GAIMS Safety Manual 12.05.22

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 51 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 39. Declining of indwelling catheters Monthly 40. Re intubation Monthly PROMS Annually 41. Joint Replacement Quarterly Quarterly MOCK DRILLS Quarterly 42. Fire emergency( Code red) Quarterly 43. Child Abduction (Code Pink) Quarterly 44. Spillage of blood or blood fluids Quarterly 45. CPR (Code Blue) Quarterly 46. Violent/Aggressive patients(Code Violet) 47. Disaster Management (Code Yellow) 48. Bomb Threat (Code Black) Sr. Content Frequency Tool to Responsibility No. Monitor Safety Rounds Rounds Safety Facility inspection round in Rounds 1 patient care and non- Monthly patient care area 2 HIRA (identify the potential Monthly risk in the organization Monitoring 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 52 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 Patient safety devices and Quarterly PM Maintenance infrastructure PM PM & Facility PM 2 Biomedical equipment Quarterly PM Bio Medical Preventive maintenance. PM Engineering PM 3 Quality Assurance of Two years PM Maintenance Radiation Equipment PM PM Maintenance 4 Utility and engineering Quarterly equipment pm pm Maintenance Maintenance 5 Electrical systems Quarterly Audits Audits Biomedical 6 Water System Quarterly engineer NA 7 Calibration of equipment Yearly Incident Operations report 8 Preventive maintenance for Quarterly Maintenance furniture Audit Audit Bio Medical 10 PM for fire related Quarterly Audits Engineering equipment’s safety officer PM for piped Medical Maintenance 11 gases , Vacuum and Quarterly & facility Maintenance compressed air & facility Audits Maintenance 1 Operational security plan Monthly & facility Maintenance 2 Water management plan Monthly & facility 3 Water tank cleaning Quarterly Maintenance 4 Contaminated water monthly & facility reporting audit Maintenance 5 Electrical safety audit Monthly & facility 6 Annual PWD inspection by Yearly authority ( Lift) 7 Hazardous material safety Monthly 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 53 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 8 Medical gas safety Monthly Audits Bio Medical Engineering 9 Monthly oxygen audit for Quarterly Audits Maintenance wastage – leakages. & facility 10 Fire audits 6 Monthly Audits Maintenance & facility Internal and external sign 11 posting for patient, families Quarterly Audits Safety team and community. Meetings Condemnation committee - 1 material not in use and Quarterly Meeting Team disposal. Surveillance 1 OT & All critical area and Air Six Surveillance Safety team conditioning equipment monthly Validation 2 Compressed air purity at Yearly Surveillance Maintenance outlet terminals & facility 3 STP water monitoring & Quarterly Surveillance Maintenance analysis & facility 4 Ambient air monitoring and Quarterly Surveillance Maintenance analysis. & facility 5 BMW -annual report yearly - Surveillance Biomedical 31st Jan engineer 6 Water quality and Monthly Surveillance HIC & portability Testing Maintenance Indicators 1 Critical equipment Monthly Indicator Biomedical downtime mapping engineer 2 Consumption of Water and Monthly Indicator Maintenance Electricity mapping & facility Mock drills 1 Spillage management Quarterly Mock drill HSK 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 54 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 2. HAZARD IDENTIFICATION AND RISK ANALYSIS DEFINITIONS Risk - the likelihood of personal injury, adverse health effects or degradation of the environment. Risk Abatement- minimizing risk or minimizing the impact of that risk. Risk assessment- the determination of the quantitative or qualitative value of risk related to a concrete situation and a recognized threat (also called hazard).Risk assessment is a step in the risk management procedure. Risk management – is the clinical and administrative activities to identify, evaluate and reduce risk of injury. Risk mitigation- a strategy to prepare for and lessen the effects of threats and disasters. Risk mitigation takes steps to reduce the negative effects of threats and disasters. Risk reduction -the conceptual framework of elements considered with the possibilities to minimize vulnerabilities and disaster risks throughout the society to avoid (prevention) or to limit (mitigation and preparedness) the adverse impacts of hazards, within broad context of sustainable development. It is the decrease in the risk of a healthcare facility, given activity and treatment process with respect to patient, staff, visitors and community. Hazard - the potential for personal injury or adverse health effects, or degradation to the Environment. POLICY 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 55 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  Management ensures patient-safety aspects and proactive risk management across the organization through Risk management plan- Identifying risks, assessing risks and managing risks. Monitor and review risk management plan yearly for continued effectiveness and results will be communicated to relevant stakeholders with the help of a Matrix. (HIRA)  Management provides resources for proactive risk assessment and risk reduction activities. Keep sufficient resources as contingency which are used to take preventive actions whenever feasible.  Management ensures integration between quality improvement, risk management and strategic planning within the organization. The management ensures that strategic planning & Quality Improvement incorporates risk management aspect in its strategic plan. PURPOSE  To provide a method for identification of hazards and control of risks and eliminated or minimized. SCOPE:  Entire Hospital PROCEDURE  Risk Management Process: STEP 1 - Hazard identification o Clinical Risk o Non-clinical risk. (Strategic, financial, operational and hazard.) The hospital safety team along with the department head or their delegated staff in the particular area shall identify all hazards associated with their work area using the most relevant method from the following list: 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 56 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 A visual inspection, o Auditing, Testing, o Technical or scientific evaluation, o An analysis of injury or near miss data, o Discussions with the end users, employees, manufactures, suppliers, or other relevant people.  Such hazards identified have to be plotted in the risk assessment matrix (HIRA matrix) as given below. STEP 2 - Risk Assessment  The risks arising from the hazards are to be assessed and rated by using the HIRA matrix. Records and other data collected during the hazard identification process shall assist with this process.  Risk can be classified as : 1. Physical Risk 2. Chemical risk 3. Biological risk 4. Fire hazard 5. Ergonomic 6. Radiation Pre-Requisites for Risk Assessment:  Risk assessment has to be done under the following circumstances or during the facility rounds taken by the Hospital Safety team.  When information is obtained about previously unknown design or manufacturing fault, or about previously unidentified hazard.  The design is revised or modified.  There is a change to a risk control measure after a review of its effectiveness. HIRA MATRIX 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 57 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  Evaluation of risk can be done through consequence of likelihood and occurrence.  Likelihood of occurrence- the chance of the hazard or event actually occurring during the day to day operations.  Consequence/Impact - Analyze potential severity of impact or consequence- the extent of the harm (injury or ill health) Impact Likelihood Rating Major Very likely 4 Moderate 3 Minor Likely 2 Negligible Unlikely 1 Never  Risk Rating - Once the likelihood and the impact of each hazardous event or situation has been decided, the risk is to be rated using the following table. Very likely Could happen frequently 4 Likely Could happen occasionally 3  Those as Unlikely Could happen, but only rarely 2 highly unlikely Never Never happened 1 with negligible injuries are the least serious (low risk) and when developing risk control strategies, HIGH ratings shall receive first priority. STEP 3 - Control and Manage risks  Priorities risks.  Take actions to alleviate these risks.  Develop contingency plans.  Educate and train staff. 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 58 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  Where a risk to health and safety has been identified, controls must be introduced to eliminate the risk, minimize it or to provide with appropriate back up controls to ensure safe work practices.  The control can be proactive or Administrative reactive controls. 1. Proactive controls: Health plans, monitoring, display, PPE, Engineering control are the proactive controls. 2. Reactive /Administrative controls: are Legal requirement, emergency conditions, MSDS, Human behavior – training, policy, protocol and PPE STEP 4 - Review  Review the hazards and control measures to ensure that no new hazards have been introduced and that the process is working effectively to identify the risks and control the hazards.  Criteria for significance is Legal concern, Risk index >= 3  Any adverse event identified throughout the hospital, existing control of the risk is considered and additional controls are established to eliminate the risk. And, the register should be updated on timely manner.  Review will be done by respective HOD, surveillance by Safety and Quality team on monthly basis to identify the existing controls are in appropriate.  Monitor and review risk management plan annually for continued effectiveness.  Communicate review results to relevant stakeholders with the help of a matrix.  At a minimum, analyze one patient safety related risk (To be done every year for appropriate improvements.  The topic for patient safety related risk assessment audit is finalized in the MRM meeting. The intent of the analysis is to eliminate unsafe actions and conditions that can cause harmful incidents. RESPONSIBILTIY:  All departmental staff RECORD:  Risk 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 59 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 3. PLAN FOR FIRE & NON FIRE EMERGENCIES AND EMERGENCY CODES POLICY:  Hospital has plans & provisions for early detection, abetment & containment of fire and non-fire related emergencies. To tackle with such emergencies different color codes has been defined in the organization as safety codes. One emergency number has been established to notify such emergencies. PURPOSE  To alert staff in case of emergency SCOPE  All Departments Sr. No Type of emergency Emergency Decided codes dial number 1 Fire emergency Code Red 444 Code Black 2 Bomb Threat/ Terrorist Attack 444 Code Blue 444 3 Collapse of person required CPR Code Yellow 444 4 Disaster Management (Internal & Code Pink External). 444 Code Violet 444 5 Infant/ Child abduction 6 Violent/ Aggressive Behavior 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 60 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 the event of an emergency and when there is a need to make a public announcement or raise an immediate alert, the staff will dial Extension number 444 and inform nature of the emergency and to announce the emergency codes.  Information Flow – For Individual Codes 1. Code Red – Fire Emergency:  Individual discovers Fire Dials Emergency contact Number “444 says Code Red and location.  All concerned HOD’s will be intimated (Medical Administrator, Head-Operations, Nursing Superintendent, Head Human Resource, Chief Medical Superintendent, Medical Director)  Shifting/evacuation of patients out of hospital as per situation and requirement The message for evacuation will be announced in the Public Address system After assessment, if required External Fire brigade will be informed. All emergency numbers are made available in front office dept. 2. Code Blue (Cardiac arrest – Cardio Pulmonary Resuscitation):  Voiced by own staff on noticing any patient non responsive.  Dials 444 and informs CODE BLUE and the location Patient made to lie flat on bed  BLS to be performed by the attending nurse immediately Code blue team arrives and takes over resuscitation as per the Hospital Code Blue Protocol. 3. Code Pink (Child Abduction):  Staff nurse on notice - informs respective in charge Shift in charge informs Security, dial number 444 says CODE PINK and location. Information from the Security to Medical Administrator, Head-Operations, Nursing Superintendent  Security along with Housekeeping and engineering staff to close all the gates including emergency exits. 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 61 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  Checking and screening is done, Patient areas to be checked by Security along with the help of nursing. In case of no trace within 1 hour, police need to be informed accordingly as per the Instructions from the Management. 4. Code Yellow:  Information Received at Emergency from various outside sources. After receiving information SLM / Manager on duty / whosoever receives the information will inform Security in charge & Medical Director / Chief Medical Superintendent. After which the Medical Director / Chief Medical Superintendent gives “Go” Signal for activating disaster plan and the person informs by dialing number 444 announces CODE YELLOW and all the departmental Heads are informed. All the doctors and staff to report to the Emergency immediately  Preliminary examination and sorting of patients will be done as per the triage protocol and attending of patients will be according to their categorization.  Additional responsibilities to be managed and supervised by various Departmental Heads Once the situation stabilizes the Medical Director / Chief Medical Superintendent gives ALL CLEAR signal. 5. Code Black: (Bomb Threat):  Information on Bomb threat received by any employee in the Hospital. Recipient of the call try to collect as much information as possible regarding the alert. Front office executive receives a call and informs HOD, Medical Director / Chief Medical Superintendent and Head Operations and gives instructions to the team on further course of action.  Departmental heads / In charges will be briefed to check their concerned areas Security in charge to update the CMS on the situation External team / brigade will be informed as per the requirement and after getting necessary permission from the CMS.  Note: Staff member shall be briefed not to make any communication about the bomb threat to any Patient/Visitor, at any stage. All Queries in this regard would be referred to CMS / MD 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 62 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 6. Code violet:  Code Violet is the hospital’s response to violent and/or aggressive persons /mobs when they pose a threat to self and/or others. Harm can come from patients, parents, families and even employees.  Whenever such behavior is found with uncontrolled nature code violet will be announce.  The Code Violet should be announced only after assessing the intensity of the situation. If it is a minor incident/fight, then it should be handled within the department itself by those encountering it, without announcing the code violet  First responders can then contact front office on 444 and inform to announce code violet along with the location. 4. CPR AND CODE BLUE POLICY  Standard guidelines are laid for the use of cardiopulmonary resuscitation (CPR).  The guidelines are followed in every situation which indicates that a patient requires cardiopulmonary resuscitation  These guidelines are comprised in the name of “CODE BLUE”, where staff is trained for the same.  CPR is given as per the guidelines in all care settings and the events during CPR are recorded in a specially designed form, in a defined chronology, for later analysis.  Events recorded during all cardiopulmonary resuscitation are analyzed by a multidisciplinary CPR audit committee. /team  Opportunities for improvement are identified and corrective, preventive measures are taken. 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 63 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 guidelines for uniform resuscitation of patient throughout the organization SCOPE  Code Blue Team,  All Hospital Staff  Medical Administrator Cardio-Pulmonary Resuscitation  Standard protocol is laid for the use of cardiopulmonary resuscitation which is followed in each case requiring CPR so that patient care is uniform. These guidelines are comprised in the name of “CODE BLUE”.  Code Blue Teams are constituted comprising of BLS/ACLS/NALS/PALS trained Healthcare Professionals.  The protocols mention each member’s Role in the emergency. The protocol also mentions how to activate CODE BLUE, and primary steps to be taken by the first and second responders till the CODE BLUE team arrives.  The events during each case requiring cardiopulmonary resuscitation are documented in a specified format.  A multidisciplinary committee, CPR Audit team comprising of CMS, Nursing Superintendent, Anesthetist /Physician does analysis within 24 hrs. of all cases requiring cardiopulmonary resuscitation to determine whether the process was conducted according to established ACLS protocols The committee shall provide further recommendations for improvement such as educating and training of CODE BLUE team members and other hospital staff.  All Hospital staff specially related to direct patient care is periodically trained in Cardiopulmonary Resuscitation, by the means of workshops and Lectures with demonstrations.  Emergency medication and equipment for intubation are made available in all patient care areas and are accessible. 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 64 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 PROCEDURES CODE BLUE CODE BLUE Team is activated in the following situations: If patient is  Unresponsive  Not moving.  No spontaneous respiration.  Agonal gasping respiration efforts.  No central carotid pulsation.  Pulse rate>140/min and32/m and < 75%.  New onset altered sensorium.  Convulsion /seizure  Warning Acute Coronary Syndrome  Any other emergency 1. RESPONSIBILITIES OF FIRST RESPONDER  The first responder (any hospital staff, medical or non-medical, who identifies any of the above situation) will call loudly “HELP CODE BLUE + Location (e.g. CODE BLUE bed no. 11 or appropriate location e.g. CT scan or OPD etc.) and start Basic Life Support  If the first responder is alone and no one is available to activate CODE BLUE, the first responder will dial 444 himself to activate the CODE BLUE and start Basic Life Support.  Instruct the second responder or himself/herself (if second responder is not available) bring the crash cart (stationed at each nursing station) at the location of incidence and continue BLS/ACLS Protocols till the CODE BLUE TEAM arrives.  After receiving the CODE BLUE call:  Announces “CODE BLUE + Location” on Public Address System (e.g. CODE BLUE BED NO. # #, WARD ##, FLOOR ##) exact location e.g. Billing section on Ground Floor. 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 65 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 2. RESPONSIBILITIES OF THE SECOND RESPONDER  Second responder is the one who heard the call of the first responder, or the one designated by the first responder.  After dialing 444 to activate CODE BLUE TEAM, Brings the crash cart into the room (stationed at each nursing station) and places it near the victim / patient’s bed.  Remove the headboard from the bed if needed.  Take over Chest compressions to relieve the first responder.  Takes care of the patient’s family and visitors, escorting them from the room after the CODE BLUE TEAM arrives  Second responder is the one who heard the call of the first responder, or the one designated by the first responder.  After dialing 444 to activate CODE BLUE TEAM, Brings the crash cart into the room (stationed at each nursing station) and places it near the victim / patient’s bed.  Remove the headboard from the bed if needed.  Take over Chest compressions to relieve the first responder.  Takes care of the patient’s family and visitors, escorting them from the room after the CODE BLUE TEAM arrives 3. THIRD MEMBER RESPONSIBILITIES (HEALTHCARE PERSONNEL ONLY)  If patient does not have adequate IV access already, the doctor /Staff Nurse inserts a large bore cannula into a large vein (e.g. median cubital).  Sets up the IV line with normal saline solution.  As soon as the code blue is announced, the designated lift shall go at the designated floor. 4. CODE BLUE TEAM. 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 66 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  It is a team of qualified and experienced (ACLS/NALS/PALS Trained) medical personnel who are trained to deliver the optimum care to the patients requiring cardiopulmonary resuscitation.  Code blue team is assigned is as follows according to patient care area. CODE BLUE STAFF DESIGNATED ROLE Team Member Member 1 –TEAM Anesthetist To Conduct Steps Of Code Blue And Give Instructions LEADER ED Medical Officer Airway And Chest Compression & Defibrillating Management Member 2 ICU/ ED Staff Nurse Airway And Chest Compression Two Ward Staff Nurses Management Member 3 Medication Management Nurse educator Recording Of Events In CPR Form Member 4 Member 5 5. RESPONSIBILITIES OF THE CODE BLUE TEAM  To reach emergently to the place from where the CODE BLUE call has originated.  To perform BLS and ACLS as per the protocol depending on the emergency situation & record the events.  Shift the patient to ICU for further management.  Discuss with the family about the situation.  Inform the Clinician in charge of the case.  Complete the documentation like CPR form, once patient is revived or shifted to ICU. 6. WHEN CODE BLUE TEAM ARRIVES: FIRST & SECOND RESPONDER’S RESPONSIBILITIES  Expected to stay in the room to give a short history of the emergency situation and possible time at which occurred. 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 67 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  Assists the CODE BLUE TEAM in patient management  Ensures other patients are also being attended. 7. When the resuscitation is over  Ensures the Code Blue form and CPR format are filled in completely and correctly by the RESIDENT of the ward and CODE BLUE team member together. Also ensures that it is signed by CODE BLUE team leader.  Ensures the completed CPR form is attached to IPD file of the patient and entry is made in the CPR Register.  Ensure CPR form is given to the member of Medical Audit & CPR committee within 24 hours. 5. CHILD ABDUCTION & CODE PINK POLICY  GAIMS hospital has policy for child abduction & Code pink. PURPOSE  The goal of these guidelines is to prevent the abduction of infants in the hospital. This goal will be achieved by:  The entire hospital staff participating in the periodic drills and review of safety measures implemented to enhance security.  The development of a multidisciplinary plan of action implemented for all suspected or actual infant abductions occurring within the hospital premises. SCOPE  Entire 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 68 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  All staff will be required to wear proper identification at all times.  Hospital scrubs and dress codes will be kept in an access-controlled area and are not to be loaned to unauthorized personnel.  Staff will ensure that infants are always in the direct line-of-sight of parents or hospital staff.  Parents will be informed of security measures at earliest opportunity after the birth of the infant.  Nursing staff will document the patient education notes.  Only hospital staff members are allowed to transport an infant while in the hospital via wheeled bassinet, incubator or cart.  Parents or staff members are NOT allowed to carry the infant outside of the mother’s room or within the facility at any time. RESPONSIBILITY  Staff Nurse, Sister In charge, Security, Safety Officer, Medical admin, Nursing Superintendent, Head Operations, Chief Medical Superintendent, Medical Director. RECORDS  Mock Drill Report 6. DISASTER MANAGEMENT PROTOCOL & CODE YELLOW POLICY 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 69 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 hospital has established a disaster management plan which covers a system to overcome all type of community emergencies, epidemics and other type of disasters.  The plan will ensure adequacy of medical supplies, equipment material identified trained personal and transportation aids will be available at the time of event.  The plan will be tested on every six months in the form of mock drills.  The plan and provisions are for early detection, abatement, contentment for such emergencies. PURPOSE  To identify the potential emergencies and handling of such emergency.  To provide policy for response to both internal and external disaster situations that may affect hospital staff, patients, visitors and the community.  Identify responsibilities of individuals and departments in the event of a disaster situation and managing them in the hospital.  Identify standard operating procedures (SOPs) for emergency activities and responses. SCOPE  All hospital area PROCEDURE CODE YELLOW 1. Scope of the Emergency Response Plan. Approved by DISASTERS Mass Casualties arising due to the communal riot, terrorist attack, explosives or industrial accidents, Earthquake, air/train/road accidents/floods. INTERNAL DISASTERS Signatory Prepared by Reviewed by Name Designation Signature

Gujarat Adani Institute of Medical Sciences G. K. General Hospital Document Code: Page no: Page 70 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 Fire and Explosion. RED Bomb Threat BLACK Infant Abduction PINK Individual Disaster requiring CPR BLUE Internal fights/Violence VIOLET Pandemic/ endemic Code pandemic 2. A copy of the authorized emergency disaster plan is always being available in the Management office and all HOD office. CODE YELLOW 1. PROCEDURE FOR MASS ADMISSION OF PATIENTS  No. of patients up to 20-25: Code Yellow. 2. DEFINITION:  Mass admission refers to arrival of 10 or more patients within half an hour period at the Emergency department. 3. COMMAND NUCLEUS AND OFFICE a) Chief Medical Superintendent / Medical Director shall act as command nucleus and the Emergency Casualty Room near shall be converted as Command Office. The command nucleus shall be assisted by the following members. I. Command Nucleus Members II. Operation Head III. Medical administrator IV. Nursing Superintendent V. Maintenance In charge VI. Head -HR 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 71 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 VII. Safety Officer VIII. Housekeeping in charge IX. CSSD b) Duty leader supported by the I. General Surgeon II. Physician III. Anesthetist IV. Orthopedician V. Radiologist VI. Pathologist VII. Blood Bank In charge. VIII. Nursing In charges IX. Operation theatre incharge X. In charge pharmacy XI. Dietician XII. In charge MRD XIII. In charge Housekeeping c) All the team members “called for” during activation of Code YELLOW will report to this command center within 5-10 minutes and proceed to the allocated area subsequently. d) HR is authorized to call for additional Medical or Non-medical staff of the hospital, after careful analysis of the severity of the disaster and the available manpower. In case of any difficulty in this manpower management or any other issue in the patient care management area, they can seek the help of the Command Nucleus, who will be available next to the Accident and Emergency department. e) TRIAGE INCHARGE: One of the Head – Emergency / SLM available during the shift shall be nominated by the Team Leader in the triage area with triage nursing staff. 4. STANDARD OPERATING PROCEDURE: 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 72 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 alert for the impending mass admission of patients due to an external disaster or internal disaster may be intimated by local administration/ police station to the Casualty Medical Officer.  The person who receive information of mass casualty due to a Disaster/ medical emergency should initiate code yellow with Details after confirmation from Managing Director.  Front office on receiving the alert will try and establish contact with the command nucleus.  Front office will immediately call the members of the Crisis Command Nucleus Members and request them to RUSH to the hospital immediately.  The telephone number, alternate telephone number and address of the Command Nucleus, Team will be always available with the Front office.  The MO will act as the patient Care Management Team Leader and Manage the Cod Yellow proceedings.  Other Team Members Command Center and perform their duties as per the action card.  The Command Nucleus will meanwhile try to gather further information on the severity of the disaster.  All doctors available in the hospital will be called to the command center by the PA system.  No doctors / staff / paramedics / non-medical staff will leave the hospital till the further orders of Command Nucleus.  The security will secure the path to the Accident and Emergency department to ensure unobstructed access for Incoming ambulances.  Doctors and staff will take up positions in the assigned areas (triage and treatment areas) as ordered by the team leader.  Triage will be done as per the protocol.  The command Nucleus will inform the local administration when the defined capacity of the  Hospital is reached and will generally accept no further cases.  The administrators on request of the Team Leader will issue order to stop the regular OPD and evacuate if necessary.  Non-emergency theater cases may be cancelled if necessary.  Existing in-patients who are fit for discharge will be discharged on priority basis. 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 73 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 Team Leader will have the authority to formally  Inactivate the CODE YELLOW and issues “ALL CLEAR” sign.  This is done after treating all the disaster victims.  The Team Leader will analyze the events during activation,  Implementation of CODE YELLOW and submit the report to the safety committee within One week of the event. The safety Committee wills discuss the event and opportunities for Improvement and submits their recommendation to the management for further action.  HR manager will inform the staff who is off duty & will be called for help from all categories wherever required.  All on duty staff will participate in the code. All nursing In charges & one resident from each floor will reach at the triage place. One nursing staff with one housekeeping staff from each floor will also come down. On duty staff will take the directions from the Intensivist/CMO to attend the triage. 5. REGISTRATION / ADMISSION OF PATIENTS:  All cases of mass casualty brought to hospital are treated as MLC. All relevant information like patient profile, two identification marks of the patients, Location details of accident / Incident and date and time to be entered in the MLC register. Information to be given to Police by the Head – Emergency / SLM  The Front office executives on duty will do the registration of patients.  Additional manpower (Service Line Managers) may be called.  The least possible time should be taken for registration.  If the patient is unconscious/unable to respond, then the Registration form for unconscious  Patients shall be used to collect the data, complete the registration and allot the CR number. In this case patients shall be identified as PH/Unknown/CR.  The triage bands are to be applied as per the triage findings.  The personal belongings of the patient will be put in a sealed plastic bag with labels (Name and CR number) marker.  All efforts should be made to contact the relatives of the patients  For the unidentified patients Information to be given to the police by the Emergency department head. 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 74 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 6. TRIAGE : TRIAGE INCHARGE:  Head – Emergency, nurses available during the shift shall be nominated to the triage area TRIAGE PRINICIPLES:  Triage will be done as per the Triage Guidelines from NDMA-2016.  Triage is the process of sorting injured people into groups based on the severity of their condition, so that the most serious cases can be treated first. The triage in charge shall initiate patient treatment efficiently when resources are insufficient, by undertaking triage based on the philosophy that ‘the sickest is seen first’ patients shall be evaluated quickly for their vital signs complaint and other key indicators to be categorized as: 1 Emergent: IMMEDIATE (RED)  The casualty requires immediate medical attention and will not survive if not seen soon. Any compromise to the casualty's respiration, hemorrhage control, or shock control could be fatal. They require immediate surgery or other life- saving intervention, and have first priority for surgical teams or transport to advanced facilities; they \"cannot wait\" but are likely to survive with immediate treatment. The assessment resuscitation diagnostic and management of this emergent category patient will be done in 10 Minutes after this patient will be shifted to ICU for further management.  This type of casualty includes: o Major hemorrhages o Severe smoke inhalation o Asphyxiating thoracic and cervico-maxillo facial injuries o Cranial trauma with rapidly progressive shock o Compound fracture o Crush injuries o Any type of shock 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 75 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 Spinal cord injuries -  Treatment Started-First aid (cleaning of the wind pipe, stopping of hemorrhages by means of hemostatic pads and positioning the casualty in the recovery position)  Resuscitation  Oxygen administration except in areas of fuel or fuel soaked clothing  Placing the injured under shelter pending further management. 2 URGENT -DELAYED (YELLOW)  The casualty requires medical attention within 30 Minutes. Injuries are potentially life-threatening, but can wait until the immediate casualties are stabilized and evacuated.  Their condition is stable for the moment but requires watching by trained persons and frequent re-triage, will need hospital care (and would receive immediate priority care under \"normal\" circumstances).  YELLOW-These types of casualty include: o Non- asphyxiating thoracic trauma o Closed fractures of the extremities o Cranial trauma without coma or shock o Injuries to soft parts. 3 NON URGENT-MINIMAL (GREEN)  \"Walking wounded,\" the casualty requires medical attention at when all higher priority patients have been evacuated, and may not require stabilization or monitoring.  They will require a doctor's care in one hour but not immediately, may wait for a number of hours or be told to go home and come back the next day.  This type of casualty includes minor injuries only. Certain accidents will occur where passengers have either minor or no injuries because these causalities could interfere with other priorities and operations it’s important that they be 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 76 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 transported from the accident site to the designated holding area where they should be re-examined.  The first qualified, medically trained person available will immediately begin initial triage.  This person will continue triage fill more qualified personnel relieve him.  Victims will be moved from triage area to a more appropriate hold area before definitive treatment is rendered. 4 EXPECTANT (BLACK)  The casualty is brought dead to the hospital. This casualty will be kept in black zone area of in accident and emergency before handing over body to relatives or mortuary.  This includes the dead bodies brought from site to the hospital and those who have died in the hospital  These bodies are stored in the designated areas so as to avoid confusion and waste of effort  Bodies will be released to appropriate authorities after paperwork is completed.  Urgent or Non Urgent categories. The assessment includes demographic detail s along with history of the patient.  The Triage nurse assesses the patients & categorizes the patient.  The triage nurse follows the triage protocols to make a nursing assessment and determine appropriate care. LOCATION OF TRIAGE AREA AFTER ANNOUNCEMENT OF CODE YELLOW  RED ZONE- ICU AREA OF ACCIDENT &EMERGENCY DEPARTMENT  YELLOW ZONE- INSIDE THE TRAUMA UNIT  GREEN ZONE- ENTERANCE OF TRAIGE AREA  BLACK ZONE- ROOM NEXT TO THE TRAIGE ROLES AND RESPONSIBLITIES/ACTION CARDS 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 77 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 MEDICAL OFFFICER  Inform Chief Medical Superintendent / Medical Director Appraise the crisis to the Management team for decision for announce of Code Yellow.  To initiate code yellow. To decide the level based on the number of cases.  Up to 20-25 persons  Inform local police station  Nobody to leave the Hospital those who are on duty till further order.  Assign senior-most Doctor for Triage and other Doctors for each of the following area red, yellow, green, duty medical officers.  Inform and co-ordinate with the Radiologist, Orthopedic Surgeon, General Surgeon and Anesthetist, Pediatrician and Obstetrics and Gynecologist, based on the requirements. o Inform the OT staff and prepare OTs if needed. o Request the Housekeeping Supervisor to arrange extra beds if required. o Update the administrators frequently on the situation. o Submit a written report within a week to Chief Medical Superintendent / Medical Director 2 NURSING SUPERVISORS  On receiving code yellow call co-ordinate with Head – Emergency  Mobilize the required staff nurses, based on Code Yellow Level  Make arrangement for extra beds/ IV stands crash carts, dressing material in GREEN and yellow areas.  Call theater In-Charge/Staff on night duty through admission counter, if needed.  Update Emergency room about OT immediately arrange for additional help in Operating Rooms and Recovery Room, based on the requirements.  Notify Anesthetist. Check supply CSSD and Pharmacy. 3 CASUALTY /NURSING INCHARGE  Receive the patients and arrange for triage. Ensure triage bands are put on to the 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 78 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  Responsible for putting triage band for all the patients as soon as the triage is done.  Allocation of received additional nursing force to the triage areas like green, yellow and red.  Safeguarding of all personal belongings and store them in the designated bags with patient identification.  Ensure that all cases are marked for MLC  After ALL CLEAR signal is given by the team Leader-Duty doctor is responsible with the ED In charge, senior staff in ED to re-equip the emergency cupboard with the prescribed contents. 4 FRONT OFFICE EXECUTIVE  Announcement of code yellow after confirmation from Head – Emergency  Display of zoning boards to the respective areas.  On receiving code yellow call co-ordinate with Medical officer.  Call Medical administrator, Operations Head, HR-Head, Nursing Superintendent.  Assign one additional person to Front office for telephonic communication.  Instruct Front office executive to obtain information and fill out available information on admission sheet immediately.  To check for all patients are registered under MLC.  Responsible for receiving personnel belongings of the patients and maintain them under safe custody till handover to the relatives or police. 5 MAINTENANCE, OPERATIONS & BIO MEDICAL ENGINEER  To check readiness of the ambulance and drivers.  To arrange for the additional electrical connections if required.  To arrange for the adequate medical gases requirements 6 HOUSE KEEPING INCHARGE  On receiving code yellow call, co-ordinate with Head – Emergency 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 79 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  Provide additional housekeeping staff (attenders) to the triage area immediately and instruct them to report the casualty ward In charge.  Assign two female Housekeeping staff for cleaning work.  Assign the personnel for arranging the Cot, Mattress, IV stand in the yellow and yellow zone  Responsible for transferring cots. 7 RADIOLOGY DEPARTMENT:  Keep ready all the machines for requested investigations.  Arrange more manpower with material if required. 8 LABORATORY  Central collection to anticipate more load from casualty.  Arrange more manpower if required. 9 BLOOD BANK SERVICES  Blood Bank in charge will contact with Head – Emergency  for emergency requirement of blood components and arrange for the same. 10 OT SERVICES  Make the Operation theaters ready , as soon as receive the call from Head – Emergency / arrange for additional staff  Keep all emergency trays ready for all types of emergency surgeries.  Keep additional dressing material ready for surgeries. 11 PHARMACY INCHARGE 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 80 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  Arrange for extra medicines and consumables for emergency. 12 SECURITY  Arrange the security personnel in all the areas to control the crowd.  Do not allow any press or Media inside the Triage area and Treatment area. 13 INFORMATION TO PRESS AND MEDIA  Only the Medical Superintendent / Medical Director are authorized to speak to the press.  No press member is allowed to visit triage or treatment rooms or any other hospital area unless authorized.  Operational head to receive the VIPs /Government officials and co-ordinate with higher officials. 14 COMMUNICATION FACILITIES The following numbers are allotted to the command center o local police station number o Local Ambulance number o Emergency ambulance services 15 Disaster Cupboard in the Emergency  Separate cupboard is arranged for Disaster in the casualty with required material in emergency.  It is responsibility of the casualty in charge to check the expiry date and stock once in a month.  The material of the cupboard will be used only on activation of code YELLOW.  The list of material is kept in the cupboard.  Emergency in charge will contact with pharmacy in charge for additional information. 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 81 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 clearance of Code yellow the material which is used during code will be replace by in charge Accident and Emergency. 16 RECOVERY PHASE OF CODE YELLOW After ALL CLEAR signal has been given by the Team Leader, the following events should happen:  The doctors and other supporting staff are appreciated by the Team leader for the response to the crisis.  The doctors and other supporting staff disperse and take up their pre-disaster positions.  The emergency cupboard is re-equipped to actual prescribed limits.  The house keeping department is responsible for safe disposal of biomedical waste and re-arrangement of the waiting areas.  A report on the activation of code YELLOW and the analysis of response of the various departments which participated is prepared. The report is submitted within one week of the event.  The safety committee discusses the report and makes modifications/ improvements to the existing protocols. 17 TRAINING OF HOSPITAL STAFF  The Secretary of the hospital safety committee will plan to conduct training sessions to the various hospital staff once in six months.  At least two mock drills in a year will be conducted.  Post event analysis is done, which will be discussed in the safety committee. Any improvement or modification to this protocol may be then done. CODE PANDEMIC  Management meetings are called action plan is decided. Action card is prepared and followed.  Government protocols are obtained and 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 82 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  Make facility available as per requirement of pandemic. Like for COVID hospital has made isolation beds available.  Arrange maximum possible availability of required facility and equipment’s. HR arranges resources. It’s a nationwide emergency, all leaves are cancelled.  All staffs are trained to handle emergency as per guidelines.  Staff safety is taken care, required PPE and vaccinations are provided.  Medicine recommended are made available.  Required documents are amended as required. Daily reporting is provided to government as per the requirement. 7. FIRE SAFETY PROGRAMME POLICY  Fire and non-fire emergency within the facilities.  The hospital has a safety plan and provision for early detection, abatement and containment office and non-fire emergency.  GAIMS has identified various fire and non-fire emergencies and codes are assigned for the same.  All members of GAIMS are expected to take personal responsibility for following the policies and procedures of hospital in the event of an emergency and act in accordance with the instructions given by the Safety Committee & Emergency Response Team. Deployed adequate and qualified personal, adequate firefighting equipment and training.  GAIMS will conduct continuous training programs, Safety audit and Safety rounds to identify and to minimize the risk of personal injury, damage to property, and reduce risk from all adverse incidents.  GAIMS will conduct mock drills twice in a year as a part of training to ensure effective management of emergency situations encountered. (Safety Manager will prepare plan of such mock drills in different emergency situations like fire, earthquake, bomb threat, violent visitor entry in the hospital, hazardous material spills, needle stick injury etc. and conduct the mock drills according to the plan. 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 83 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  Results of the drills will be utilized to identify discrepancies and improve the response of emergency team members for better control over detection, containment and abatement of fire and non-fire emergencies.)  Display of exit plan, dedicated emergency illumination system. PURPOSE & SCOPE  Educating & train employees for safety in Hospital. Employees need to understand their role in safety and emergency preparedness.  Individual departments are responsible for developing department specific emergency plans to minimize the risk & recover from an emergency as quickly as possible. SAFETY PLAN: Fire Safety Plan includes:  Building information  Fire Hazard Identification & Risk analysis–  Installation of fire frightening equipment  Fire prevention  Evacuation plan for guidelines of evacuation in case of fire emergency.  Training for various emergency situations.  Composition of Various Teams for handling Fire emergency and train them accordingly.  Mock drills: Regular rehearsals for Fire Fighting & Evacuation shall be carried out for preparedness. Conclusion of every mock drill, the variations are identified, reason for the same analyzed, debriefing of the drill conducted and necessary corrective and preventive action taken.  Regular Maintenance of Firefighting Equipment’s ensures that the equipment’s work when they are needed. Maintenance adhere to manufactures /statutory recommendation.  Safe exit and display. 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 84 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 OBJECTIVE  To effectively handle any fire emergency at the Hospital.  To understand the dynamics of fire and to learn the various methods to fight to protect our lives and the lives of the patient. SCOPE:  Hospital Wide BUILDING INFORMATION FLOOR DEPARTMENT Basement All OPD’S Ground floor Sample Collection Area Basement X-ray CSSD MRD & D-MRD Government Pharmacy Store Pharmacy OPD Pharmacy Store Central Store Front Desk & Billing Gynec & Obstetrics Ward, OT & ICU 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 85 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 First floor Radiology ER ER Registration Bio Medical Engineering Manifold Room Sakhi One Stop MOD Room RMO Office Government MLC MRD MLC Medical Officer Room Security Room Medical Director Office Chief Medical Superintendent Office Head Quality Office Head Operations Office Head Medical Admin Office Head HR Office Nursing Superintendent Office Security Control Room Conference Hall IT Department HR Office Operations team office 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 86 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 Second Floor Hospital Pantry Third Floor Blood Bank NICU ENT Pediatric Ward PICU Orthopedics Ward Male Medicine Ward Female Medicine Ward ART Centre Thalassemia Central Lab RN-TCP Centre MOT Complex MICU SICU Surgical Ward Ophthal ward & OT Respiratory Medicine Ward Dialysis Special Room Hospital Kitchen Staff Dining Area 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 87 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  Fire safety is everyone's responsibility. All employees should know how to prevent and respond to fires, and are responsible for adhering to Hospital policy regarding fire emergencies. On the other hand, management will responsible to train all employees in these aspects. 1 MANAGEMENT  Management determines the Hospital fire prevention and protection policies. Management will provide adequate controls to provide a safe workplace, and will provide adequate resources and training to its employees to encourage fire prevention and the safest possible response in the event of a fire emergency. 2 FIRE SAFETY INCHARGE  Fire Safety in charge shall manage the Fire Prevention Plan for Hospital, and shall maintain all records pertaining to the plan. He shall also:  Develop and administer Hospital fire prevention training program.  Ensure that fire control equipment and systems are properly maintained.  Control fuel source hazards.  Conduct fire risk surveys and make recommendations 3 HEAD OF THE DEPARTMENT:  HOD’s are responsible for ensuring that employees receive appropriate fire safety training. They maintain good housekeeping in their department. They notify Safety in charge whenever changes in operation lead to increase in the risk of fire. HOD’s are also responsible for enforcing fire prevention and protection policies. 4 EMPLOYEES: 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 88 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 employees shall:  Complete all required training before working without supervision.  Participate in mock drills to practice and be prepared to comb at fire.  Conduct operations safely to limit the risk of fire.  Report potential fire hazards to their supervisors.  Follow fire emergency procedures TYPES OF FIRE HAZARDS  The following sections address the major workplace fire hazards at Hospital facilities and the procedures for controlling the hazards. 1 Electrical Fire Hazards:  Electrical system failures and the misuse of electrical equipment are leading causes of workplace fires. Fires can result from lose ground connections, wiring with frayed insulation, overloaded fuses, circuits, motors, or outlets. To prevent electrical fires, employees shall:  Make sure that worn wires are replaced.  Use only appropriately rated fuses.  Never use extension cords as substitutes for wiring improvements.  Use only approved extension cords  Check wiring in hazardous locations where the risk of fire is especially high.  Check electrical equipment to ensure that it is either properly grounded or double insulated.  Ensure adequate spacing while performing maintenance. 2 Office Fire Hazards:  Fire risks are not limited to Hospital premises area. Fires in offices have become more likely because of the increased use of electrical equipment, such as computers and fax machines. To prevent office fires, employees shall: o Avoid overloading circuits with office equipment. 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 89 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 Provide good ventilation for each equipment.  Turn off nonessential electrical equipment at the end of each workday.  Keep storage areas clear of rubbish.  Ensure that trash and paper set aside for recycling is not allowed to accumulate.  Departmental employee shall regularly evaluate the presence of explosive materials in their area.  Certain substances can ignite at relatively low temperatures or pose a risk of catastrophic explosion if ignited. Such substances obviously require special care and handling.  As a process, such hazardous materials need to be identified and it should be known to all employees working in that area so that they take all necessary precautions during handling, storage, use of these materials. Class ‘A’ Explosives These include common Explosive materials (wood, paper, cloth, rubber, and plastics) that can act as fuel and are found in non-specialized areas such as offices. To handle Class A Explosive s safely:  Dispose of waste daily.  Keep trash in metal-lined receptacles with tight-fitting covers (metal wastebaskets that are emptied every day do not need to be covered).  Keep work areas clean and free of fuel paths that could allow a fire to spread.  Keep Explosive s away from accidental ignition sources, such as hot plates, soldering irons, or other heat- or spark-producing devices.  Do not order excessive amounts of Explosives.  Make frequent inspections to anticipate fires before they start Class ‘B’ Explosives: These include flammable and Explosive liquids (oils, greases, tars, oil-based paints, and lacquers), flammable gases, and flammable aerosols. 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 90 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 handle Class B Explosive s safely:  Use only approved pumps, taking suction from the top, to dispense liquids from tanks, drums, barrels, or similar containers (or use approved self-closing valves or faucets).  Do not dispense Class B flammable liquids into containers unless the nozzle and container are electrically interconnected by contact or by a bonding wire. Either the tank or container must be grounded.  Do not use a flammable liquid as a cleaning agent inside a building (the only exception is in closed machine approved for cleaning with flammable liquids).  Does not use, handle, or store Class B Explosive s near exits, stairs, or any other areas normally used as exits.  Do not weld, cut, grind, or use unsafe electrical appliances or equipment near Class ‘B’ Explosives.  Do not generate heat, allow an open flame, or smoke near Class B Explosives.  Know the location of and how to use the nearest portable fire extinguisher rated for Class ‘'B’ fire.  Fire prevention guideline Good Housekeeping to prevent fire hazards: To limit the risk of fires, employees shall take the following precautions:  Minimize the storage of Explosive materials.  Make sure that doors, hallways, stairs, and other exit routes are kept free of obstructions.  Use and store flammable materials in well- ventilated areas away from ignition sources.  Use only nonflammable cleaning products.  Keep incompatible (i.e., chemically reactive) substances away from each other.  Keep equipment in good working order i.e. inspect electrical wiring and appliances regularly and keep motors and machine tools free of dust and grease.  Ensure that heating units are safeguarded.  Report all gas leaks immediately. 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 91 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  Responsible Person shall ensure that all gas leaks are repaired immediately upon notification.  Repair and clean up flammable liquid leaks immediately.  Excessive paper, plastic, cardboards and wooden scrap will not be allowed to accumulate in office. Waste shall be separated and stored in identified place of Garbage storage. Also ensure that it is to be sent for disposal as per housekeeping schedule.  Used bandage/cotton etc., will not be allowed to accumulate. All bio medical waste to be stored in identified bins and store at designated area. It shall be sent for disposed of to life secure agency regularly.  Keep work areas free of dust, lint, sawdust, scraps, and similar material.  Do not rely on extension cords if wiring improvements are needed, and take care not to overload circuits with multiple pieces of equipment.  Ensure that required hot work permits are obtained.  Do not smoke inside the premises.  Turn off electrical equipment when not in use.  Old and frayed electric cables damaged switch boards, loose fixtures and sparking appliances, will be reported in writing to the Maintenance and biomedical Engineering Department by the concerned department, managers, and supervisors for immediate repair/replacement. Follow-up action will be taken until work is complete.  Chemicals and oil stored in material store will be stacked in small stocks with adequate spacing in between. Stocks will be governed by respective statutory and regulatory requirements governing the same.  Catering manager /contractor will be personally responsible for operation and safety of Liquid Petroleum gas (LPG) installation in the canteen.  He will ensure that all valves on the main feed pipeline and regulators on the gas stoves are shut, when not in use.  Unauthorized fires will not be lit in the hospital premises. An authorized fire will be completely snuffed before close of work.  Fireworks are not permitted inside the hospital  Private electric appliances like heaters, immersion rods are not allowed inside the hospital. Security will ensure during checking of bags at entry door. 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 92 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  Duplicate keys of all offices, stores, and departments will be deposited with security, and kept in the duplicate key box. All concerned will complete this action.  Firefighting equipment will not be removed or misused for industrial / administrative purposes. Department concerned will prohibit people foe any such misuse.  Tapping of hydrant lines of industrial / administrative use is a serious violation of the safety policies. Engineering Department will ensure that existing underground and surface tapping are disconnected immediately.  Whenever a new structure is to be built or an old structure is modified, Project / Engineering Department will involve the fire safety officer at the planning stage for projecting the fire safety requirements. The project / Engineering Department will consult the Fire Safety Manager whenever any work site is used involving inflammable material Components of the Programme:  Introduction to Fire  Components of fire  Classification of fire  Methods of extinguishing fire  Fire Extinguisher  Types of Fire Extinguishers  How to use a fire extinguisher?  Fire Fighting System in our hospital  Points to remember in case of afire  Roles and responsibilities 1. PROCEDURE  Fire can be technically defined as: the rapid oxidation of a material in the chemical process of combustion, releasing heat, light, and various reaction products. 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 93 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 flame is the visible portion of the fire and consists of glowing hot gases. If hot enough, the gases may become ionized to produce plasma. Depending on the substances alight, and any impurities outside, the color of the flame and the fire's intensity might vary.  Fire in its most common form can result in conflagration, which has the potential to cause physical damage through burning. Fire is an important process that affects ecological systems across the globe. The negative effects of fire include decreased water purity, increased soil erosion, an increase in atmospheric pollutants and an increased hazard to human life. 2. Components of Fire:  Combustion takes place when Oxygen, Source of Heat & Explosive Material combine together & reach The Ignition Temperature.  Hence for a fire reaction to take place, it requires a source of heat, flammable material and oxygen to complete the chain.  The same principle has been shown below as the fire triangle. Basics of fire 1 Theory and Elements of Fire  Fire is a chemical reaction involving rapid oxidation (burning) of fuel.”  It is the rapid oxidation of a fuel, producing heat and light. To produce a fire, the following are required 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 94 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 2 Basics of Fire a. FUEL - Any combustible material (flammable gases, liquids, solids). Most solids and liquids must vaporize before they will burn. o Chemicals o Acetone, Alcohols, Ether, Xylene, Toluene, Benzene etc o Gases o Hydrogen, Natural Gas o Plastics o PCs, Cable Insulations, Research Equipment o Wood o Desks, Benches, Furniture o Waste materials b. OXYGEN - Sufficient oxygen (present in the air, oxidizing substances) must be present in the atmosphere surrounding the fuel for fire to burn. o A natural component of air @ 21% o Enriched atmospheres, > 21% oxygen o labs, oxygen storage o Situations where oxygen / air is more difficult to control: o Outdoors o Automatic ventilation systems 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 95 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 Open doors or windows c. HEAT – Sufficient heat energy (hot surfaces, electrical equipment, smoking, naked lights) must be applied to raise the fuel to its ignition temperature o Heating Appliances o Research and computer equipment o Other electrical equipment o Smoking materials o Cooking Area o Classes and Types of Fire 3. Classification Of Fire: Depending on the source, fire can have classified in to 5 categories. 1 “A” Class Fire – General / Domestic Fire: Fire involving ordinary Explosive materials like wood, paper, textile etc. 2 “B” Class Fire - Liquid (Oil) Fire: Fire involving inflammable liquids like oil, organic solvents, petroleum products, varnish, paints, etc. 3 “C” Class Fire - Gaseous Fire: Fire Involving Gaseous Substances Like L.P.G., Ammonia, Methane Etc. 4 “D” Class Fire - Metallic Fire: Fire Involving Burnings & Powders of Explosive Metals Like Magnesium, Aluminum, Zinc Etc. where the burning is reactive to water. It Requires Special Extinguishing Agent to extinguish this type of Fire. Usually this type of Fire is encountered in industries. 5 “E” Class Fire - Electric Fire: Fire involving electrical equipment with live electric current flowing in the equipment 4. Methods of Extinguishing Fire: The major three types of extinguishing a fire are: 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 96 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  Starvation  Smothering system  Cooling system 1 Starvation: - The method of removing Explosive material from the fire is known as starvation. Explosive material is the food of any class of fire. Therefore, this method is applicable in all classes of fires wherever it is possible to remove the Explosive materials from the vicinity of fire. 2 Smothering system The method of cutting off oxygen supply from the fire by blanketing is known as Smothering. It can be done by a Fire blanket, Foam type extinguisher or Dry Chemical Powder, Carbon Dioxide (co2) 3 Cooling system The method of cooling down the temperature, the source of heat is known as the cooling system. E.G. Spraying water on burning wood. 5. Fire Extinguisher: A fire extinguisher is an active fire protection device used to extinguish or control small fires, often in emergency situations. It is not intended for use on an out-of- control fire, such as one which has reached the ceiling, endangers the user (i.e. no escape route, smoke, explosion hazard, etc.), or otherwise requires the expertise of a fire department. Typically, a fire extinguisher consists of a hand-held cylindrical pressure vessel containing an agent which can be discharged to extinguish a fire. 6. Types of Fire Extinguisher: 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 97 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 Depending on the type of fire, appropriate fire extinguisher is to be used to put off the fire. 1 Water type fire extinguisher for type A fires where Cooling system works as the principle to put of the fire. 2 Carbon di oxide (CO2) can be used for B, C & E classes of fire and it works on the principle of smothering. 7. Fire Fighting System in Our Hospital: 1 Fire Hydrant System- Fire Hose Reel/ Fire Hydrant and risers 2 Sprinkler System 3 Fire alarm System – Control Panel 4 Fire Extinguishers 5 Smoke Detectors 6 Emergency exit signs 7 Maintenance of firefighting equipment 8 Fire water /reservoir /static tank 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 98 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 Fire Extinguisher: a) General Operating Instructions for Fire Extinguishers:  NEVER attempt to extinguish a large fire with a portable fire extinguisher. It is never wise to attempt to extinguish any fire without someone alerting the fire 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 99 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 department. If the fire is not blocking your exit from the area of fire origin, it may be extinguished by someone trained to do so.  Take the fire extinguisher out from its installation place.  P -Pull the safety pin on the extinguisher. Grasp the extinguisher neck with one hand and pull the pin with the other hand. Stand back 5 to 8 feet from the fire.  A -Aim at the base of the fire (unless it is a grease fire on a range top) In the case of a grease fire, stand back and aim a little above the base.  S -Squeeze the handle to discharge the extinguisher media.  S -Sweep from side to side until the fire is extinguished or the extinguisher is empty. Do not hold the extinguisher in one spot. Note: Every extinguisher has a label of operating method with picture. Fire extinguisher will discharge between 30 seconds to 90 seconds; Range of jet is 3 feet to 18 feet it depends up on type of extinguishers. b) Inspection, Refilling & Testing:  Inspection: Inspection and efficiency test shall be conducted once in a six month for all fire equipment’s by licensed contractor to ensure performance in case of emergency.  An inspection tag shall be attached to each extinguisher, which indicates the record of inspection or testing.  Refilling: Refilling of Dry chemical powder (cartridge type) & carbon dioxide type shall be done once in five years & when it will be emptied.  Hydraulic Test: The testing interval depends upon the type of fire extinguisher. Schedule of hydraulic testing is given below. c) Check Points of Inspection of fire extinguisher(s):  Portable extinguishers require periodic maintenance. It is recommended to ensure that the building is protected with the appropriate fire extinguishers. Any necessary repairs or recharges can be done onsite. 2 Fire Hose Reels Operation: 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 100 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  Purpose: Fire hose reels are installed in buildings specifically to provide occupants with the means of suppressing or extinguishing fire.  Installation: Fire hose reels are located on each floor provide a reasonably accessible and controlled supply of water to combat a potential fire risk. A control nozzle attached to the end of the hose enables the operator to control the direction and flow of water to the fire.  Use & Operation: Fire hose reels located in buildings are to be used by building occupants to fight fire, especially when they are trapped and cannot escape to an emergency EXIT. The fire hoses are connected to the mains water supply, or Fire Systems Feeds. Some fire hose reels are located in cabinets whilst others are visible on the wall in fire cells. They require appropriate signage indicating their location and fuel risk suitability.  Operation: Fire hose reels are all very similar in operation. This is the generic procedure: o Ensure the nozzle or jet is in the closed position o Turn on the main valve (some will not let the nozzle out until this is done) o Pull the hose off the drum, towards the fire o Open the nozzle or valve and direct the stream of water at the fire  Canvas Fire Hoses: Canvas fire hoses attached to or adjacent to fire hydrant points are installed only for use by the Fire Brigade or an Emergency Response Team who are trained to handle the same. They must not be used by untrained personnel as injury or excessive property damage may result.  Maintenance of Hose Reels: Signatory Prepared by Reviewed by Approved by Name Designation Signature