GAIMS Safety Manual 12.05.22

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 251 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  GAIMS hospital laboratory scope commensurate with the services provided by the organization. Services are available round the clock. Laboratory has adequate space and layout prevents cross contamination.  All tests where results required for emergency management are available within the premises. Report the results to the patient in unique format in a standardized manner.  All reports include the name of organization, the name of patient, Patient’s registration no. (CR), Lab Requisition No., Reference range (if applicable) and the name and signature of the person reporting the test result. Laboratory has qualified pathologist and micro biologist. All the reports are signed by them as per law.  All outsource reports incorporate all above details along with outsource lab reference number and are printed on the outsource lab letterhead. PROCEDURE ORDERING OF TEST OUTPATIENTS (OPD)  Treating doctor prescribes the required laboratory test in the OPD case paper of the patient & fills a laboratory test requisition slip.  Patient/ relatives visit the cash counter with the laboratory test requisition slip for payment of the charges for the prescribed test.  The cashier collects the user charges for the prescribed test as per indicated in the laboratory test requisition slip & enters the details. A lab collection center person collects the outsourced test in the designated register & assigns a patients sample identification number to the patient. Receipt for the payment of the user charges is handed over the patient relatives by the cashier/lab collection center person. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 252 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Patient visits the sample collection area of the laboratory department & submits the laboratory test requisition slip along with the payment receipt to the laboratory attendant.  The patient details including the name of the patient, age, sex, patients sample identification number, tests to be performed, referring doctor are entered in the record register.  Patients are requested to wait in the waiting area of the department till they are called. Patient’s sample collection is done strictly on the basis of “first come first serve”.  Patients are called in the sample collection area of the department as per their turn. The laboratory technician collects the patient’s sample, stores the same in leak proof containers, labels the container with the patient’s name, patients sample identification number & sample type.  Patients are informed about the time & day for collecting the test reports. IN PATIENT (IPD)  The treating doctor prescribes the required laboratory test in the patient’s case sheet, fills the laboratory test requisition slip & forwards the same to the ward nurse.  Patient relatives are informed about the test to be performed by the ward nurse.  The ward nurse collects the patient’s sample, stores them in leak proof containers, labels the sample with patient’s name, age, sex, sample type, patients sample  Identification number as indicated in the laboratory test requisition slip.  Nurses collect the samples and send it to laboratory with requisition.  Samples are received in the laboratory, records relating to the name of the patient,  Age, sex, sample type & patients sample identification number are entered in the record book. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 253 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Tests are performed & reports generated. All reports are signed, dated clearly by authorized Laboratory personnel.  The reports are forwarded directly to the staff nurse of the designated inpatient care area from where patients, sample was collected the prescribed test.  Tests are performed & reports generated.  All reports are signed, dated clearly by Pathologists.  Patients/relatives collect the report from the reception area of the laboratory at the mentioned time & day. RESPONSIBILITY  All hospital clinical staff  laboratory staff PATIENT IDENTIFICATION OPD PATIENT  After ordering the tests on the OPD basis from consultant’s patient goes to phlebotomists for collection of sample.  Patients’ identity is confirmed by the phlebotomist before the collection. IPD PATIENTS  The samples are collected in the wards / ICU request is raised through HMIS.  After receipt of the sample the sample is inspected to confirm adequacy of volume, free rom factors like hemolysis which may interfere with the analyses.  Repeat samples are requested if so desired.  A sample label include :- o CR No. o Name of the patient. o Age and sex of patient Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 254 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL o Name of the test Responsibility  Technician PATIENT PREPARATION Procedure  Proper patient preparation is essential for the test results to be meaningful.  In preparing the patient for phlebotomy, care should be taken to minimize factors related to activities that might influence laboratory determinations.  Specific inquiry is made to correct for non-compliance with given instructions.  12 hours fasting is essential for tests like lipid profile, fasting blood sugar, E.S.R.  For post-prandial blood sugar blood sample is collected exactly after 2 hours of lunch, dinner, and breakfast.  For fasting and post- prandial blood sugar samples ask whether the patient is diabetic and the last dose of medication if the patient is diabetic.  For test like Prothrombin Time ask the patient about the anticoagulant dose previous medication.  For test like Partial Thromboplastin Time check whether the patient is on anticoagulant or on heparin.  In case of Prothrombin Time and Partial Thromboplastin Time sample is to be processed within1 hour.  For test like T3, T4 and TSH ask about last dose of medication.  For Beta-HCG and Triple marker tests & Urine Pregnancy Test ask the last menstrual period date.  For urine routine and culture ask patient to give preferably morning midstream sample in the respective containers.  For sputum routine and culture ask patient to give preferably first morning sputum sample. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 255 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  For 24 hours urine test ask the patient to collect container containing preservative (Boric acid powder) from pathology department. Ask the patient to empty the bladder by voiding urine, sample just before the start collection (i.e12 .00 a.m.) & collect urine sample thereafter from 12.00am to next day (24 hours).  For 24 hours urinary VMA test ask the patient not to take milk products for 2 days prior to the test  For samples coming from outside the Hospital check the sample first for patients name written the vial or vacationer, check for the presence of clot in EDTA citrate or heparinized vacationer  If the sample is hemolyser insufficient for testing, ask for repeat collection of the sample in the appropriate vacutainer.  Patient variables such as age, gender, diet, smoking and alcohol intake, exercise, medications, physical and emotional stress and whether the patient is supine, sitting or standing at the time of phlebotomy, activation, resulting in erroneous coagulation results. Traumatic phlebotomy can result in an artificially short PT or PTT. Responsibility  Technician. SPECIMEN COLLECTION  Place of collection: - For out patient’s lab collection is done in collection room which is opened from 9 am to 5 pm & Sunday it’s closed. During closing hours of phlebotomy room, sample is collected in the emergency. Procedure  Verify that computer – printed labels match requisitions.  If a fasting specimen is required, confirm that the fasting order has been followed. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 256 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Assemble equipment and supplies including collection tubes, tourniquet & preparations for cleansing the area, syringes if necessary, sterile blood collection needle & holder used to secure the needle.  Ask the patient to close his fist so the veins are more palpable.  Cleanse the venipuncture site with sterilium /alcohol based skin disinfectant; Begin at the puncture site & clean outward in a circular motion.  Allow the area to dry. Do not touch the swabbed area with any un- sterile object.  Apply a tourniquet several inches above the puncture site. Never leave the tourniquet in place longer than one minute.  Complete the software entry after completing the collection procedure. RESPONSIBILITY  Pathology Technician/Casualty nurses staff. PERFORM THE VENI- PUNCTURE  Enter the skin at approximately 15 degree angle to the arm, with the level of the needle facing upwards.  Follow the geography of the vein with the needle.  Insert the needle smoothly and fairly rapidly to minimize patient discomfort Do not bury the needle.  If using a syringe, pull back on the barrel with a slow, even tension as blood flows into the syringe.  Do not pull back too quickly to avoid hemolysis or collapsing the vein.  If using an evacuated system, as soon as the needle is in the vein, ease the tube forward in the holder as far as it will go, firmly securing the needle holder in place.  When the tube has filled, remove it by grasping the end of the tube and pull gently to withdraw.  Release the tourniquet when blood begins to flow. Never withdraw the needle without removing the tourniquet. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 257 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  After all the blood has been withdrawn, have the patient relax his fist. Do not allow the patient to pump the hand.  Apply an adhesive bandage strip over the cotton ball or gauze to adequately stop bleeding and avoid hematoma.  Check the condition of the patient, e.g. whether patient is faint and that bleeding is under control. Always anticipate that a syncope episode may occur.  Dispose of contaminated material such as needles, syringes & cotton in designated hard cased container (sharps container). Do not recap or remove the needle by hand but use appropriate device designed for this function. COVID POSITIVE PATIENT SAMPLE COLLECTION Sample collection for COVID patient is as follows  Collect the respective sample according to consultant/specialist doctor.  Sterilize the sample container by using 1% sodium hypochlorite solution and then send to lab with informed lab requisition  Lab received sample again by sterilizing them with 1% Sodium hypochlorite solution and process.  Use all personnel protective equipment during sample processing.  Before and after processing hand hygiene is must to follow. URINE COLLECTION Types of Urine Specimen 1. A single Specimen  This is the first morning voiding, a specimen is the morning is the most concentrated and has acidic PH in which formed elements (cells and casts) are well preserved. This specimen is used for routine examination, fasting glucose, proteins, nitrite, microscopic analysis for cellular elements, pregnancy test, orthostatic proteinuria, and bacteriological analysis. 2. The Random Specimen Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 258 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  This is also a single specimen collected at any time of day. It is used for routine urine examination. 3. Post prandial Specimen  Collected two hours after the meal in the afternoon is requested for estimation of glucose to monitor insulin therapy in diabetes mellitus. 4. 24 hour specimen  After getting up in the morning, the first urine is discarded. All the urine voided subsequently during the rest of the day and the night is collected in a large bottle [clean bottle of 2 liter capacity with a cap]. The first urine after getting up in the morning on the next day is also collected. The urine should be preserved at 4-60C during the period of the collection. The container is then immediately transported to the laboratory. The urine is thoroughly mixed and an aliquot is used for testing. This method is used for quantitative estimation of proteins and hormones. COLLECTION METHODS 1. Midstream specimen  This is used for all types of examinations. After voiding initial half of urine into the toilet, a part of urine is collected into the bottle. First half of the stream serves to flush out contaminating cells and microbes from the urethra and perineum. Subsequent stream is collected which is from the urinary bladder. 2. Clean catch specimen  This is recommended for bacteriologic culture .In men glands penis is sufficiently exposed and cleaned with soap and water .In women urethral opening should be sufficiently exposed, washed with soapy cotton balls, rinsed with water saturated cotton, and holding the labia apart, the initial urine is Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 259 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL allowed to pass into the toilet and the remaining is voided into the bottle .This method avoids contamination of urine with the vaginal fluids. 3. Catheter specimen  This is used for bacteriological study or culture in bed ridden, ill patient or in patient with obstruction of urinary tract. It is usually avoided in ambulatory patients since it carries the risk of introduction of infection. 4. Infants  In infants, a clean plastic bag can be attached around the genitalia and left in place for some time. HANDLING & TRANSPORTATION OF SAMPLES.  All samples are properly labeled with the patient’s name, unique patient sample identification number, sample type & patient type i.e. OPD or in case IPD the specific ward from where the patient’s sample has been collected is also indicated in the label.  Sample without proper label as per the guideline stated above would be rejected. In such case the sample is returned to the specific area from where it has been collected.  Vacuum containers are used for transfer of samples from the specific point of collection to the main laboratory area so that there is no spillage. Samples which are to be outsourced are separated into serum or plasma as required, sample bullets prepared, labeled, record entered in the outsourced register & then transferred to the specific outsourced lab.  Staff responsible for handling of patient samples is required to wear appropriate personal protective equipment which include gloves, aprons, face mask. MICROBIOLOGY PATIENT PREPARATION, SAMPLE COLLECTION AND TRANSPORTATION Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 260 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 1. PUS  1ml in sterile test tube or swab dipped in pus and placed in sterile tube or can be collected by aspiration from abscess. Swab stick should not be broken at the time of collection.  Storage - Room Temperature 2. THROAT SWAB  Hold the tongue down with the tongue depressor.  Use a strong light source to locate areas of inflammation and exudates. (Posterior pharynx and the tonsillar region of the throat behind the uvula).  Rub the area back and forth with a sterile cotton swab.  Sample the posterior pharyngeal wall at the end to avoid gagging by the patient.  Withdraw the swab without touching cheeks, teeth or gums and insert into a sterile test tube. To prevent drying add some sterile saline  Storage - Store at Room Temperature 3. SPUTUM  Required - Select a good wide-mouthed sputum container.  Method of collection: o Collect an early morning sample after rinsing the mouth with water. o Instruct the patient to inhale deeply 2-3 times, cough up deeply from the chest and spit in the sputum container by bringing it closer to the mouth. Store specimen at room temperature for up to 2 hours or at 4°C, if a delay in transport. o A good sputum sample is thick purulent and sufficient in amount. Label specimen and make sure the Lab form is filled properly. o For diagnosis of the tuberculosis, sputum should be collected on 3 consecutive days.  Storage - It can be refrigerated at up to 24 hours Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 261 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 4. BRONCHIAL ALVEOLAR LAVAGE (BAL)  Specimen Requirements - Submit 25 mL of saline lavage in a sterile container.  Specimen Handling - Specimen MUST be received in the laboratory within 2 hours  Storage - Store specimen at room temperature. DO NOT refrigerate.  Additional Information - If multiple test requests are made, clearly prioritize by indicating #1, #2, etc. on requisition. 5. ENDOTRACHEAL ASPIRATE  Specimen Requirements/Acceptable specimen: - aspirated tracheal suction material. Submit specimen in a sterile container.  Specimen Handling: Store specimen at 4°C.  Additional Information  Indicate Candida/Yeast on requisition if required.  Endotracheal tube aspirates are contaminated with upper respiratory tract flora and a criterion for interpretation is the same as for sputum. Specimen is NOT suitable for anaerobic culture. 6. URINE  Give the patient sterile, dry, leak proof container with instructions to collect mid- stream urine sample after cleaning local parts.  The normal flora of anterior urethra is flushed out by passing first portion of urine before collection of specimen of urine for culture.  Subsequent midstream urine is collected in a test tube.  For urinary tuberculosis, early morning samples on 3 consecutive days or a 24 hrs. specimen in a large sterile bottle should be collected.  Preservation  For 24 hrs. specimen 1% boric acid is used as a preservative.  If delay is more than 2 to 3 hrs. then store the urine in refrigerator. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 262 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Precaution o Do not collect urine directly from catheter urine Bag. o Early morning, mid-stream urine sample is preferred. 7. BLOOD CULTURE  Vein puncture- Blood culture how much?  Venous blood o 0.5 – 2 ml for infants o 2-5 ml in 20ml blood culture media for children o 5-10 ml in 50ml blood culture media for adults  When? o As early as possible and before starting antibiotics TRANSPORT  Collect into blood culture bottles (with Glucose broth Or Bile broth).  Should be transported at ambient temperature  Remove plastic flip – cap from each culture bottle.  After palpating the vein, clean the site for vein puncture with Spirit for at least 30 seconds  Next clean with Spirit (tincture iodine) in concentric circles away from the puncture site covering an area of 1-2” in diameter.  Collect required amount of blood with a sterile needle and syringe.  Transfer with the needle into the blood culture bottle.  Shake the bottle properly to prevent clotting.  Can be kept at room temperature.  Always label the bottle and with the patient details mention time & date of collection. Lab form should be completed properly.  Avoid transferring hemolysed blood. 8. EAR, NASAL AND CONJUNCTIVAL SWABS Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 263 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Collect with sterile swab stick. Kept in sterile test tubes.  For screening nasal carriers of Methicillin Resistant Staphylococcus aureus (MRSA) – nasal swab should be collected.  For detecting meningococcal carriers- West’s postnasal swabs are used (swabs prepared on wire and bent at an angle, so that it touches the nasopharynx). 9. CEREBROSPINAL FLUID (CSF).  When do we collect? o The specimen must be taken by a physician experienced in the procedure. o Collect as early in the disease as possible, before starting the antibiotics o Submit a minimum of 1-4 mL CSF in sterile tube.  Specimen Handling: o DO NOT refrigerate. o Store specimen at room temperature. o Specimen must be received in laboratory within 1 hour of collection for optimal recovery of organisms.  Additional Information o Clearly specify tests required on the requisition. o Kept in incubator at 370C or at room temperature, if there is delay in transportation. CSF sample should not be refrigerated (except for virus studies). Sample is centrifuged at 2000rpm for 15 mins. Sediment is removed with capillary pipette for processing. 10. CATHETER TIPS  Acceptable specimens: intravenous or intra-arterial tips.  Collect distal 2-3 cm of line tip.  Submit specimen in sterile tube.  Specimen Handling o DO NOT refrigerate. o Store specimen at room temperature. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 264 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Additional Information-Large drainage tube tips and urine catheter tips are NOT acceptable. 11. OTHER BODY FLUIDS  Pleural, peritoneal, pericardial, ascetic, synovial fluids etc. are collected in sterile screw capped tubes. SPECIMENS FOR ANAEROBIC ISOLATIONS  If material is scanty – swabs are collected from depth of the wound and dipped in Stuart’s transport medium, processed in the laboratory within 2 hrs. of collection.  If material is plenty (pus or aspirate) – the specimen is withdrawn in sterile syringe and needle and the tip of the needle is sealed with a sterile rubber cork, transported to the laboratory and processed within 2 hrs. of collection.  Body fluids collected in sterile small screw capped vials. Vials should be completely filled up with the specimen so as to prevent air entry. SPECIMENS FOR FUNGAL ISOLATIONS  Skin – The lesion should be wiped with spirit or sterile water. The periphery of the lesion is scraped with a sterile scalpel and collected in a sterile Petri dish. Lesion should be free from topical antifungal agents for at least one week.  Hair – The affected area is cleaned with spirit, 10-12 hairs plucked with sterile forceps and put in a sterile Petri dish.  Nail- The debris under the nail is collected with scalpel; flakes picked up if present and put in a sterile Petri dish. If the nail is completely damaged, it is cut into small pieces and put in sterile Petri dish. BODY FLUIDS OTHER THAN CSF – IN STERILE SCREW CAPPED TUBES  CSF – In sterile screw capped tubes. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 265 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Curettage from sinuses and grains of mycetoma – collected in 2-3 ml of sterile saline. Gauze is kept over the sinuses overnight and the grains get collected there. The grains are washed in several changes of sterile saline, then crushed within two glass slides and processed  Corneal scrapings – Local anesthetic is applied over the eyes, lid is retraced with retractor and with the help of the blunt edge of sterile scalpel blade (no. 15), and the ulcered area is scraped away from the papillary area. Scarring are kept in sterile Petri dish or taken on a sterile swab stick moistened with broth.  Sputum – In sterile screw- capped bottles.  Biopsy – Skin is decontaminated. Then by autoclaved instruments, biopsy is cut into small pieces, crushed in mortar and pestle with little Sabouraud’s broth and processed. It may also be collected in sterile test tubes or Petri dish and then processed as above. FOR SEROLOGY  5 ml blood is collected in plain test tubes. After blood clots, serum is poured in a separate plastic vial or test tube. Two samples are collected – one in acute phase and another in convalescent phase after 7-10 days. Blood should not be hemolysed. STOOL SPECIMEN COLLECTION When should it be collected?  Collect soon after onset of diarrhea  For viruses :< 48hrs of onset,  For bacteria :< 4days after onset of illness.  PREFERABLY BEFORE STARTING ANTIBIOTICS  If required two or three samples can be collected on consecutive/alternate days. Instructions for collecting faeces Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 266 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Label the specimen container clearly with patients name and date of collection. (If a specimen container is not available, a clean jar with a screw-top lid may be used.) Lab form should be completed properly  Pass faeces directly into the container. Do not contaminate the faeces with urine. Or  Place a separate clean container with a wide opening (for example, an ice-cream container), or plastic wrap or newspaper in the toilet bowl. Transfer enough faeces with spatula to at least half fill the specimen container.  Screw the lid on the specimen container firmly. Place it in a sealed plastic bag. COLLECTION OF RECTAL SWAB  This method of sampling is less satisfactory than collecting faeces. It is not appropriate for parasitology.  Moisten a cotton swab with sterile saline.  Insert it inside the anal sphincter and go up to 2-4 cm inside the rectum.  Gently rotate up to 90 degrees, so that faeces cover the swab.  Withdraw the swab  Place it in transport medium, break off the top portion of swab stick and discard  Label the specimen and place it in a plastic bag  Lab form should be completed properly. Handling and transport  If delay of more than two hours is anticipated, inoculate the specimen in a transport medium  Cary Blair medium: for bacterial pathogens (Salmonella, Shigella, Esch. coli and Vibrio). Should reach laboratory in 2-3 days’ time. Can keep at room temperature.  V.R. Fluid: For Cholera should reach laboratory in 2-3 days’ time. Can keep at room temperature.  For viruses keep in fridge (4ºC-8ºC) Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 267 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  DO NOT FREEZE Note  Specimen should be appropriate and collected at appropriate time.  If possible specimen should be collected before patient receiving anti- microbiotics.  Enough material and adequate number of samples should be collected.  Contamination should be avoided.  All specimens should be labeled with patient name, ward, date and time of collection and patient’s registration no.  Request form should be complete along with detailed clinical information and possible etiology.  All samples should be transported to the laboratory rapidly and processed within 2 hrs. of collection SPECIMEN TRANSPORT PROCEDURE  Transport of blood, urine and other fluids and tissue specimens from collection site to laboratory is an important part of processing, specimens should be received by the laboratory staff within 45 min of collection .For urgent test samples should be received by the laboratory staff as early as possible .e.g-TROP T,TROP I,CKMB etc.  For analysis of unstable constituents such as ammonia, plasma rennin activity, blood gas specimens must be kept at 40C immediately after collection and they should be transported with icepack.  All laboratory specimens must be transported in a safe and convenient to prevent biohazard, exposure or contamination of the specimen. Broken of leaking specimens are a biohazard to those who may come in contact with them, and the problem requires recollection of a new specimen. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 268 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL RESPONSIBILITY  Technician. /Housekeeping staff SAMPLE ANALYSIS PROCEDURE  Ideally all measurements should be performed within one hour after collection.  A blood specimen should ideally be centrifuged as soon as clot formation is complete. (About 20 min at room temperature).  Prolonged contact of serum with cell clot beyond 2 hours can cause significant changes in certain constitutes such as glucose, potassium, phosphorus, creatinine, AST and ALT.  Allow adequate time for clotting to prevent latent fibrin formation which may cause undesirable clogging of automated chemistry analyzers.  Centrifuge blood for 10 minutes at a 2000 rpm in stopper container. If analysis is to be delayed for more than 4 hours, store serum or plasma at 40C to 60C until analysis.  If the specimen cannot be analyzed immediately, the separated serum is stored in capped tubes at 40C.  Samples are centrifuged and either directly loaded onto the analyzer for biochemistry tests, or aliquot into sample cups and then loaded onto the equipment.  Water quality calibration of balances, calibration of glassware and pipettes, stability of electrical power and temperature of heating baths refrigerator, freezers and centrifuges is periodically monitored. Some important considerations:  12-14 hours fasting is essential for tests like lipid profile, fasting blood sugar, E.S.R. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 269 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  For post prandial blood sugar blood sample is collected exactly after 2 hours of complete on of lunch, dinner or breakfast  For post glucose blood sugar blood sample is collected exactly after 2 hours of glucose intake.  For fasting and post-prandial blood sugar samples ask whether the patient is diabetic & the last dose of medication if the patient is diabetic.  For test like Prothrombin Time ask the patient about the previous medication.  For test like Partial Thromboplastin Time check whether the patient is on anticoagulant or on heparin within 1 hour.  For test like T3, T4 and TSH ask about last dose of medication.  For Beta-HCG and Triple marker tests & Urine Pregnancy Test ask the last menstrual date.  For drug assay ask last dose of medication.  For urine routine and culture ask patient to give preferably morning mid-stream urine in the respective containers.  For sputum routine and culture ask patient to give preferably first morning sputum sample.  For semen test patient is advised to have an abstinence of 3 days from intercourse and sample has to be collected in a clean sterile container without contamination of urine sample, note down the time of semen collection & sample has to be sent to laboratory within 30 mins.  For 24 hours urine test ask the patient to collect container containing preservative from pathology department. Ask the patient to empty the bladder by voiding urine sample just before the start of collection and collect urine sample thereafter from 00 a.m. to next day 00a.m (24hours).  For 24 hours urinary VMA test, ask the patient not to take milk products for 2 days prior to the test. For outside collected samples check the sample first for patients name written on the container or vacutainer, check for the presence of clot in EDTA citrate or heparinized vacutainers. If the sample is hemolysed or Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 270 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL in sufficient for testing ask for repeat collection of the sample in the appropriate vacutainers.  Patient variables such as age, gender, diet, smoking and alcohol intake, exercise, medications, physical and emotional stress and whether the patient is supine, sitting or standing at the time of phlebotomy.  Prolonged placement of the tourniquet can lead to changes in the of coagulation proteins in the plasma as well as platelets activation, resulting in erroneous coagulation results.  Traumatic phlebotomy can result in an artificially short PT or PTT. SPECIMEN STORAGE AND DISCARD POLICY POLICY  Reproducibility of the results is ensured. PURPOSE  To maintain test parameters in unchanged condition PROCEDURE Storage  Hematology, Biochemistry, Serology, immunology stored in refrigerator in the rack labeled with date at 2-80C for 48 hours.  Clinical pathology samples (Urine/Stool/Fluid/Semen) stored for 12 hours,  Microbiology samples stored up to final reporting.  Histopathology samples are stored in formalin at room temperature for one month. DISPOSAL OF SPECIMEN  All specimens are discarded as per the biomedical waste management policy of the hospital. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 271 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Urine & stool samples are discarded every day.  All blood samples are discarded after two days.  All isolates & used media are decontaminated by autoclaving & then discarded into yellow bin. Disposal Method  Specimen Bulb  Autoclave at 15 lbs for 30minutes and discarded.  Glass slide and Glass tubes  After examining slides (wet mount slides and stained slides) immerse in 1 % sodium hypochlorite solution and then wash as per Washing SOPs.  Glass tubes are also immersed in 1% hypochlorite solution and washed as per Washing SOPs.  Syringes and needles  After blood collection, the needle is discarded in the discarding instrument and then the blood is emptied inside the vacutainer. Discard the remaining syringe in 1%sodium hypochlorite solution and then drain the hypochlorite solution in sewage and discard the syringes in yellow bag.  Urine and other liquid specimen  After Autoclaving at 15lbs for 30minutes, content is drained in sewage and containers are discarded in yellow bag Histopathology samples are discarded in yellow bag.  Processed culture Plate and Solid media Tubes  Autoclaved at 15lbs for 30 minutes and then media is discarded in sewage and plates and glass tubes are washed with soap and water solution.  Specimen Container in Microbiology laboratory  Autoclaved at 15lbs for 30 minutes and then discarded in yellow bag.  All soiled cotton - All soiled cotton is discarded in yellow bag. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 272 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Hand gloves are also immersed in 1% sodium hypochlorite solution and discarded in Red Bag. Contact period is 30 minutes,  Micropipette tips are also immersed in 1 % sodium hypochlorite solution immediately. And after 30 minutes washed with soap solution. Dry in hot air oven if the tips are to be reused or after treating with 1% sodium hypochlorite solution (contact period – 30 minutes) discard in yellow bag.  Masks are discarded directly in yellow bag.  Expired reagents, Reagent Kits, staining kits, antibiotic discs, serological sera’s are discarded as per product discard protocol written on same. If disposal protocol is s not available, then discard this in yellow bag. RESPONSIBILITY  Technician. POLICY  Lab has defined turnaround time (TAT) for all the tests. Lab follows the TATs and report actual data to hospital.  The Hospital laboratory shall define the turnaround time for all tests. The organization should ensure the availability of adequate staff, materials and equipment to make the laboratory results available within the defined time frame. PURPOSE  The turnaround time could different for different tests and could be decided based on the nature of the test, the criticality of test and urgency of test result.  Turnaround time: - TAT stands for turnaround time & it can be defined as a period of time which is required for completing events. In case of laboratory it is expressed as turnaround time which is taken for the event of laboratory tests. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 273 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  As crucial decision based on diagnosis depends on outcomes of these tests for which period of time of reporting can be classified as Urgent & routine. Urgent tests are defined as follows:-  URGENT: -Urgent cases pertain to such patients who have to undergo immediate laboratory investigation in case the treating doctor suspects any form of medical emergency which can be confirmed by the laboratory investigation TURNAROUND TIME FOR LABORATORY TESTS DEPARTMENT WISE TURN OUT TIME Sr.no Name of Department Approximate TAT of the test 1 Haematology 6 Hours 2 Biochemistry 6 Hours 3 Serology 6 Hours 4 Cytology 6 Hours 5 Coagulation 6 Hours MICROBIOLOGY DEPARTMENT Approximate TAT of the test Sr.no Name of Department 48 hrs 1 Culture and Sensitivity (Pus, Urine, MRSA screening, Body fluid, Tissue, sputum, stool etc.) except Blood culture and sensitivity Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 274 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL Gram Staining, AFB Staining, India 24 hrs 2 Ink preparation, Hanging Drop, 24hrs KOH mount 48hrs 3 Settle Plate reporting 48hrs 8-10 days 4 Biological Indicator 5 Environmental aerobic Swab 6 Anaerobic swab TAT FOR URGENT TEST Sr.no Name of Department Approximate TAT of the test 1 CPK (CK – NAC) 30 min 2 CPK – MB 30 min 3 30 min 4 CSF Routine 30 min 5 Electrolyte 30 min 6 30 min 7 Trop I 30 min 8 Trop T 30 min 9 Interleukin 6 30 min NT-pro bnp Pro calcitonin Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 275 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 32. RECALL / AMMENDMENT OF REPORTS POLICY  The hospital has defined mechanism for recall and/ amendment of reports to all areas in the hospital where investigations are reported. PURPOSE  To provide correct report to patient for treatment of patient. SCOPE  All OPD and IPD patients PROCEDURE  If there is some error identified, recall of the reports is required. The recall shall be intimated to the medical administration department & will be recorded in the Report recall register.  This protocol is applicable to all are as in the hospital where investigations are reported o Laboratory services o Radiology services o ECHO, TMT services o Endoscopy, Bronchoscopy etc.  The consultant who has authorized the original report is responsible for adhering to the defined protocol. Report and copies of it are removed from all clinical areas, medical records, and hospital information system.  Previous report which is incorrect to be submitted in the respective diagnostic department.  All hard copies of old report in the IP/OP file, are to be stamped with the seal / stamp stating: Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 276 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL GAIMS HOSPITAL KINDLY IGNORE THIS REPORT- AMENDED REPORT HAS BEEN REALEASED Date  Date of recall/ amendment and additional interpretation if any to be mentioned in the report recall register.  When the report has been handed over to the Outpatient and the patient has left the premises, Telephonic information is to be given to the patient about the amendment made and the patient can be requested to collect the amended report.  It is the responsibility of the respective Consultants of the particular department, releasing the amended report to ensure that these all is placed in the previous report.  When report is issued to the patient, amended report is made available to the patient by hard copy or soft copy. Patient is asked to ignore previous one. Same shall be documented.  In situations where the amendments call for a change in treatment plan, the reporting consultant is responsible for orally/ written information to the referring physician about the change in report.  All amended reports are to be analyzed and corrective and preventive actions to be implemented. RESPONSIBILITY  Authorizing Consultants,  Doctors  Nurses  Technicians. REPORT Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 277 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Recall Register. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 278 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 33. ABSCOND PROCEDURE POLICY  GAIMS hospital has the mechanism to follow when patient is absconded from the hospital. PURPOSE  To outline the action to be taken by staff in the event of a patient missing/absconding from the wards/hospital departments without information. SCOPE Definition A patient is considered abscond when:  He leaves the hospital premises without informing in the ward staffs.  Fails to return at an agreed time. PROCEDURE  If the patient has been noticed absent on the bed, Staff nurse immediately informs to the, nursing in charge / SLM  Staff nurses and doctors on duty shall search the patients in the hospital premises with the help of security.  Dial on the patient’s contact number. If the patient is at home, the patient and his relatives are asking to come to the hospital within two hours to complete discharge formalities.  If the patient is not found in the hospital premises/at house within half an hour, then they should inform to the treating consultant of the patient, Medical administrator/ Head Operations and Nursing Superintendent. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 279 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  If the patient is safe and return to the ward, the ward nurse/MO assesses the patient and makes a note in patients’ medical record with date and time with the full event. Takes sign of patient.  The nurse on duty/Nurse In charge/ward, SLM shall contact to all relevant personnel that the patient is returned to the ward.  If the patient is located and refuses to return, attempt should be made to convince the patient to return.  If the patient is still refuses, the nurse In-charge will discuss the case to the treating consultant that the patient is not ready to hospitalize again.  If the patient is refusing, the relatives shall come to the hospital and complete the discharge procedure/DAMA within 2 hrs.  If the patient is not located or the relatives are not ready to come to the hospital inform the police about abscond of the patient with his details within 4hrs.  Record all events in the patient’s medical record with date and time.  Prepare a report of patient abscond and submit it to the Medical director and/or Chief Medical Superintendent within 24 hrs. RESPONSIBILITY  Medical Director  Chief Medical Superintendent  Head Operations  Medical Administrator  Nursing Superintendent  Nursing Supervisors  Service Line Managers  Security & Nurses  MO RECORD Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 280 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Progress Notes, letter to police station Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 281 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL 34. PREVENTION OF ADVERSE EVENT- WRONG PATIENT, WRONG PROCEDURE, WRONG SITE POLICY  GAIMS hospital adheres the policy to prevent adverse events like wrong site, wrong patient and wrong surgery. PURPOSE  To ensure correct site for surgery.  To reduce the surgical errors. PROCEDURE  Anaesthetist and nurses should perform Time in given in WHO surgical safety checklist.  After all the surgical team members are gathered to initiate the surgery the circulatory nurse along with the patient’s medical record will announce to acknowledge each component:  Patient identity should be confirmed using a minimum of two identifiers  Procedure to be performed confirmed  Patient site marking verified  Procedure location, including correct side to be verified.  Applicable pre-procedure medications, equipment, imaging set and confirmed  Time-out should be documented in the patient’s medical record  If patient needs to be repositioned, procedure altered, or any other factor that leads in any way to a gap in the planned procedure, a new Time-out should be performed  This should be documented using WHO surgical safety checklist before intra and after surgery Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 282 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL RESPONSIBILITY  Nurses  Surgeons  Anaesthetist  Technicians RECORDS  Incident Form 35. POLICY ON CLINICAL PROCEDURE POLICY  The Hospital has documented guidelines to perform safe clinical procedure.  Procedures are performed based on the clinical need of the patient by privileged doctor.  Informed consent is obtained before performing procedure.  Procedure will be performed under standard precaution and using safety check list.  All procedures are monitored during and after and documented in the patient’s record. PURPOSE  To perform safe clinical procedures to prevent adverse events and desired outcome. SCOPE  Patient undergoing procedures. PROCEDURE Prepared by Reviewed by Approved by Signatory Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 283 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  All the clinical procedures are done by the clinicians who are privileged to do so. Clinician takes decision on clinical need of the patient and standard treatment guidelines. When multiple procedure options exist, the decision is based on the option where best outcome is possible and considering patient’s wish and safety.  All the clinical procedures are documented in the clinical manuals in a defined format where broad guidelines are written. Clinical procedures like Central Line insertion, Intercostal Drainage, Tracheostomy, Pleural / Ascitic tapping, dialysis etc.  It mentions who can do the procedure, pre-procedure instructions, conduct of the procedure, and post procedure instruction and care.  Before performing procedure brief assessment is done.  While performing procedure to avoid any adverse event safety CHECKLIST is followed. Checklist is based on the WHO safe surgery check list.  Check list includes checking of minimum two patient’s identifiers before performing procedure – CR No. and Patient name.  Checklist mitigates risk of wrong site and side. Thus checklist helps to ensure correct patient, procedure and site.  Before performing procedures; procedure is explained to the patient/ relatives and appropriate informed consent is obtained by performing doctor for performing procedure.  Clinical team involved follows standard asepsis precautions while performing procedure.  Reuse of the material is followed as per reuse policy defined by HIC department of the hospital and appropriate record is kept. All the staff is trained on the standard aseptic precautions.  During and after procedures clinical parameters are monitored and documented in the medical record by privileged staff.  Post procedure details are documented in the clinical records & signed, date, time, named. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 284 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Clinical audits are performed to check the compliance. RESPONSIBILITY  Procedure performing consultant  Nurse RECORDS  Procedure safety Check-list  Consent 36. POLICY ON SEDATION POLICY  GAIMS hospital has a policy to guide consistent administration of procedural moderate sedation. Before administration informed written consent has to be obtained.  Sedation is administered by competent and trained person.  The person monitoring is different from the person performing the procedure  Intra & post procedure monitoring for sedation is done & documented.  Hospital has a criteria for discharge from observation or recovery area. (COP 12 g)  The facility where moderate sedation is provided has resuscitation equipment’s and trained manpower to manage the patient in the deeper level of sedation. PURPOSE Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 285 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  To provide safe and consistent care of patients requiring moderate sedation for various Procedures. SCOPE  ICU, OT, Radiology PROCEDURE  The hospital has identified procedures where moderate sedation is required. Procedures like : o Endoscopy o Bronchoscopy o Tracheostomy o Certain MRI  The patient shall be assessed by the clinician in charge. Need of sedation is assessed. Orders are written.  Patient Selection - Candidates for conscious sedation are those patients who have to undergo painful or difficult procedures where cooperation and/or comfort will be difficult or impossible without pharmacologic support  Anaesthesiologist or Clinician or trained post graduate residents can administer the sedation.  Patients are screened for potential risk factors by the Anaesthesiologist or Clinician. Patients present complaints, history of medication, surgery, investigations, history of allergy are assessed and noted down.  The ultimate decision for patient selection shall be of the Anaesthesiologist under consultation with the Clinician In charge.  The decision about which agent to use shall be based on the goals of sedation, type of procedure, the condition; risk associated and age of the patient. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 286 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  The patient and relatives shall be informed about the risks, benefits and alternatives if any for the type of sedation and consent is obtained. Intra -procedure (drug administration) Monitoring- following parameters are mapped and documented.  Vital signs, including RR, HR and blood pressure  Rhythm – can monitor on monitor.  Oxygen saturation  The staff nurse shall verify whether all the documentation pertaining to sedation administration is complete.  All aseptic precautions shall be taken for administration of sedation. Post procedural Monitoring -Frequent monitoring (preferably every 10 min) shall be carried out after administering sedatives to the patient. Monitoring shall include the following- o Blood Pressure is recorded. o Heart Rate is recorded continuously o Respiratory rate & rhythm is recorded. o Oxygen Saturation is recorded. o Level of Consciousness (sedation scale) is recorded every 10 minutes o ECG is monitored in patients on monitor.  The monitoring done shall be recorded in the moderate sedation monitoring form.  Person monitoring is trained for monitoring post sedation parameters. Should be able to monitor apnoea and airway obstruction or any other adverse event. Any deviation should be informed immediately to anaesthesiologist.  Hospital has defined criteria for discharge from recovery or observation based on ALDERATE score mentioned in miller’s aesthesia. Clinician or anaesthetist has privilege to apply it. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 287 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Alderete score 9 or 10 out of 10 is considered adequate for discharge from observation.  All the facilities where moderate sedation is provided that is ICU, OT complex, MRI complex has resuscitation equipment’.  All the facilities trained manpower is made available. RESPONSIBILITY  Anaesthesiologist /Clinician/Nursing staff/SLM RECORDS  sedation form 37. PREVENTION OF PATIENT FALL POLICY  Hospital identifies and manages all patients who are at the risk of fall. PURPOSE  To reduce risk of mortality and morbidity. SCOPE  All patients PROCEDURE: Risk identification and assessment- of fall Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 288 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  All patients are screened for the risk of fall in nursing assessment.  Risk of fall is identified by nurses and assessed by the tool using Morse fall scale.  For all high risk and moderate risk patients universal fall precautions are followed and documented in the care plan. Management  Patient who are at risk as per the scale are managed as per the universal fall precaution guideline.  Following strategies are made to prevent patients fall and all staffs are made aware of the same: 1. EDUCATION  Staff training to increase awareness of high risk patients and prevention strategies.  All the healthcare workers should be trained and evaluated for this programme.  Educating the patients and family about the risk of falling, safety issues and their mobility limitations. The same should be documented in patient’s record. Educate the patient relatives for need of assistance (toileting and ambulation)  Teaching patients to make position changes slowly. Familiarize the patient with the environment. Have the patient demonstrate call bell use. 2. ENVIRONMENTAL ISSUE  Decreasing obstacles and clutters.  Night light at bedside and toilets.  Having grab bars near toilets.  All repairs to be attended without delay E.g. slippery floor.  Have sturdy handrails in patient bathrooms, room, and hallway. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 289 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  MEDICATIONS-Risks related to medications include- o Receiving prescribed medications along with doctor’s advice. o Checking patients receiving, laxatives, diuretics, antihypertensive, etc. o Limitations combinations of medications when possible  MOBILITY - Prevention of risk related to mobility o Use of Non-skid footwear. o Providing physiotherapy. o Instructing patients to rise slowly whenever required.  MENTAL STATE-Altered mental status is one of the common identified risk factor for falling and the interventions include – o Reorienting confused patients. o Orientation patients to the hospital environment. o Placement of bed near nurse’s station. o One attendant should accompany patient. o BED REST  When patient is in bed following care can be taken- o Ensure the patient is in low position. o Ensure bed brakes are on. o Ensure bed side rails are In UP position. o Ensure patients required items are within reach of patient.  WHEEL CHAIRS AND CHAIRS o Use safety straps or seat belts in chairs. o Ensure support to prevent slipping from chairs. o Side rails are always UP. RESPONSIBILITY  Clinician In charge  MO Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 290 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Staff Nurse,  SLM  Housekeeping,  All health care givers. RECORDS  Nursing assessment form 38. PREVENTON OF PRESSURE ULCER POLICY  GAIMS has established the procedure for identifying the patients who are potential for pressure ulcer development and prevents them by implementing prevention protocol in a timely manner. PURPOSE  To prevent Pressure ulcer SCOPE  IPD Patients PROCEDURE  All the patients are assessed as per Braden scale for the risk of developing Pressure ulcer at the time of admission and reassessment is done during every shift change and documented it in the Nursing assessment and nurse’s handover checklist. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 291 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Assess the patient’s condition at the time of admission for the following criteria: o Sensory perception o Moisture o Activity o Mobility o Nutrition o Friction/shear.  The Braden scale score is calculated as follows: o Low risk : 15 or 16 o Moderate risk: 13 – 14 o High risk : 12 or less  If the score is less than 17 then we have to initiate the skin care.  Assess skin and identify severity of ulcer development.  Inspect the skin of all bed ridden patients and clean; apply spirit, powder and moisturizer on it.  Turn bedridden patients every 2 hourly.  Change of position to be maintained in position chart and back care is documented in nurse’s notes.  Massage the area gently to increase circulation over bony prominences using following techniques  Effleurage  Effleurage is a massage technique that aims to warm up the tissues, improve blood flow, stimulate the peripheral nerves, relax the muscles, and palpate the tissues. Effleurage is always performed at the start of massage to introduce touch to the patient. Effleurage involves a wide range of stroking movements, usually done using the fingers and the whole palm of the hand. The pressure applied should depend on the purpose of the massage.  Petri sage-  Petri sage is used to mobilise fluids, stretch muscle fibres, and encourage muscle relaxation. Basic movements involve compressing, picking up, then releasing the Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 292 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL soft tissues. Alternate movements between compressing and releasing of the tissues help stimulate the circulation, relieving the pain any muscular disorders may cause. Generally, this massage technique is used if the patient wants a deeper effect than effleurage.  Friction Rub  Friction is a massage technique used for exploratory purposes. It may be used to separate muscle fibres or to break down recent scar tissue. It may also be used to break down any knots or adhesions that build up in the body of the muscle. When frictions are performed for exploratory purposes, staff must use the sensory pad of his thumb to palpate any trigger points in the tissue. This allows discovering abnormalities in the tissues. Frictions must be done very carefully and not for a long time as it may irritate the tissue and cause inflammation.  Tapotment/ Vibration- It boost circulation and increases the power of muscles. Moving your hand back and forth on the client’s body without leaving contact.  Provide good skin care by keeping the skin clean and dry.  On admission if the patient has bed sore or skin pill, enter it in nurse’s notes and specific remark in nursing assessment form with nature of wound.  Initiate the pressure reducing equipment such as air mattresses.  Nursing In charges to ensure that bedridden patients are repositioned at proper intervals.  Nurses to ensure that no patient develops a Pressure ulcer unless the patient’s medical condition shows that the pressure ulcers were unavoidable.  For e.g. those patients whom we cannot mobilize due to his predisposing factors. (Spine/ Fractures surgery, etc.) If the patient gets admitted with pressure ulcer or developed pressure ulcer in the hospital:  If the patient gets admitted with Pressure ulcer, nurses have to assess the stage Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 293 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL and site of pressure ulcer and it should be documented in the nurse’s notes and nursing assessment form.  At the same it should be informed to the patient’s relatives and documented in counselling form. Stages of Pressure Ulcer: As per National Pressure Ulcer Advisory Panel (NPUAP) Stage 1 Pressure Injury: Non-blanchable erythema of intact skin (Alteration in intact skin)  In this stage of pressure ulcer we see alteration in intact skin. The ulcer appears as a defined area of persistent redness in lightly pigmented skin Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis  Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Stage 3 Pressure Injury: Full-thickness skin loss  Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epiboly (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Stage 4 Pressure Injury: Full-thickness skin and tissue loss  Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. o Once the stage of pressure ulcer is identified, nurses will take the following steps: o Maintain aseptic precaution while doing dressing for a pressure ulcer. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 294 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL o Ultraviolet rays to be initiated to reduce the degree of bed sore. o Position change and Back care to be initiated for further worsening. o Oxygen therapy. o Air bed installation to relieve pressure. o High protein diet RESPONSIBILITY  MO  Nursing Staff RECORDS  Nursing Assessment form  Nurses handover 39. DVT PROPHYLAXIS POLICY  GAIMS hospital establishes a procedure to prevent development of deep vein thrombosis. What is DVT?  Deep vein thrombosis occurs when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the legs.  Deep vein thrombosis can cause leg pain or swelling, but may occur without any symptoms. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 295 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Deep vein thrombosis is a serious condition because blood clots in the veins can break loose, travel through the bloodstream, and obstruct the lungs, blocking blood flow. PURPOSE  To prevent the patients from developing deep vein thrombosis. PROCEDURE  Following are the patients are more prone to develop DVT: o Elderly (older than 70) o Immobile patients o History of DVT/PE o Critical ill patients admitted to intensive care unit (ICU) o Stroke with lower extremity paralysis o Advanced congestive heart failure (CHF) o Acute respiratory failure o Thrombophilia o Recent surgery or trauma o Obesity o Ongoing hormonal therapy  Based on thrombosis risk, patients are classified into low risk, moderate risk, and high risk for DVT. o Low-risk patients: Young patients with no risk factors for VTE. No need for prophylaxis o Moderate-risk patients: With at least 1 risk factor, pharmacological prophylaxis is preferred with or without mechanical prophylaxis o High-risk patients: With multiple risk factors, pharmacological prophylaxis is preferred with mechanical prophylaxis Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 296 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Assessment of a patient for the risk of deep vein thrombosis by MO is done on DVT Risk assessment form on the basis of following score : o Well Score for DVT o Padua Prediction score o Wells score for PE  If a patient present with signs and symptoms of DVT, an assessment of general medical history and a physical examination. Following pharmacological or mechanical agents are used to prevent DVT Pharmacological Agents  Low-molecular-weight heparin 5000 units subcutaneously once daily  Unfractionated heparin: 5000 units subcutaneously every 8 to 12 hours  Warfarin Mechanical Agents  Graduated compression stockings (GCS) If any of the above patients are observed,  Provide comfort. Elevation of the affected extremity, graduated compression stockings, warm application, and ambulation are adjuncts to the therapy that can remove or reduce discomfort.  Compression therapy. Graduated compression stockings reduce the calibre of the superficial veins in the leg and increase flow in the deep veins.  External compression devices and wraps are short stretch elastic wraps that are applied from the toes to the knees in a 50% spiral overlap;  Intermittent pneumatic compression devices increase blood velocity beyond that produced by the stockings. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 297 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Positioning and exercise: When patient is on bed rest, the feet and lower legs should be elevated periodically above the level of the heart and active and passive leg exercises should be performed to increase venous flow. RESPONSIBILITY  Consultant, MO, Nursing Staff RECORD  DVT Risk Assessment form  Care Bundle Checklist 40. RESTRAIN OF PATIENTS POLICY  It is the policy of GAIMS Hospital that during patient cares, restraints (Physical and Chemical) are to be used only in clinically appropriate and adequately justified situations.  Decision to initiate restraint, stating conditions/ circumstances in which restraints require initiation, shall be clearly documented by the consultant and or resident medical officer.  Healthcare workers associated shall be trained and retrained where necessary in control and restraint techniques and monitoring. PURPOSE  To give guidelines for care of patients under restraints SCOPE  OPD and IPD patients Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 298 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL PROCEDURE  Restraint is any method (chemical or physical) of restricting an individual's freedom of movement, physical activity, or normal access to the body. Following are the situations where need of restrain arises-  To prevent interference/obstruction with medical treatments (such as self- extubation and intubations).  To protect medical devices (such as intravenous lines, indwelling urinary catheters, and feeding tubes).  To prevent falls and injury of any kind.  To control disruptive behaviour (such as agitation, wandering, and combativeness)  To preclude the possibility of harming self, staff and other patients. Chemical restraints  Chemical restraint shall mean the use of drugs or chemicals for the purpose of controlling acute or episodic aggressive behaviour by the patient.  Drugs administered on a regular basis, as a part of the treatment plan and for the purpose of treating the symptoms of mental, emotional or behavioural disorders are not to be considered chemical restraints. Physical restraint  Physical restraints are protective devices employed to prevent a patient from harming himself or other, to immobilize a part to restrict activity and to promote a feeling of security in a patient who needs control. Physical restraints include bandages; cuffs etc.  Type of physical restraints: The common types of restraints are made up of linen, canvas, leather and plastic. Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 299 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  Anklets and wristlets- these shall be used to restrict the activity of limbs in patient who is potentially harmful to himself or other to prevent the patient from removing any appliances used in the treatment and to immobilize one or more limbs during a procedure. e.g. suturing a wound.  Elbow and knee restraints- The purpose of elbow and knee restraints is to prevent flexion of the elbow and knee joint. This done by applying splints around the elbow or knee joint.  Mummy restraints- These restraints are used to restrict movements of the limbs in a small child during a procedure. This can be done by wrapping the body with a towel.  Chest binders- These shall be used for both children and adults. The jackets or binder are usually put on with straps behind or bed sheets, which are then tied to the bed frame under the mattress, thus preventing the patient from sitting on the bed. Chest restrains are also used for a patient who is sitting on a chair or wheel chair to maintain his position and to prevent him from falling.  Side rails-These shall be attached to both sides of the bed to prevent the patient from getting out or falling out of bed Order for Restrain  Restraints shall be applied with only a Clinician In charge’s order that defines the reason for restraint, type of restraint to be used, and duration for which the restraint may be applied.  This time limit shall not exceed one calendar day, after which new orders are required, if restraints must be continued.  In emergency situations, (i.e., self-extubation), if the Clinician In charge is not available to issue the restraint order, mechanical restraint is initiated by a registered nurse/clinical assistant based on an appropriate assessment of the patient Signatory Prepared by Reviewed by Approved by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 300 of 331 GAIMS/SFT/MANUAL/01/REV 00 Issue No:01 Issue date: 10/03/2022 Reference : NABH 5th Edition Revision No: 00 Revision date: 10/03/2023 Effective date:10/03/2022 SAFETY MANUAL  In such a case, the Clinician In charge is notified within 12 hours of the initiation of restraint and a written order is obtained from that Clinician In charge or team in his next visit to the patient.  Verbal restraint orders shall be counter-signed by the Clinician In charge or team within 24 hours of the initiation of restraint.  Restraint is applied only by staffs that have appropriate training and knowledge of using restrain. Ongoing Care and Monitoring:  Patient is monitored one hourly to determine the following: o Position, circulation, and skin integrity of restrained area o Maintenance of privacy and comfortable body and room temperature. o Appropriate application of the device(s). o Toileting and fluid needs. o Nutrition o Range of motion o Restraint reduction or removal  Patients are positioned for safety and comfort Patients are ensured for active or passive range of motion to the affected joint(s) as medically necessary.  The patient and/or family, whenever possible, is educated regarding: o Reason for restraint o Care of restrained patients o Criteria necessary for release from restraint. REASSESSMENT OF USE  The Clinician, in collaboration with the health care team, evaluates the patient at the end of the prescribed duration of restraint to determine the need for continuation of restraint.  If restraint remains necessary, the order shall be renewed. In the absence of order renewal, restraints shall be removed by the responsible nursing staff. Signatory Prepared by Reviewed by Approved by Name Designation Signature