hospital Categories
84
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.
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
EHR 16 7 7 7 9 4 7 2 2 11 4 1 6 11 5
Patient Registration
System
25 0 5 17 0 3 9 0 2 14 1 1 16 3 3
Patient Clinical
Examination Notes
4 4 22 2 5 13 4 2 5 5 2 9 1 1 20
Patient Investigation
Lab Reports
20 3 7 8 5 7 6 1 4 11 2 3 9 1 12
Patient Radiological
Investigation Reports
15 5 10 12 2 6 7 1 3 10 3 3 13 4 4
Trauma Registry 5 10 15 2 4 14 6 1 4 4 2 9 1 2 19
Injury Surveillance
System
3 4 23 0 3 16 3 3 4 1 2 12 0 0 22
ED Surveillance System 7 4 19 3 4 12 3 3 5 4 0 11 0 0 22
Data Retrieval System 14 3 13 5 7 7 5 2 4 6 4 5 2 3 17
*n: number of hospitals, ED: Emergency department, EHR: Electronic Health Record
85
Figure 39: Zone-wise Comparison of Data Management System in Hospitals
86
Out of all five zones of India, north east was found weak in sector of computerized data
management system.
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
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
Best Practices for Data Management System was observed in Ruban Memorial Hospital,
Asian Hospital, and Primus Super Speciality Hospital (with 100% score).
87
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.
Table34: 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)
SF NSF NF SF NSF NF SF NSF NF SF NSF NF
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
88
& 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)
SF NSF NF SF NSF NF SF NSF NF SF NSF NF SF NSF NF
Central Govt Funds
for ED Services
0 3 12 1 5 9 0 3 2 1 0 6 1 2 11
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)
Figure 42: Zone-wise ccomparison of Financing in Hospitals
89
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)
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
90
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
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.
91
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
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%)
92
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.
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.
93
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.
94
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
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
95
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
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)
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
ofspecialist 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.
Note: A total of 357 staff members including doctors were recorded for Civil Hospital,
Ahemdabad (Medical College) in ED.
96
Table 40: Comparison of Emergency Cases and Manpower in categories of Hospitals
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.
97
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
Yes 69 67 66
Partial 20 23 18
No 6 5 11
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.
98
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).
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
Table42: 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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Mobile bed for
resuscitation
10 2 8 10 4 6 4 2 14 17 1 2 19 0 1
Crash cart 12 5 3 11 5 4 11 5 4 17 2 1 19 0 1
Hard cervical collar 9 0 11 5 3 12 3 0 16 16 0 4 16 1 3
Oxygen supply by
pipeline
15 2 3 15 0 5 4 1 15 19 1 0 18 0 2
Oxygen cylinder 18 1 1 19 1 0 19 0 1 19 1 0 20 0 0
Suction machine 16 3 0 19 1 0 18 1 1 18 2 0 20 0 0
Multipara monitor 15 12 4 13 1 6 9 4 7 18 1 1 18 1 1
Simple/transport
monitor
10 3 7 12 1 7 7 3 10 16 1 3 19 0 1
Defibrillator 13 5 2 13 2 5 8 6 6 18 1 1 18 1 1
All types of forceps 11 3 6 10 5 4 9 5 6 17 3 0 18 2 0
Transport ventilator 7 1 12 4 1 15 2 2 16 14 2 4 13 2 5
AMBU bag 17 2 1 15 5 0 16 2 2 18 2 0 17 1 1
Suprapubic cathetor 8 4 8 4 1 15 2 1 17 14 1 5 13 0 7
Light source 10 1 9 12 2 6 12 2 6 16 1 3 18 1 1
Stethoscopoe 14 3 3 18 0 1 19 1 0 18 1 1 19 0 0
99
Oropharyngeal airway
blades
14 3 3 14 4 2 10 4 6 20 0 0 19 0 1
LMA (Lanryngeal
Mask Airway)
9 0 11 3 2 15 2 1 16 15 0 5 14 0 6
Tourniquet 12 1 7 12 2 6 9 0 11 16 1 3 19 0 0
Pelvic binder & bed-
sheets with clips
6 4 10 2 3 15 4 1 15 12 0 8 13 0 7
Needle holder and
suture material
15 3 2 17 1 1 13 6 1 19 1 0 20 0 0
Vaginal speculum 8 3 9 6 3 10 9 3 8 13 2 5 14 0 5
Ryles tubes 13 6 1 13 7 0 13 6 1 19 1 0 18 0 2
Foley's catheter 13 5 2 13 7 0 12 7 1 19 1 0 18 0 2
Laryngoscope 14 6 0 15 4 1 12 5 3 19 1 0 18 1 1
Endotracheal tubes 14 6 0 16 4 0 10 6 4 18 2 0 19 0 1
Chest tubes with
water seal drain
11 5 4 7 4 8 3 3 14 18 1 1 16 1 3
Blood pressure
monitor
17 2 1 17 2 1 17 3 0 19 1 0 20 0 0
ECG machine 17 3 0 17 2 1 17 1 2 20 0 0 20 0 0
Ultrasonic nebulizer 12 3 5 10 4 5 7 2 11 15 2 3 18 0 2
IV cannula and IV
infusion sets
16 2 2 15 5 0 19 1 0 19 1 0 19 1 0
Syringes and
disposable needles
17 2 1 19 1 0 20 0 0 20 0 0 19 1 0
Broselow tape 1 2 16 0 1 18 2 1 16 11 0 9 10 0 10
Protoscope 14 1 5 8 1 11 8 2 10 16 1 3 15 0 5
Fluid Warmer 3 2 15 3 0 17 2 4 14 7 2 11 10 0 10
Dressing sets 6 4 0 17 2 1 11 5 4 19 1 0 20 0 0
Personal protecting
equipments
11 8 1 14 4 2 10 7 2 18 2 0 18 1 1
Central line of all sizes 9 3 8 2 5 12 2 2 16 16 3 1 17 1 2
Capnography 5 3 12 2 1 16 1 2 17 8 3 9 9 1 10
Infusion pump and
syringe drivers
10 2 8 7 1 12 5 1 14 18 2 0 19 0 1
Spine board with sling
& scotch tape all sizes
5 2 13 6 2 12 1 1 17 13 0 7 16 0 4
Splints for all
fractures
9 8 3 5 10 5 3 7 10 14 3 3 15 3 2
Non-invasive and
invasive ventilators
10 2 8 3 4 13 3 2 15 16 3 1 15 1 4
Incubators 9 2 7 2 1 17 1 2 17 8 3 9 9 2 9
Emergency
Cricothyroidotomy kit
7 1 12 2 1 17 1 2 17 8 2 10 11 1 8
Emergency
Thoracotomy set
7 0 13 2 1 16 1 0 19 8 1 11 8 2 10
Emergency
Decompressive
craniotomy sets
7 1 11 2 1 17 1 0 19 6 3 11 8 2 10
Emergency
Thrombectomy sets
4 0 15 0 2 18 0 0 20 7 1 12 6 2 11
Phototherapy unit 9 2 7 1 1 17 3 2 15 5 3 12 8 2 10
*n-number of hospitals, AMBU- Artificial Manual Breathing Unit, ECG- Electrocardiography, IV- Intravenous,
ED-Emergency Department
100
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
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%)
101
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.
102
Table43: 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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Hemogram- Hb,
Hct, TLC, DLC,
Platelet
10 0 8 8 0 8 9 0 10 9 3 7 10 0 7
Random blood
Sugar
16 0 3 13 0 4 14 1 4 17 0 2 14 0 3
Coagulation profile:
PT, APTT, INR
3 0 11 5 1 10 6 0 13 7 2 9 10 0 7
Electrolytes: Na, K,
Cl,Ca
9 0 10 7 0 9 7 1 11 11 2 6 10 0 7
Blood Urea &
Serum Creatinine
11 0 8 6 0 9 8 0 11 8 3 7 10 0 7
Blood Gas Analysis 6 2 11 6 1 9 1 1 17 13 2 4 11 0 6
Cardiac enzymes,
Trop-I, Trop-T
7 3 9 4 1 11 5 0 14 11 4 3 11 0 6
Serum Amylase 7 1 11 5 0 10 2 2 15 5 3 10 10 0 7
D-Dimer 1 1 16 2 0 13 1 0 18 6 2 10 9 0 8
Pro-BNP 0 1 17 2 0 13 1 0 18 4 2 12 10 0 7
Urinary ketones 9 1 9 9 0 8 7 1 11 12 2 5 12 0 5
Plasma Ketones 1 1 16 2 0 13 0 0 19 4 2 12 7 0 10
Toxicology
Screening-Urinary
0 0 18 0 0 15 0 0 19 0 2 16 4 0 13
Serum osmolality 1 0 17 3 0 12 0 0 19 3 2 13 8 0 9
Urine osmolality 1 0 17 2 0 13 0 0 19 3 2 13 9 0 8
Pregnancy test 10 2 7 9 0 7 13 0 6 13 1 4 11 0 6
Thromboelastogram
(TEG)
0 0 19 0 0 14 0 0 19 1 2 16 2 1 14
Peak Expiratory
Flowmeter
0 0 19 0 1 14 0 0 19 6 1 11 10 0 7
Microscopy: Thin &
Thick Smear
3 1 13 6 0 10 8 0 11 7 2 9 10 0 7
Rapid Diagnostic
Test (Malaria)
6 0 12 5 1 10 8 0 11 7 2 9 10 0 7
CSF: Microscopy &
Gram staining
4 1 12 3 1 11 2 1 16 6 2 10 9 0 8
Portable USG 4 1 12 3 1 11 0 1 18 15 1 4 14 0 4
Echocardiography 7 0 10 4 1 11 2 0 17 13 2 4 13 1 4
Portable X ray 11 1 7 7 1 7 3 4 12 17 1 2 13 2 3
CT Scan 10 0 7 7 0 8 3 0 14 8 3 8 10 0 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
103
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)
Yes Partial No Yes Partial No Yes Partial No Yes Partial No Yes Partial No
Hemogram- Hb,
Hct, TLC, DLC,
Platelet
19 0 1 19 0 0 19 0 0 16 0 1 15 0 0
Random blood
Sugar
17 0 2 17 0 2 18 0 1 15 0 2 14 0 1
Coagulation profile:
PT, APTT, INR
17 0 3 13 2 4 11 0 8 18 0 0 15 0 0
Electrolytes: Na, K,
Cl,Ca
17 0 2 17 0 2 15 0 4 17 0 0 15 0 0
Blood Urea &
Serum Creatinine
19 0 0 18 1 0 17 0 2 17 0 0 15 0 0
Blood Gas Analysis 12 1 6 10 1 8 1 1 17 16 0 1 14 0 1
Cardiac enzymes,
Trop-I, Trop-T
11 4 4 9 4 6 6 0 13 17 0 1 14 0 1
Serum Amylase 16 1 2 12 1 5 6 1 12 17 0 1 15 0 0
D-Dimer 10 0 10 4 0 14 1 0 18 15 1 2 14 0 1
Pro-BNP 8 0 12 4 0 14 1 0 18 14 1 3 14 0 1
Urinary ketones 14 2 3 16 0 3 14 1 4 17 0 0 14 0 1
Plasma Ketones 10 1 9 6 1 11 2 0 17 13 0 5 11 0 4
Toxicology
Screening-Urinary
7 1 12 2 0 16 1 0 18 11 1 6 6 1 9
Serum osmolality 8 1 11 5 0 13 1 0 18 15 0 3 14 0 1
Urine osmolality 8 2 10 8 0 10 1 1 17 15 0 3 15 0 0
Pregnancy test 18 0 1 17 0 2 18 0 1 17 0 1 14 0 1
Thromboelastogram
(TEG)
3 0 16 1 0 16 1 0 18 9 0 8 4 0 11
Peak Expiratory
Flowmeter
4 1 14 5 0 13 2 0 17 15 0 3 9 0 6
Microscopy: Thin &
Thick Smear
18 1 1 18 1 0 16 2 1 18 0 0 15 0 0
Rapid Diagnostic
Test (Malaria)
16 0 3 18 1 0 17 0 2 18 0 0 14 0 1
CSF: Microscopy &
Gram staining
14 2 4 13 1 4 4 2 13 18 0 0 14 0 1
Portable USG 13 2 5 7 1 10 2 1 16 13 1 2 12 0 3
Echocardiography 18 1 1 9 1 9 2 1 16 16 1 0 14 0 1
Portable X ray 14 2 2 10 3 5 4 6 9 15 0 1 14 0 1
CT Scan 16 1 1 10 0 8 6 0 11 17 0 0 13 0 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
104
Figure 50: Comparison of Point of Care Lab for ED & for Hospital on % basis of
compliance
Suggestions:
All healthcare facilities should have either basic point of care lab in emergency department or
emergency lab in hospital for 24*7
105
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.
Figure 51: Chart of Essential medicines for Hospitals
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).
Essential Medicines: Themedicinesthat "satisfy the priority health
care needs of the population". These are themedicationsto 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
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
Other essential
medicines (n=71):
The essential
medicines other than
resuscitation
medicines included
in this category
Majority of
essential
medicines were
available in
facilities at time
of assessment
106
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.
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
107
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 Med ical 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
108
LIVE
OBSERVATION
109
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
110
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
111
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
112
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.
113
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.
114
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
115
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)
Yes No Yes No
Triage 38 (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
116
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
117
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.
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.
118
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.
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
119
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).
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
120
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)
Yes No Yes No
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:
1. District Hospital, Tenali
2. Deen Dayal Upadhyay Hospital, Shimla
3. Morigaon Civil Hospital, Assam
121
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
122
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)
Figure64: 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)
123
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.
124
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)
Yes No Yes No
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)
74 395
Figure 66: Comparison of Trauma Management in NABH accredited and non-NABH
accredited hospitals
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
Best Practice for CT Scan in District Hospitals:
1. District Hospital, Tenali
2. Deen Dayal Upadhyay Hospital, Shimla
3. HNB Base Hospital, Shimla
125
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
126
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
127
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.
128
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 Hospitals
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
129
Figure 72: Representation of Triaged Patient Satisfaction for care provided by Hospital
Categories
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.
130
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
Figure 73: Graphically representation of Referral of Patient by Category of Hospitals
131
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.
Figure 74: Hub and Spoke Model for National Forward and Backward Referral Policy
132
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.
133
Live
observation
(one day data of
emergency)
134
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
135
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
136
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.
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%) 15 21(37%) 15 13.5 (54%)
LAMA 19 3.5 (1%) 19 3 (3%) 19 3.5 (3%) 18 1 (2%) 18 3 (12%)
Discharge 15 55 (12%) 15 50 (49%) 15 17 (17%) 15 22.5 (39%) 15 6.5 (26%)
Death 18 2 (0%) 18 1.5 (1%) 17 1 (1%) 16 1 (2%) 16 1 (4%)
Death due to Trauma /
injury / Road traffic
accidents
15 2 (0%) 14 1 (1%) 16 3 (3%) 13 0 (0%) 13 1 (4%)
*n: Number of Hospitals, ED: Emergency department, LAMA: Leave against medical advice
137
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.
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 Pain 144
5.5
[10.2]
1-46
1.23 85
3 [4.5]
1-28
2.91 51
3 [4.2]
2-15
2.91 84
4 [4.2]
1-13
7.02 40
2 [2.5]
1-15
8
Stroke 75
5 [5]
1-42
1.12 19
1 [1]
1-10
0.97 25
3 [3]
1-9
2.91 30
2 [1.5]
1-9
3.51 14
1 [1.5]
1-5
4
Altered Mental
Status
136
18 [25]
1-70
4.04 59
3 [3]
1-17
2.91 20
3 [1.5]
1-5
2.91 27
2 [1]
1-6
3.51 16
1 [1]
1-4
4
Trauma/Road
traffic
accident/injuries
599
18 [25]
1-210
4.04 175
5 [10.5]
1-45
4.85 130
4.5 [6]
1-40
4.37 143
3 [10]
1-35
5.26 60
3 [4]
1-20
12
Respiratory
Distress
165
9 [21]
2-40
2.02 144
6.5 [8.2]
1-38
6.31 62
4 [9]
1-17
3.88 83
6.5 [4.5]
2-22
11.40 41
4 [4]
1-7
16
Pain in
Abdomen
232
13 [13]
2-72
2.91 164
7 [7.5]
1-36
6.80 161
15 [17]
1-27
14.56 123
8 [5]
2-18
14.04 48
3 [4]
1-11
12
Poisoning 67
2.5 [6.7]
1-30
0.56 115
2 [3.5]
1-79
1.94 6
1 [0.5]
1-3
0.97 20
3 [4.7]
1-6
5.26 3
1 [0]
1-1
4
Snake Bite 38
1 [4]
1-21
0.22 24
4 [2]
2-10
3.88 4
1 [0.5]
1-2
0.97 10
4 [2]
1-5
7.02 1
1 [0]
1-1
4
Fever 206
8 [24]
1-36
1.79 262
11.5 [12.7]
1-72
11.17 251
12 [15]
2-80
11.65 148
6 [7]
1-42
10.53 65
4 [7]
1-13
16
Pregnancy
related
200
26 [25]
1-140
5.83 41
4.5 [3]
2-10
4.37 15
2 [0.7]
1-5
1.94 43
2 [2]
1-30
3.51 3
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
138
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).
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).
Table64: 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
1.35 47
4 [5.5]
1-21
3.88 11
2 [1] 1-
3
1.94 28
1 [3.7]
1-18
1.75 35
2 [14.5]
2-31
8
Diarrheal
Disease
86
3.5
[11.7]
1-25
0.78 34
3 [2]
1-7
2.91 35
3 [2] 2-
9
2.91 29
2 [2] 1-
16
3.51 106
2 [26.5]
1-101
8
Altered Mental
Status
19
1.5 [1.5]
1-7
0.34 2
1 [0]
1-1
0.97 3
1.5 [0.5] 1-
2
1.46 6
3 [2] 1-
5
5.26 1
1 [0]
1-1
4
Trauma/Road
traffic
accident/injuries
43
6 [5]
1-10
1.35 16
2 [2]
1-5
1.94 34
4 [3] 1-
17
3.88 11
1 [1] 1-
4
1.75 18
3 [6.5]
1-14
12
Seizure 29
2 [4]
1-10
0.45 12
1.5 [1]
1-5
1.46 7
2 [0.2]
1-2
1.94 10
1 [1] 1-
5
1.75 3
1.5 [0.5]
1-2
6
Pain in
Abdomen
102 2 [4] 0.45 33 2 [1] 1.94 20
3 [2.5]
1-5
2.91 24
2 [1.2]
1-12
3.51 15
15 [0]
15-15
60
139
1-12 1, 12
Poisoning 13
4 [0.5]
4-5
0.90 0 0 0.00 0 0 0.00 2
2 [0] 2-
2
3.51 2
2 [0]
2-2
8
Snake Bite 4
1 [0.5]
1-2
0.22 0 0 0.00 4
2 [1] 1-
3
1.94 1
1 [0] 1-
1
1.75 0 0 0
Fever 159
6 [23.5]
1-47
1.35 70
3 [4]
1-26
2.91 35
2 [2.5]
1-11
1.94 67
5 [10]
1-21
8.77 112
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.
140
COMPARISON OF
EMERGENCY
CARE SERVICES
IN VARIOUS
SYSTEMS
141
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.
Figure 76: Summary of Hospital Blood bank in hospitals with academic emergency
medicine and without academic emergency medicine
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)
142
Figure 77: Summary of Definitive Care Services in hospitals with academic emergency
medicine and without academic emergency medicine
Figure 78: Summary of Disaster Managementin hospitals with academic emergency
medicine and without academic emergency medicine
143
Figure 79: Summary of Continuous Quality Improvement in hospitals with academic
emergency medicine and without academic emergency medicine
144
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
145
Figure 83: Summary of Emergency Care Protocols in hospitals with academic
emergency medicine and without academic emergency medicine
146
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
Figure 85: Summary of Hospital Blood protocols in Secondary Care Centres
147
Figure 86: Summary of Emergency Operative Services in Secondary Care Centres
Figure 87: Summary of ED Protocols / SOP / Guidelines in Secondary Care Centres
148
Figure 88: Summary of Continuous Quality Improvement in Secondary Care Centres
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)
149
Figure 90: Summary of Critical Care Services in Secondary Care Centres
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
150
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 availability 65% 75% 10
ED and massive blood transfusion
protocol
17% 25% 10
Emergency operative services 37% 77% 12
Periodic mock drill 15% 57% 29
Periodic training programs for staff 18% 77% 29
Regular audits 32% 82% 35
Communication in ED 40% 72% 71
Referral policy 42% 75% 74
151
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
152
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.
153
DISCUSSION
154
DISCUSSION
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 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.
155
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.
156
CONCLUSIONS
157
CONCLUSION S
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.
158
KEY
SUGGESTIONS
159
SUMMARY OF KEY SUGGESTIONS EMERGING FROM
THE STUDY
HEADING SUGGESTIONS
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-
1. Upgrade them into medical college
2. Develop residency programme (DNB)
3. 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
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
160
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
161
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
162
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
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
163
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
o Hub and Spoke Model
o Structured referral protocols
o 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.
164
KEY POLICY
RECOMMENDA
TIONS
165
SUGGESTED KEY POLICY RECOMMENDATION S
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 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
166
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.
167
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.
168
refeRENCES
169
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S173-80.
173
ANNEXURE-I
174
LIST OF HOSPITALS
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
- - -
3 Punjab
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
4 Uttarakhand -
HNB Base
Hospital
Coronation
Hospital,
Dehradun
- -
5
Utttar
Pradesh
-
Civil Hospital-
Lucknow
-
RML Hospital,
Lucknow
Charak Hospital
Dubagga
6 Chandigarh -
Government
Superspeciality
Hospital, Sector-
16
Civil Hospital
Sector-22,
Chandigarh
-
Max
Superspeciality
Hospital, Mohali
7 Rajasthan
SMS Medical
College &
Hospital, Jaipur
Hari Baksh
Kanwatia
Hospital, Jaipur
Govt. BDM
Hospital,
Kotputli
Fortis Hospital,
Jaipur
Birla Hospital-
CK Birla, Jaipur
8 Delhi - - -
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
1 Gujarat
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
175
2 Maharashtra
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
4 Chhattisgarh -
District
Hospital,
Dhamtari
District
Hospital,
Tikarpara,
Raipur
-
Ramkrishna
CARE Hospital,
Pachpedhi
5 Goa
Goa Medical
College, Panaji
-
North Goa
District
Hospital,
Mapusa
- -
EAST ZONE
1 Bihar PMCH, Patna AIIMS Patna
Sadar Hospital,
Gaya
Paras HMRI
Hospital, Patna
Ruban Memorial
Hospital
Patliputra
3 Orissa -
AIIMS,
Bhubneshwar
District
Headquarter
Hospital, Puri
Capital Hospital,
Bhubneshwar
Care Hospital,
Bhubneshwar
4
West
Bengal
IPGMER &
SSKM
- - -
Ruby General
Hospital
NORTH EAST ZONE
1 Sikkim
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
3 Assam
Gauhati Medical
College and
Hospital,
Guwahati
-
Morigaon Civil
Hospital
GNRC
Hospital,
Guwahati
NemcareSupersp
ecialty Hospital,
Guwahati
4 Meghalaya -
Civil Hospital
Shillong
- - -
5 Nagaland - -
District
Hospital, Peren
-
Christian
Institute of
Health Science
and Research
6 Manipur RIMS, Imphal -
District
Hospital,
Bishnupur
-
Shija Hospital &
Research
Institute,
Lamphelpat,
Imphal
176
7 Tripura
Agartala
Government
Medical College
& G B Pant
Hospital
-
Gomti District
Hospital,
Udaipur
Tripura medical
college&
BRAM
Teaching
Hospital,
Agartala
-
8 Mizoram -
Zoram Medical
College
Civil Hospital,
Aizawl
Synod Hospital
(Presbyterian
Hospital)
-
SOUTH ZONE
1 Telangana -
District
Hospital, Karim
Nagar,
Hyderabad
District
Hospital, King
Koti, Hyderabad
Yashoda
Hospital,
Malakpet,
Hyderabad
-
2 Karnataka
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
4 Kerala
Trivandrum Govt
Medical College
District
Hospital,
Neyyattinkara
District
Hospital,
Peroorkada
Cosmopolitan
Hospitals Pvt
Ltd
G G Hospital
5 Tamil Nadu
Madras Medical
College
Madras Railway
Hospital,
Madras
(Southern
Railway
Headquarters
Hospital)
- Apollo Hospital -
6 Pondicherry
JIPMER,
Pondicherry
Indira Gandhi
Government
General
Hospital,
Pondicherry
- - -
177
ANNEXURE-II
178
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 1
st
Jan 2018 to 31
st
Dec 2018)
Adult
Pediatric
(Age- 0 to …..)
6.
Total number of patients visited in emergency (During 1
st
Jan 2018 to 31
st
Dec 2018)
Adult
Pediatric
(Age- 0 to …..)
7.
Total number of death of trauma patients in emergency department
(During 1
st
Jan 2018 to 31
st
Dec 2018)
Adult
Pediatric
(Age- 0 to …..)
8.
Total number of patient’s death due to road traffic injury in
emergency department (During 1
st
Jan 2018 to 31
st
Dec 2018)
Adult
Pediatric
(Age- 0 to …..)
9.
Total number of patients which are brought dead to the hospital
(During 1
st
Jan 2018 to 31
st
Dec 2018)
Adult
Pediatric
(Age- 0 to …..)
10.
Total number of Medicolegal cases attended in Emergency (During 1
st
Jan 2018 to 31
st
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 ELEMENTS Check 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
…………………. /Data Not Available
179
7. ED Blood Transfusion Protocol Written protocol SCORE
8. Massive Blood Transfusion Protocol Written protocol SCORE
2. DEFINITIVE CARE SERVICES(Score: 1-No, 2- Partial, 3- Yes)
*NOTE: Question no 12 to 16 is not applicable for district hospital
SN. OBJECTIVE ELEMENTS Check 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
3. HOSPITAL AMBULANCE SERVICES(Score: 1-No, 2- Partial, 3- Yes)
SN. OBJECTIVE ELEMENTS Check point 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)
180
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) SCORE
SECTION-C: ED PROTOCOL/SOP AND GUIDELINES (Score: 1-No, 2- Partial, 3- Yes)
SN. OBJECTIVE ELEMENTS Check 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.)
a) SCORE
b) SCORE
c) SCORE
d) REMARKS
2. a) Do you have documented triage guidelines
and protocol?
b) 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
a) SCORE
b) REMARKS
3. a) Do you have documented policies and
procedures which guide the transfer of
patients into the organization?
b) If yes, only documented/ implemented?
c) If implemented, off-on implemented/
regular?
d) 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.
a) SCORE
b) SCORE
c) SCORE
d) REMARKS
4. a) 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?
b) If yes, only documented/ implemented?
c) If implemented, off-on implemented/
regular?
d) If no, what is the protocol?
Documentation of referrals,
advance communication, written
orders by treating doctor and
consent of the attendant/patient
taken.
a) SCORE
b) SCORE
c) SCORE
d) REMARKS
181
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.)
a) SCORE
b) REMARKS
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.
a) SCORE
b) REMARKS
7. a) Do you have documented disaster
management plan?
b) If no, which procedure you follow?
a) 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)
SN OBJECTIVE ELEMENTS Check point SCORE 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 Interview SCORE
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
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)
182
SN OBJECTIVE ELEMENTS Check point SCORE 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 a) Do you have separate disaster stock
in ED?
b) If yes, for how many patients (e.g. 50,
100)?
Admin interview/ Facility visit [Medical supplies,
manpower, medicines etc.]
a) SCORE
b) NUMB
ER
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
SECTION-F: CONTINUOUS QUALITY IMPROVEMENT(Score: 1-No, 2- Partial, 3- Yes)
SN. OBJECTIVE ELEMENTS CHECK 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 interview
SCORE
7. Do you have Central Empowered
Hospital committee for continuous
quality improvement of Emergency
services?
Admin interview
SCORE
SECTION-G: DATA MANAGEMENT SYSTEM (Score: 1-No, 2- Partial, 3- Yes)
183
SN. OBJECTIVE ELEMENTS CHECK 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 ELEMENTS CHECK POINT SCORE REMARKS
11.. Do you have Central Govt. funds for Emergency and Trauma
services?
Admin interview SCORE
2. Do you have dedicated State Govt. funds for Emergency and
Trauma services?
Admin interview SCORE
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 interview SCORE
5. Is there any delay in release of funds? Admin interview SCORE
Annexure-1
PHYSICAL INFRASTRUCTURE
1. Outside Emergency(Score: 1-No, 2- Partial, 3- Yes)
SN Objective points Check point
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
2. Does the access road of hospital is wide
enough?
Can pass three ambulances at a time
3. Does the vehicles parked on the way /in People are using as parking lot
Score
Score
Score
Score
184
front of emergency department?
4. Does the hospital have separate access for
ambulance services?
Sufficient space for Ambulance offloading and turn-around
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
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
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
8. Seamless flow of the patient Unidirectional flow, separate entrance, no crisscross.
9. Does the services provided to the patients
are clearly defined, displayed prominently?
signage/ boards
10. Does the names of the doctors and nursing
staff on shift/duty/call are displayed and
updated?
11. Is important Telephone numbers are
displayed in hospital?
numbers including emergency no, ambulance, blood bank, police,
referral centers etc. displayed
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.
13. Do you have adequate waiting area?
It has comfortable seating , information board
14. Do you have safe drinking water facility?
24hrs drinking water facility
15. a) Do you have functional male toilets?
b) Do you have functional female toilets?
c) 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)
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
17. Do you have Cafeteria facility for the family
members/ attendants?
18. Do you have police control room?
19. Do you have Emergency Registration Counter?
20. Do you have ambulance driver’s room?
Ambulance drivers
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
a) Score
b) Score
c) Score
Score
Score
Score
Score
Score
Remarks (if any):
185
2.INSIDE EMERGENCY (Score: 1-No, 2- Partial, 3- Yes)
SN Objective Elements Check Point
1. Do you have emergency department
with adequate space as per patient
load (Circulation space and open space)?
Admin interview / 1000 m
2
per 100patient daily load (NQAS
standards),Corridors are broad enough (2-3m) for easy movement of
stretcher
and Trolley
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)
3. Do you have demarcated station for
doctors and nurses?
Preferably in the center from where all beds are visible
4. Do you have demarcated plaster
room?
5. Do you have dedicated Isolation
rooms (Emergency Infections)?
Negative pressure and separate AHUe.g. Swine flu/Ebola pts.
6. Do you have dedicated minor OT?
7. Do you have provision for Emergency
OT?
8. Do you have point of care lab? Designated lab area in emergency
9. Do you have linkage to other facility
on the same floor?
Radiology department, OT, Lab etc.
10. Do you have separate room for
examination of rape / sexual assault
victim?
As per One stop Centre
11. Do you have availability of sexual
assault forensic evidence kit?
Kit has protocols and guidelines for collection of
Forensic evidence.
12. Do you have counselling services for
Sexual assault / domestic violence
cases?
13. Do you have demarcated area for
keeping dead bodies?
14. Do you have availability of clean
utility room?
15. Do you have availability of dirty utility
room?
16. Do you have store? Storage to refrigerate, keep equipment
& Emergency supplies
17. Do you have curtains/screens at
point of care?
Privacy and dignity of patients maintained.
18. Do you have demarcated duty room
for doctors?
19. Do you have demarcated duty room
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
Score
186
for nursing staff?
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
4. Gynecology&
Obstetrics
Consultant
187
Resident
5. Orthopedics Consultant
Resident
6. Radiology Consultant
Resident
7. Anesthesia Consultant
Resident
8. Critical care Consultant
Resident
9. Ophthalmology Consultant
Resident
10. ENT Consultant
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
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
188
Resident
25. Neuro Radiology Consultant
Resident
26. Pediatric Surgery Consultant
Resident
27. Neonatology Consultant
Resident
28. Hematology Consultant
Resident
29. Oncology Consultant
Resident
Annexure-3
EQUIPMENTS& SUPPLIES IN ED:
BIO MEDICAL EQUIPMENT (Score: 1-No, 2- Partial, 3- Yes)
SN. OBJECTIVE ELEMENT Check 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
189
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
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
190
Annexure-4
POINT OF CARE LAB(Score: 1-No, 2- Partial, 3- Yes)
S. No. Point of Care Lab In ED
In Hospital
Remarks
1. Hemogram- Hb, Hct, TLC, DLC, Platelet Score Score Remarks
2. Random Blood Sugar Score Score Remarks
3. Coagulation Profile: PT, APTT, INR Score Score Remarks
4. Electrolytes: Na, K, Cl, Ca Score Score Remarks
5. Blood Urea & Serum Creatinine Score Score Remarks
6. Blood Gas Analysis Score Score Remarks
7. Cardiac enzymes, Trop-I, Trop-T, Score Score Remarks
8. Serum Amylase Score Score Remarks
9. D-dimer, Score Score Remarks
10. Pro-BNP Score Score Remarks
11. Urinary Ketones Score Score Remarks
12. Plasma Ketones Score Score Remarks
13. Toxicology screening- Urinary Score Score Remarks
14. Serum osmolality Score Score Remarks
15. Urine osmolality Score Score Remarks
16. Pregnancy test Score Score Remarks
17. Thromboelastogram (TEG) Score Score Remarks
18. Peak expiratory Flowmeter Score 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 staining Score Score Remarks
22. Portable USG (Bed side/Point of Care) Score Score Remarks
23. Echocardiography Score Score Remarks
24. Portable X-ray (Bed side/Point of Care) Score Score Remarks
Remarks (if any):
191
25. CT scan Score Score Remarks
Annexure-5
ESSENTIAL MEDICINES FOR EMERGENCY (Score: 1-No, 2- Partial, 3- Yes)
S. No. Drug Name Score S. No. Drug Name Score
1. Oxygen medicinal gas Score 27. Phenobarbitone Score
2. Thiopentone sodium Score 28. Phenytoin Score
3. Lignocaine hydrochloride (Jelly sterile) Score 29. Amoxicillin + Clavulanic acid Score
4. Lignocaine hydrochloride (Inj.) Score 30. Ampicillin sodium Score
5. Atropine Score 31. Benzathine penicillin Score
6. Diazepam Score 32. Cefotaxime Score
7. Diclofenac Score 33 Ceftriaxone powder Score
8. Ibuprofen Score 34. Amikacin Score
9. Paracetamol (Tablet) Score 35. Ciprofloxacin Score
10. Paracetamol (Syrup) Score 36. Gentamycin sulphate Score
11. Paracetamol (Inj.) Score 37. Metronidazole Score
12. Morphine sulphate Score 38. Heparin sodium Score
13. Tramadol hydrochloride (Tablet) Score 39. Ethamsylate Score
14. Tramadol hydrochloride (Inj.) Score 40. Vitamin K Score
15. Cetrizine Score 41. Plasma volume exppander Score
16.. Pheniramine maleate Score 42. Diltiazem Score
17. Dexamethasone disodium Score 43. Glycerinetrinitrate Score
18. Hydrocortisone sodium Succinate Score 44. Glycerinetrinitratenitroglycerine Score
19. Adrenaline Score 45. Isosorbidemononitrate Score
20. Charcoal activated Score 46. Isosorbidedinitrate Score
21. Antisnake venom Score 47. Adenosine phosphate Score
22. Calcium gluconate Score 48. Dobutamine Score
23. Naloxone hydrochloride Score 49. Dopamine hydrochloride Score
24. Pralidoxime (PAM) Score 50. Streptokinase Score
25. Lorazepam Score 51. Potassium permanganate Score
26. Magnesium sulphate Score 52. Silver sulfadiazine Score
Remarks (if any):
192
53. Calamine lotion Score 78. Xylometazoline Score
54. Povidone iodine (Solution) Score 79. Glycerine Score
55. Povidone iodine (Ointment) Score 80. Oxytocin Score
56. Furosemide Score 81. Haloperidol Score
57. Mannitol Score 82. Alprazolam Score
58. Rantidine Score 83. Aminophylline Score
59. Metoclopramide hydrochloride Score 84. Ipratropium bromide – aerosol Score
60. Prochlorperazine Score 85. Salbutamol sulphate Score
61. Ondansetron Score 86. Etophylline + Theophylline Score
62. Promethazine hydrochloride Score 87. Budesonide Score
63. Promethazine Score 88. Glucose/dextrose Score
64. Hyiscine butyl bromide Score 89. Glucose with sodium chloride/saline Score
65. Glycerine saline Score 90. Potassium chloride Score
66. Oral rehydration salts Score 91. Ringer lactate Score
67. Insulin (soluble) Score 92. Sodium bicarbonate Score
68. Intermediate-acting insulin (Lente) Score 93. Sodium chloride Score
69. Anti-Rabies Immunoglobulin Score 94. Water for injection Score
70. Tetanus vaccine Score 95. Artesunate Score
71. Anti-Rabies vaccine Score 96. Artemether Score
72. Neostigmine Score 97. Quinine (Dihydrochloride) Score
73. Ciprofloxacin Score 98. Chloroquinine phosphate Score
74. Atropine sulphate Score 99. Amiodarone Score
75. Tropicamide + Phenylepherine Score 100. Digoxin Score
76. Sodium carboxymethyl cellulose Score 101. Pantoprazole Score
77. Saline Score
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 Car
Date of Inspection:
Remarks (if any):
193
INITIAL ASSESSMENT AND REASSESSMENT
(Score: 1-No/Never, 2- Partial, 3- Yes (24X7 basis)
SN OBJECTIVE ELEMENTS Check 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:
Red Yellow Green Disposal 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:
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 Elements
Patient 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 Reason Please 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 Reason Please Specify
Door To Needle(<30min) YES/ NO
If No, than score the
reasons
Manpower Training Supplies Infrastructure
Policy or
Guidelines
194
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please 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 Reason Please Specify
Objective Elements
Patient 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 Reason Please 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 Reason Please 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 Reason Please 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 Reason Please Specify
Objective Elements
Patient 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 Reason Please 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 Reason Please Specify
Door To Needle(<30min) YES/ NO
195
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 Reason Please 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 Reason Please Specify
Objective Elements
Patient 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 Reason Please 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 Reason Please 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 Reason Please 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 Reason Please Specify
Objective Elements
Patient 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 Reason Please 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)
196
Any Other Reason Please 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 Reason Please 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 Reason Please 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
Objective Elements Patient 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 Reason Please 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 Reason Please 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 Reason Please 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)
197
Any Other Reason Please 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 Reason Please Specify
Objective Elements Patient 2
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 Reason Please 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 Reason Please 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 Reason Please 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 Reason Please 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 Reason Please Specify
Objective Elements Patient 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 Reason Please 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 Reason Please Specify
198
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 Reason Please 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 Reason Please 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 Reason Please Specify
Objective Elements Patient 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 Reason Please 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 Reason Please 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 Reason Please 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 Reason Please 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 Reason Please Specify
Objective Elements Patient 5
Door to Doctor (<10min) YES/ NO
199
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 Reason Please 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 Reason Please 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 Reason Please 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 Reason Please 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 Reason Please 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
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 Elements Patient 1
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
200
Door to CT completion time in
Head Injury (<45min)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Disposal time (Arrival time to
Admission/Transfer out/Death
declaration time)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Objective Elements Patient 2
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Door to CT completion time in
Head Injury (<45min)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Disposal time (Arrival time to
Admission/Transfer out/Death
declaration time)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Objective Elements Patient 3
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Door to CT completion time in
Head Injury (<45min)
YES/ NO
If No, than reason Manpower Training Supplies Infrastructure
Policy or
Guidelines
201
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Disposal time (Arrival time to
Admission/Transfer out/Death
declaration time)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Objective Elements Patient 4
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Door to CT completion time in
Head Injury (<45min)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Disposal time (Arrival time to
Admission/Transfer out/Death
declaration time)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason Please Specify
Objective Elements
Patient 5
Door to Resuscitation time
(<15min)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason
Please Specify
Door to CT completion time in
Head Injury (<45min)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
202
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason
Please Specify
Disposal time (Arrival time to
Admission/Transfer out/Death
declaration time)
YES/ NO
If No, than reason
Manpower Training Supplies Infrastructure
Policy or
Guidelines
Score (1-5) Score (1-5) Score (1-5) Score (1-5) Score (1-5)
Any Other Reason
Please Specify
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:
o Private Security Guard Yes/No
If yes, Available for 24*7 basis Yes/No
o Police Available Yes/No
If yes, Available for 24*7 basis Yes/No
o 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?
If yes, please ask the patient satisfaction level based on the scale:
Extremely Very Moderately Slightly Not at all
Yes/No
Yes/No
203
Satisfied Satisfied Satisfied Satisfied Satisfied
☐ ☐ ☐ ☐ ☐
If not satisfied, reason…………….
2. For Patient in Yellow Triage;
2.1. Does the patient/relative is satisfied with the emergency department services?
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 Green Triage;
1.1. Does the patient/relative is satisfied with the emergency department
services?
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
24Hours
Health Facility Name:-
Time:
Date:
Yes/No
Yes/No
204
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)
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)
205
☐☐☐☐☐☐☐☐☐☐☐
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☐☐☐☐☐☐☐☐☐☐☐
☐☐☐☐☐☐☐☐☐☐☐
Adult Patients
(Please tick one check box for one patient)
Pediatric Patients
(Please tick one check box for one patient)
1. Chest Pain Patients 1. Respiratory distress
2. Stroke 2. Diarrheal disease
3. Altered Mental status 3. Altered Mental status
206
☐☐☐☐☐☐☐☐☐ ☐☐
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☐☐☐☐☐☐☐☐☐☐☐
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 Distress 5. Seizure
6. Pain abdomen 6. Pain abdomen
207
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Adult Patients
(Please tick one check box for one patient)
7. Poisoning
Pediatric Patients
(Please tick one check box for one patient)
7. Poisoning
8. Snake Bite 8. Snake Bite
9. Fever 9.Fever
☐☐☐☐☐☐☐☐☐☐☐
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Adult Patients
(Please tick one check box for one patient)
10. Pregnancy Related
209
ANNEXURE-III
210
LIST OF SCIENTIFIC ADVISORY COMMITTEE
MEMBERS
S. No. Name of Member Designation E-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
7.
Dr. Jayaraj Mymbilly
Balakrishnan
Professor & Head of
Department of
Emergency Medicine,
KMC, Mangalore
jayarajmb2004@gmail.com
211
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
212
17. Dr. Yogesh Suri
Senior Advisor, NITI
Aayog, New Delhi
yogesh.suri@nic.in
213
ANNEXURE-IV
214
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.
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.
215
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 Dr. Praveen Aggarwal Dr. Tej Prakash Sinha
Principal Investigator Co-Investigator Co-Investigator
Department of Emergency Department of Emergency Department of Emergency
Medicine JPN Apex Trauma Medicine JPN Apex Trauma Medicine JPN Apex Trauma
Centre, AIIMS, New Delhi Centre, AIIMS, New Delhi Centre, AIIMS, New Delhi
Email:sanjeevbhoi@gmail.com Email:peekay_124@hotmail.com Email:drsinha1234@gmail.com
216
ANNEXURE-V
217
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.
218
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
219
ANNEXURE-VI
220
Overall Summary of Other Specialist / Super Specialist
Available in Hospital {Median [IQR] Min-Max} by Category of
Hospitals
Depar
tment
Design
ation
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] 2-21 4 [2] 1-7 2 [2] 1-8 4.5 [4] 2-11 4 [2] 2-6
24 x 7 Physically Present 3 [1] 1-3 3 [0] 1-3 2 [1] 1-3 3 [0] 3-5 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [0] 1-3 3 [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] 2-15 3 [1] 2-4
10.5 [10.2] 1-
15
4.5 [3.5] 1-6
24 x 7 Physically Present 3 [0] 2-3 3 [1] 1-3 2.5 [0.5] 2-3 3 [0] 3-5 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [0] 3-3 3 [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] 2-24 6 [3] 1-9 2 [2] 1-6 6.5 [5.7] 2-11 3 [2.5] 1-4
24 x 7 Physically Present 3 [1] 1-3 3 [1] 2-4 3 [0.5] 2-3 3 [0] 3-7 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [0] 1-3 3 [0] 3-3 3 [0] 3-3 3 [0.7] 1-3
Empanelled / As and when
required
0 3 [0] 3-3 0 3 [0] 3-3 0
Resident
During OPD Hours only 20 [22] 2-53 4 [7] 2-14 2 [2.5] 1-6 14 [5.5] 4-15 3 [1] 2-6
24 x 7 Physically Present 3 [0] 3-3 3 [1] 1-3 1 [0] 1-1 3 [0] 3-6 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 2 [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] 2-10 3 [4] 1-9 2 [1] 1-6 3 [2.5] 1-7 3 [1] 1-5
24 x 7 Physically Present 2 [1] 1-3 2 [2] 1-3 2 [0] 2-2 3 [0] 3-7 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [1] 1-3 3 [0] 3-3 3 [0] 3-3 3 [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] 2-20 6 [2.5] 4-9 4 [1.5] 1-4 8.5 [0.5] 8-9 3.5 [0.5] 3-4
24 x 7 Physically Present 3 [0] 3-3 3 [0.5] 1-3 2 [1] 1-3 3 [0] 3-8 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 2 [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] 1-7 2 [1] 1-10 5 [2.7] 1-18 3 [0.7] 3-6
24 x 7 Physically Present 2 [1] 1-3 3 [0.2] 2-3 3 [0.2] 2-3 3 [0] 3-7 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [1] 1-3 3 [0] 3-7 3 [0] 3-3 3 [0] 3-3
Empanelled / As and when
required
0 3 [0] 3-3 0 10 [0] 10-10 3 [0] 3-3
221
Resident
During OPD Hours only 9 [9.5] 1-33 5 [1.5] 2-8 4 [1] 1-5 10 [4.5] 2-11 3.5 [0.5] 3-4
24 x 7 Physically Present 3 [0] 3-4 3 [0.5] 2-3 3 [0.5] 2-3 3 [0] 3-10 3 [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
Orthopedics
Consultant
During OPD Hours only 6.5 [6.2] 2-14 3 [4] 1-6 1 [2] 1-5 4.5 [4.2] 1-8 2 [1.5] 1-4
24 x 7 Physically Present 3 [1] 1-3 3 [0.2] 2-3 2 [1] 1-3 3 [0] 3-9 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [1] 1-3 3 [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] 1-38 6 [2] 5-9 0 7.5 [1.5] 6-9 2 [1] 1-3
24 x 7 Physically Present 3 [0] 3-4 3 [1.5] 1-3 1 [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] 1-4 1 [1.5] 1-4 3 [1.5] 1-4 1.5 [1.7] 1-5
24 x 7 Physically Present 3 [0] 3-3 2 [1] 1-3 3 [0] 3-3 3 [0] 3-4 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [0.5] 1-3 2 [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] 2-2 1 [0] 1-1 4 [1] 3-5 6.5 [3.5] 3-10
24 x 7 Physically Present 3 [0] 3-5 2 [2] 1-3 1 [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
Anesthesia
Consultant
During OPD Hours only 11 [9.5] 2-39 4 [5.5] 1-10 2 [2.2] 1-7 7.5 [5.2] 3-23 3 [4.5] 1-11
24 x 7 Physically Present 3 [0] 3-3 3 [0] 1-4 3 [1] 1-3 3 [0] 3-5 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [0.5] 1-3 3 [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 10 [22.7] 1-45 6.5 [5.5] 2-9 2 [1.5] 1-4 6 [2] 6-10 6.5 [3.5] 3-10
24 x 7 Physically Present 3 [0] 3-4 3 [1] 1-4 2 [1] 1-3 3 [0] 3-8 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 2 [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] 1-4 3 [3] 1-13
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 3 [0] 1-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 2 [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] 2-2 4.5 [1.5] 3-6 4 [1] 3-5
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 2 [0] 2-2 0 0 0
222
Empanelled / As and when
required
0 0 0 0 0
Ophthalmology
Consultant
During OPD Hours only 3 [3] 1-10 2 [1] 1-5 1 [2.2] 1-5 3 [2.5] 1-5 2 [1.5] 1-6
24 x 7 Physically Present 3 [0] 3-3 2 [2] 1-3 2.5 [0.5] 2-3 2 [1] 1-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [0] 3-3 3 [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] 3-3 3 [0.5] 1-3 1 [0] 1-1 3 [0] 3-3 0
On Call during Non-OPD
Hours
3 [0.2] 2-3 2 [0] 2-2 0 0 0
Empanelled / As and when
required
0 0 0 0 0
ENT
Consultant
During OPD Hours only 5 [4.2] 1-10 2 [1.5] 1-4 1 [1.5] 1-6 3 [2] 1-6 2 [0.5] 1-3
24 x 7 Physically Present 3 [0] 3-3 1 [1] 1-3 2 [0] 2-2 3.5 [0.5] 3-4 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [0] 1-3 3 [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] 1-23 2 [1.5] 1-4 0 4 [2] 2-6 3 [0] 3-3
24 x 7 Physically Present 3 [0] 3-3 3 [0] 1-3 2 [0] 2-2 3 [0] 3-3 0
On Call during Non-OPD
Hours
3 [0.2] 2-3 2 [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] 1-3 1 [0] 1-4 3 (1.5] 1-5 2 [2] 1-3
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 2 [1] 1, 3 0
On Call during Non-OPD
Hours
3 [0] 1-3 3 [0] 1-3 3 [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] 3-3 3 [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] 1-7 2 [1.5] 1-4 1 [0.2] 1-4 2 [0.7] 2-3 3 [1] 1-3
24 x 7 Physically Present 3 [0] 3-3 3 [1] 1-3 0 2.5 [0.5] 2-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 1-3 3 [0] 1-3 3 [0.5] 1-3 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 [6] 2-14 3.5 [0.5] 3-4 0 2.5 [0.5] 2-3 0
24 x 7 Physically Present 3 [0] 3-3 3 [1] 1-3 1 [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
Fore nsic Med icine
Con sult ant
During OPD Hours only 2 [9] 1-10 1 [2] 1-6 1 [0] 1-1 3 [2] 1-4 0
24 x 7 Physically Present 3 [0] 3-3 3 [1] 1-3 0 3 [0] 3-3 0
223
On Call during Non-OPD
Hours
3 [0] 1-3 3 [0] 1-3 3 [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] 2-2 4 [5.5] 3-25 2 [1] 1-5 3.5 [1.7] 1-11 2 [0] 1-3
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [0] 3-3 3 [0.5] 3-4 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 1 [0] 1-1 0 1 [0] 1-1 0 3 [0] 3-3
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 3 [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
Transfusion Medicine / Blood
Bank
Consultant
During OPD Hours only 2 [2.2] 1-4 1 [2] 1-4 1 [0.5] 1-5 1 [1.5] 1-4 1 [1] 1-4
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 3 [1.5] 1-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [0] 3-3 3 [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] 1-6 4 [2] 2-6 3 [1] 2-4 3 [2] 1-11 1 [1.5] 1-4
24 x 7 Physically Present 0 0 0 0 0
On Call during Non-OPD
Hours
3 [0] 1-3 3 [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] 3-3 3 [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] 1-1 1 [0] 1-1 3 [2] 1-6 1.5 [1.2] 1-3
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 3 [0.5] 1-3 1 [0] 1-1 3 [0] 1-3 3 [0] 3-3
Empanelled / As and when
required
0 3 [0] 3-3 0 0 0
Resident
During OPD Hours only 6 [0] 6-6 1 [0] 1-1 0 3 [0] 3-3 3 [0] 3-3
224
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] 2-3 2 [0.5] 2-3
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 3 [0.2] 3-4 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 1-3 3 [0.5] 1-3 1 [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] 1-3 2 [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] 2-5 1 [0] 1-1 2 [0] 2-2 3 [1] 2-4 2 [2] 1-3
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 3 [1] 1-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 1-3 3 [0.5] 1-3 1 [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] 3-3 3 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 2 [0] 2-2 0 0 0
Empanelled / As and when
required
0 0 0 0 0
Plastic Surgery
C
o
nsultant
During OPD Hours only 3 [2.7] 1-5 1 [0] 1-1 1 [0] 1-1 1 [1] 1-3 2 [1] 1-3
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 2.5 [0.5] 2-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 1-3 3 [0.5] 1-3 1 [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] 1-4 1 [0] 1-1 0 0 2.5 [1.5] 1-4
24 x 7 Physically Present 3 [0] 2-3 3 [0] 3-3 0 3 [0] 3-3 0
On Call during Non-OPD
Hours
3 [0] 3-3 2 [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] 2-2 1 [0] 1-1 1 [0.5] 1-3 1 [0.2] 1-2
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 1 [0] 1-1 3 [0] 3-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 1-3 2 [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] 3-3 1 [0] 1-1 0 3 [0] 3-3 0
On Call during Non-OPD
Hours
2 [1] 1-3 2 [0] 2-2 0 0 0
Empanelled / As and when
required
0 0 0 0 0
225
Gastroenterology
Consultant
During OPD Hours only 1.5 [1.7] 1-5 2 [0] 2-2 2 [0] 2-2 1 [2] 1-4 1 [2] 1-5
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 3 [0.5] 3-4 3 [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
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] 3-3 2 [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] 1-3 2 [0] 2-2 1 [0] 1-1 2 [2] 1-4 2 [2.5] 1-5
24 x 7 Physically Present 3 [0] 3-3 0 0 3 [0.2] 2-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 1-3 3 [0] 1-3 1 [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] 2-4 1 [0] 1-1 0 0 0
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 3 [0] 3-3 0
On Call during Non-OPD
Hours
3 [0] 3-3 2 [0] 2-2 1 [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] 1-4 1 [0] 1-1 1 [0] 1-1 3 [0.7] 1-3 1 [1] 1-3
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 1-3 3 [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] 1-8 1 [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] 3-3 3 [0] 3-3 0 0 0
Empanelled / As and when
required
0 2.5 [0.5] 2-3 0 0 0
Neuro Radiology
Consultant
During OPD Hours only 0 0 0 2 [1] 1-3 0
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 3 [0] 3-3 3 [0] 3-3
On Call during Non-OPD
Hours
2 [1] 1-3 1 [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
Consulta
nt
During OPD Hours only 2 [2.2] 1-4 1 [0] 1-1 0 1 [1] 1-3 1 [1] 1, 3
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 2 [1] 1-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 1-3 3 [0.5] 1-3 0 3 [0] 3-3 3 [0] 2-3
226
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] 3-3 3 [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] 2-4 1 [0.5] 1-3
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 3 [0.5] 1-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 2 [1] 1-3 3 [0] 3-3 3 [0] 3-3 3 [0] 3-3
Empanelled / As and when
required
0 0 0 0 0
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] 3-3 2 [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] 1-5 2 [1] 1-3
24 x 7 Physically Present 3 [0] 3-3 3 [0.5] 2-3 0 3 [0] 3-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 3-3 2 [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] 4-4 1 [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] 1-1 2 [2.2] 1-4 1 [3.5] 1-8
24 x 7 Physically Present 3 [0] 3-3 3 [0] 3-3 0 3 [0.5] 1-3 3 [0] 3-3
On Call during Non-OPD
Hours
3 [0] 1-3 3 [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] 1-3 2 [0] 2-2 0 0 0
Empanelled / As and when
required
0 0 0 0 0
227
ANNEXURE-VII
228
LIST OF OTHER PARTICIPANTS IN STUDY
Research Officers
Name Designation State Email
1.
Ms Dolly
Sharma
Research Officer, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi manyachaudhary7@gmail.com
2.
Dr Monica
Sindhu
Research Officer, Dept of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi Monicasindhu11@gmail.com
National Assessors
Name Designation State Email
3.
Dr Adarsh S
B
Senior Resident , Dept of
Emergency Medicine, JSS Medical
College, JSS Academy of Higher
Education, Mysuru, Karnataka
Karnataka adarshashu6789@gmail.com
4.
Dr Ajay
MD, Emergency Medicine, JIPMER,
Puducherry
Puducherry aj.ai.inn@gmail.com
5.
Dr Ajit
Baviskar
Professor, Dept of Emergency
Medicine, DY Patil Medical college
Maharashtra drbaviskar@hotmail.com
6.
Dr Ajith
Venugopalan
HOD, Dept of Emergency Medicine,
MOSC kolenchery, Ernakulam
Kerala ajith.v123@gmail.com
7.
Dr Akilan
Elangovan
Assistant Professor, Department of
Emergency Medicine
Tamil Nadu akey6986@gmail.com
8.
Dr Amit
Kumar
Singh
Junior Resident, Dept of Emergency
Medicine, JPNATC, AIIMS, New
Delhi
Delhi dr.aks2888@gmail.com
9.
Dr Anil
Kumar
Associate Professor and HOD, Dept
of Trauma and Emergency
Medicine, AIIMS Patna
Patna dranil4@gmail.com
10.
Dr Ankit
Sharma
Junior Resident, Dept of Trauma and
Emergency Medicine, AIIMS
Bhubaneswar
Orissa chetan91_sharma@rediffmail.com
11.
Dr Apoorva
Gomber
Junior Resident, Dept of Pathology,
RML Hospital, New Delhi
Delhi drapoorvagomber@gmail.com
12.
Dr Arun
Prasad
Associate Professor, Dept of Trauma
and Emergency Medicine, AIIMS
Patna drarunpd@gmail.com
229
Patna
13.
Dr Arushi
Ghai
MD, Community Medicine, AIIMS,
New Delhi
Delhi ritin.mohindra@gmail.com
14.
Dr Ashok
Kumar
Associate Professor/ CNO AIIMS,
Jodhpur
Rajasthan ashokbishnoi11@gmail.com
15.
Dr
Awaneesh
Katiyar
Dept of Trauma and Emergency
Medicine, AIIMS Rishikesh
Uttarakhand -
16.
Dr Bharat
Bhushan
Bhardwaj
Assistant Professor, Dept of Trauma
and Emergency Medicine, AIIMS
Rishikesh
Uttarakhand bharatbbhardwaj@gmail.com
17.
Dr Bharat
Choudhary
Assistant Professor, Dept of Trauma
& Emergency (Pediatrics), AIIMS,
Jodhpur
Rajasthan drbharatpaeder@gmail.com
18.
Dr Bharath
G
Junior Resident, JPNATC, AIIMS,
New Delhi
Delhi bharathg531@gmail.com
19.
Dr Brunda R
L
Junior Resident, JPNATC, AIIMS,
New Delhi
Delhi bru1471992@gmail.com
20.
Dr Chandra
Prakash
Senior Resident, Dept of Emergency
Medicine, AIIMS New Delhi
Delhi chandraprakashpatlauni@gmail.com
21.
Dr Cyril G
Cherian
Emergency department, District
Hospital, Aluva, Ernakulum
Kerala cyrilgc@gmail.com
22.
Dr D
Srikanth
Consultant Surgeon & Nodal Officer
for Trauma Care Emergency,
Trivandrum District Hospital
Kerala drdsrikanth@gmail.com
23.
Dr Debayan
Sinha Roy
Junior Resident, SSKM Hospital,
Calcutta
West Bengal debayansinharoy@gmail.com
24.
Dr Deepti Junior Resident, AIIMS, New Delhi Delhi ritin.mohindra@gmail.com
25.
Dr Dipak
Kumar
Sharma
Professor of Surgery & HOD of
Emergency Medicine, Govt. Medical
college, Guwahati
Assam dipakkumarsarma@hotmail.com
26.
Dr Gaurav
Kumar
Senior Resident, Department of
Emergency Medicine, AIIMS, New
Delhi
Delhi gauravmuvalia07@gmail.com
27.
Dr
Ghanashya
mTimilsina
Junior Resident, Dept. of Emergency
Medicines, JPNATC, AIIMS, New
Delhi
Delhi ghanashyam.timilsina@gmail.com
230
28.
Dr
Gummadida
la Manoj
kumar
Senior Resident, Dept of Emergency
Medicine, AIIMS, New Delhi
Delhi drmanoj2k8@gmail.com
29.
Dr Harshad
Dongare
Associate Professor, Dept of
Anaesthesia, Incharge of Emergency
Dept, SSMF Dr Jogalekar Hospital
Shirwal
Maharashtra harshaddoc@gmail.com
30.
Dr Kalyan
Bora
1
st
Year, PGT, GMCH, Guwahati Assam kalyanborah1987@gmail.com
31.
Dr Kishen
Goel
Senior Resident, Dept of Critical
Care, AIIMS Bhubaneswar
Orissa goelkishen@gmail.com
32.
Dr Linu
Sekhar
Assistant Professor and Incharge,
Sree Gokulam Medical college,
Trivandrum
Kerala linu24886@gmail.com
33.
Dr M
Sukumar
Senior Resident, Dept of Emergency
Medicine, JPNATC, AIIMS, New
Delhi
Delhi mrsuku@gmail.com
34.
Dr Madhu
Srinivasaran
gan
Assistant Professor, Dept of
Emergency Medicine, JSS Medical
College, JSS Academy of Higher
Education, Mysuru, Karnataka
Karnataka madhu@jssuni.edu.in
35.
Dr
Mahaveer
Singh Rodha
Associate Professor, Dept of Trauma
& Emergency, AIIMS, Jodhpur
Rajasthan msrodha@gmail.com
36.
Dr Manoj
Nagar
Assistant Professor, Dept of Trauma
and Emergency Medicine, AIIMS
Bhopal
MP manoj.ortho@aiimsbhopal.edu.in
37.
Dr Manzoor
Ahmed
Rather
Consultant Anaesthesia in Critical
Care, Directorate of Health Services,
Jammu & Kashmir
Kashmir drmanzoor22@gmail.com
38.
Dr Mayuri
Mhatre
Senior Resident, Dept. of
Emergency Medicine, MGM
Medical College, Navi Mumbai
Maharashtra dr_mayuri@hotmail.com
39.
Dr Md
Sabah
Siddiqui
Associate Professor, Dept of Internal
Medicine, AIIMS Raipur
Chhattisgarh dr.sabahsiddiqui@gmail.com
40.
Dr Md
Sharjeel
Khan
Junior Resident, SSKM Hospital,
Calcutta
West Bengal mdsharjeelkhan@gmail.com
231
41.
Dr
Meenaloshni
Jayaseelan
Junior Resident Delhi sinna.loshi@gmail.com
42.
Dr Megha
Yashwant
Solasakar
Register, ICU, Joglekar Hospital,
Shirwal
Maharashtra dr.meghasolasakar@gmail.com
43.
Dr Midhun
Mohan N
Provisional Assistant Professor,
Govt Medical College, Kozhikode
Kerala midhun6486@gmail.com
44.
Dr
Mohameed
Haneef M
HOD and Consultant, Dept of
Emergency Medicine, Medical Trust
Hospital, Ernakulam
Kerala haneef_farook@rediffmail.com
45.
Dr Monesh
Bhandari
Medical Officer (Academics),
Symbiosis Institute of Health
Sciences
Maharashtra moneshbhandari@gmail.com
46.
Dr Nazrul
Islam
3
rd
Year, PGT, GMCH, Guwahati Assam nazrulislam3009@gmail.com
47.
Dr Nidhi
Kaeley
Assistant Professor, Dept of
Emergency Medicine, AIIMS
Rishikesh
Uttarakhand drnidhi_kaeley@yahoo.com
48.
Dr
NipinKalal
Assisstant Professor/ ANS AIIMS,
Jodhpur
Rajasthan kalalnipin@gmail.com
49.
Dr Nirjala
Devi
Junior Resident, JNIMS, Imphal Manipur nirjalawayenbam@gmail.com
50.
Dr Nisarg S
Senior Resident , Dept of
Emergency Medicine, JSS Medical
College, JSS Academy of Higher
Education, Mysuru, Karnataka
Karnataka Snisarg84@gmail.com
51.
Dr Nitin
Borker
Associate Professor, Dept of
Pediatric Surgery, AIIMS Raipur
Chhattisgarh drnitinborkar25@gmail.com
52.
Dr Nitin
Kashyap
Associate Professor, Dept of CTVS,
AIIMS Raipur
Chhattisgarh nitinkashyap1@yahoo.com
53.
Dr Paresh
Mahabal
Medical Officer, Goa Goa ritin.mohindra@gmail.com
54.
Dr Prabin
Medical Officer, UPHC, Kakching,
Imphal
Manipur prabinkh@gmail.com
55.
Dr Prawal
Shrimal
Junior Resident, Dept of Emergency
Medicine, JPNATC, AIIMS, New
Delhi
Delhi prawalaiimspulse@gmail.com
56. z
o
Dr R. Senior Resident, Emergency
Puducherry drsurendar18@gmail.com
232
o
r
Surendar Medicine, JIPMER, Puducherry
57.
Dr Rachana
Assistant Professor, Dept of
Emergency Medicine, KMC
Mangalore
Karnataka rachana2806@gmail.com
58.
Dr
Rajeshwari
Vhora
Consultant, Emergency and Critical
Care, Global Hospital
Maharashtra drrajeshwarivhora@gmail.com
59.
Dr
Ramkaran
Chaudhary
Associate Professor, Dept of
surgery, AIIMS, Jodhpur
Rajasthan rkmoond@gmail.com
60.
Dr Ravindra
Vishwakarm
a
Register, ICU, Vishwaraj Hospital,
Pune
Maharashtra ramashrayv@gmail.com
61.
Dr Rina
Parikh
Assistant Professor, Dept of
Emergency Medicine, SSG Hospital
and Medical college, Baroda
Gujarat drrinaparikh77@gmail.com
62.
Dr Ritin
Mohindra
Assistant Professor, Dept of
Emergency Medicine, AIIMS New
Delhi
Delhi ritin.mohindra@gmail.com
63.
Dr Sakshi
Yadav
MD, Emergency Medicine, AIIMS,
New Delhi
Delhi sakshiyadav788@gmail.com
64.
Dr Sangeeta
Sahoo
Assistant Professor, Dept of Trauma
and Emergency Medicine, AIIMS
Bhubaneswar
Orissa drsangeeta.asth@gmail.com
65.
Dr Saurabh
Saigal
Associate Professor, Dept of
Anesthesia and Critical Care, AIIMS
Bhopal
MP
saurabh.criticalcare@aiimsbhopal.ed
u.in
66.
Dr Shandeep
Singh
Medical Officer, Medical
Directorate, Lamchel, Imphal
Manipur shaninsunville@gmail.com
67.
Dr
Shivasheesh
Rath
Junior Resident, Dept of Trauma and
Emergency Medicine, AIIMS
Bhubaneswar
Orissa drsrath8@gmail.com
68.
Dr Shreyas
Patel
Assistant Professor, Dept of
Emergency Medicine, SSG Hospital
and Medical college, Baroda
Gujarat shreyas384@gmail.com
69.
Dr
Subhankar
Paul
Senior Resident, Dept of Emergency
Medicine, JPNATC, AIIMS, New
Delhi
Delhi subhankargmch@gmail.com
70.
Dr
Sudhanshu
Senior Resident, Emergency,
AIIMS, Bhopal
MP sudhanshu.mgmc@gmail.com
233
Agarwal
71.
Dr Suprith C
Senior Resident, Dept of Emergency
Medicine, JPNATC, AIIMS, New
Delhi
Delhi c.suprith@gmail.com
72.
Dr Suvan
Kanti
Chowdhury
Senior Resident, Dept. of
Emergency Medicine, GMCH,
Guwahati
Assam suvanchowdhary@gmail.com
73.
Dr Tanmay
Dutta
Associate Professor, Dept of
Orthopedics, SSKM Hospital,
Calcutta
West Bengal tanmayortho@yahoo.com
74.
Dr Vignan
Kappagantu
Junior Resident, Department of
Emergency Medicine, JPNATC,
AIIMS, New Delhi
Delhi vignan_1504@yahoo.co.in
75.
Dr Y. Tato
Assistant Professor and Surgical
Specialist, TRIHMS Hospital
Naharlagun
Arunachal
Pradesh
yijum@yahoo.com
76.
Dr. Bansi
Dilipbhai
Trambadia
Intern Doctor, SSG Hospital and
Medical college, Baroda
Gujarat bansitrambadia@yahoo.co.in
77.
Dr.Bhumiben
Mukeshbhai
Patel
Intern Doctor, SSG Hospital and
Medical college, Baroda
Gujarat patelbhumi0703@gmail.com
78.
Dr.
Himanshu
Rameshchan
dra Patel
Intern Doctor, SSG Hospital and
Medical college, Baroda
Gujarat Himanshupatel9061@gmail.com
79.
Dr. Hiren
Dahyabhai
Vaghela
Intern Doctor, SSG Hospital and
Medical college, Baroda
Gujarat hirenvaghela28@gmail.com
80.
Dr. Krunal
Kumar
Pancholi
Assistant Professor, Dept of
Emergency Medicine, SSG Hospital
and Medical college, Baroda
Gujarat krunalpancholi90@gmail.com
81.
Dr. Madhur
Uniyal
Assistant Professor, Dept. of Trauma
Surgery, AIIMS, Rishikesh
Uttarakhand drmadhuruniyal@gmail.com
82.
Dr. Malay
Mukeshbhai
Rathod
Intern Doctor, SSG Hospital and
Medical college, Baroda
Gujarat malayrathod22@gmail.com
83.
Dr. Mihir
Haresh
kumar Patel
Intern Doctor, SSG Hospital and
Medical college, Baroda
Gujarat mihirpatel1265@gmail.com
234
84.
Dr. Shivani
Patel
Intern Doctor, SSG Hospital and
Medical college, Baroda
Gujarat shivanip4796@gmail.com
85.
Dr. Shreya
Rajiv
Dholakia
Intern Doctor, SSG Hospital and
Medical college, Baroda
Gujarat shreya.d125@gmail.com
86.
Dr.Sojitra
Amit kumar
Ramnik bhai
Intern Doctor, SSG Hospital and
Medical college, Baroda
Gujarat amit.sojitra42@gmail.com
87.
Dr.Tapan
Jitendra
kumar Patel
Intern Doctor, SSG Hospital and
Medical college, Baroda
Gujarat pateltapan2404@gmail.com
88.
Mr A.
Ahamed
Tutor, Emergency & Trauma care
Technology, SRM Medical College
Hospital & Research Centre,
Kattankulathur
Tamil Nadu ahamedkhan108@gmail.com
89.
Mr
Arunkumar
T A
Nursing officer, Dept of Trauma &
Emergency, AIIMS Raipur
Chhattisgarh arunthekkumkovil@gmail.com
90.
Mr Aswin S
Pillai
Nursing officer, Dept of Trauma &
Emergency, AIIMS Raipur
Chhattisgarh aswinspillai009@gmail.com
91.
Mr Bhanwar
Lal Dewna
Senior Nursing Officer, Department
of Emergency Medicine, AIIMS,
Jodhpur
Rajasthan bldewna@gmail.com
92.
Mr
DheeneshbabuL
akshminarayana
n
Nursing Officer, Department of
Emergency Medicine, AIIMS, New
Delhi
Delhi dheeneshbabu@gmail.com
93.
Mr Dinesh
Sridhar
Nursing Officer, Department of
Emergency Medicine, AIIMS, New
Delhi
Delhi dinodinesh.s1991@gmail.com
94.
Mr J
Jayamuruga
n
Manager-Clinical Operations, SRM
University Hospital, Potheri,
Chennai
Tamil Nadu jay202398@gmail.com
95.
Mr Prakash
Mahala
Senior Nursing Officer, Incharge
Emergency Medicine, AIIMS,
Rishikesh
Uttarakhand prakashjpmmahala@gmail.com
96.
Mr Rashad
Nursing Officer, WHO CC for
Emergency & Trauma Care, SEAR,
JPNATC, AIIMS, New Delhi
Delhi -
97.
Mr
Sreekanth
Vijayan
Nursing officer, Dept of Trauma &
Emergency, AIIMS Raipur
Chhattisgarh Sreekanthvijayan4@gmail.com
235
98.
Mr Srinivas
SHRI
Nursing Officer, Department of
Emergency Medicine, AIIMS, New
Delhi
Delhi mrsuku@gmail.com
99.
Mr Suneesh
S
Staff Nurse, General Hospital,
Neyyattinkara
Kerala Email_suneeshbadari@gmail.com
100.
Mr Vikas
Choudhary
Nursing Tutor/ ANS, AIIMS,
Jodhpur
Rajasthan vikasss.1988@gmail.com
101.
Mrs Jincy
Jose
Nursing officer, Dept of Trauma &
Emergency, AIIMS Raipur
Chhattisgarh Jinjose06@gmail.com
102.
Mrs Pratibha
S L
Staff Nurse, Gr1, General Hospital,
Neyyattinkara
Kerala prathibhantanta@gmail.com
103.
Ms Isha
Kaushik
Nursing Officer, Department of
Emergency Medicine, AIIMS, New
Delhi
Delhi ishukaushik28@gmail.com
104.
Ms Nirmal
Thakur
Public Relation Officer, Department
of Emergency Medicine, AIIMS,
New Delhi
Delhi Neeru.rjpt.2007@gmail.com
105.
Ms
Ramandeep
kaur
Nursing Officer, Department of
Emergency Medicine, AIIMS, New
Delhi
Delhi bhangoo0073@gmail.com
106.
Ms Roopa
Rawat
Nursing Officer, WHO CC for
Emergency & Trauma Care, SEAR,
JPNATC, AIIMS, New Delhi
Delhi rooparawat84@gmail.com
107.
Ms Stephy
Kennady
Nursing Officer, Dept. of
Emergency Medicines, JPNATC,
AIIMS, New Delhi
Delhi stephykennady95@gmail.com
108.
Ms. Varsha
Devi
Nursing Officer, Department of
pediatrics, AIIMS, New Delhi
Delhi varshaniepgi@gmail.com
109.
Pulimela
Aswan
Kumar
Nursing Officer, AIIMS, Raipur Chhattisgarh aswansunny239@gmail.com
236
ANNEXURE-VIII
237
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
Dr A K
Gupta (DHS)-
9418015368
Dr Ravi Chand
(DME)-
9418028446
IGMC, Shimla
Dr Mukand Lal
(Principal)
principal-igmc-hp@gov.in
District Hospital,
Shimla
Dr 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, Mohali Dr Sunil bhavna.ahuja@fortishealthcare.com
Shivam Multi Super
Speciality
Hospital, Hoshiarpur
Navtej Bassa
navtej.bassan@gmail.com
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 -
238
6. Chandigarh
Government
Superspeciality
Hospital
Dr Satbir -
Civil Hospital, Sec-22 Dr 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
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 Dr. Sujoy Das Thakur dr.tanushree.sidharth@carehospitals.com
239
Hospital, Pachpedhi (HOD)
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)
-
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, Papumpare trihmsap@gmail.com
Bakin Pertin General
Hospital, Pasighat
Dr Y Darang -
Ramakrishanan
Mission Hospital,
Itanagar
-
rkmitanagar@gmail.com
itanagar@rkmm.org
18. Assam
Gauhati Medical
College and Hospital,
Guwahati
- superintendentgmch@gmail.com
Morigaon Civil - jtdhsmorigaon2017@gmail.com
240
hospital, Guwahati
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
College
Dr 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
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. Guntur Medical - gmc_gtr@ap.nic.in
241
Andhra
Pradesh
College, Guntur
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
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.reena.kr@gmail.com
242
Dr Sucheta (ED Head)
Artemis Hospital
Dr Sumit Ray (Chief of
Medical Services)
sumit.ray@artemishospitals.com
Jaipur Golden Hospital - drnishithmittal@yahoo.co.in
243
ANNEXURE-IX
244
Comparative of Compliance among Medical College
S.
No
Name of Hospitals Hospital
Services
ED
Protocol/
SOP/
Guidelines
Safety &
Security
Disaster
managemen
t
Continuous
Quality
Managemen
t
Data
Managemen
t System
Financing Physical
Infrastructu
re
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%
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%
245
Comparative of Compliance among Government Hospitals more than 300 beds
S.
No
Name of Hospitals Hospital
Services
ED
Protocol/
SOP/
Guidelines
Safety &
Security
Disaster
manageme
nt
Continuous
Quality
Manageme
nt
Data
Manageme
nt System
Financing Physical
Infrastruct
ure
Equipment
& Supplies
in ED
Essential
medicine in
ED
Overall
Complianc
e
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%
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%
246
Comparative of Compliance among Government Hospitals less than 300 beds
S.
No
Name of Hospitals Hospital
Services
ED
Protocol/
SOP/
Guidelines
Safety &
Security
Disaster
managemen
t
Continuous
Quality
Managemen
t
Data
Managemen
t System
Financing Physical
Infrastructu
re
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%
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%
247
Comparative of Compliance among Private Hospitals more than 300 beds
S.
No
Name of Hospitals Hospital
Services
ED
Protocol/
SOP/
Guidelines
Safety &
Security
Disaster
manageme
nt
Continuous
Quality
Manageme
nt
Data
Manageme
nt System
Financing Physical
Infrastruct
ure
Equipment
& Supplies
in ED
Essential
medicine in
ED
Overall
Complianc
e
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%
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%
248
Comparative of Compliance among Private Hospitals less than 300 beds
S.
No
Name of Hospitals Hospital
Services
ED
Protocol/
SOP/
Guidelines
Safety &
Security
Disaster
managemen
t
Continuous
Quality
Managemen
t
Data
Managemen
t System
Financing Physical
Infrastructu
re
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%
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%
249
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%
250
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%)
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%)
251
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%)
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%)
4 Meghalaya -
Civil Hospital Shillong,
Meghalaya
(42%)
- - -
5 Nagaland - -
District Hospital, Peren,
Nagaland
(24%)
-
Christian Institute of Health
Science and Research
(52%)
252
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%)
-
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%)
- - -