Apex Manual

CHACHA NEHRU BAL CHIKITSALAYA
APEX MANUAL VERSION 4.7
CHACHA NEHRU BAL CHIKITSALAYA

GOVT. OF NCT OF DELHI
APEX MANUAL
VERSION 4.7
Dated: October 2020
CONTENT
1 OUTPATIENT SERVICES 01
2 EMERGENCY DEPARTMENT 12
3 INPATIENT SERVICE (PEDIATRIC MEDICINE) 26
4 PEDIATRIC INTENSIVE CARE UNIT (PICU) 36
5 NEONATAL INTENSIVE CARE UNIT (NICU) 50
6 HEMODIALYSIS UNIT 61
7 DEPARTMENT OF DERMATOLOGY 73
8 DEPARTMENT OF PEDIATRIC SURGERY 79
9 DEPARTMENT OF ORTHOPEDIC SURGERY 91
10 DEPARTMENT OF OPHTHALMOLOGY 101
11 DEPARTMENT OF ENT 107
12 DEPARTMENT OF DENTAL SURGERY 114
13 DEPARTMENT OF ANESTHESIA 119
14 DEPARTMENT OF CSSD 149
15 OPERATION THEATRE 164
16 NURSING PROCEDURES 217
17 LABORATORY DIVISION 252
18 DEPARTMENT OF RADIOLOGY AND IMAGING SERVICES 337
CNBC Manual Version 4.7

19 MANUAL OF LAUNDRY 377
20 DEPARTMENT OF PHYSIOTHERAPY 386
21 DEPARTMENT OF OCCUPATIONAL THERAPY 400
22 DIETETICS 417
23 MEDICAL RECORDS 440
24 CODE PINK POLICY 458
25 MANUAL FOR OPERATIONS (SECURITY) 464
26 DEPARTMENT OF TRANSPORTATION (AMBULANCE) 486
27 PRIVATE WARD 493
28 HOSPITAL WIDE POLICIES 499
29 PHARMACY 644
30 DEPARTMENT OF GAS MANIFOLD 661
31 MATERIAL MANAGEMENT (PURCHASE, STORE AND MAINTENANCE) 680
32 DEPARTMENT OF SPEECH THERAPY 784
33 DEPARTMENT OF MEDICAL SOCIAL WORKER 794
34 CLINICAL PSYCHOLOGY 801
812
35 ENDOSCOPY UNIT
819
36 SARI (SEVERE ACUTE RESPIRATORY ILLNESS)

1 Outpatient Services
Date created: 1st May 2008
Approved by: Director
Responsibility of Department of Outpatient

updating:
Last reviewed/ August 2020

updated on:
Version (CNBC/OPD/1/ver.1.1)
1
1 Outpatient Services ............................................................................................................................................1
1.1 Amendment Record Sheet .........................................................................................................................3
1.2 Introduction: ................................................................................................................................................4
1.3 Purpose: .....................................................................................................................................................4
1.4 Scope: .........................................................................................................................................................4
1.5 Responsible Persons: .................................................................................................................................4
1.6 Registration Process...................................................................................................................................4
1.7 Follow-up Patient ........................................................................................................................................5
1.8 Flow Chart of the Registration Process and OPD consultation: .................................................................6
1.9 Special Clinics ............................................................................................................................................8
1.10 Records Generated ..................................................................................................................................... 11
2
1.1 Amendment Record Sheet
S.No. Clause Date of Amendment Amendment Made Reason s of Sign of QM

No. Amendments
st
1. 1.7 1 July 2014 Change in follow up For more clarification
consultation process
st
2. 1.8.3.1 1 July 2014 Change in days of Due to change in days of
special clinics special clinics
3. 1.6.3 Dec 2014 In case any clarification Previously not
sorts by reception they mentioned.
can contact MO IC
OPD.
3
1.2 Introduction:
1.2.1 Chacha Nehru Bal Chikitsalaya is super- 1.4 Scope:

specialitylty hospital catering all children
under 12 years of agee. For those children 1.4.1 Registration of patients
requiring long term treatment and registered
for that particular disease before attaining 1.4.2 Consulting with doctors in different
12years of age, they are taken care of and chambers for case evaluation, diagnosis and
followed up till they become 14 years of age. treatment in general OPD
OPD facility is available for all pediatric
specialty and sub-specialty from Monday to 1.4.3 Laboratory investigation facilities – routine,
Saturday special, radiological
1.1.1 In addition to routine OPD, other facilities 1.4.4 Immunization services

and services like immunization, pharmacy,
physiotherapy and occupational therapy, 1.4.5 Consultation with doctors / appropriate
psychology- assessment and counseling, personnel in other specialty services like
OTS centre, Integrated testing and Surgery, Orthopedics, Eye, ENT, Dental,
counseling centre (ICTC), laboratory and Dermatology, Physiotherapy, Occupational,
imaging (X-ray , CT Scan and USG services Speech therapy, dietary advice, DOT center,
etc. are also provided on OPD basis. HIV counseling on the same day with the
same registration process
1.2.2 Patients coming to OPD are entertained at
registration counter, when OPD card is 1.4.6 Pharmacy Services
made and then directed to respective OPD o Specialty clinics for long term follow up for
chambers after recording their height & chronic ailments like Chest clinic,
weight. They are directed for re-registration
Gastroenterology, Hematology, Nephrology,
in case treating physician suggests any
other consultation. If follow- up is required, , Neurology, Development clinic and
patients are asked to come on specific unit Newborn High-Risk clinic.
days.
1.5 Responsible Persons:
1.3 Purpose:
1.5.1 Consultants and Sr. Residents, staff nurses,
1.3.1 Treatment of diseases / ailments of children trained personnel in appropriate fields
coming to this hospital
1.6 Registration Process
1.3.2 Planning proper investigation and treatment
in cases where immediate relief to problems 1.7 Enquiry Relating to Availability of
are not possible concerned doctor in the OPD:
1.3.3 Admission of patients into the hospital from 1.7.1 Routine information’s regarding availability
OPD if required of consultants, their OPD days and timings
are provided at the display board at the
reception area. In case of walk in enquiries,
any inquiry is entertained at the registration
reception counter.
1.7.2 In case of any clarification sort by the

reception staff on the services provided,
4
they can contact to the MO IC OPD & patient registration counter), no new card is
followed by the director. made however, only the old card is stamped
with the appropriate date.
1.7.3 There is no system of prior appointment.
The hospital entertains any patient walking
1.8.1 OPD Consultation Process
at any time.
1.8.1.1 Doctors Consultation Process in OPD
1.7.4 The hospital entertains any patient walking 1. The OPD assistants (Nursing orderlies) help
at any time in between 08-30am to 12- in directing the patients with their OPD cards
00noon during Monday to Friday & 08-30 to to different OPD chambers for consultation.
11-30am on saturdays on first come first At every room the NOs maintain a register
serve basis noting the serial number of the patients on
‘First come First serve’ basis. Patients are
1.7.5 OPD Registration Process (New Patient) let in for consultation with the doctor serially;
however patients requiring immediate
1.7.6 Patients have to register at the registration medical attention are given priority.
counter located in the OPD waiting area. 2. Initial assessment of patient is done by
consultants and resident doctors in different
1.7.7 At the registration counter a registration card OPD rooms, and provisional diagnosis is
is made that contains Name, Age, Sex, made. if OPD clinician require any diet
Weight, height, immunization status, father’s referral, patient get referred to asst. dietician
name, address and also a ID number. .In case patient needs laboratory
investigations / X-rays etc., the appropriate
1.7.8 The whole process is computerized. In the forms are filled and the patient is directed
registration card the number of the room to to the respective rooms for the
which the patient is supposed to go to meet investigations Patient’s details with
the doctor, is also written down. A serial provisional diagnosis, investigations etc are
number is also given in the OPD cards in a noted down in the OPD card. A record of
helpdesk and they are directed to show the provisional diagnosis is also maintained at
patient accordingly, so that chaos near OPD OPD chamber.
area is controlled and pay justice to first 3. Once the diagnosis is arrived at the
come fist serve basis. appropriate treatment is advised and the
Patients/ attendants are directed to
1.7.9 . In the registration card, OPD day’s dispensary to collect the prescribed
different units are also stamped. The medicines. Based on the condition of the
patients are supposed to visit the OPD in patient, they are advised to go back home or
these days only for particular ailments if get admitted in the emergency ward of the
subsequent visits are necessary hospital.
4. Cases where follow up visit is required the
1.7.10 Online registration facility is also available same is mentioned in the OPD card and
introduced recently. It may be done after patients/ Relatives are informed by the
opening the hospital website. doctor about the date for the next follow up
visit.
1.8 Follow-up Patient 5. Documentation of reassessment and further
Patient is asked to come for follow up, if treatment is done.
necessary, on the specific unit days e.g.
Monday- Thursday, Tuesday-Friday and 1.8.2 Nursing Process in OPD
Wednesday-Saturday so that he can be Injections and Vaccinations as instructed by
attended by the same unit doctors. For the treating doctor are administered by the
these subsequent visits the patient has to nursing staff.
get registered in a different counter (old
5
1.9 Flow Chart of the Registration Process and OPD consultation:
01. For First Consultation:
Patient comes to registration counter.
Entry in the computer by the person at this
Counter.
Unique patient ID Registration no. is

generated and
entered in the OPD card
OPD card with patient’s name, gender, age,

sex, address, Registration no. and also OPD
room no he is supposed to consult, is handed
over to the patient
Height & weight is checked and recorded in the OPD card
A help desk Is provided for the patient to be provided with token number of the particular OPD so that easy
flow of OPD and first come first serve system is maintained.
(NOW A DAYS NO TOKEN IS GIVEN- THIS LINE MAY BE OMITED)
Goes to laboratory /x-ray dept.for

investigations (if any is advised)
The OPD card with Patient collects the report from registration
prescribed treatments counter/ or other rooms in case directed so.
handed over to patient.
Goes to the dispensary to Scheduled for Admission

Scheduled for next visit
collect the prescribed and inpatient treatment if
needed.
medicine.
6
1.9.1 Follow up Consultation:
Patient comes with old OPD card at the registration counter.
OPD card is stamped and dated by the registration staff
and handed over to the patient.
Height and weight of patient is done
Token number for concerned OPD room is provided
Directed to doctors chamber
Assessment done by doctor and treatment prescribed..
Patient goes for further investigation (if any)
Collects report
Scheduled for next visit Scheduled for Admission and
Inpatient treatment.
7
1.10 Special Clinics
1.10.1 Introduction: 1.10.4 Responsibility Persons: Faculty /
Consultants
1.10.1.1 CNBC is a tertiary level teaching hospital
dedicated to the care of pediatric patients 1.10.5 Process:
with a vision to also provide super-
specialty pediatric services in addition to 1.10.5.1 Out- Patient Specialty Clinic Referral
general pediatric health care needs. Process (New Patient): These apply to
Specialized outpatient clinics in different ambulatory patients and not requiring
disciplines are held to provide emergent inpatient services. Health care
comprehensive care to children in need of professionals working in this hospital or
special care. Children are referred from the elsewhere can refer patients. All patients
general OPD to special clinic by the have to be routed through the general
specialist in charge. OPD of the concerned Specialist, who will
perform initial evaluation regarding need
for specialty clinic care. Patient is then
1.10.2 Purpose: To provide guidelines for given date and time of appointment for the
regarding special clinics of the Department initial registration in the Specialty Clinic by
of Pediatrics the specialist in charge. Direct referral to
the Specialty Clinic is not encouraged.
1.10.3 Scope:
1.10.3.1 Care of (long term follow up) of patients 1.10.5.2 Out- Patient Specialty Clinic
with chronic illness needing chronic Registration Process (New Patient):
medication and Follow-up Special clinics Patients referred to the specialty clinic of
run in the department are as follows the hospital arrive at the Help Desk
– counter of the hospital. At the registration
counter the following information about the
Name of Clinics Days
patients are fed into the system:
a. Name , b)Age of the patient, c) Income
status, d) Residential address, e) Religion.
Chest Clinic Friday Afternoon
Seizure & CNS Clinic Friday Afternoon
Development Clinic Friday Afternoon
Endocrinology Clinic Friday afternoon
Hematology Clinic Monday afternoon
Gastroenterology Clinic Tuesday Afternoon
High risk Clinic Tuesday Afternoon
Nephrology Clinic Monday afternoon
Neurology Clinic Friday Afternoon
This special clinic are held in the OPD complex

8
1.10.5.3 The system generates a Unique Patient ID
number. A registration slip is prepared with
the Unique Patient ID number. The Unique 1.10.6.1 Patients get drugs that are prescribed in
patient id is entered into a new set of case the dispensary. Initial medication to cover
paper and the same is handed to the the immediate symptoms of patients is
patient. In the registration card name of the suggested. Evidence based medicine and
special clinic to which the patient is clinical practice guidelines are adopted to
referred is also entered. guide patient whenever possible and
required. Based on the investigations/
1.10.5.4 Follow Up Patient diagnosis record, treatment plan devised
and final medicines prescribed. The patient
1.10.5.4.1 Patient attendants are asked to come for / relative are directed to the dispensary for
follow up at intervals given by the collecting the prescribed medicines. Based
consultant incharge of the special clinic. on the condition of the patient, they are
At every subsequent visit the patient advised to go Initial medication to cover
presents the registration card in the the immediate symptoms of patients is
registration counter. The clerk at the suggested. Evidence based medicine and
registration counter registers the patient clinical practice guidelines are adopted to
and stamps the old registration card with guide patient whenever possible and
date. The patient is then directed to the required. Based on the investigations/
concerned specialist for follow up diagnosis record, treatment plan devised
consultation. and final medicines prescribed. The patient
/ relative are directed to the dispensary for
1.10.6 Specialty Clinic Consultation Process: collecting the prescribed. The patient /
Doctors Consultation Process in the Specialty relative are directed to the dispensary for
Clinic: The patient along with the registration card collecting the prescribed medicines. Based
goes to the appropriate room of the specialty clinic on the condition of the patient, they are
and Visits the doctor’s n their respective rooms. advised to go back home or get admitted
Patients are called by the doctor on the basis of in the inpatients wards of the hospital.
‘First come first examined basis’ however patients
requiring immediate medical attention are given 1.10.6.2 For follow up visit, appointment date is
priority. Patients are given appropriate treatment and given by the Consultant and the same is
advice and also investigated if needed. Clinic record recorded in the case record.
is maintained in the specialty Clinic on a pre- Documentation of reassessment and
designed Performa and kept in the Clinic for future further treatment is done Educative
evaluation. Provisional diagnosis made and materials regarding the disease are
investigations suggested. In case of laboratory / distributed to patient and relatives as
radiology investigations are to be performed, needed and appropriate.
appropriate investigation/ requisition forms are filled
by the doctor. Initial assessment results and plan of
care are documented which has to be followed by
patient.
9
1.10.7 Flow Chart of the Out Patient Specialty Clinic Registration Process and Consultation:
For First Consultation:
Patient comes to registration counter.
Referral note with initials of the specialist in charge,

date is checked
Filing of registration form at counter.
Entry in the computer by the person at this counter.
Unique patient ID no. is generated
A registration card is handed over mentioning patient’s

name, Outpatient no. and, visit no., caste religion,
gender, age, occupation, income status, address. The
registration no.
Directed to consultation’s chamber and assessment

done by the doctor.
Appropriate entries made in the registration card and

treatment
The case paper is handed over to Goes to laboratory for investigation

Patient with prescription. (if any)
Patient collects the report from the

Scheduled for Scheduled for Admission laboratory.
next visit and Inpatient treatment.
10
1.10.8 Follow up Consultation:
Patient comes with old case paper at registration counter.
Date of appointment checked
Case paper is stamped and dated by the registration clerk and

handed over
Consultant evaluates and suggests further treatment plan
Next appointment date given by the consultant
Patient goes for further investigation (if any)
Collects report & further investigation (if any)
Scheduled for next Scheduled for Admission

visit and Inpatient treatment.
1.11 Records Generated

1. OPD Patient Attendance Record
2. Registration
3. Patient Case Paper
4. Clinic Case Record
5. Investigation Requisition Form
11
2 Emergency Department
Responsibility of Department of Paediatric Medicine

updating:
Last reviewed / August 2020

Updated on:
Version (CNBC/ Emergency/2/ ver.1.0)
12
2 Emergency Department ...................................................................................................................................12
2.1 Amendment sheet ........................................................................................................................................ 14
2.2 Introduction: .................................................................................................................................................. 15
2.3 Purpose: ....................................................................................................................................................... 15
2.4 Scope of services: ........................................................................................................................................ 15
2.5 Responsible Persons .................................................................................................................................... 15
2.6 Policies of Emergency Services: .................................................................................................................. 15
2.7 Emergency Registration Process:- ............................................................................................................... 15
2.8 Triage............................................................................................................................................................ 18
2.9 Patient condition ........................................................................................................................................... 17
2.10 Color coding for triage: .................................................................................................................................. 17
2.11 Admission Policy ........................................................................................................................................... 17
2.12 Equipment and Supplies: .............................................................................................................................. 17
2.13 Transfer of admitted patients to other hospital ............................................................................................ 17
2.14 Policy for shifting out of patients from ER/ Ward for Diagnostic tests ...................................................... 18
2.15 Leaving on Request .................................................................................................................................. 19
2.16 Abscond .................................................................................................................................................... 20
2.17 Death ........................................................................................................................................................ 20
2.18 Transfer to the ward /ICU ......................................................................................................................... 20
2.19 Admission ................................................................................................................................................. 21
2.20 Discharge Process Policy ......................................................................................................................... 22
2.21 Leave Against Medical Advice (LAMA): ................................................................................................... 23
2.22 Medico legal cases Policy: ....................................................................................................................... 24
2.23 Brought in Dead Patient’s Policy .............................................................................................................. 25
13
2.1 Amendment sheet
S .no. Date of Clause no. Amendment made Reasons of amendment Sign of QM
Amendment
1 July 2014 2.5.2 Addition of CMO in
responsible person As it was not added earlier
2 July 2014 2.8.1 Change in triage process For clarification of Triage
process.
3 July 2014 2.20 Discharge Process Policy To make the policy more
is modified detailed and clear
4 February As it was not added earlier

2015 2.1.1 2.20.4 2.1.2 Editing done in
discharge policy
for Medication
instructions in the
discharge
summary should
be in an
understandable
manner (by the
patient)e.g. 12
hourly/ 24 hourly
instead of BD /OD
orders.
5 March 2018 As it was not added earlier

2.1.3 2.1.4 Triage Protocol
14
2.2 Introduction: 2.5.3 Senior and junior residents
2.2.1 Emergency services are provided round the 2.5.4 Nursing Sister and staff
clock including lab services. It is a 15bedded
casualty area well equipped with all 2.5.5 Nursing staff
emergency equipments. There are 3 doctors
and trained Nursing staff at any point of time. 2.6 Policies of Emergency Services:
Security guards check the flow of patients & 1. Emergency Department offers comprehensive
guide the patients to the doctor. Admitted emergency care 24 X 7.
Patients are treated under the guidance of 2. Senior and Junior residents are available
senior Resident who keeps the consultant well round the clock in emergency
informed regarding the status of the patients. department.Trained nursing staff ison duty
round the clock.
2.3 Purpose: 3. Consultants are available on call, after duty
hours
2.3.1 Provision of immediate relief to and 4. Security guards are appointed to guide the
management of the patients arriving at the patient’s caretakers and supervise the entry
hospital with acute medical and surgical and exit of people to avoid chaos in casualty.
emergencies with regardless of age, sex, race, 5. Ambulance services is available 24X 7.
creed, national origin, criminal status,
immigration status, type of medical illness. 2.7 Emergency Registration Process:-
2.4 Scope of services: 2.7.1 Patients seeking to avail the Emergency

facility of the hospital arrive at the Emergency
2.4.1 Emergency Department manages all patients counter of the hospital. At the registration
in the pediatric age group with acute problems counter the following information about the
according to protocol. In case of need for other patients are fed into the system:
specialist’s opinion, necessary steps are
taken. 2.7.2 a. Name
b. Father Name
2.4.2 Medico legal cases are also handled including
documentation of clinical condition and all
c. Age/sex of the patient
particulars and information to police.
d. Residential Address
2.4.3 Patients are screened regarding need for
admission and the rest are advised and sent
home. 2.7.3 The system generates a Unique Patient ID
number.
2.5 Responsible Persons
2.5.1 Consultants
2.5.2 Casualty Medical Officer
15
2.8 Triage
2.8.1 Triage is done by the Doctor/Nursing staff
Patient brought to the Triage room
Initial assessment done by nurse within 10 minutes

of arrival of patient Initial assessment includes Level
of consciousness,Temp, BP,PR,RR, Spo2 to be
checked
Brought in dead
Stable Unstable
SR informed
Assessment by SR Confirms and declares
Resuscitation dead
ABC secured Documents on casualty
SR examines Card and Brought in
Advice given dead certificate is
Sent home or refer provided to the NOK of
to emergency SR patient.
to keep under
observation. any
patient requiring
observation for
more than 4 hrs Admission
must be Management
admitted.all patient
requiring any form
of iv medication
need to be
admitted.
18
Triage Protocol:
19
2.10 Color coding for triage:
2.9 Patient condition 2.10.1 Critical patients: Red band
2.9.1 HIPAA standards have established five one- 2.10.2 Serious patients: Yellow band
word conditions reports which are meant to
describe a patient or current condition. 2.10.3 Fair patients :Green band
1. Undetermined. Patient or resident is
awaiting physician and/or assessment. 2.10.4 Dead body : Black band
2. Good: Vital signs are stable and within
normal limits. Patient or resident is 2.11 Admission Policy
conscious and comfortable. Indicators are
excellent. 2.11.1 The Senior Resident / consultants decide
3. Fair: Vital signs are stable and within normal regarding children to be admitted and
limits. Patient or resident is conscious, but admission papers are made in the
may be uncomfortable. Indicators are registration counter. Detailed history,
favourable. examination and management to be
4. Serious: Vital signs may be unstable and not documented
within normal limits. Patient or resident is
acutely ill. Indicators are questionable. 2.11.2 Two surrogate consents are obtained before
5. Critical: Vital signs are unstable and not admission:
within normal limits. Patient or resident may a) Consent for admission
be unconscious. Indicators are b) Declaration that patient has no valuables
unfavourable. with them.
2.9.2 Clinicians find the “critical, but stable” term 2.11.3 All accessories and jewelry worn by the
useful when discussing cases among patient shall be removed and handed over to
themselves because it helps them the key attendant.
differentiate patients or residents who are
expected to recover from those whose 2.11.4 Treatment is carried out by the nursing staff.
prognosis is worse. But a critical condition
means that at least some vital signs are 2.11.5 Consultants to be kept well informed about
unstable, so this is inherently contradictory. all admissions and their management
Access to emergency waiting line is
prioritised according to clinical needs of 2.11.6 Emergency lab is functional for basic
the patients- emergency investigations 24x7.
a. Unstable patient on initial assessment of 2.12 Equipment and Supplies:

nurse
2.12.1 The following equipment and supplies are
b. Patient seem drowsy in parents lap in available in the Emergency Department at
line. all times:
a) Cardiac and respiratory monitoring
c.Convulsing child equipment
b) Crash Cart with defibrillator
D.Child in respiratory distress c) Laryngoscopes and endo tracheal tubes
d) Minor surgical instruments
E.Colour seems blue/pale
e) Oxygen supplies
f) Suction equipment
g) Ventilator assistant equipment including
airways, bag valve device
h) ECG machine
i) Vascular cut down sets Splints
j) Foley’s catheters and collection system
17
2.13 Transfer of admitted patients to other hospital
Transfer out of patients from ER / ward (non availability of facilities)
Decision to shift out the patient by the consultant
Transfer out process initiated by the SR

(ward / ER)
* Ensure availability of bed / other required facilities with the ER-MO of the
transferring hospital. Details of the patient should be communicated verbally
* Ambulance requisition form filled up, Ambulance driver informed
* Ambulance equipment to be checked, drugs to be checked.
Ambulance check list signed by the nurse
* Doctor to accompany the patient care during the transfer.
* To check all the required documents- Transfer out summary, investigation reports to
be handed over to the patient attendant.
Details of the transferring hospital (if available) to be filled in the
ER book / patient medical record.
Shift out the patient
17
2.14 Policy for shifting out of patients from ER/ Ward for Diagnostic tests
Shifting out of patients for diagnostic tests
Investigation ordered by consultant and Requisition from given
Appointment time and data with the diagnostics is fixed
Stable patient
Unstable patient
* Requisition letter with patient * Requisition letter with patient

details collected accompanying details collected accompanying
the patient the patient
* Ambulance equipment to be
Checked, drugs to be checked. * Ambulance driver to shift the patient
* Junior resident to accompany from the unit to ambulance in the
the patient Ambulance trolley.
* Unstable patient will be accompanied
by Junior resident
* Ambulance equipments to be checked,
drugs to be checked
Shift the patient
18
2.15 Leaving on Request
Stable patient Unstable patient
Decision to shift patient by patient at tender against medical device.

Consequence of leaving on request for patient is explained to patient /
patient attendant
Leaving on request form is filled and signed by the attendant
Patient made fit to transfer
Discharge Summary,
Investigation reports to be Discharge summary, investigation reports to be
handed over to the patient / handed over to the patient / patient attendant by
patient attendant by the doctor. the doctor.
Repeat vitals of the patient to Repeat vitals of the patient to be checked
be checked before the transfer. before the transfer.
* Ambulance to be arranged by the patient party.

* Patient is AMBU bagged till the patient is shifted
to the ambulance and is handed over to the patient
at tender
Shift out the patient
19
2.16 Abscond
2.16.1 Staff informs the doctor regarding the patient’s absence.
2.16.2 Abscond form is filled by the resident doctor.
2.16.3 All details of last examination, probable diagnosis and treatment is duly mentioned and documented
2.16.4 The admission file along with the filled abscond form is sent to MRD.
2.17 Death
2.17.1 In the event of death of an inpatient / ER, SR will verify the cause of death with the concerned consultant/
consultant on call.
2.17.2 Death certificate will be issued by the CMO/SR.
2.17.3 No Death certificate will be issued by the SR without consultation.
2.18 Transfer to the ward /ICU
2.18.1 The SR in the casualty decides regarding patients who need ICU care according to the Protocol and if
possible discusses with the consultant
2.18.2 The ICU resident in charge is informed who arrange to receive the patient and informs the Consultant- in-
charge ICU
2.18.3 The patient’s ABC is secured and is transferred on a trolley accompanied by junior resident and Nursing
orderly (NO).
2.18.4 The patients who can be managed in the ward are transferred to the ward the next day.
2.18.5 The ward is informed about the number. of transfers and to arrange the vacant beds.
2.18.6 Documentation in transfer out register shall include the patient’s ID, any special investigation report, or
any equipment etc.
2.18.7 The patients are accompanied by NO along with their files and are handed over to the sister on duty in
the ward.
20
Chacha Nehru BalChikitsalaya, Delhi
Policy No:-CNBC/ADM/03
Released on: 1st May 2008
Revised on: August 2020
Approved by Director
Prepared By Dr Saikia
2.19 Admission
2.19.1 Policy
2.19.6 In the event of admission of unidentified
2.19.2 Patients in CNBC are admitted to the and unaccompanied patients. The following
hospital through the emergency department action will be taken:
and also the outpatient department.
1. Patients will be identified as a number in
2.19.3 Admissions are processed for children in place of name Column and so on and then
age group 0-12 yrs on a recommendation of admitted if required.
doctor attending the case. The child’s 2. Date and time patient was brought in to be
parents / Family Members wilfully wish to recorded
get the patient admitted in hospital. 3. Information about the person who brought
the patient to the hospital will be recorded.
4. Identification Marks of the patients to be
2.19.4 Follow-up patients of chronic illness may be
noted down
admitted till the age of 14yrs and if deemed
necessary 5. The condition in which the patient was
brought in is to be documented
6. Case shall be treated as MLC case
2.19.5 Admissions are not processed ifDoctor
advises admission but parents / attendants /
2.19.7 The accessories and jewellery worn by the
Guardian do not wish to admit the patient.
patient will be removed and handed over to
the key attendant at the time of admission.
21
Policy No:-CNBC/Discharge/04
Approved by
Director
Prepared By Dr.Saikia
2.20 Discharge Process Policy summary along with the death certificate
shall be given to the next of kin.
2.20.1 The discharge process is initiated by the
treating doctor who advises discharge after 2.20.8 The copy of death certificate from the
assessing the condition of the patient hospital is sent to local MCD office and
with regards to fitness for discharge. patient is educated about the same (How
and from where the certificate is to be
2.20.2 The senior resident writes a summary of the obtained)
case.
2.20.3 The format of the discharge slip is pre-

decided and includes patient’s name, unique
(CRno.), patient ID number,date of
admission,date of discharge,reason for
admission, clinical features,
diagnosis,investigations, treatment given
patient’s condition at the time of discharge.
The treatment advised at discharge and
followup advise should be in an
understandable manner by the patient.
2.20.4 Medication instructions in the discharge

summary should be in an understandable
manner (by the patient)e.g. 12 hourly/ 24
hourly instead of BD /OD orders.
2.20.5 Discharge summary should incorporate

about when and how to obtain urgent care.
2.20.6 The discharge summary is issued by the

nurse who explains the content of the same
to the patient Any clarification required is
provided by the senior resident. The above
procedure is followed in cases of Leaving on
request, Discharge on request, Referral.
2.20.7 In case of death, the summary of the case

also includes the cause of death. Death
22
Policy No:-CNBC/LAMA/05
Revised on: :August 2020
2.21 Leave Against Medical Advice (LAMA):
2.21.1 Purpose:To ensure that the parent/ guardian understands the consequences of his/her actions
2.21.2 Details
a) If a parent / Guardian wishes to take the patient against medical advice, the Unit In-charge and
Head of the concerned department have to be notified at the earliest.
b) Efforts should be made to elicit the reasons for wanting to leave against medical advice.
c) If the parent / guardian insist on leaving and do not want to speak with the guardian, the same
should be documented in the medical record.
d) After the patient physician has explained the potential risks and consequences of leaving, the
parents / guardian should sign the “Leave against medical advice” form.
e) If the patient / guardian refuses to sign the against medical advice form, it should be documented
in the medical record that the risk and consequences of leaving have been discussed and that the
parents / guardian refuses to sign the form, the same shall be integrated in Records.
f) The case summary including lab reports and treatment given shall be patient will be given the
case summary, and all medical reports as applicable.
2.21.3 Absconding patient:

1. A patient may be termed as absconding if he/she is found missing from the ward without the
information to the ward staff.
2. As soon as a patient is found missing from the ward, the nurse will beinformed and all efforts will
be made to trace him/her.
3. If the patient cannot be traced in the hospital within one hour thereafter, the patient will be
declared as absconded, the same will be recorded in the patients file and the following will be
informed.
a) Director
b) Head of Office
c) Treating doctor
4. The Head of office will initiate suitable action thereafter, as follows:

a) The next of kin of the patient will be immediately informed by telephone.
b) The patient will be discharged in absentia.
c) Police intimation will be done.
d) An inventory of the personal effects of the patient will be taken and the items will be sealed and
handed over to care taker for safe keeping. Aseparate register will be maintained by care taker
for this purpose.
23
Policy No:-CNBC/MLC/06
Prepared By QMD
2.22 Medico legal cases Policy: 2.22.4 Any documents/documentation concern

to MLC patient should be marked ‘MLC’
2.22.1 Any patients received under the below with red ink . MLC number to be written
mentioned situations to be added to in all the documents,.Including
MLC (Medico Legal Cases) admission, discharge & death register.
a. Accidents
b. Death occurring under suspicious conditions 2.22.5 MLC patients should not be
discharged/separated without the
c. Assault permission of HODs/Unit Heads/CMO.
d. Burns
2.22.6 In the absence of CMO, SR on duty in
e. Poisoning
emergency ward will be informed by
nursing staff.
f. Brought Dead
2.22.7 All separation/transfer to the other
g. physician develops a doubt on the patient’s
hospitals, discharge or death is also to
injury or death be informed to the above mentioned
officers who can inform police through
proper channel.
2.22.2 CNBC has one MLC reporting register 2.22.8 All investigation reports and evidential
which is available in the Emergency materials are to be preserved. Staff
Ward . nurse on duty will be responsible to
ensure preservation till separation and
2.22.3 Triplicate forms are filled and MRD after that.
information to police given by
CMO/Senior resident in Emergency 2.22.9 Any personal belongings to be
Ward. accounted and sealed& handed over to
. care taker.
24
Policy No:-CNBC/Brought in dead/07
Prepared By QMD
2.23 Brought in Dead Patient’s Policy
2.23.1 Definition
Brought in dead (B.I.D.)/Dead on arrival odour, resuscitation should not be
(DoA) is a term used to indicate that a patient attempted.
was found to be already clinically dead upon the
arrival of professional medical assistance.
b) ECG is taken before explaining to the
parents.
a) An emergency card is made for any
c) Parents are well explained about the
patient brought in, even if initial
condition of the patient when he/she
assessment shows doubt in vital signs.
was brought to emergency.
b) Every finding by doctor and nurse to be
d) Declareddead, body will be cleaned &
documented in the emergency card.
wrapped in mortuary sheet before
c) When presented with a pulse
handing over to the Next of Kin.
less patient, medical professionals are
e) Due respect will be given to the body
required to perform Cardiopulmonary
during handling.
resuscitation, it must be continued until
f) Death certificate and gate pass is
an ECG shows plain graph which is a
provided.
proof that a doctor can legally declare
g) In case the relative refuses to receive
the patient dead.
the body, MLC is to be initiated.
d) Maintain that life-saving efforts should
h) Body is handed over to the police and
be attempted on all patients to assure
send to LNJP mortuary.
parents that all possible actions were
i) This policy is applicable for any age
performed to save their child.
group.
e) Injuries like decapitation or other
catastrophic brain trauma, incineration,
severed body, and injuries that do not
permit effective administration of CPR &
obvious that the patient is non-viable.
2.23.2 Obvious decomposition.

a) General look indicating that the body
has been pulse less and in the same
position long enough for blood to sink
and collect within the body, creating
purplish discolorations at the lowest
points of the body (with respect
to gravity),and an extremely offensive
25
3 Inpatient Service (Pediatric Medicine)
Responsibility of Department of Pediatric Medicine

updating:
Last Reviewed August 2020

/updated on:
Version (CNBC/IPD/3/Ver.1.0)
26
3 Inpatient Service (Pediatric Medicine) ............................................................................................................. 26
3.1 Amendment sheet .................................................................................................................................... 28
3.1 Introduction .................................................................................................................................................... 29
3.2 Purpose: .................................................................................................................................................. 29
3.3 Scope: ...................................................................................................................................................... 29
3.4 Process: ................................................................................................................................................... 29
3.5 Patient Admission Policy ......................................................................................................................... 30
3.6 Shifting of Patient to the inpatient care facilities:- .................................................................................... 30
3.7 Discharge process ................................................................................................................................... 30
3.8 Death cases ............................................................................................................................................. 31
3.9 Policy: Medico legal cases....................................................................................................................... 32
27
3.1 Amendment sheet
S.No. Clause Date of Amendment Made Reasons of Amendments Sign of QM
No. Amendment
st
1. 3.3 1 July 2014 Discharge register At present single register is
replaced with admission used for admission and
and discharge register discharge documentation.
2. 3.7.2 26 Feb 2018 Discharge policy is To make more clear.

updated regarding
acknowledge by
patient’s relative.
28
3.1 Introduction:
It is a 134 bedded department distributed among 3 units. Wards are well equipped with all emergency
equipments. The senior Residents along with the junior Residents manage the patients. Consultants take
rounds of their respective units and proper documentation is made. Trained Nursing staff is present round
the clock who execute the treatment orders.
3.2 Purpose:
This policy relates to services to patients admitted in the hospital. It involves diagnostic work up, giving
right care, maintaining appropriate facilities for admitted patients.
3.3 Scope:
This policy is applicable to all patients admitted in the inpatient facilities of the hospital from the following
areas:
1. Out Patient Department
2. Emergency Department
3.1.3. Responsibility Persons:
Pediatricians, Resident doctors
3.4 Process:
3.4.1 Admission of Patient from Out Patient Department into inpatient ward
Patients are admitted from the Out Patient Department of the hospital if the treating Consultant/doctor
advises inpatient admission in writing. Patients are admitted if it is found that he is sick needing
hospitalization, or he needs further investigations and also observations that is not possible on OPD basis
or needs treatment that is not possible on OPD basis. All such patients advised admission are initially
admitted in the emergency ward; next day he is shifted to the inpatient wards.
3.4.2 Admission of patient from Emergency Department into the inpatient ward
All patients admitted into the emergency ward are shifted to the inpatient wards next day. Nursing orderly
accompanies all patients while being transferred to the inpatient wards. During shifting appropriate
measures are taken to prevent any untoward problems on the way; doctors accompany the patient with
oxygen and other tools if required. All admissions and transfers are made as pre instructions from
consultants/senior residents.
29
3.4.3 In Patient Registration process:-
1. All patients advised admission to the inpatient facilities of the hospital, are required to be
registered. Patient relatives are required to provide the following necessary information at the
registration counter: a. Name and ID number b. Father’s Name c. Age of the patient d.
Residential address
2. The above mentioned data are fed into the systems, patient registered and Patient Unique
Identification number (for new patients) and inpatient admission number is generated and patient
new case file made. Nurse on duty than made an entry of the patient in to the admission register
available in the emergency ward.
3.5 Patient Admission Policy

1. All patients requiring admission are admitted as per Delhi govt. policy.
2. While admitting patient in the inpatient facilities either from the Out Patient Department or the
Emergency Department, care is taken to ensure that patients are admitted if the required
treatment is available in the hospital.
3. Patients who cannot be admitted in the hospital due to non-
availability of bed, required medical care is given including first aid and immediately transferred to
any other hospital as per the wish of the patient /relatives.
4. General Consent is taken from all patients relatives at the time of admission of the patient.
3.6 Shifting of Patient to the inpatient care facilities:-

1. Before transferring the patients to the ward, nurse on duty enters the patient’s details in to the
discharge register & in the transfer book. Patient is shifted to the inpatient facilities accompanied
by a nurse or hospital attendant who also carry the transfer book. In case of serious patients, a
resident doctor accompanies the patient. Patient handed over to the concerned ward / ICU or OT
nurse along with the patient’s case record. The nurse on duty countersign in the transfer book
after receiving the patients. The on duty nursing staff in the respective inpatient facilities checks
the following information and enters the same in the admission register of the ward:
* Patient’s name
* ID number of patient
* Name of the Consultant
* Treatment details on patient file including doctors orders
2. Patient is shifted to the bed, made comfortable and treatment initiated. Ward Nurse records the
date, time, reasons for admission and the type of case in the patient admission/ discharge
register.
3. Patient is assessed at the earliest by treating consultant after getting admitted to ward.
3.7 Discharge process
3.7.1 The discharge process is initiated by the treating doctor who advices discharge. The doctor writes
a summary of the case on discharge card. The pediatricians countersign summary of the case
30
and hand over the discharge summary to the nurse on duty. The nurse enters the personal
information of the patient into the admission and discharge register and explains the content of
the discharge summary to the patient’s relatives. The nurse then hand over one copy of the
discharge summary to the patient’s relative and attaches another copy into the case sheet of the
patient. The above procedure is followed in cases of LAMA and DOR.
3.7.2 Signature of the patient relative ( name and relationship with patient ) to be taken in Admission
and Discharge Register under the heading of “Discharge summary received by” after proper
explanation and handing over of discharge slip to the patient’s relative.
3.8 Death cases

1. In case of patient’s death, death certificate is filled up by the doctor on duty and countersigned by
the pediatrician. The pediatrician then hands over the death certificate to the nurse on duty.
2. After entering the patient’s information in the admission and death register, the nurse hands over
one copy of the death certificate to the patient’s relatives and attaches another copy into the case
sheet of the patient.
31
Chacha Nehru Bal Chikitsalaya, Delhi
Policy No:-CNBC/MLC/06
st
Released on: 1 May 2008
Prepared By Dr.Anup Mohta
3.9 Policy: Medico legal cases
3.9.1 Policy: Refer Section 2.12
3.9.2 Flow Chart of the Registration Process:
Patient’s relative received at admission counter
Registration slip made by the admission counter staff.
Patient record file containing the registration slip, case papers and visitor
Passes are handed over to patient’s relative, who then hand over the case papers &
registration slip to nurse on duty in the emergency ward.
Nurse on duty makes an entry of the patient’s details into the admission register.
Before transferring the patients to the ward, nurse on duty enters the patient’s
details in to the admission and discharge register & in the transfer book.
Patient sent to ward along with the case record.
32
4 Pediatric Intensive Care Unit (PICU)
Responsibility of Department of PICU

updating:

Updated on:
Version (CNBC/PICU/4/Ver.1.2)
36
4 Pediatric Intensive Care Unit (PICU) ................................................................................................................ 36
4.1 Amendment Sheet ................................................................................................................................... 38
4.2 Introduction .............................................................................................................................................. 39
4.3 Services / Facilities at PICU .................................................................................................................... 39
4.4 Purpose of PICU: ..................................................................................................................................... 39
4.5 Scope of services: ................................................................................................................................... 39
4.6 Person Responsible ................................................................................................................................. 39
4.7 Admission of Patient to PICU from Emergency department ................................................................... 40
4.8 Admission of patient to PICU from inpatient department ........................................................................ 40
4.9 Patient admission Policy .......................................................................................................................... 40
4.10 Admission criteria to level 3 care PICU ................................................................................................... 41
4.11 Admission criteria to level 2 care (step down / High dependency PICU) ................................................ 43
4.12 Discharge / Transfer Criteria.................................................................................................................... 43
4.13 Death ....................................................................................................................................................... 44
4.14 Flow Chart Registration Process: ............................................................................................................ 45
4.15 Policy for shifting out of patients from PICU for Diagnostic tests ............................................................ 46
4.16 Records Generated: ................................................................................................................................ 47
4.17 Quality Indicator of PICU ......................................................................................................................... 47
4.18 Infection Control Practices in PICU ......................................................................................................... 48
4.19 Staff and equipment................................................................................................................................. 48
4.20 Training of staff ........................................................................................................................................ 49
4.21 Restraint Policy: ....................................................................................................................................... 49
4.22 End of Life care: - .................................................................................................................................... 49
4.23 Vulnerable Patient: - ................................................................................................................................ 49
37
4.1 Amendment Sheet
S.No. Clause No. Date of Amendment Made Reasons of Amendments Sign of QM
Amendment
1 4.3 1st July 2014 Addition of Previously not mentioned
services/facilities at
PICU
2 4.17 1st July 2014 Addition of departmental Previously not mentioned
Quality indicators
3. 4.18-20 August 2020 Infection control Previously not mentioned

practices, Staff and
equipment, Training
38
4.2 Introduction 4.4 Purpose of PICU:
4.2.1 The Pediatric intensive care unit at CNBC 4.4.1 The purpose of this policy is to provide
is an integrated team comprising doctors, Secondary care services to the community
nurses and the allied health professionals. admitted in CNBC with the aims that:
4.2.2 The Service is divided into two groups i.e. 4.4.2 Patients can receive the level of care
- pediatric intensive care – level III appropriate for their condition.
(tertiary) and level II (step down/high
dependency unit) 4.4.3 Utilization of PICU can be optimized
4.3 Services / Facilities at PICU 4.4.4 Patients satisfaction in enhanced for

continuous improvements.
4.3.1 CNBC, PICU is 12 bedded units. Patients 4.5 Scope of services:

from all over Delhi, NCR and western U.P
are treated. 4.5.1 This policy is applicable to all patient
Transferred / Admitted to PICU from
4.3.2 PICU has 7 ventilators with the facility to following areas:
monitor vitals Through Multiparameter 6 1. Emergency Department
channel monitors, & also NIBP, intra
arterial BP (IBP), CVP monitoring. AED 2. Wards/ Inpatient Department
(Automated external defibrillator), Wall
mounted Suction and portable suction
machines. Crash cart, Manual Defibrillator,
infusion pumps and emergency oxygen 4.6 Person Responsible
cylinder.
4.6.1 Treating consultant, Medical officer,
4.3.3 In house 24 hr. services available for Residents and Nursing staff
ABG, bedside sugar monitoring.
4.6.2 Ancillary staff – ICU Technician
4.3.4 Follow up clinics of patients who were
admitted with critical sickness especially 4.6.3 Physiotherapist, Dietician, Radiographer,
who required artificial ventilation, who PICU at CNBC offers comprehensive
suffered asphyxias. intensive care 24 hours a day. Medical
officer who is Qualified Pediatrician with
4.3.5 Other programmes - good airway and pediatric advances life
 Research support skills and offer round the clock
 In service lecture programme for nursing service in PICU. Medical officer on duty
staff. call consultant In case of Critical situation
 Orientation of new staff. of patient apart from routine working hours
 Teaching of P.G. candidates. of CNBC and consultant attend the case.
39
4.7 Admission of Patient to PICU from Patient is transferred to PICU with proper
Emergency department escort of doctor and nursing staff and
detail Transfer summery, which includes
4.7.1 Patient presenting to emergency Patient identification / Registration detail.
department immediately evaluated by
emergency 4.8.1.1 Detailed history of patient.
4.7.2 Department staff and given initial 4.8.1.2 Clinical finding and Provisional / final
treatment and stabilized based on diagnosis.
evidence based medicine.
4.8.1.3 Details of treatment given.
4.7.3 If patient needs PICU care (between are
group of 29days of life to 12 years) then 4.8.1.4 All investigation done till date.
medical officer from emergency
department informs PICU medical officer 4.8.1.5 Course of patient during stay in ward.
regarding transfer of patient.
4.8.1.6 Reason for transfer to PICU.
4.7.4 Depending on the availability of bed in
PICU and proper indication of transfer, 4.9 Patient admission Policy
patient is transferred to PICU with proper Two level of PICU care are provided at CNBC –
escort of Medical officer/resident and
nursing orderly. A Transfer summery
which includes following information must
be sent with the patient -
4.7.4.1 Patient identification / Registration detail
4.7.4.2 Patient History noted.
4.7.4.3 Initial assessment/ Physical finding /

vitals recorded.
4.7.4.4 Preliminary diagnosis made and

treatment given.
4.7.4.5 If emergency blood / investigation

sample taken.
4.8 Admission of patient to PICU from

inpatient department
4.8.1 If patient admitted in inpatient department

at CNBC between age group of 29days
life to 12 Years, who subsequently needs
PICU care, medical officer of inpatient
department offers emergency
management to the patient and stabilizes
the patient and then inform medical officer
PICU regarding transfer of patient.
Depending on availability of bed in PICU,
40
4.9.1 Level 3 (Tertiary) care equipped with 4.10.2 Cardiovascular system
ventilator beds and other intensive care
facility. Patient with severs, life-threatening or unstable
cardiovascular disease. Conditions
4.9.2 Level 2 (Step down / high dependency include, but are not limited to:
unit) care which is nearby in a separate
area. 4.10.2.1.1 Shock,Post cardiopulmonary
resuscitation, Life threatening
dysrhythmias, Uncontrolled congenital
heart failure with or without the need
4.10 Admission criteria to level 3 care PICU
for mechanical ventilation, Congenital
4.10.1 Respiratory system heart failure with uncontrolled cardio
respiratory status, After high- risk
1. Patient with severe or potentially life cardiovascular and intrathoracic
threatening pulmonary or airway disease. procedure
Conditions include, but not limited to-
4.10.3 Neurological
2. Endotracheal intubation or potential need
for emergency endotracheal intubation 1. Patient with acute or potential life
and mechanical ventilation, regardless of threatening or unstable neurological
etiology (priority given to salvageable disease. Conditions Include but are not
patient) limited to-
3. Rapidly progressive pulmonary, lower or 2. Seizure unresponsive to therapy or

upper airway disease of high severity requiring continuous infusion of
with risk of progression to respiratory anticonvulsive agent.
failure.
3. Acutely and severely altered sensorium
4. Acute barotraumas compromising the where neurological detoriation or
upper or lower airway. depression is likely or unpredictable or
coma with the potential for airway
Compromise.
4. Acute inflammation and infection of the

spinal cord, meninges or brain with
neurologic depression, metabolic and
hormonal abnormalities and respiratory
or hemodynamic compromise or the
possibility of increased intracranial
pressure.
5. Progressive neuromuscular dysfunction

with or without altered sensorium
requiring cardio vascular monitoring and /
or respiratory support.
6. Spinal cord compression or impending

compression.
41
4.10.4 Hematology / Oncology 4.10.7 Gastrointestinal
4.10.5 Patients with life threatening on unstable 1. - Severe acute gastrointestinal bleeding
hematologic an oncologic disease and leading to homodynamic or respiratory
active life threatening bleeding. Conditions
include, but are not limited to. Severe 2. -Instability.
coagulopathy, Severe anemia resulting in
haemodynamic and / or respiratory 3. -After emergency endoscopy for removal
compromise. of foreign body
..
4. -Acute hepatic failure leading to coma,
4.10.6 Endocrine / Metabolic homodynamic or respiratory instability.
1. Patient with life threatening and unstable
endocrinal and metabolic disease.
4.10.8 Others
Conditions Include but are not limited to-
1. -Renal failure
2. Severe diabetic ketoacidosis requiring
intensive therapy. 2. -Acute poisoning with potential acute
decompensation of major organ systems.
3. Other electrolyte abnormality such as:
3. -Multi organ dysfunction syndrome.
4. Hyperkalemia, requiring cardiac
monitoring and acute therapeutic
intervention.
5. -Severe hypo- and hypernatremia.
6. -Hypo-and Hyperglycemia requiring

intensive monitoring.-
7. -Hypo – Hyperglycemia requiring intensive

monitoring.
8. -Severe metabolic acidosis requiring

bicarbonate Infusion, intensive monitoring
and complex interventions.
9. -Complex interventions required to

maintain fluid balance.
42
4.11 Admission criteria to level 2 care (step 4.12 Discharge / Transfer Criteria
down / High dependency PICU)
4.12.1 Patients in the PICU will be evaluated and
4.11.1 The usual admission criteria to level 2 considered for discharge based on the
care are. reversal of the disease process or
resolution of the unstable physiologic
1. All ward patient requiring close condition that prompted admission to the
monitoring due to potentially unstable unit, and it is determined that the need for
conditions. complex intervention exceeding general
patient care unit capabilities is no longer
2. Croup (laryngo- tracheo bronchitis) needed.
requiring oxygen.
4.12.2 Transfer / discharge will be based on the
3. Asthma requiring hourly nebulization / following criteria:
mental status change. 1. Stable hemodynamic parameters.
4. All patient requiring more than 50% 2. Stable respiratory status (patient extubated
oxygen to maintain saturation. with stable arterial blood gases) and airway
patency;
5. Severe Dehydration with mental
status change. 3. Minimal oxygen requirements (<50%)
6. Patients with episode of apnea. 4. Intravenous ionotropic support,
vasodilators, and anti arrhythmic drugs are
7. Patients recovering from critical
no longer required or, when applicable, low
illness (Level 3 care), but requiring
doses of these medications can be
close monitoring.
administered safely in otherwise stable
patients in a designated patient care unit;
5. Cardiac dysrhythmias are controlled;
6. Neurological stability with control of

seizures;
7. Removal of all hemodynamic monitoring

catheters;
8. Chronically mechanically ventilated patients

whose critical illness has been reversed or
resolved and who are otherwise stable may
be discharged to a designated patient care
unit that routinely manages chronically
ventilated patients, when applicable, or to
home;
9. Routine peritoneal or hemodialysis with

resolution of critical illness not exceeding
general patient care unit guidelines;
43
10. The health care team and the
patient’s family, after careful assessment,
determine that there is no benefit in
keeping the child in the PICU or that the
course of treatment is medically futile.
4.13 Death
4.13.1 In the event of death of an inpatient/, SR

will verify the cause of death with the
concerned consultant/ consultant on call.
4.13.2 Death certificate will be issued by the SR.
4.13.3 No Death certificate will be issued by the

SR without consultation.
4.14 Refusal policy
4.13.1 If PICU bed strength is full, with no

possibility of vacancy to accommodate further sick
patients, the parents are to be given option to try
and seek PICU facilities in other Government
facilities with guidance and summary about
patients’ updated condition from PICU SR under
supervision of consultant.
4.13.2 If child is critically ill due to a condition that

requires intervention by superspecialities currently
not available in CNBC- cardiac surgery, trauma,
neurosurgery, transplant etc.
Such child may be referred to higher centre for

superspeciality care under supervision of
Consultant PICU.
44
4.14 Flow Chart Registration Process:
Patient’s relative directed to admission counter
Admission slip filled by the registration counter staff
Relatives sign consent for admission for not keeping any

valuables with them.
Patient record file containing the registration slip, admission

form, case Papers and visitor passes over to attendant
patient shifted to PICU if indicated after stabilization in

emergency ward
High risk consent taken and prognosis explained to attendants.
45
4.15 Policy for shifting out of patients from PICU for Diagnostic tests
Investigation ordered by consultant and

Requisition form given
Appointment time and date with the diagnostics is fixed with the
specific centre
Stable patient Unstable patient
* Requisition letter with patient

details collected accompanying * Requisition letter with patient
the patient details collected accompanying the
patient
* Ambulance equipments to be * Ambulance driver to shift the patient from the

checked, drugs to be checked. unit to ambulance in the ambulance trolley.
* Junior resident to accompany the * Unstable patient will be accompanied by
patient Senior resident.
* Ambulance equipments to be checked, drugs
to be checked before leaving to centre.
Shift the patient
46
4.16 Records Generated:
4.16.1 - PICU Admission Register. (Maintained by nursing staff)
4.16.2 - PICU Admission Register (Maintained by doctor)
4.16.3 - PICU culture registrar (Maintained by doctor)
4.16.4 - Patient Case file
4.16.5 - Investigation requisition form
4.16.6 - Inpatient Admission request form
4.16.7 - Informed Consent form
4.16.8 - Patient feedback form.
4.17 Quality Indicator of PICU
4.17.1 Readmission in PICU within 48 hours of discharge/transfer.
4.17.2 Re-intubation within 48 hours of extubation.
4.17.3 Crude Death rate.
4.17.4 Accidental removal of tubes and catheter.
4.17.5 Outcome of ventilated patients.
4.17.6 Critical equipment downtime.
4.17.7 PICU mortality rate
4.17.8 VAP rate
47
4.18 Infection Control Practices in PICU
4.18.1 Detailed Infection control practices related to Critical areas(ICU) are mentioned in HIC manual.
But some are listed here.-
4.18.2 Standard precautions all the times practiced in ICU by all personel
4.18.3 Each shift cleaning,Dusting,Bed making,Carbolization are done
4.18.4 All VAP,CAUTI ,Invasive lines bundles followed by staff.
4.18.5 KPI by HIC team captured,analyzed.
4.18.6 Training to staff about infection control practices done.
4.19 Staff and equipment
4.19.1 Adequate staff and equipment available in PICU so that ventilated patient :Nurse ratio=1:1,and
Non ventilated: nurse ratio (4:1).
4.19.2 Equipment available-Ventilators,Multi para Monitors,Defibrillators,ABG machine,Biosafety

cabinet,Isolation room,Invasive lines,Air mattress,Oxygen and air pipeline etc.
4.19.3 Infrastructure and equipment is upgraded with the scope and complexities of functioning and with
requirement.
4.19.4 4 Staff is trained as soon new equipment comes to PICU.
4.19.5 5 All equipment is under AMC/PMC. They are calibrated annually.
48
4.20 Training of staff
4.20.1 SOPS of PICU
4.20.2 End of life care
4.20.3 Restraint policy
4.20.4 Counseling policy
4.20.5 Infection Control policy
4.20.6 Quality assurance of PICU
4.20.7 All codes especially code blue and BLS and ACLS of pediatric age group
4.20.8 Vulnerable age group care and SOPS
4.21 Restraint Policy: - Please refer 28.26, Hospital wide policies
4.22 End of Life care: - Please refer 28.20, Hospital wide policies
4.23 Vulnerable Patient: - please refer 28.24, Hospital wide policies
49
5 Neonatal Intensive Care Unit (NICU)
Responsibility of Department of NICU

updating:

updated on:
(CNBC/NICU/5/ver.1.2)
50
5 Neonatal Intensive Care Unit (NICU) .............................................................................................................. 48
5.1 Amendment sheet .................................................................................................................................... 50
5.2 Introduction .............................................................................................................................................. 51
5.3 Services / Facilities at NICU .................................................................................................................... 51
5.4 Other programmes - ................................................................................................................................ 51
5.5 Neonatal services: ................................................................................................................................... 51
5.6 Functions: ................................................................................................................................................ 51
5.7 Purpose: .................................................................................................................................................. 51
5.8 Scope: ...................................................................................................................................................... 51
5.9 Process: ................................................................................................................................................... 51
5.10 Admission policy for NICU II:................................................................................................................... 52
5.11 Policy in case of unavailability of ventilator for new admissions: ............................................................ 52
5.12 Policy in case of unavailabilty of ventilator for admitted patient: ............................................................. 52
5.13 Policies of NICU Services: ...................................................................................................................... 52
5.14 Equipment and Supplies: ........................................................................................................................ 52
5.15 Shifting of Patient to the NICU ................................................................................................................ 52
5.16 Flow Chart of the Admission Process: .................................................................................................... 54
5.17 Records Generated ................................................................................................................................. 55
5.18 Pink band policy- ..................................................................................................................................... 55
5.19 Policy to admit patients from other hospitals: .......................................................................................... 55
5.20 Policy for shifting out of patients from NICU for Diagnostic tests ............................................................ 56
5.21 Crash card policy- ................................................................................................................................... 57
5.22 Discharge policy ...................................................................................................................................... 57
5.23 Policy for Transfers Out Of or Into Intensive Care Units ......................................................................... 57
5.24 Death ....................................................................................................................................................... 58
5.25 Policy for availability of KMC beds in NICU: ........................................................................................... 58
5.26 Management of patient during non-availability of bed in NICU ............................................................... 58
51
5.1 Amendment sheet
S.No. Clause Date of Amendment Made Reasons of Sign of QM
No. Amendment Amendments
1. 5.6.1 July2014 Editing in person responsible For more clarification
2. 5.13 July 2014 Addition of departmental Quality Previously not

indicators mentioned
3. 5.3 Dec 2014 Change in the facilities available As per Hospital
at NICU requirements
4. 5.10 Dec 2014 Admission policy for NICU II Previously not
mentioned
5. 5.11 Dec 2014 Policy in case of unavailability of Previously not
ventilator for new admissions: mentioned
6. 5.12 Dec 2014 Policy in case of unavailability of Previously not

ventilator for admitted patient mentioned
7. 5.18 Dec 2014 Addition of Pink band policy Previously not
mentioned
8. 5.20 Dec 2014 Crash card policy- Previously not
mentioned
9. 5.24 Dec 2014 Policy for availability of KMC Previously not
beds in NICU mentioned
10. 5.3.11 Dec 2015 Previously not
Services / Facilities at NICU are mentioned
updated with It has been
accreditated as level IIIA by
National Neonatology of forum It
11. 5.15.4 Dec 2015

Patient attendant will be To update the policy
counseled after admission and of Shifting of Patient
daily after consultant rounds to the NICU
and signature will be taken from
patients on a patient information
communication sheet.
12. 5.19 Dec 2015
Policy to admit patients from Previously not
other hospitals: mentioned
52
.
5.2 Introduction
5.2.1 The Neonatal services at CNBC is an 5.6 Functions:

integrated team comprising doctors, nurses Provision of comprehensive neonatal services of the
and the allied health professionals. highest standards to the hospitals and its patients &
5.2.1.1 The Service is divided into two groups i.e. - to referrals from the state as a whole, by
Neonatal intensive care – level III and development and maintenance of exemplary clinical
neonatal special Care (SCBU I and II) and nursing practice including consulting, teaching
and research
5.3 Services / Facilities at NICU
5.7 Purpose:
5.3.1.1 CNBC, NICU is 35 bedded out born NICU.
It has been accreditated as level IIIA by The purpose of this policy is to provide secondary &
National Neonatology of forum It caters tertiary care services to the community admitted in
patients from all over the Delhi, NCR and CNBC with the aim to provide immediate relief and
western U.P. special care to LBW, VLBW and special group of
population.
5.3.1.2 At NICU we have 1 High frequency
Ventilator, 5 ventilators and 6 CPAP
machines with the facility to monitor vitals 5.8 Scope:
Through Multipara 6 channel monitors, & This policy is applicable to all patients admitted in
also NIBP monitoring. the inpatient facilities of the hospital from the
following areas:
5.3.1.3 In house 24 hr. services available for
bedside bilirubin and sugar monitoring. 1. Out Patient Department
5.3.1.4 24 hr emergency services available for
2. Emergency Department
hematological, and biochemical test, and
bed side radiological services.
5.8.1 Responsible Persons:
5.3.1.5 Laminar flow is available to prepare TPN & 1. Treating Consultant
other antibiotics aseptically. 2. Medical Officer
3. Nursing staff
5.3.1.6 High risk follow up clinics of babies below
1000 gms B.W., or<34 weeks, those who
required artificial ventilation or, who 5.9 Process:
suffered asphyxias.
5.9.1 Admission of Patient from Emergency
5.4 Other programmes - Departments of the Hospital
1. Research: ICMR programmes,thesis and 5.9.1.1 Patients brought to the Emergency
dissertationof DNB students. Department of the hospital by Ambulance
2. In service lecture programme for nursing or by other transport are received at the
staff. emergency entrance and immediately
3. Orientation of new staff. wheeled to the Emergency Department.
4. Teaching of P.G. candidates. The Casualty Medical Officer attends the
patient immediately and initiates treatment.
5.5 Neonatal services: Initial treatment is initiated in the following
Of the hospital comprises consultative, clinical, and process:
nursing care, together with integrated special 1. Patient History taken
(level II) and intensive (level III) care and neonatal
2. Vitals Signs taken and recorded
surgery.
53
3. Thorough examination of the 5. Security guards are appointed to guide the
patients undertaken patient’s caretakers and supervise the entry
and exit of people to avoid chaos in
4. Maintain the temperature, treat casualty.
hypoglycemia 6. Ambulance service is available 24 hrs a day
5.9.1.2 The consultant doctor/specialist of the 5.14 Equipment and Supplies:

required specialty is called over phone.
Patients details informed and consultant’s 5.14.1 The following equipment and supplies are
guidelines recorded. Patient is admitted in available in the NICU at all times:
the inpatients wards. Incase the consultant 1. Cardiac and respiratory monitoring
advice immediate transfer of the patient to equipment
NICU is initiated immediately by the 2. Laryngoscopes and endotracheal tubes
Medical Officer. The inpatient admission 3. Ventilators both conventional and high
request form is filled by the Medical Officer frequency.
which is countersigned by the concerned 4. CPAP machine
consultant within the next 24 hours. 5. Central oxygen supply
6. Central suction supply
5.10 Admission policy for NICU II: 7. Infant warmers with bassinet
8. Non invasive B.P. monitoring
5.10.1 All the neonates will be admitted to NICU I 9. Central C.V.P. monitoring
first and then after the clinical rounds of 10. Long lines
consultants patient will be shifted to NICU II 11. Infusion pumps
12. Splints
5.10.2 In case if any patient admitted to NICU II 13. Suction equipment
has clinical deterioration will be again shifted 14. Ventilator assistant equipment including
to NICU I. airways, bag valve device
15. ECG machine
5.11 Policy in case of unavailability of ventilator 16. Portable ABG machine
for new admissions:
In case if there is no bed available or ventilator 5.15 Shifting of Patient to the NICU
available the attendants of patient will be counseled
5.15.1 After decision is made to admit the patient in
and prognosticated and if they want, patient will be the inpatient facilities of the hospital, bed
shifted to some other hospital after proper availability confirmed, Consent is obtained
stabilization in a transport ambulance. from patient relatives, patient registered and
patient bed prepared, patient is shifted to the
5.12 Policy in case of unavailabilty of ventilator NICU along with the patient case record.
for admitted patient: The on duty nursing staff in the respective
Any neonate admitted to NICU Iif initially was not on inpatient facilities check the following
information:
ventilator but after some dayrequiring ventilation and
1. Checking patient name
if ventilator is not available in NICU then that patient
2. ID number of patient
will be shifted Back tocasulity with manual bag and 3. Reassessment done.
tube ventilation 4. Name of the Consultant
5. Treatment details on patient file including
5.13 Policies of NICU Services: doctors orders
1. NICU offers comprehensive emergency care
24hours a day.
2. Senior and Junior residents to be present
24hrs in the emergency.
3. Trained nursing staff to be on duty round the
clock
4. Consultants are available on call, after duty
hours
54
5.15.2 Patient is shifted to the bed, made
comfortable and treatment initiated. Ward
Nurse records the dated, time, reasons for 5.15.4 Patient attendent will be counselled after
admission and the type of case in the patient admission and daily after consultant rounds and
admission / discharge register. signature will be taken from patients on a patient
information communication sheet.
5.15.3 Patient is assessed within immediately by
treating consultant/SR after getting admitted
to NICU.
55
5.16 Flow Chart of the Admission Process:
Admission slip filled by the counter staff.
Relatives sign general consent & another consent which states

they have no valuables in possession
Patient record file containing the registration slip, admission
form, case Papers and visitor passes handed over to attendant
Shifted to NICU after stabilization in emergency ward.
High risk consent taken and prognosis explained to attendants.
56
5.17 Records Generated
5.17.1 Patient Case File
5.17.2 Investigation requisition form
5.17.3 Inpatient Admission Request form
5.17.4 General Consent and High Risk Consent form
5.17.5 Patient Admission/Discharge Register
5.17.6 Patient Transfer Register
5.18 Pink band policy-
5.18.1 For the security reasons both mother and baby were given same number of pink colored bands and only
mothers or attendants wearing pink bands are allowed to come inside the NICU. Pink bands only be
removed at the time of discharge by the security man of main gate and will behind over to NICU of
concerning area.
5.19 Policy to admit patients from other hospitals:
5.19.1 Patient will be given a chance to admit in NICU of CNBC if beds or ventilators are available, referral
hospital needs to send a written summary of all the treatment given to patient .patient will be called when
beds/ventilator are available in NICU and no other patients eligible for NICU are there in emergency as
CNBC.
57
5.20 Policy for shifting out of patients from NICU for Diagnostic tests
Investigation ordered by consultant and
Requisition form given
Appointment time and date with the diagnostics is fixed
Stable patient
Unstable patient

details collected accompanying
detail collected accompanying
the patient
the patient
* Ambulance driver to shift the patient

* Ambulance equipments to be
from the unit to ambulance in the
checked, drugs to be checked.
ambulance trolley.
* Junior resident to accompany the
* Unstable patient will be accompanied
Patient
by Junior resident
* Ambulance equipments to be checked,
drugs to be checked
Shift the patient
58
5.21 Crash card policy-
5.21.1 Few drugs which are not required for neonatal resuscitation like inj.Xylocard, are omitted from
crash cart trolly.
5.21.2 Postoperative patients- patients shifted from opertation theatre after any surgery will be shifted by
senior Resident of anaesthesia/surgery and in NICU patient will behandover to senior resident
NICU with all vital parameters of patient checked infront of senior Resident of Anaesthesia and
NICU.
5.22 Discharge policy
5.22.1 Babies breast or spoon feeds well
5.22.2 Adequate weight gain for 3 consecutive days
5.22.3 All acute problems have resolved
5.22.4 Babies birth weight preferably >1.5 Kg
5.22.5 Mother should be confident of managing the baby
5.22.6 Screening USG, ROP, metabolic profile and neurological examination have been recorded
5.23 Policy for Transfers Out Of or Into Intensive Care Units
5.23.1 All patients being transferred to wards or to the regular nursery from the Intensive Care Unit, Must
have a detailed transfer summary written on the chart at the time of transfer.
5.23.2 Transfer orders must include the service and specific attending name to whome the patient is
being transferred.
5.23.3 At the time the transfer order is completed, the house officer primarily responsible for the patient
in the PICU/ NICU must personally communicate with the senior house officer and attending who
will assume responsibility for this patient; the senior house officer shall then notify the PL-1.
5.23.4 When a patient is transferred from the ward or regular nursery to the Pediatric Intensive Care or
the Neonatal Intensive Care, a transfer summary should be written on the chart and direct
communication should occur between the transferring and receiving house officer and attending.
5.23.5 In both instances above, the house officer assuming the primary responsibility for the care of this
patient will be notified immediately by the Unit Clerk upon arrival of the patient to the floor/ unit.
5.23.6 At times, when things are extremely busy so that a thorough and complete transfer summary is
not practical, a brief note stating the major problems must be written and direct verbal
communication made with the resident to assume care. When things settle down, the resident
transferring the patient should write a more detailed transfer note.
5.23.7 Whenever possible, transfer from intensive care units to the ward or regular nursery, should be
accomplished as early in the day as possible.
59
5.24 Death
5.24.1 In the event of death of an inpatient/, SR will verify the cause of death with the concerned
consultant/ consultant on call.
5.24.2 Death certificate will be issued by the SR.
5.24.3 No Death certificate will be issued by the SR without consultation.
5.25 Policy for availability of KMC beds in NICU:
5.25.1 There are only 07 KMC beds in NICU.IIKMC beds are only given to those mother whose babies
are ready to shift out from NICU to KMC room and mothers need to give KMC and feeds their
baby for weight gain.
Policy No: CNBC/NICU
Released on: 18/02/2011
Prepared by: HOD NICU
5.26 Management of patient during non-availability of bed in NICU
5.26.1 Purpose: To manage the patient in case of shortage of bed in the NICU.
5.26.2 Scope: Emergency department and NICU
5.26.3 Responsibility: Doctors (Emergency and NICU) & Nurses.
5.26.4 Policy: In case beds are not available, patients are managed in the open care system in the
emergency department, where doctors from NICU will monitor the patients and infusion pump etc.
are made available to the patient till the bed is arranged in the NICU or patient is transferred to
the other hospital in case of non- availability of ventilator or beds.
60
6 Hemodialysis Unit
Created on: 2010
Responsibility of Updating: Department of Hemodialysis
Updated on December 2015
(CNBC/ Dialysis/6/ver.1.2)
Revision done on December 2019
Revision done on 23.08.2020
61
6 Hemodialysis Unit ............................................................................................................................... 61
6.1 Amendment Record Sheet .......................................................................................................... 63
6.2 Hierarchy of the Hemodialysis Unit ............................................................................................. 65
6.3 Job Responsibility: ...................................................................................................................... 65
6.4 Policy: .......................................................................................................................................... 65
6.5 Scope .......................................................................................................................................... 65
6.6 Purpose of policy ......................................................................................................................... 66
6.7 Procedure .................................................................................................................................... 66
6.8 Personnel .................................................................................................................................... 67
6.9 Patients ....................................................................................................................................... 67
6.10 Equipment and Supplies ......................................................................................................... 67
6.11 Disinfection Schedule for Hemodialysis: as per recommendation of the company ................ 69
6.12 Vascular Access for Hemodialysis .......................................................................................... 70
6.13 Diagnosis and treatment ......................................................................................................... 71
6.14 Dialyzer Reuse ........................................................................................................................ 71
6.15 Anticoagulation ........................................................................................................................ 71
6.17 Reference: ............................................................................................................................... 72
62
S.no Clause Date of Amendment Reasons Sign

. no. Amendme Made Of of QM
nt Amendment
1. 6.9.1 25/3/13 Vaccination for Hepatitis B (HBV) in patients Not mentioned earlier
undergoing maintenance hemodialysis
2. 6.9.2 25/3/13 Serology repeated every 6 monthly For more clarification
3. 6.12 25/3/13 Change in disinfectants For more clarification
4 6.13.2 25/3/13 Change of antibiotic heparin lock from Organisms cultured are
(B) Injection Vancomycin to Injection Gentamicin pseudomonas in almost all
culture reports, sensitive to
Gentamicin
5 6.7.1.1 1/7/14 Addition of informed consent prior to the Earlier it was not mentioned
procedure
6 6.7.1.1 18/1/16 In addition to MOIC, any other trained doctor One more trained pediatric
may put hemodialysis catheter. Doctor writes nephrologist has joined
hemodialysis prescription after putting the recently, so dialysis unit has
catheter. now two pediatric
nephrologists.
7 6.8.7 18/1/16 All unvaccinated health care workers in High risk area
hemodialysis unit must receive complete
vaccination against hepatitis B (3 doses at
0,1 and 6 months), followed by anti-HbS titer
estimation after 1-2 month of last dose of
vaccine
8 6.12.2B 18/1/16 Catheter lock changed from vancomycin to All infections in hemodialysis
Gentamicin heparin combination unit during last 5 years were
due to gram negative
organisms.
9 6.9.2 15/12/17 ESRD patients on maintenance hemodialysis Tendency to fall in anti-Hbs
should have annual anti-HBs titer estimation. titer in ESRD patients on
Should receive a booster dose of HBV, if titer dialysis over time and high
becomes <10U/L. risk of HBV infection
10 6.5.1 12.07.19 Hemodialysis is performed in two shifts daily To meet the increased
from 8AM to 8 PM, except on Sundays and hemodialysis sessions
gazetted holidays. requirements with increasing
number of patients
11 6.7.1.1 12.07.19 Consent for hemodialysis procedure is valid

for maximum of 6 months duration; however,
the attendant endorses the consent at each
visit for hemodialysis.
12 6.4.1.1 23.08.202 Dialysis unit has 3 stations for hemodialysis. With procurement of two
0 There are five trained nursing staffs. new hemodialysis machines,
one more extra port has
been created from
distribution loop of existing
water treatment unit to
accommodate third
63
hemodialysis machine.
13. 6.5.1 23.08.202 In special circumstances, hemodialysis unit

0 opens even on Sundays/gazetted holidays to
meet dialysis requirements.
14. 6.10.2.1 23.08.202 All surfaces and equipment in the dialysis Practice of using 1%
0 unit are cleaned and disinfected with 1% hypochlorite as a surface
hypochlorite after each patient shift. For disinfectant after each
metallic surfaces; like door handles, keys etc patient shift has been started
are disinfected with 70% alcohol. during COVID-19 pandemic
13. 6.10.3.3 23.08.202 Water testing for microbiological Earlier, we used to do
0 contaminants (bacterial growth expressed in annual comprehensive water
CFU/ml and endotoxin level) are done on testing in addition to monthly
monthly basis. Comprehensive water testing; culture of water from
including chemical, microbiological and different points of water
endotoxin test are done once in a year. treatment unit. Endotoxin
level on monthly basis has
been started since February
2020.
64
6.2 Hierarchy of the Hemodialysis Unit
M.O. I/C
Dialysis unit
Trained Staff Dialysis

Nurse Technician
Nursing Orderly
6.3 Job Responsibility: 6.3.3 Technician:
6.3.1 M.O. In-charge: 1. Maintenance and disinfection of
1. Selection of patients for hemodialysis. hemodialysis machine
2. Cleaning and disinfection of R.O. System.

2. Vascular access for hemodialysis or
plasma exchange (femoral or internal
jugular vein) 6.4 Policy:
3. Writing hemodialysis prescription 6.4.1 Strength
6.3.2 Staff Nurse: 6.4.1.1 This unit of CNBC has 3 hemodialysis

1. Connect and disconnect the patient with stations with 250 L capacity of water
Hemodialysis machine. treatment unit, five trained nursing
staffs, one dialysis assistant and two
2. Monitoring of vital parameters.
pediatric nephrologists.
3. Administration of Medication.
6.5 Scope
4. Withdrawal of blood samples
6.5.1 This unit provides hemodialysis facility
5. Data recording and maintenance to patients (≤ 12 years old) admitted
65
with acute renal failure and maintenance 6.6 Purpose of policy
hemodialysis in patients with end stage
6.6.1 The purpose of this policy is to optimize
renal disease (ESRD) awaiting renal
the treatment and minimize the risk of
transplantation or alternative modality of
the transmission of infections from
dialysis like continuous ambulatory
patient to patient and between patients
peritoneal dialysis (CAPD).
and employees.
Hemodialysis is performed in two shifts
daily from 8 AM to 8 PM, except on
6.7 Procedure
Sundays and gazetted holidays. Under
special circumstances hemodialysis 6.7.1 Initiation of Hemodialysis
unit is opened on Sundays/gazetted
6.7.1.1 MOIC of pediatric hemodialysis unit or
holidays to meet the dialysis need of
any other trained doctor inserts
enrolled patients. We do not provide
hemodialysis catheter under all aseptic
hemodialysis facility for walk in patients.
precautions. Most preferred site is femoral
Patients coming for maintenance
vein followed by right internal jugular vein,
hemodialysis are admitted in Dialysis
left internal jugular vein and subclavian
unit as a short admission and
vein. If there is a future plan of creation of
discharged on same day with advice to
AV fistula, subclavian route is avoided
come for hemodialysis on next allotted
because of risk of subclavian vein stenosis.
date. Case sheet of the patient with a
Informed consent of attendant is taken
copy of discharge is sent to MRD,
before insertion of catheter and initiation of
whereas a copy of hemodialysis record
hemodialysis.
performa is retained in the hemodialysis
unit to be kept in patient’s folder. Consent for hemodialysis procedure is valid for
maximum of 6 months duration; however, the
6.5.2 Therapeutic plasma exchange is also
attendant endorses the consent at each visit for
done by membrane plasma separation
hemodialysis. After catheterization, doctor
(MPS) utilizing highly permeable hollow-
writes a prescription for the patient undergoing
fiber filters and appropriately modified
hemodialysis in a predesigned hemodialysis
dialysis equipment.
record performa.
6.5.3 Patients with HBsAg, HCV and HIV
6.7.1.2 Trained nursing staff is responsible for
positive report are not dialyzed as we
connecting patients to the
don’t have a separate machine for these
hemodialysis machine and
patients. These patients are referred to
discontinuing dialysis.
LNJP hospital where separate machine
for these patients are available
66
6.7.1.3 Dialysis assistant is responsible for 6.8.7 All staffs working in hemodialysis unit
initiation and termination of must receive vaccination against
hemodialysis, cleaning and hepatitis B, followed by documentation
disinfection of hemodialysis machines of anti HBsAb titer in protective range.
and water treatment unit.
6.9 Patients
6.8 Personnel
6.9.1 Patients undergoing hemodialysis must
6.8.1 Proper hand washing technique is have an HBsAg, anti HCV Ab and HIV
essential before and after contact with serology drawn prior to initiation of
the patients and as necessary. hemodialysis.
6.8.2 Personnel must not eat or drink in 6.9.2 All dialysis patients will have HBsAg,
dialysis treatment area. anti HCV Ab and HIV serology repeated
every six monthly. Annual anti-HBs titer
6.8.3 Personnel will wear disposable gloves at
estimation will be done in children on
all times when handling blood, blood
maintenance hemodialysis. Children
products, or patient secretions.
with titer<10mu/ml will receive a booster
dose of HB vaccine, followed by repeat
6.8.4 During the dialysis procedure gloves
titer estimation after 1-2 months. Blood
should be worn even when taking blood
counts, renal function tests, calcium,
pressure, injecting heparin or antibiotics,
phosphorous, alkaline phosphatase and
or starting IV fluids. Personnel should
lipid profile are done monthly. Serum
never touch surfaces with gloved hands
paratharmone (PTH), ferritin, folate and
that will subsequently be touched with
vitamin B12 levels are done every three-
ungloved hands before being
six monthly.
disinfected.
6.9.3 In case the child develops chills with

6.8.5 Staff shall wear gloves, face masks, and
fever during dialysis, blood samples for
aprons during blood draw, initiation, and
culture are sent from catheter site and
termination of hemodialysis.
peripheral vein.
6.8.6 Personnel exposures to blood or blood
6.10 Equipment and Supplies
products by needle sticks, cuts,
contamination of mucous membranes or
6.10.1 Disposable Equipment and Supplies:
eyes are to be reported to infection
control nurse (ICN). An Incident Form
must be completed as per hospital
policies.
67
6.10.1.1 All disposable equipment that has 6.10.2.3 After each use, all dialysis machines
come into contact with blood or blood will undergo heat disinfection, as per
products will be considered infectious the contracted company’s Heat
waste and disposed of by gloved Disinfection policy.
personnel. Items should be bagged,
6.10.2.4 Clamps, scissors, and other non-
and then discarded in the infectious
disposable items should not be used
waste container.
for more than one patient unless they
6.10.1.2 All used disposable tubing and have been appropriately disinfected.
disposable dialyzers will be removed
6.10.2.5 All counter tops will be cleaned with
and discarded by dialysis assistant
1% hypochlorite solution after each
after patient use as described above in
patient shift. Daily room cleaning will
Section 6.10.1.1.
also be provided by Housekeeping
6.10.1.3 Contaminated needles and syringes Services.
will be disposed of in rigid, puncture-
6.10.3 Specimen Collection and Handling
proof containers.
6.10.3.1 Extreme caution must be employed

6.10.2 Non-disposable Equipment and
when drawing blood for laboratory
Supplies:
testing. Gloves and face masks will be
6.10.2.1 All equipment maintenance is worn while drawing specimens.
performed by the contracted company.
6.10.3.2 Blood spills will be cleaned
Dialysis machine is surface cleaned
immediately with a 1:10 solution of
with hospital approved disinfectant
bleach/water. During cleaning, gloves
solution after each session of
will be worn.
hemodialysis. All surfaces and
equipment in the dialysis unit are
cleaned and disinfected with 1%
hypochlorite after each patient shift.
For metallic surfaces; like door
handles, keys etc are disinfected with
70% alcohol. Gloves will be worn
during the cleaning procedure.
6.10.2.2 All dialysis machines will undergo

testing as per the contracted
company’s policy prior to initiation of
hemodialysis.
68
6.10.3.3 Bacterial monitoring of water for 6.11.5 Disinfection of product water storage
preparing dialysis fluid and dialysate tank and distribution system with
st
fluid are collected and sent to puresteril/hypochlorite: 1 week of
Microbiology department on a monthly every month.
basis. Water testing for microbiological
6.11.6 Culture of water from various sites (
contaminants (bacterial growth
product water, storage tank) and
expressed in CFU/ml and endotoxin
st
dialysate: 1 week every month.
level) are done on monthly basis from
an outsourced laboratory.
6.11.7 Washing Biocarbonate container: After
Comprehensive water testing;
every dialysis.
including chemical, microbiological
and endotoxin test are done once in a 6.11.8 Carbolization of Hemodailysis room:
year. Daily.
6.10.3.4 Specimens should be clearly labeled 6.11.9 Changing Cidex container: Every 14
and should include the following Days.
information: initials of person collecting
st
specimen, date, time, specimen 6.11.10 Washing of H.D. Room: 1 week every
source (i.e., dialysate fluid or dialysis month.
water), and the machine from which
6.11.11 Fumigation of H.D. Room with
the source was collected.
st
Ecoshield: 1 week every month.
6.11 Disinfection Schedule for
Hemodialysis: as per recommendation
of the company
6.11.1 Disinfection of HD machine with

puresteril: Every Tuesday & Friday.
6.11.2 Hot disinfection of HD machine with

citrosteril: After every dialysis.
6.11.3 Front cleaning of HD machine with

puresteril/hypochlorite: Every Monday.
6.11.4 Disinfection/ washing of R.O. inlet filter

of H.D. Machine with
puresteril/hypochlorite: Every Thursday.
69
6.12 Vascular Access for Hemodialysis 2. After each dialysis, catheter hubs or
blood line connectors should be
6.12.1 Temporary vs. Permanent
soaked in povidone iodine for 3-5
6.12.1.1 The necessity for vascular access in minutes. The catheter should be
patients with renal failure can be covered with a sterile dry dressing.
temporary or permanent. The B. Catheter locks- After patient is
necessity for temporary access may disconnected from hemodialysis
vary from several hours (single machine, each catheter port is locked
dialysis) to a few months (if used to with 1.5 ml of antibiotic heparin solution
dialyze while waiting for an (Gentamicin 4mg with heparin
arteriovenous [AV] fistula to mature or 2500IU/ml).
till renal transplantation is done).

C. Infection- Hemodialysis catheters
6.12.1.2 Temporary vascular access is created can be complicated by exit site
by percutaneous insertion of a infections, bacteremia and distant
catheter into a large vein (femoral, infections.
internal jugular or subclavian vein)

Prevention of infection
when immediate hemodialysis is
necessary. Many times this temporary 1. Aseptic insertion and handling of the
vascular access keeps on providing catheters
access for months or years until an 2. Minimize duration of catheter use
alternative modality of dialysis gets
available.
6.12.1.3 Permanent vascular access is created

by making arteriovenous (AV) fistula.
6.12.2 Care and use of venous catheters
A. Dressing-
1. During catheter connect and
disconnect procedures, both dialysis
staff and patient should wear surgical
masks. The lumen and catheter tips
should never remain open to air. A
cap or syringe should always be
placed on or in the catheter lumen
while maintaining a clean field under
the catheter connectors.
70
6.13 Diagnosis and treatment growth. Ideally the catheter should be
removed. In most of the cases where
6.13.1 Exit site infection- characterized by
catheter has been recently placed and
purulent discharge at the exit site with or
there is no evidence of exit site
without redness, pain, swelling and
infection, new catheter is placed on the
crusting. If there is erythema and/ or
same site over a guide wire. If catheter
crust but no purulent discharge, one can
has been there for more than 3 months
usually treat with local antibiotics. The
and patient develops clinical symptoms
catheter must be removed and
related with catheter related bacteremia,
parenteral antibiotics should be started if
new catheter is placed at different site.
systemic signs of infection develop
0
(leukocytosis or temperature>38 C), if 6.13.4 Distant infection- includes infection of
pus can be expressed from the tract of other sites in association with bacteremia such
the catheter, or if the infection persists as endocarditis, osteomyelitis, septic arthiritis,
or recurs after an initial local use of spinal abscess, septic pulmonary emboli,
antibiotics. myocardial abscess and septic death. It should
be treated with catheter removal and longer
6.13.2 Bacteremia- defined as positive
duration (6 weeks) of antibiotic therapy.
peripheral blood culture in a patient with
signs and symptoms of infection such as 6.14 Dialyzer Reuse
fever, chills, nausea, headache, After a dialyzer is used, it is rinsed with water to
hypotension and elevated white cell wash blood, disinfected with Renalin and then
count. Bacteremia is confirmed to be reused. One dialyzer is reused 3-4 times.
catheter related if no other source is
found and (1) the same organism is 6.15 Anticoagulation
cultured from the catheter, or (2) Needed to prevent clot formation in
symptoms rapidly resolve after catheter extracorporeal circuit during HD. Routine
removal. Heparin is used at the initiation of HD, dose 50
IU/ kg followed by 25 IU/Kg Hourly.
6.13.3 Treatment should be started promptly
after obtaining blood cultures, 6.16 Quality Assurance in Dialysis
empirically with injection Ceftazidime
1.Monthly Endotoxin testin
and Amikacin, which can be changed
later on depending on culture sensitivity 2. RO Water testing
report. Injections should be given post
3.Catheter related infection rate
dialysis and continued for 3 weeks.
Antibiotics should be discontinued
promptly if blood cultures had no
71
6.17 Reference:
1. Daugirdas JT, Blake PJ, Ing TS.

Handbook of Dialysis.Fourth edition.
Lippincott Williams & Wilkins.
2. Dialysis therapy. Nissenson & Fine.
Third edition. Henley & Belfus. An
imprint of Elsevier.
72
7 Department of Dermatology
st
Date created: 1 May 2008
Responsibility of Department of Dermatology

updating:
Last reviewed / updated August 2020

on:
Version (CNBC/Dermatology/07/1.1)

73
7 Department of Dermatology ................................................................................................................ 73
7.1 Amendment Sheet ...................................................................................................................... 75
7.2 Introduction:- ............................................................................................................................... 76
7.3 Hierarchy of the department........................................................................................................ 76
7.4 Department Timings .................................................................................................................... 76
7.5 Out Patient Department .............................................................................................................. 76
7.6 Scope of services ........................................................................................................................ 77
7.7 Special services .......................................................................................................................... 77
7.8 Special clinics .............................................................................................................................. 78
7.9 Policy of referral: ......................................................................................................................... 78
7.10 Policy during Covid 19 Pandemic ............................................................................................... 78

74
7.1 Amendment Sheet
S. Claus Date of Amendment Reasons Sign
no e No. Amendment Made Of of QM
. Amendment
1. 7.3 27th Deleted one junior resident for OPD work and added two assistant As some
Aug’2010 professors. changes in the
hierarchy have
been occurred.
2. 7.1 27th Added Introduction For more
Aug’2010 clarification
3. 7.5 27th Deleted the statement “The dermatology department of CNBC To make the
Aug’2010 caters to all kind of patients for skin problems” and added the things more
statement “ Outpatient consultation is offered to all pediatric specific and
patients who visits the hospital on working days from 9:00am- clear.
1:00pm”
4 7.6 27th Addition made: Various genodermatoses including congenital To make clear
Aug’2010 naevi. and detailed
Infectious diseases like bacterial and viral infections and cutaneous
tuberculosis
Papulosquamous disorders like psoriasis, lichen planus.
Childhood eczemas like atopic dermatitis, seborrheic dermatitis etc.
Skin changes at puberty.
Cutaneous emergencies like erythroderma, urticaria, toxic
epidermal necrolysis, drug hypersensitivity syndrome,
staphylococcal scalded skin syndrome
5 7.7 27th Deleted: patch testing with standard antigens and antigens for For more
Aug’2010 footwear dermatitis in cases with suspected contact dermatitis. clarification
Additions made:
Radiofrequency ablasions made for viral warts
Intralesional steroid injections
Needle extirpation for the molluscumcontagiosum and millia
Paring of corns and calluses
Vitiligo surgery (minipunch grafting, suction blister grafting, split
skin grafting) and chemosurgery by phenolisation.
Certain special procedures like electrocautery, nail surgeries, skin
biopsies are performed under local anesthesia after taking consent.
6 _____ 27th Deleted : Contact dermatitis with patch testing _______
Aug’2010 Atopic dermatitis clinic
7 7.9 27th Additions made: Confirmed leprosy cases after classification are For more
Aug’2010 reffered to LN Hospital for receiving multidrug therapy. clarification
Cases requiring management of medical problems are referred to
pediatric department.
Patients with large Keloids/ contractures are referred to dept. of
Burns and plastic surgery, LN Hospital.
8 7.3 Dec 2014 Addition of Staff nurse in Hierarchy of the department Previously not
added
9 Dec 2014 Expansion of Special services For more
clarification
10 7.3 March 2016 Correction in Hierarchy of the department For better
administrative
purposes
11 7.10 August 2020 Policy during Covid 19 Pandemic As per the
requirement of
Covid 19
preventions

75
7.2 Introduction:-
7.2.1 The Department of dermatology at CNBC takes care of all kind of pediatric skin disorders in the
children upto 12 years of age. This includes patient presenting in the OPD as well as admitted
patient requiring dermatological consultation.
7.3 Hierarchy of the department

a) Asst. Professors, Dermatology
b) Senior Resident in Dermatology
c) Staff nurse
d) Nursing orderly
7.4 Department Timings
7.4.1 Outpatient consultation is offered to all pediatric patients who visits the hospital on working days
from 9:00am- 1:00pm”. Special clinics, focusing on specific problems are run in the afternoon
from 2:00 p.m to 4:00 p.m
7.5 Out Patient Department
7.5.1.1 All new patients have to get registered from the central registration counter and acquire an OPD
card with registration number.
7.5.1.2 All follow-up patients also get registered at the Central Registration counter by simply
presenting their respective OPD cards.
7.5.1.3 All cross references from other Departments are seen in the OPD after registration in the central
registration counter.
7.5.1.4 The patients then report to the Outpatient Room No. 150.
7.5.1.5 Patients requiring certain special investigations (as detailed below) are referred to main
Laboratory, Room No. 145.
.

76
7.6 Scope of services
7.6.1 The Dermatology department at CNBC caters to skin, hair, nail and mucosal problems presenting
in children up to the age of 12 years. Apart from common skin problems, the skin problems in
children include:
7.6.2 Various Neonatal dermatoses
7.6.3 Various genodermatoses including congenital naevi
7.6.4 Atopic dermatitis
7.6.5 Infectious diseases like bacterial and viral infections and tuberculosis
7.6.6 Papulosquamous disorders like psoriasis, lichen planus.
7.6.7 Childhood eczemas like atopic dermatitis, seborrheic dermatitis etc.
7.6.8 Disorders of pigmentation like vitiligo, albinism
7.6.9 Skin changes at puberty.
7.6.10 Cutaneous emergencies like erythroderma, urticaria, toxic epidermal necrolysis, drug
hypersensitivity syndrome, staphylococcal scalded skin syndrome
7.6.11 Relevant history is taken from the informants and patients are thoroughly examined. Special
examination techniques like examination under magnification or with a wood’s lamp are done as
and when required.
7.6.12 Investigations which are routinely resorted to include examination of KOH preparations (for fungal
infections); Gram’s or Giemsa stain examination (for bacterial or viral infections); slit skin smear
(in cases with suspected leprosy); pus culture or routine hematologic investigations. For these the
patients are referred to Room No. 145 (Laboratory).
7.6.13 Depending on the diagnosis, patients are prescribed treatment and called for follow up. Some
cases may need to undergo a skin biopsy. Such patients are given the earliest appointment
(preferably, the same day).
7.6.14 Apart from diagnosing skin diseases and any associated internal problems for which appropriate
treatment is suggested, we also emphasize on patient education regarding basic skin care
especially in neonates. Patient education is also important in the prevention of spread of skin
infections like scabies and pyodermas and also in the care of children with atopic dermatitis.
7.7 Special services
7.7.1 Special services offered at CNBC include

a) Chemical cautery with trichloro-aceticacid
b) Electrocautery for viral warts, pyogenic granulomas and other skin growths.
c) Radiofrequency ablations made for viral warts
d) Intralesional steroid injections
e) Needle extirpation for the molluscumcontagiosum and millia
f) Paring of corns and calluses
g) Excision of larger skin growths.

77
h) Skin biopsies for diagnostic purposes
i) Incision and drainage for abcesses
j) Sclerotherapy with polidocanol for hemangiomas
k) Nail surgeries like nail avulsion, nail biopsies or treatment for ingrown toe nail.
l) Vitiligo surgery (minipunchgrafting, suction blister grafting, split skin grafting)
m) Certain special procedures like electrocautery, nail surgeries, skin biopsies are performed under
local anesthesia after taking consent.
n) Intralesionalbleomycin for palmar and plantar warts
o) Narrowband UVB phototherapy for vitiligo,psoriasis and other phototherapy responsive
dermatoses
7.8 Special clinics
7.8.1 The department also runs special weekly clinics wherein methodical records of response to
treatment and disease progression are maintained. These clinics focus on
a) Vitiligo and its response to topical and oral therapies
b) Cutaneous vascular malformations especially hemangiomas
7.9 Policy of referral:
7.9.1 Certain cases requiring surgical intervention for larger growths and larger abscesses are referred
to Department of Pediatric Surgery.
7.9.2 Cases requiring management of medical problems are referred to pediatric department.
7.9.3 Patients with large Keloids/ contractures are referred to dept. of Burns and plastic surgery, LN
Hospital.
7.9.4 Confirmed leprosy cases after classification are referred to LN Hospital for receiving multidrug
therapy.
7.10 Policy during Covid 19 Pandemic
7.10.1 Required PPE to be used by examiner.
7.10.2 One patient relative is allowed only with one patient inside OPD room.
7.10.3 Hand hygiene is to be strictly performed in between the patients..

78
8 Department of Pediatric Surgery
st
Date created: 1 May 2008
Responsibility of Department of Pediatric Surgery

Updating:

on:
Version (CNBC/ Ped.Surgery/08/1.1)
79
8 Department of Pediatric Surgery 79
8.1 Amendment sheet 81
8.2 Introduction:- 82
8.3 Scope of Services: 82
8.4 Policy 83
8.5 Admission Policy for Department of Pediatric Surgery, CNBC 84
8.6 Policy on Appointments for Surgery: 85
8.7 Preoperative Care 86
8.8 On the morning of surgery 86
8.9 Post-Operative Care 87
8.10 Immediate recovery period 88
8.11 After the patient is settled 88
8.12 Day Care Surgery 89
8.13 High Dependency Unit 89
8.14 Criteria of shifting to and from Operation Theatre 90
8.15 Quality Indicator 90
80
8.1 Amendment sheet
S.No. Clause No. Date of Amendment Made Reasons of Sign of QM
Amendment Amendments
st
1. 8.7 1 July 2014 Modification of informed To standardize
consent the process
st
2. 8.15 1 July 2014 Addition of Previously not
departmental Quality mentioned
indicators
3. 8.15 August 2020 List of Quality indicator revised

revised
81
8.2 Introduction:-
8.2.1 Department of Pediatric Surgery is a 46 bedded unit including a six bedded high dependency unit
which admits patients requiring surgical interventions. The patients requiring routine and
emergency surgery are admitted in the Department. Senior and junior residents of the department
provide round the clock services under the guidance of the consultants. Fully trained nursing staff
provides nursing care to the patients. The residents also provide care to the patients referred
from other departments of the hospital.
8.3 Scope of Services:
8.3.1 To provide out-patient services to all the patients requiring surgical consultation.
8.3.2 To provide emergency surgical care to all the patients attending the emergency department of
CNBC except cardiac, neurosurgical ,multitrauma and burns management. Primary resuscitation
will be done in such cases and transferred to a centre with such facilities to manage these cases.
8.3.3 To perform all surgical procedures in children in age group 0-12 years except neurosurgery,
plastic surgery, polytrauma (multi trauma) and cardiac surgery, case older than 12 years maybe
admitted if on follow-up of the hospital till 14years of age.
8.3.4 To provide post-doctoral education in the form of DNB/MCh (Pediatric Surgery)
8.3.5 To provide training in Pediatric Surgery to nursing students.
8.3.6 To provide in-service training to doctors, nursing personnel and paramedical staff in essential
surgical care.
8.3.7 To perform research and publish scientific publications.
82
8.4 Policy
8.4.1 Policy for Patient Attending the Out Patient
8.4.2 All new patients will acquire an OPD card with registration number from the central registration
counter.
8.4.3 All follow-up patients will be examined in the OPD after getting registered in the Central
Registration counter.
8.4.4 All cross references from other Departments will be seen in the OPD after registration in the
central registration counter.
8.4.5 They will report to the Out-patient Rooms 132/136 in turn as the series number given to them by
a nursing orderly soon after their registration. All the patients will be seen according to this
number on fist come first serve basis.
8.4.6 All cases will be seen by the residents/consultants.
8.4.7 Decision for any major surgical intervention will be ratified by the Consultant.
8.4.8 Any minor surgical procedure- dressing, suture removal, incision and drainage etc. will be
performed in the Minor OT, Room No. 151 by the resident.
8.4.9 All medicines available in the hospital will be given from the hospital pharmacy.
8.4.10 All investigations will be done in the hospital. Patients requiring any investigation not available in
the hospital will be referred to the LN/GB Pant Hospital or other hospitals as necessary.
83
8.5 Admission Policy for Department of Pediatric Surgery, CNBC
8.5.1 All the patients under Pediatric Surgery will be admitted in the Pediatric Surgery ward located at
Vth floor of the ward block.
8.5.2 The patients who have been given appointment will be admitted from the Out-patient Department
on the advice of Consultant.
8.5.3 Routine cases will undergo a review pre-anesthetic checkup before admission.
8.5.4 Emergency admission will be done in the pediatric surgery ward on the advice of the consultant in
the routine hospital hours and by the Resident on duty after consultation with the Consultant –on-
call on the day.
8.5.5 Emergency admissions will have the management plan reviewed by the consultant within 24
hours of admission.
8.5.6 Patients requiring urgent emergency surgical procedure under general anesthesia after routine
working hours will be referred to another government hospital where facilities are available.
8.5.7 Patients who do not require immediate emergency surgical procedure will be admitted,
investigated and stabilized and surgery will be performed at the earliest possible time.
8.5.8 After admission form the OPD/Emergency, patient will go to the Admission facility and get
admission card prepared.
8.5.9 Thereafter they will go to the Pediatric Surgery Ward and will be given a bed by the nursing
personnel.
8.5.10 The resident on duty will examine the patient within 30 minutes of admission and prepare the
admission file.
84
8.6 Policy on Appointments for Surgery:
8.6.1 All surgical patients will be seen in the outpatient department.
8.6.2 Decision for any surgical intervention will be made after opinion of the Consultant.
8.6.3 Consultant/resident will explain the diagnosis, procedure required, surgical options available,
possible outcomes and complications to the parent/legal guardian of the child in a language
understood by the parent/guardian.
8.6.4 Department will perform all surgical procedures in the Hospital EXCEPT cardiac surgery, plastic
surgery,multitrauma and neurosurgery. Cases requiring such specialties will be referred to a
government hospital providing such services.
8.6.5 All relevant laboratory/radiological diagnostic investigations will be done in the outpatient
department.
8.6.6 Patients will be referred to pre-anesthetic checkup for anesthetic clearance for the surgical
procedure. Any investigation or cross reference as advised by anesthesiologist will be obtained.
8.6.7 Patients will be referred to PAC clinic for review one week prior to provisional date of surgery.
They will be given re-appointment if found unfit.
8.6.8 Provisional date for admission for surgical procedures will be given on first come first serve basis
only after pre-anesthetic clearance. Patients requiring early surgery may be given an early date
as feasible.
8.6.9 Parents of the patients requiring arrangement of blood for surgical procedure will be referred to
mother centre at Lok Nayak Hospital for donation. Any blood transfusion will be done against
donation only. In case the guardians are not able to arrange for donation in time and the patient
requires life-saving transfusion, it will be provided after certification from consultant.
8.6.10 The appointments will be given to avail about 5.5 hours on weekdays and 3 hours on Saturday
(leaving 1.5 and 1 hour respectively for anesthesia).
8.6.11 Cases requiring emergency surgical procedures will get preference over all other surgical cases.
8.6.12 Any case requiring early surgery i.e. malignancy will be accommodated at the earliest possible
date. If required, previously dated patients may be rescheduled.
8.6.13 The patients coming on the date of admission will be admitted by the Consultant in the OPD
room. The patients will have to come in the O.P.D. by 11.00 AM for admission. If the patients do
not report till this time, any other available patient needing admission may be admitted on the
discretion of the consultant.
85
8.7 Preoperative Care
8.7.1 At the time of arrival in the ward
8.7.2 Familiarize with the patient and the family and show them the bed.
8.7.3 Explain the nature of the surgery, pre-medication and preparation. Make an attempt to involve the
parents as much as possible in care.
8.7.4 Clear instructions should be given.
8.7.5 Record the patient’s vital signs including pulse rate, temperature, blood pressure, respiratory rate
within 30mins of admission.
8.7.6 Record current weight and height/ length of the child on the case sheet.
8.7.7 Surgeon who is operating or his team member obtains surrogate informed consent by the
previous evening of planned surgery.
8.7.8 Anesthetists obtain surrogate informed consent by the evening of planned surgery.
8.7.9 Validity of consent is 72hrs.
8.7.10 In case surgery could not be conducted within 72hrs fresh consent to be taken.
8.8 On the morning of surgery
8.8.1 Give the child a bath on the morning of the surgery with special care to proposed operative site,
umbilicus, elbows and knees, nail beds etc.
8.8.2 Remove any polish on the nails.
8.8.3 Remove all the jewelry or metallic belongings.
8.8.4 Tie and secure long hair of the patient.
8.8.5 Remove any prosthesis like denture, plate, hearing aid, and spectacles.
8.8.6 Report any loose tooth to the anesthetist.
8.8.7 Inform any focus of infection or respiratory tract infection to the consultant concerned.
8.8.8 Check that the consent for anesthesia &surgery is signed by parent/legal guardian
8.8.9 Preparation of the part is usually unnecessary in children.
8.8.10 Keeps the patient fasting as per direction of the anesthetist. It is usually not more than 4 hours in
younger children. If longer duration of fasting is required, administer intravenous fluids as per the
directions.
8.8.11 Give premedication to the child at the prescribed time.
8.8.12 Any special preparation like gastric lavage, enema or bowel wash should be given to the patient.
86
8.8.13 While shifting the patient to operation theatre
8.8.14 Send the patient to operating room in the prescribed dress with proper identification slip or
wristband with correct name, hospital identity number and diagnosis/procedure. Ensure side
marking.
8.8.15 Transfer of the patient should be very smooth on a trolley.
8.8.16 Neonate should be shifted for surgery in an incubator so as to prevent hypothermia during
transfer. If incubator is not available, wrap the neonate in cotton and cover well.
8.8.17 All the relevant laboratory investigations and special reports should accompany the patient to the
operation theater.
8.8.18 Secure all the intubations, if any
8.9 Post-Operative Care
8.9.1 Aim of the postoperative care is to assure uneventful quick recovery from anesthesia and
prevention of the complications. The recovery period is divided into three phases for
convenience: i) immediate recovery period, ii) intermediate stage and iii) return to normalcy. The
level of care by the nurse depends on the stage of recovery.
8.9.2 Preparation before the patient is received in postoperative area
8.9.3 The postoperative recovery nurse is responsible for care in the most critical period. She should
prepare for receiving the child. The bed that is kept ready should have tilt facility and side
supports.
8.9.4 All the resuscitative equipment including ventilators and drugs should be kept available by the
side.
8.9.5 Suction and oxygen points should be checked.
8.9.6 Blood pressure monitor and pulse oximeter should be available.
8.9.7 All procedures are documented accurately in patient’s record.
87
8.10 Immediate recovery period
8.10.1 As soon as the child is received, check and record vital signs.
8.10.2 Note the nature of the procedure, special precautions or postoperative position and any other
instructions.
8.10.3 If there is any sign of shock or apnea, anesthetist should be informed immediately.
8.10.4 All the intubating catheters including intravenous or central venous line, naso-gastric tube,
endotracheal tube or airway, intercostal tube and urinary catheter are secured to prevent
inadvertent removal.
8.10.5 The postoperative orders about fluids and antibiotics are carried out. Strict intake – output record
is maintained.
8.10.6 Analgesics are given as per as per advice to relieve discomfort and pain.
8.10.7 The dressings are checked for any bleeding or tightness.If there is excessive soakage, inform the
concerned surgeon.
8.10.8 Pain score chart is maintained
8.11 After the patient is settled
8.11.1 The parents are informed about the surgery and postoperative progress at regular interval to
relieve anxiety and concern.
8.11.2 The patient is shifted to the ward for intermediate care once he/she is conscious; maintains
his/her airway on his/her own and his/her vitals and color is satisfactory.
8.11.3 The intermediate care nurse continues with the same post-operative care including monitoring of
vital signs, drains and catheters. The frequency of monitoring is reduced.
8.11.4 Hydration and nutrition is maintained.
8.11.5 Return to normalcy: Care in the ward
8.11.6 Look for the early signs of infection and inform to the surgeon.
8.11.7 The patient is ambulated early. If mobility is expected to be delayed, range of movement
exercises and frequent change of posture is done. He is encouraged to cough and perform deep
breathing exercises.
8.11.8 When oral fluid and diet intake has been resumed, proper diet is given. Small quantity of clear
liquids are begun and gradually increased.
8.11.9 When planning discharge, clear instructions about drug advice, rest, diet and follow-up visits are
given to the parents.
88
8.12 Day Care Surgery
8.12.1 Minor procedures that require general anesthesia and require minimal post-operative monitoring
may be done on a day care basis. Some of the common conditions included in this category are:
a) Inguinal Hernia
b) Hydrocele
c) Umbilical Hernia
d) Subcutaneous swellings like cysts
e) Circumcision – For phimosis and ritual
f) Diagnostic Cystoscopy
g) DJ Stent removal
8.12.2 Only patients more than 6 months that can take appropriate care at home and have amenable
urgent medical help in case of complication shall be operated on Day Care Basis.
8.12.3 The decision to operate on day care basis shall be taken in OPD by the consultant after
explaining the parent/ guardian the pros and cons of the procedure. The patients coming from far
off places and apprehensive parents may be accommodated in routine list.
8.12.4 The dates shall be given on first come first serve basis. There shall be 5 patients dated for a
particular day. All such patients shall be called one week prior to the scheduled date for review
and pre-anesthetic check-up. Once confirmed the pre-op instructions shall be provided one day
prior to scheduled date of surgery in the OPD by the consultant.
8.12.5 The patients will be admitted in the hospitalon the morning of surgery at around 8 a.m. The
patients after making the admission cards made from emergency will report to the resident at the
th
5 floor ward who shall re-explain about the procedure to the parents/guardians and get the
informed consent. The site of the surgery will be marked. The nurse on duty will provide the
special clean dress to all patients and the name band on the wrist. The patients will be shifted to
the routine OT with the nursing orderly from the OT before 8:45 a.m.
8.12.6 In the OT, the nurse will receive the patients and confirm the identity and the pre-op check list.
The morning PAC will be done by the anesthesia resident and surgery of the first case started at
9 a.m. All the procedures should finish by 2 p.m. so as to have at least 2 hours of monitoring time
in immediate post-operative ward. The anesthetist will evaluate the patient and allow them orally.
Once the child has taken and tolerated orally and passed urine, shall the patient be discharged by
the surgery resident/consultant. The discharge should include the notes of condition at discharge,
the advice at home and phone numbers to contact in case of emergency/complication.
8.13 High Dependency Unit

th
8.13.1 The six-bedded unit in the 5 floor ward takes care of patients critically ill in need of close
monitoring, either before or after surgery, or as a step down from ICU. The unit has 3 radiant
warmer bed and 3 normal beds. The unit has 2 multipara-monitors for continuous monitoring and
crash cart.
8.13.2 The unit is manned by a dedicated nurse at all times and the resident in the ward oversees all the
patients.
8.13.3 Special care is taken for maintaining hygiene in the HDU. No doubling is allowed on any of the
bed. No one is allowed with his/her shoes on without shoe cover. Woolens are not allowed. A
89
separate hand rub is placed by each bedside for use by the medical/ paramedical staff and the
attendants before and after touching the patients to avoid cross infection. No outside clothes are
allowed for the patients.
8.13.4 The patients are monitored for vitals every 2 hourly by the nurse and strict input-output charting is
maintained.
8.14 Criteria of shifting to and from Operation Theatre
8.14.1 All patients will have their pre-anesthetic check in the ward one day prior for routine cases and on
the morning of surgery for emergency cases. Once the patient are declared fit, and have given
consent for the procedure, the patient will be shifted to the operation theatre. The routine cases
will be shifted to the operation theatre in the morning at 8:30 – 8:45 a.m. and the emergency
cases will be shifted when called by the anesthetists.
8.14.2 The patients will be observed in the post-operative ward in the operation theatre by the nurse
under the guidance of the anesthetist in immediate post-operative period. The patients will be
shifted to the ward after the patient has come out of sedation, as evaluated by the anesthetist.
th
8.14.3 Telephonic follow up of all day care operated patient done from 7 day of operation, for
30days,once in every week.
8.14.4 In case of any fever,pus/serous fluid/oozing from the operated site;tenderness or induration
around the wound ,the patient is asked report to surgery OPD or in emergency if they contact
ICN,are directed to report to Causality.
8.14.5 The concerned surgeon is informed about the patient’s condition and his vsit to surgery Dept.
8.15 Quality Indicator
8.15.1 Mortality rate-Neonatal Mortality rate
8.15.2 Neonatal surgery rate
8.15.3 Neonatal admission rate
8.15.4 Re- exploration rate
8.15.5 Negative appendectomy rate
8.15.6 Accidental removal of catheter
8.15.7 Percentage of cases who received prophylactic antibiotics within specified time frame
8.15.8 Percentage of rescheduling of surgeries
8.15.9 Surgical site infection rate

8.15.12 Percentage of unplanned return to OT
90
9 Department of Orthopedic Surgery
Responsibility of Department of Orthopedic surgery

updating:
Last reviewed/ Dec 2019,August 2020

updated on:
version (CNBC/Orthopedic/09/ver.1.1)
91
9 Department of Orthopedic Surgery ....................................................................................... 91
9.1 Amendment sheet .......................................................................................................... 93
9.2 Scope ............................................................................................................................. 94
9.3 Orthopaedic Surgery services include: .......................................................................... 94
9.4 Facilities not available as on date:- ............................................................................... 94
9.5 Hierarchy of Orthopedic Surgery Department ............................................................... 95
9.6 Responsibilities of senior residents:- ............................................................................. 96
9.7 Flow Process of the Department ................................................................................... 96
9.8 In-Patient Department.................................................................................................... 97
9.9 Protocol for Surgery ....................................................................................................... 98
9.10 Preoperative Care ...................................................................................................... 98
9.11 Post-Operative Care .................................................................................................. 99
9.12 Quality Indicator ....................................................................................................... 100
92
9.1 Amendment sheet
st
1. 9.12 1 July Addition of departmental Previously not
2014 Quality indicators mentioned
2. 9.3.12 23rd New scopes in services Addition of new

9.3.13 November scope in
2015 services
3. 9.12 23rd Proven microbiological Change in KPI
November infection in planned
2015 surgically operated
orthopedic cases out of total
operated cases.
4. 9.12 22nd Change in departmental Change in KPI
August indicators
2020 Deletion of “Number of
arthroscopies performed”.
5. 9.7.1.4 22nd Covid 19 scenario: One Covid 19
August attendant with one patient scenario
2020 emphasized.
Examination of multiple
patients in the outpatient
department at one time
avoided.
Patients and attendants
encouraged to follow social
distancing and wear of
masks.
93
9.2 Scope
9.2.1 The Orthopaedic Surgery department at

CNBC takes care of all kinds of 9.4 Facilities not available as on date:-
paediatricorthopaedic and trauma situations
in children upto 12 years of age. The 9.4.1 Surgeries of craniovertebral junction,
orthopaedic team receives and takes care of surgeries requiring opening of thoracic cage.
all major and minor trauma and other
orthopaedic emergencies during the routine 9.4.2 Advanced oncosurgery requiring
hospital working hours. replantation and reconstructive surgery.
9.2.2 The orthopaedic department is managed by 9.4.3 Microvascular procedures such as free flaps
hospital and visiting consultants and senior requiring use of operating microscope.
residents.
9.4.4 Management of polytrauma patients.
9.3 Orthopaedic Surgery services include:
9.3.1 Medical and surgical treatment of various

paediatricorthopaedic disorders.
9.3.2 Paediatric metabolic bone diseases like

rickets and their sequaele.
9.3.3 Paediatric fractures.
9.3.4 Congenital anomalies and deformities.
9.3.5 Treatment of sports and ligament injuries.
9.3.6 Neoplastic lesions of bone.
9.3.7 Congenital and acquired disorders such as

cerebral palsy.
9.3.8 Acquired post infective disorders e.g. post

polio residual paralysis etc.
9.3.9 Acute and chronic osteomyelitis and other

bone infections.
9.3.10 Osteoarticular infections of joints and their

sequaele.
9.3.11 Osteoarticular tubercular infections e.g.

Pott’s spine, tuberculosis of hip etc.
9.3.12 Spinal surgeries and scoliosis correction.
9.3.13 Advance hip surgery including surgical hip

dislocation.
94
9.5 Hierarchy of Orthopedic Surgery Department
Director
H.O.D Orthopedic Surgery
S.R Orthopedic Surgery
Staff Nurse
Nursing Orderly
95
9.6 Responsibilities of senior residents:- 9.7 Flow Process of the Department
9.6.1 Senior resident is responsible for 9.7.1 Out Patient Department

comprehensive care of patients- both
outpatient and inpatient.
9.7.1.1 All new patients will acquire an OPD
9.6.2 He will examine patient in the outpatient card with registration number from the
department and is responsible for their central registration counter.
disease management.
9.7.1.2 All follow-up patients will be examined
9.6.3 Any minor surgical procedure- dressing,
in the OPD after getting registered in
suture removal, incision and drainage
etc will be performed in the side room the Central Registration counter.
Room no. 39 by the resident.
9.7.1.3 All cross references from other
9.6.4 Senior resident is responsible for Departments will be seen in the OPD
preoperative workup of surgical patients. after registration in the central
registration counter.
9.6.5 He will assist consultant in major
surgical procedures and himself 9.7.1.4 They will report to the Out patient
undertake emergency surgical Room 39 and get a number form the
procedures. nursing personnel. All the patients will
be seen according to this number on
9.6.6 He is responsible for postoperative
monitoring and care of operated fist come first basis.
patients. i. Covid 19 scenario: One attendant with
one patient emphasized.
9.6.7 Senior resident is responsible for record ii. Examination of multiple patients in the
keeping and maintenance of inpatient outpatient department at one time
records. avoided.
iii. Patients and attendants encouraged to
9.6.8 He will assist the consultant in patient follow social distancing and wear of
care and other assignments where masks.
deemed necessary.
96
9.7.1.5 All cases will be seen by the 9.8 In-Patient Department
residents/consultants. Cases requiring
surgical intervention will be reviewed 9.8.1 Admission Protocol
by the consultant before disposal.
9.8.1.1 All the patients under Pediatric
9.7.1.6 Decision for any major surgical Orthopedic Surgery will be admitted in
intervention will be ratified by the the Pediatric Surgery ward located at
Consultant. Vth floor of the ward block.
9.7.1.7 Any minor surgical procedure- 9.8.1.2 The patients who have been given
dressing, suture removal, incision and appointment will be admitted from the
drainage etc will be performed in the Outpatient Department on the advice
side room Room no. 39 by the of Consultant.
resident.
9.8.1.3 Routine cases will undergo a review
9.7.1.8 All medicines available in the hospital pre-anesthetic checkup before
will be given from the hospital admission.
pharmacy.
9.8.1.4 Emergency admission will be done in
9.7.1.9 All investigations will be done in the the pediatric surgery ward on the
hospital. Patients requiring any advise of the consultant in the routine
investigation not available in the hospital hours and by the Resident on
hospital will be referred to the LN/GB duty after consultation with the
Pant Hospital. Consultant –on-call on the day.
9.8.1.5 Emergency admissions will have the

management plan reviewed by the
consultant within 24 hours of
admission.
9.8.1.6 Patients requiring urgent emergency

surgical procedure under general
anaesthesia after routine working
hours will be referred to another
government hospital where facilities
are available.
9.8.1.7 Patients who do not require immediate

emergency surgical procedure will be
admitted, investigated and stabilized
and surgery will be performed at the
earliest possible time.
97
9.8.1.8 Patients requiring admission on the 9.9.1.6 Patients will be referred to pre-
day prior to the special investigations anesthetic checkup for anesthetic
will be admitted from Out Patient clearance for the surgical procedure.
Department by the Consultant. Any investigation or cross reference as
advised by anesthesiologist will be
9.8.1.9 After admission form the obtained.
OPD/Emergency, patient will go to the
Admission facility and get admission 9.9.1.7 Patients will be referred to PAC clinic
card prepared. for review one week prior to
provisional date of surgery. They will
9.8.1.10 Thereafter they will go to the Pediatric be given re-appointment if found unfit.
Surgery Ward and will be given a bed
by the nursing personnel. 9.9.1.8 Provisional date for admission for
surgical procedures will be given on
9.8.1.11 The resident on duty will examine the first-cum first basis only after pre-
patient within one hour of admission anesthetic clearance. The consultant
and prepare the admission file. will maintain a register for provisional
date of surgery given to the patients.
9.9 Protocol for Surgery
9.9.1.9 Parents of the patients requiring
9.9.1 Appointments for Surgery: arrangement of blood for surgical
9.9.1.1 All surgical patients will be seen in the procedure will be referred to Lok
outpatient department. Nayak Hospital for donation. Any
blood transfusion will be done against
9.9.1.2 Decision for any surgical intervention donation only.
will be made after opinion of the
Consultant. 9.9.1.10 An appointment will be given for two
major and two minor procedures on a
9.9.1.3 Consultant/resident will explain the week day. Cases requiring emergency
diagnosis, procedure required, surgical surgical procedures will get preference
options available, possible outcomes over all other surgical cases.
and complications to the parent/legal
guardian of the child in a language 9.9.1.11 Any case requiring early surgery i.e.
understood by the parent/guardian. malignancy will be accommodated at
the earliest possible date. If required,
9.9.1.4 Department will perform all surgical previously dated patients may be
procedures in the Hospital EXCEPT as rescheduled.
mentioned as facilities not
available.Cases requiring such 9.9.1.12 The patients coming on the date of
specialties will be referred to a admission will be admitted by the
government hospital providing such Consultant in the OPD room. The
services. patients will have to come in the
O.P.D. by 11.00 AM for admission. If
9.9.1.5 All relevant laboratory/radiological the patients do not report till this time,
diagnostic investigations will be done any other available patient needing
in the outpatient department. admission may be admitted on the
9.10 Preoperative Care
98
9.10.1 At the time of arrival in the ward 9.10.2.10 Keeps the child fasting as per direction
of the anesthetist. It is usually not
9.10.1.1 Familiarize with the patient and the more than 4 hours in younger children.
family and show them the bed.
If longer duration of fasting is required,
administer intravenous fluids as per
9.10.1.2 Explain the nature of the surgery, pre-
the directions.
medication and preparation. Make an
attempt to involve the parents as much 9.10.2.11 Give premedication to the child at the
as possible in care.
prescribed time.
9.10.1.3 Clear instructions should be given. 9.10.2.12 Any special preparation like enema
should be given to the patient.
9.10.1.4 Record the child’s vital signs including
pulse rate, temperature, blood
pressure, respiratory rate on
9.10.3 While shifting the patient to operation
admission.
theatre
9.10.1.5 Record current weight of the child on 9.10.3.1 Send the child to operating room in the
the case sheet. prescribed dress with proper
identification slip or wristband with
9.10.2 On the morning of surgery correct name, hospital identity number
9.10.2.1 Give the child a bath on the morning of and diagnosis/procedure.
the surgery with special care to
9.10.3.2 Transfer of the child should be very
proposed operative site, perineal
smooth on a trolley.
region etc.
9.10.3.3 Neonate should be shifted for surgery
9.10.2.2 Remove any polish on the nails.
in an incubator so as to prevent
9.10.2.3 Remove all the jewellery or metallic hypothermia during transfer. If
belongings. incubator is not available, wrap the
neonate in cotton and cover well.
9.10.2.4 Tie and secure long hair of the child.
9.10.3.4 All the relevant laboratory
9.10.2.5 Remove any prosthesis like denture, investigations and special reports
plate, hearing aid, and spectacles. should accompany the patient to the
operation theater.
9.10.2.6 Report any loose tooth to the
anesthetist. 9.10.3.5 Secure all the intubations, if any,
inserted prior to surgery.
9.10.2.7 Inform any focus of infection or
respiratory tract infection to the
consultant concerned. 9.11 Post-Operative Care
9.10.2.8 Check that the consent for surgery is

signed by parent/legal guardian 9.11.1 Aim of the postoperative care is to
assure uneventful quick recovery
9.10.2.9 Preparation of the part is usually from anesthesia and prevention of
unnecessary in children. the complications. The recovery
period is divided into three phases for
convenience: i) immediate recovery
period, ii) intermediate stage and iii)
return to normalcy. The level of care
99
by the nurse depends on the stage of 9.11.15 The parents are informed about the
recovery. surgery and postoperative progress
at regular interval to relieve anxiety
9.11.2 Preparation before the child is and concern.
received in postoperative area. The
postoperative recovery nurse is 9.11.16 The child is shifted to the ward for
responsible for care in the most intermediate care once he conscious;
critical period. She should prepare for maintains his airway on his own and
receiving the child. The bed that is his vitals and color is satisfactory.
kept ready should have tilt facility and
side supports. 9.11.17 The intermediate care nurse
continues with the same post-
9.11.3 All the resuscitative equipment operative care including monitoring of
including ventilators and drugs vital signs, drains and catheters. The
should be kept available by the side. frequency of monitoring is reduced.
9.11.4 Suction and oxygen points should be 9.11.18 Hydration and nutrition is maintained.
checked.
9.11.19 Return to normalcy: Care in the ward
9.11.5 Blood pressure monitor and pulse-
oximeter should be available. 9.11.20 Look for the early signs of infection
and inform to the surgeon.
9.11.6 Immediate recovery period
9.11.21 The child is ambulated early. If
9.11.7 As soon as the child is received, mobility is expected to be delayed,
check and record vital signs. range of movement exercises and
frequent change of posture is done.
9.11.8 Note the nature of the procedure, He is encouraged to cough and
special precautions or postoperative perform deep breathing exercises.
position and any other instructions.
9.11.22 When oral fluid and diet intake has
9.11.9 If there is any sign of shock, been resumed, proper diet is given.
anesthetist should be informed Small quantity of clear liquids are
immediately. begun and gradually increased.
9.11.10 All the intubating catheters including 9.11.23 When planning discharge, clear
intravenous or central venous line, instructions about drug advice, rest,
naso-gastric tube, endotracheal tube diet and follow-up visits are given to
or airway, intercostal tube and the parents.
urinary catheter are secured to
prevent inadvertent removal.
9.12 Quality Indicator
9.11.11 The postoperative orders about fluids
and antibiotics are carried out. Strict 9.12.1 Proven microbiological infection in
intake – output record is maintained. planned surgically operated orthopedic
cases out of total operated cases.
9.11.12 Analgesics are given as per as per
advice to relieve discomfort and pain.
9.11.13 The dressings are checked for any

bleeding or tightness. If there is
excessive soakage, inform the
concerned surgeon.
9.11.14 After the patient is settled
100
10 Department Of Ophthalmology
Responsibility of Department of Ophthalmology

updating:

updated on:
Version (CNBC/ Ophthalmology/10/Ver.1.2)
101
10 Department Of Ophthalmology ........................................................................................101
10.1 Amendment sheet .................................................................................................103
10.2 Scope of Services .................................................................................................104
10.3 Ophthalmology Facilities Available ........................................................................104
10.4 Facilities not available ...........................................................................................104
10.5 Appointments for Eye Surgery (to be performed in Routine Eye operation theatre)
……………………………………………………………………………………………..104
10.6 Policy and Procedure ............................................................................................105
10.7 During Covid 19 pandemic ....................................................................................106
102
10.1 Amendment sheet
1 10.6.4 added 27.12.14 Regarding documentation of Was not there

implants previously
2 10.6.6 30-8-2020 During Covid 19 pandemic Was not there

period previously
103
10.2 Scope of Services 10.4 Facilities not available
10.2.1 The Ophthalmology Department at 10.4.1 Contact lens clinic for patients with high
CNBC is dedicated to providing state-of- refractory errors, anisometropia and
the- art eye care ranging from routine other disorders.
eye examinations to complex surgical
procedures for patients aged 0-12 10.4.2 Laser treatment of grade iii and grade iv
years. R.O.P. cases.
10.3 Ophthalmology Facilities Available 10.5 Appointments for Eye Surgery (to be
performed in Routine Eye operation
10.3.1 The department provides theatre)
comprehensive eye care on outpatient
basis using state of the art equipment 10.5.1 All surgical patients will be seen in the
outpatient department.
10.3.2 It performs refractions, prescribes
corrective spectacles and performs 10.5.2 Decision for any surgical intervention
other tests to help maintain good vision. will be made after opinion of the
Consultant.
10.3.3 Strabismus and Neuro-
Ophthalmological work-up and 10.5.3 Consultant/resident will explain the
management of squint cases including diagnosis, procedure required, surgical
surgeries, occlusion, macular options available, possible outcomes
stimulation and eye muscle exercises. and complications to the parent/legal
guardian of the child in a language
10.3.4 Management of congenital and understood by the parent/guardian.
developmental Cataract cases with
surgery and Intra-Ocular lens implants. 10.5.4 All relevant laboratory/radiological
diagnostic investigations will be done in
10.3.5 Glaucoma work-up and surgeries, the outpatient department.
10.3.6 Oculoplastic surgeries for various eyelid 10.5.5 Patients will be referred to pre-
disorders anesthetic checkup for anesthetic
clearance for the surgical procedure.
10.3.7 Retinal disorders and treatment Any investigation or cross reference as
wherever possible advised by anesthesiologist will be
obtained.
10.3.8 Retinopathy of Prematurity(ROP)
Screening with indirect ophthalmoscopy 10.5.6 Patients will be referred to PAC clinic for
and referral to a tertiary eye care centre review one week prior to provisional
for cases requiring treatment. date of surgery. They will be given re-
appointment if found unfit.
10.3.9 Counseling of parents regarding
hygiene, dietary habits, proper 10.5.7 Provisional date for admission for
illumination and posture while reading surgical procedures will be given on
for their children. first-cum first basis only after pre-
anesthetic clearance.
10.3.10 Ophthalmic emergency services are
available at present from 9 am to 4 pm 10.5.8 Parents of the patients requiring
only, after which patients are referred to arrangement of blood for surgical
a tertiary eye care centre with procedure will be referred to Lok Nayak
emergency facilities. Hospital for donation. Any blood
104
transfusion will be done against filmed / photographed, specific consent
donation only. of the patient will be obtained.
7. **In case patient of children /adults who
10.5.9 Cases requiring emergency surgical are not in a positive to sign consent the
procedures will get preference over all nearest blood relative of the patient
other surgical cases. should asked be to sign
8. Use of intra-ocular lenses after cataract
10.5.10 Any case requiring early surgery i.e. surgery is according to accepted and
malignancy will be accommodated at standard guidelines.
the earliest possible date. If required,
previously dated patients may be 9. The hospital procures intra-ocular
rescheduled. lenses on tender basis. Multiple lens
powers are stocked, and issued as per
10.5.11 The patients coming on the date of
admission will be admitted by the demand.
Consultant in the OPD room. The
patients will have to come in the O.P.D. 10. Patient's family is counseled regarding
by 11.00 AM for admission. If the need for intra-ocular lenses
patients do not report till this time, any implantation, before the cataract
other available patient needing surgery. Benefits and possible
admission may be admitted on the complications, aftercare etc are also
explained.
10.6 Policy and Procedure
10.6.2 Pre-Operative Preparation
10.6.1 For Patient Undergoing Surgical 1. Pre-operative instruction by the
Procedure doctor should be precise and should
1. All cases being taken up for surgery in include.
the hospital will be full examined by a 2. How long the patient is to be kept
qualified specialist in the respective fasting
surgical discipline. 3. Specify the part to be prepared
2. Prior to surgery the following must be 4. Pre-operative medication
ensured: 5. Time of wheeling into OT.
3. Patient has been examined, 6. Action by Ward Sister
investigated and evaluated appropriately 7. Put patient I.D. band/ sticker on chest
4. In case of coexisting medical / cardiac 8. Identify & mark the limb / part to be
condition / opinion, of the concerned operated
specialist must be sought before listing 9. Follow pre-operation order
the patient for surgery. 10. Ensure consent has been signed
5. Pre Anesthesia check:- all patient 11. Transfer the patient to OT, with case
requiring surgery will be assessed pre- documents
operatively by the anesthetist. This will 10.6.3 Action in OT:
be applicable for cases to be operated
under GA/LA/Regional Blocks / Spinal 1 Sister in charge will receive the patient
anesthesia etc. and ensure action on per OT protocols
6. Informed Consent: the consultant in
charge of the case will be responsible to 2.Surgery: Surgery will be carried out by
inform the attendant about the nature of trained & qualified doctors, following all
the surgical procedure being done the aseptic precautions and assisted by trained
expected benefit there of the risks OT staff.
associated with the procedure.
Signature of the patient attendant** will 3.Post Operation: Following surgery, patient
be obtained on the Informed consent will be detained in the post operative area
form, which will be countersigned by the
doctor. In case the procedure is to be and is to be transferred to ward / ICU only
105
after written instructions from the 7. Follow up of cases is done every 3-6
anesthetist. months depending on degree of the
refractive error.
10.6.4 Documentation: 8. In cases having anisometropia or
amblyopia occlusion therapy is also
1. All documents such as operative notes,
advised with every 3 monthly follow
anesthetist charts, post operative note etc
up.
must be complete before the patient leaves
the OT complex. Case sheet & necessary
entry into the HIS must be completed soon
after surgery. Details must include name of
10.7 During Covid 19 pandemic
surgeon / Asst., name of Anesthetist,
procedure code & name. 1. Face shield to be used by examiner
in addition to routine PPE. It's of
2.In cases of IOL implants being inserted in greater significance during indirect
the eye, the details of the IOL used i.e. ophthalmoscope of young pediatric
manufacturer’s name, type of IOL, its power cases especially while performing
along with the patient ID would be put on the ROP screening, as risk of aerosol
patient’s case sheet, discharge slip and O.T. transmission is higher when
Register. infant/toddler is crying.
2. Slit lamps should have transparent
barriers.
3. COVID test and consent is
10.6.5 For Patients Undergoing Refraction
mandatory before performing any
1. Visual Acuity test of each eye is done
surgical procedure involving any
separately
type of anesthesia.
2. Examination of the anterior segment to
rule any other disease which may cause
poor vision.
3. If either eye has a visual acuity of less
than 6/6 refraction is performed under
cycloplegia.
4. Cycloplegic drug is to be used as per
age of child a) For ages up to 5
years and below Atropine eye ointment
TDS for 3 days and patient to be called
th
on 4 day. b)for children above 5
years of age Homatropine/Tropicamide
eye drops are to be used -1 drop every
5 minutes three times and refraction is
done after 45 to 50 minutes same day.
5. Refraction is to be followed by a
thorough fundus examination to exclude
any retinal pathology.
6. Child is called for final prescription of
spectacles(post mydriatic test)after 15
days in cases dilated with atropine and
rd
on the 3 day in cases of
tropicamide/homatropine.
106
11 Department of ENT
Approved by: Director-Dr B L Sherwal
Responsibility of Dr Neha-HOD Department of ENT

updating:
Last Reviewed/ Updated August 2020

on:
Version (CNBC/ENT/11/VER.1.1)
107
11 Department of ENT ............................................................................................................. 107
11.1 Amendmentsheet ..................................................................................................... 109
11.2 Scope Of services .................................................................................................... 110
11.3 ENT Facilities available ........................................................................................... 110
11.4 Facilities not available as on date but having Future Scope: .................................. 110
11.5 Appointments for ENT Surgery ................................................................................ 110
11.6 Policy and Procedure ............................................................................................... 111
11.7 Pre-Operative Preparation ....................................................................................... 111
11.8 Documentation:- ...................................................................................................... 111
11.9 SOP For Covid Pandemic ....................................................................................... 112
108
11.1 AmendmentSheet
S.No. Clause Date of Amendment Made Reason of Signature of
No. Amendment Amendment Quality
Manager
1 11.4 July’2011 CT Scan deleted from the Column As CT Scan

Facility not available facility is now
available in the
Hospital
st
2 11.2.2 1 July 2014 Addition in scope of services-(All Previously not
procedures are documented mentioned
accurately in patient’s record.)
3 11.3.4 March’2016 Facilities not

11.1.1 Diagnostic facilities available
include pure tone
audiometry, free field
audiometry, impedance
audiometry, otoacoustic
emissions testing etc
deleted from the Column
ENT facilities available
4 11.3.5 March’2016 Facility not
11.1.2 Hearing aid trial available
andhearing aid advice
deleted from the Column
ENT facilities available
5 11.3.8 March’2016 As Speech
11.1.3 Addition in ENT Facilities Therapist is
Available - Speech now available
Therapy in the hospital
6 11.4.3 December Facility not

2017 11.1.4 Ulrasonography and head available has
- neck Doppler facility future scope
7 11.9 August 2020 Spread of

11.1.5 SOP FOR COVID 19
DEPARTMENT OF ENT Pandemics
DURING COVID
PANDEMIC
109
11.2 Scope Of services 11.5 Appointments for ENT Surgery (to be
performed in Routine ENT operation theatre)
11.2.1 The ENT department at CNBC is dedicated to
providing state-of-the-art Ear, Nose & Throat care 11.5.1.1 All surgical patients will be seen in the outpatient
ranging from routine OPD care to complex surgical department.
procedures to patients aged 0-12 years.
11.5.1.2 Decision for any surgical intervention will be made
11.2.2 All procedures are documented accurately in patient after opinion of the Consultant.
record.
11.5.1.3 Consultant/resident will explain the diagnosis,
11.3 ENT Facilities available procedure required, surgical options available,
possible outcomes and complications to the
11.3.1 Routine ENT OPD facility, available daily from 9 am parent/legal guardian of the child in a language
to 1 pm.
understood by the parent/guardian.
11.3.2 Comprehensive ENT care on outpatient basis with
11.5.1.4 All relevant laboratory/radiological diagnostic
state of the art equipment.
investigations will be done in the outpatient
11.3.3 Minor OT procedures on outpatient basis e.g. Ear department. Patients requiring MRI scan will be
Wax removal, Foreign body removal, Incision referred to any major government hospital.
&drainage, antiseptic dressings etc.
11.5.1.5 Patients will be referred to pre-anesthetic checkup
11.3.4 Ear surgeries including Myringoplasty, for anesthetic clearance for the surgical
tympanoplasty, mastoidectomy etc. procedure. Any investigation or cross reference
as advised by anesthesiologist will be obtained.
11.3.5 Nasal endoscopy and all routine nasal surgeries.
11.5.1.6 Patients will be referred to PAC clinic for review
11.3.6 Oral cavity, Throat and Head &Neck surgeries. one week prior to provisional date of surgery.
They will be given re-appointment if found unfit
11.3.7 ENT emergency services are available at present
only during routine working hours.
11.5.1.7 Provisional date for admission for surgical
11.3.8 Speech Therapy for different Speech related procedures will be given on first-cum first basis
problems are given, as & when required. only after pre- anesthetic clearance.
11.4 Facilities not available as on date but having 11.5.1.8 Parents of the patients requiring arrangement of
Future Scope: blood for surgical procedure will be referred to Lok
Nayak Hospital for donation. Any blood
11.4.1 Cochlear Implant Surgery transfusion will be done against donation only.
11.4.2 Round the clock emergency ENT services 11.5.1.9 Cases requiring emergency surgical procedures
11.4.3 Ultrasonography/DOPPLER in head and neck will get preference over all other surgical cases.
11.5.1.10 Any case requiring early surgery i.e. malignancy,

Will be accommodated at the earliest possible
date. If required, previously dated patients may be
rescheduled.
110
11.5.1.11 The patients coming on the date of admission will 11.7 Pre-Operative Preparation
be admitted in the ward. The patients will have to
come in the O.P.D. by 11.00 AM for admission. If 11.7.1 Pre-operative instruction by the doctor should be
the patients do not report till this time, any other precise and should include.
available patient needing admission may be 11.7.1.1 How long the patient is to be kept fasting.
admitted on the discretion of the consultant.
11.7.1.2 Specify the part to be prepared.
11.6 Policy and Procedure
11.7.1.3 Pre-operative medication.
11.6.1 For Patient Undergoing Surgical Procedure
11.7.1.4 Time of wheeling into OT.
11.6.1.1 All cases being taken up for surgery in the
hospital will be full examined by a qualified 11.7.2 Action by Ward Sister
specialist in the respective surgical discipline.
11.7.2.1 Put patient I.D. band / sticker on chest.
11.6.1.2 Prior to surgery the following must be ensured:
11.7.2.2 Identify & mark the limb / part to be operated.
11.6.1.2.1 Patient has been examined, investigated and
evaluated appropriately. 11.7.2.3 Follow pre-operation order.
11.6.1.2.2 In case of coexisting medical I cardiac condition, 11.7.2.4 Ensure consent has been signed.
opinion of the concerned specialist must be
11.7.2.5 Transfer the patient to OT, with case documents.
sought before listing the patient for surgery.
11.6.1.2.3 Pre Anesthesia check:- all patient requiring 11.7.3 Action in OT: Sister in charge will receive the patient
and ensure action as per OT protocols.
surgery will be assessed preoperatively by the
anesthetist. This will be applicable for cases to be 11.7.4 Surgery: Surgery will be carried out by trained
operated under GA/LA/Regional Blocks etc. &qualified doctors, following all aseptic precautions
Informed Consent: the Consultant in charge of the and assisted by trained OT staff.
case will be responsible to inform the attendant
about the nature of the surgical procedure being 11.7.5 Post Operation: Following surgery, patient will be
done, the expected benefit thereof, the risks detained in the post operative area and is to be
transferred to ward I ICU only after written
associated with the procedure. Signature of the
instructions from the anesthetist.
patient attendant will be obtained on the Informed
consent form, which will be countersigned by the 11.8 Documentation:-
doctor. In case the procedure is to be filmed I
photographed, specific consent of the patient will 11.8.1 All procedures are documented accurately in the
be obtained. patient record. such as operative notes, anesthetist
charts, post operative notes etc must be completed
11.6.1.2.4 In case patient of children / adults who are not in before the patient leaves the OT complex. Case
a position to sign consent, the nearest blood sheet & necessary entries must be completed soon
after surgery. Details must include name of surgeon
relative of the patient will be asked to sign.
I Asst., name of Anesthetist, procedure code
&name.
111
11.9 SOP FOR DEPARTMENT OF ENT DURING COVID PANDEMIC CHACHA NEHRU BAL
CHIKITSALAYA, DELHI
The Government of INDIA has published “Advisory for safe ENT practice" on 03/06/2020
We are following same guidelines with some changes /modification as per feasibility in our pediatric
setup.
11.9.1 ENT OPD PROTOCOLS

1. Keep ENT OPD door open during OPD hours.
2. All fever,cough,cold, shortness of breath cases will be referred to flu corner.
3. Only one relative will be allowed with child in OPD chamber.
4. Face mask is mandatory for all in OPD.
5. Maintain adequate distance between the staff and patient as well as between patients in waiting area.
6. Appropiate PPE for HCW.
7. Use Hand Sanitizer /Hand washing after examining each patient.
8.Avoid the use of mobile phones, laptop and no tea breaks in OPD.
9 No OPD Endoscopies, indirect laryngoscopies, Tracheostomy tube change should be done (if required
to be done in OT with proper PPE)
10.Frequent cleaning of door knobs, tables and other furniture with sodium hypochlorite solution and/or
70% alcohol.
11. Most of the ENT procedures are aerosol generating procedures and preferably to be done in OT with
proper PPE as per guidelines; however, some high-risk procedures commonly performed outside the
operating room in our setup are----
I. Foreign body ear and nose

II. Nasal packing and removal
III. Routine suctioning of patients with tracheostomy tubes
IV. Aspiration and drainage of neck abscesses
These above-mentioned procedures to be done while wearing appropriate PPE including face shield, N-
95 Mask & shoe cover. And sanitization of area after procedure should be done.
11.9.2 PRE-OP & OT PROTOCOLS

1. All patients to be treated as a suspected Covid positive case unless proven otherwise. If possible,
determine the covid-19 status of the patient beforehand.
2. Extra precautions are to be taken for allENT procedures , due to following reasons
#Aerosol generating proceduresincludes : powered instrumentation in mucosal head and neck

surgery, tracheostomy & tracheostomy care, rigid laryngoscopy, bronchoscopy, endoscopic Sinus
112
surgery, mastoid surgery, foreign body of nose and throat, peritonsillar abscess drainage, nasal
packing, oral and oropharyngeal procedures.
#High risk procedures in ENT are:
- Any operation involving nasal mucosa, oral pharyngeal and pulmonary secretions (Considering
the high viral titres in these surfaces)
- use of laser, drill, micro-debrider, harmonic scalpel, electrocautery. Use of these energy devices
generate aerosols.
3.Xray chest PA view is mandatory in all preop cases.
4. Consent should be discussed with relatives regarding need of procedure, added risk during covid
pandemic and covering a clear statement that hospital as well as healthcare workers will not be
responsible for risk of Covid -19 exposure and potential consequences.
5. All precautions in shifting of patient, OT environment, donning and doffing area should be taken as
per hospital OT policy.
6. use of PPE as per recent guidelines.
7. No COVID positive patients to have surgeries in OT designated for non-covid cases.
8.COVID 19 positive patients to be operated only for emergency indications in OT designated for
COVID positive patients.
11.9.3 ENT WARD PROTOCOLS

1. General guidelines - distancing of atleast two meters in between patients, proper sanitization,
minimum visitors, minimum belongings are allowed.
2. Separate area for patients with high aerosol generating potential (eg. Tracheostomized children)
113
12 Department of Dental Surgery
Date created: May 2008
Responsibility of Department of Dental Surgery

updating:
Last Reviewed/ August 2020

Updated on:
version (CNBC/Dental surgery/12/Ver.1.2)
114
12 Department of Dental Surgery.......................................................................................................... 114
Amendment sheet ................................................................................................................................. 116
Scope of services ................................................................................................................................. 117
Department Timings:- ........................................................................................................................... 117
Out Patient Department ........................................................................................................................ 117
Policy of acceptance: ............................................................................................................................ 117
Policy of referral: ................................................................................................................................... 117
Policy during Covid 19 Pandemic ......................................................................................................... 118
115
Amendment sheet

st
1 12.2.10 1 July 2014 Addition in scope of Previously not
services-(All procedures mentioned
are documented
accurately in patient
record.)
2 12.2.3 Dec 2014 Previously not

Addition of Composite mentioned
esthetic material in
Scope of services
3 12.8 August 2020 Covid 19 pandemic

Policy during Covid 19
Pandemic
116
Scope of services
12.1.1 First and foremost Oral hygiene 12.1.12 The Department is managed by one
instructions are given as that is the key to consultant, J.R, one dental hygienist, one
keep dental problems at bay. nursing staff, one nursing orderly.
12.1.2 Dental X-Rays: Intra Oral Peri Apical view Out Patient Department
x-rays are taken and then developed
within the department. Depending on the 12.1.13 All new patients have to get them
radiological findings appointments are registered from the central registration
given. counter and acquire an OPD card with
registration number.
12.1.3 Restorations/Fillings: Various temporary
and permanent restorations are done 12.1.14 All follow-up patients also get themselves
depending on the situation. The temporary registered at the Central Registration
materials include IRMs, Zinc oxide counter by simply presenting their
eugenol/ Calcium Hydroxide etc. and respective OPD cards.
permanent materials include GICs both
anterior and posterior, LCR. Miracle mix, 12.1.15 All cross references from other
et al./ Composite esthetic material. Departments are seen in the OPD after
registration in the central registration
12.1.4 Indirect pulp capping in primary teeth counter.
which are very close to pulpal exposure.
12.1.16 They then report to the Outpatient Room
12.1.5 Direct pulp capping in primary teeth which No. 133.
the pulpal exposure is bare minimal.
12.1.17 The new cases are seen on first come first
12.1.6 Pulpotomies in primary teeth where only basis. Patient is examined and depending
the coronal part of pulp is involved. on the problem, medicated if necessary
and the diagnosis, procedure required,
12.1.7 Pulpectomies in primary teeth where the options available, possible outcomes and
entire pulp is involved. complications to the parent/legal guardian
of the child in a language understood by
12.1.8 Root Canal Treatment (RCTs) of the parent/guardian and then an
permanent teeth where pulpal pathology is appointment is given.
seen.
12.1.18 The follow-up cases are also treated by
12.1.9 Oral Prophylaxis in patients with poor oral appointments given.
hygiene. Minor surgeries such as
extraction. Policy of acceptance:
12.1.10 All procedures are documented accurately 12.1.19 All patients who show up in the dental
in patient record. OPD of pediatric age are seen and
treated.
Department Timings:-
Policy of referral:
12.1.11 The dental department of C.N.B.C. caters
to all kinds of pediatric patients with dental 12.1.20 Any major case requiring surgical
problems who visit the hospital on working intervention are referred to higher
days from 9.00am to 4.00p.m. on week government centers which are well
days and 9:00a.m. to 2.00p.m. on equipped to handle such cases.
Saturdays.
117
Policy during Covid 19 Pandemic
12.1.21 Required PPE to be used by examiner.
12.1.22 One patient relative is allowed only with

one patient inside OPD room.
12.1.23 Hand hygiene is to be strictly performed in

between the patients.
118
13 Department of Anesthesia
Responsibility of Department of Anesthesia

updating:
Last updated /Reviewed August 2020

On:
Version (CNBC/ Anesthesia/13/Ver.1.3)
119
13 Department of Anesthesia ............................................................................................................................ 119
13.1 Amendment Sheet ............................................................................................................................ 122
13.2 Scope of Services:- ........................................................................................................................... 123
13.3 Hierarchy Chart of Operation Theater ............................................................................................... 123
13.4 Protocols for Operation Theatre (O.T.) ............................................................................................. 124
13.5 Pre-Operative:- .................................................................................................................................. 124
13.6 Intra-Op (O.T.):- ................................................................................................................................ 124
13.7 Blood Transfusion:- ........................................................................................................................... 124
13.8 Tourniquet:- ....................................................................................................................................... 124
13.9 Pain assessment & management:- ................................................................................................... 124
13.10 Perioperative fluid Management:- ..................................................................................................... 125
13.11 Temperature control:-........................................................................................................................ 125
13.12 Sedation Policy :- .............................................................................................................................. 125
13.13 Monitored Anaesthesia care (MAC):- ................................................................................................ 125
13.14 Narcotics in Anesthesia:- .................................................................................................................. 125
13.15 CPR in OT:- ....................................................................................................................................... 125
13.16 Post-Operative:- ................................................................................................................................ 125
13.17 Period of stay:- .................................................................................................................................. 125
13.18 Monitoring:- ....................................................................................................................................... 125
13.19 Equipments & Drug’s:- ...................................................................................................................... 126
13.20 Oxygen:- ............................................................................................................................................ 126
13.21 Environment:- .................................................................................................................................... 126
13.22 Scheduling of Surgeries & List of Major Equipments:- ..................................................................... 126
13.23 Outcome Monitoring:- ....................................................................................................................... 127
13.24 Inventory Management of Narcotic drugs:- ....................................................................................... 127
13.25 Protocols for Pre-Anesthesia Checkup (P.A.C.) Clinic ..................................................................... 128
13.26 PAC for Emergency Surgery: - ......................................................................................................... 128
13.27 Definitions Of Sedation ..................................................................................................................... 129
13.28 Anesthesia......................................................................................................................................... 129
13.29 Goals ................................................................................................................................................. 129
13.30 Indications:- ....................................................................................................................................... 130
13.31 Protocol for Sedation ............................................................................................................................. 130
13.32 Pre-procedure Assessment............................................................................................................... 130
13.33 Pre-Medications ................................................................................................................................ 131
13.34 Monitoring During Procedure ............................................................................................................ 131
13.34 Post-Procedure Assessment ............................................................................................................ 131
13.35 Pediatric Post-procedure/Post-sedation Recovery Score ................................................................. 132
13.36 Qualifications ..................................................................................................................................... 133
13.37 Common Complication ...................................................................................................................... 133
120
13.38 Dosing Recommendations for Adult and Pediatric Patients ............................................................. 133
13.39 NPO Recommendations for Non-Intubated Patients ........................................................................ 133
13.40 Pain Management Protocol ............................................................................................................... 134
13.41 Role and Scope ................................................................................................................................. 134
13.42 Goals ................................................................................................................................................. 134
13.43 Procedure .......................................................................................................................................... 135
13.46 Nursing Care:- ................................................................................................................................... 135
13.47 Critical incidents during Anaesthesia ................................................................................................ 136
13.48 Definition -Adverse Events Or Critical Incident Under Anesthesia ................................................... 136
13.49 List of Events ..................................................................................................................................... 136
13.50 Proposed Variables and Their Definitions ......................................................................................... 137
13.51 Anaesthesia policies for Perioperative management during covid-19 pandemic- ............................ 145
13.52 Policies For Implantable Prosthesis And Medical Supplies .............................................................. 148
121
13.1 Amendment Sheet
S.n Date of Reasons of Sign of
Clause no. Amendment Made
o. Amendment Amendment QM
Previously not
1. 13.2.2 25.03.2013 Sedation for C.T.Scan, G.I. Endoscopy added
mentioned.
In Pre-operative Para at point no.2 received
2. 13.5.2 25.03.2013 Error removed
replaced by reviewed.
In Intra-operative Para: Daily checklist for
Previously not
3. 13.6.1 25.03.2013 medical gas safety added & Anesthesia crash
mentioned.
cart described.
In Intra-operative Para: Epidural block top-up Previously not
4. 13.9.3 25.03.2013
added mentioned.
13.12.1 & Previously not
5. 25.03.2013 Protocol for Narcotics & CPR added
13.14 mentioned.
PAC for emergency cases: In point (b) policy
Previously not
6. 13.24 25.03.2013 described for case in which ventilator not
mentioned.
available.
Pre-Anesthesia Checkup of patients For more
7 13.25 Dec 2014
scheduled for surgery clarification
Addition of Morning PAC is also done in OT
Previously not
8 13.5.4 Dec 2014 after shifting of patients to theatre immediately
mentioned
before surgery in Pre-Operative.
Consent for anesthesia is taken in the ward a
day prior during bed-side PAC. except for day Previously not
9 13.5.5 Dec 2014
care cases in which consent is taken on the mentioned
day of surgery in Pre-Operative.
Any change in plan of anesthesia is captured Previously not
10 13.6.5 Dec 2014
as one of the Quality Indicator. mentioned
For more
11 13.7 Dec 2014 Expansion of period of stay
clarification
Director & Technical Supervisor(OT) added in Previously not
12 13.3 Dec 2015
Hierarchy Chart mentioned.
List of Major Equipments in Anesthesia Previously not
13 13.22 Dec 2015
Department added. mentioned.
New
Previously not
14 clause Dec 2015 List of Outcome monitoring (KPI”S) Added
mentioned
added
New
Previously not
15 clause Dec 2015 Inventory Management of Narcotic Drugs
mentioned
added
Definition -Adverse Events Or Critical Previously not
17 13.48 Dec 2019
Incident Under Anesthesia mentioned
Anaesthesia policies for Perioperative
Covid 19
18 13.51 30.08 .2020 management during covid-19 pandemic-
Pandemic
Policies For Implantable Prosthesis And
Previously it was
19 13.52 August 2020 Medical Supplies
not updated.
122
13.2 Scope of Services:-
13.2.1 Giving anaesthesia for elective surgeries.
13.2.2 Giving anaesthesia for emergency surgeries
13.2.3 Giving sedation for minor procedures for C.T.Scan, G.I.Endoscopies.
13.2.4 Doing intraoperative pain assessment & pain management.
13.2.5 Doing Pre-Anaesthesia Checkup of patients scheduled for surgery.
13.3 Hierarchy Chart of Operation Theater
Director
Medical Superintendent
HOD(Anesthesia)
MO I/C ‘s
Technical MO I/C ‘s Nursing Sister (OT)

Supervisor (OT)
MO I/C ‘s Staff Nurse
O.T.Technician
Ancillary Staff
(N.O. & SK)
O.T.Assistant
123
13.4 Protocols for Operation Theatre (O.T.) 13.6.5 Any change in plan of anesthesia is
captured as one of the Quality Indicator.
13.5 Pre-Operative:-
13.6.6 Steps of G.A. are premedication,
13.5.1 OT lists are received by the induction, maintenance & then reversal.
anesthesiologists one day prior to date of Drugs & dosages are selected as per
surgery. patient profile.
13.5.2 Patients are again reviewed by 13.6.7 In regional Anesthesia patients are
anesthesiologists one day prior. given sedation in appropriate doses
followed by regional blocks.
13.5.3 Patient’s are shifted two hours prior
to the pre-operative room with part 13.6.8 Pulse rate, ECG, B.P., SPO2, &
prepared. Etco2 is monitored blood loss, in every
case.
13.5.4 Morning PAC is also done in OT
after shifting of patients to theatre 13.6.9 CVP line & arterial lines are put
immediately before surgery. when required.
13.5.5 Consent for anesthesia is taken in 13.6.10 Documentation of the whole

the ward a day prior during bed-side PAC. procedure & monitoring is done in case
except for day care cases in which sheet in anesthesia chart.
consent is taken on the day of surgery.
13.6.11 O.T. in time, induction time,
13.5.6 Patients are checked thoroughly, incision time & O.T. out time are noted in
NPO status confirmed, consent for anesthesia chart.
anesthesia & different procedures done is
taken/checked by anesthesiologists is 13.6.12 Any untoward event during
taken, and arrangement for blood is anesthesia & surgery are noted &
checked .Anesthesiologist introduces self managed accordingly.
to patient & attendants.
13.5.7 O.T. trolley is prepared i.e. all the 13.7 Blood Transfusion:-
drugs are made in advance and all the
anesthesia equipments are checked.
13.7.1 Patients are transfused properly
cross matched blood in O.T. if required.
13.6 Intra-Op (O.T.):- Checked & signed by anesthesiologist.
13.6.1 Daily checklist for medical gas 13.7.2 Monitoring for transfusion reaction
safety by senior resident & technician on is done & if any adverse reaction
duty. happens, they are documented &
management is done accordingly.
13.6.2 Anesthesia crash cart checklist as
approved by the Anesthesia department is 13.8 Tourniquet:-
different from the checklist of the crash
cart used hospital wide.
13.8.1 If tourniquet is used during surgery,
anesthesiologist note down the tourniquet
13.6.3 Patient is taken on O.T. Table with time, if time exceeds surgeons are asked
O.T. clothes and all the accessories are to release the tourniquet.
taken off in pre-op room.
13.9 Pain assessment & management:-
13.6.4 Plan of Anesthesia is
selected as per indication, out of
13.9.1 Pain assessment in intra-op period
G.A./Regional/combined.
&tends to write pain scoring in
124
anaesthesia chart & do proper pain double lock cabinet, one key of the
management. narcotic cabinet kept with Anesthesia
faculty & another key of this cabinet kept
13.9.2 Pain management is done by with Technical Incharge. All the empty
various routes i.e. epidural, intravenous, ampoules of narcotic drugs kept whole the
intramuscular, suppositories, local month and these empty ampoules
infiltration etc. using various drugs i.e. disposed to bio medical waste cell of this
opioids,local anaesthetics,non-opioids etc. hospital through proper channel. Daily
narcotic consumption record maintained &
13.9.3 In case of epidural block regular duly verified by medical superintendent on
top-ups are given. Epidural catheter is daily basis.Separate stock register &
kept upto period of maximum 72 hours. indent book maintained in the department.
13.10 Perioperative fluid Management:- 13.15 CPR in OT:-
13.10.1 This is done by 13.15.1 CPR is done by the

anaesthesiologist covering fasting, designated team, anesthesiologist takes
maintanence & surgical losses. Type of over as incharge of the team. Code blue
fluid is selected as indicated. team is not called in OT. Resuscitation
notes are filled by SR & the same is sent
13.11 Temperature control:- to PICU Incharge ( Code blue secretary).
13.11.1 Anaesthesiologists monitor 13.16 Post-Operative:-

body temperature of patients & maintain
normal range in intra-op period. Various 13.16.1 Staffing:- Post-op room/
warming techniques like fluid -warmers, recovery room or PACU (post anaesthesia
warming mattresses, warm blankets, care unit) is managed by trained nursing
radiant warmers, blowers etc. are used staff of O.T.
effectively. Documentation of the temp.
monitoring is done in the anaesthesia 13.17 Period of stay:-
chart.
13.17.1 All the patients are kept in the
13.12 Sedation Policy :- post-op room for a period of maximum 2
hrs. after which they get shifted to
13.12.1 While giving the sedation respective wards & shifting is advised by
patient is checked for NPO status, PAC anaesthesiologist.
done , drugs &dosages are selected
according to indication, consent for 13.17.2 Discharge criteria is mentioned
sedation is taken. Complete monitoring is along with shifting time
done with full preparation for general
anaesthesia & intubation & anaesthesia 13.17.3 The patients who need ICU
chart(notes) is filled. care are directly shifted to ICU.
13.13 Monitored Anaesthesia care (MAC):- 13.17.4 Patients who have undergone
day care surgery are discharged from post
13.13.1 This is the scenario where no operative ward at or after 4:00pm, after
drugs are required; cases are done only in meeting discharge criteria.
the presence of anaesthesiologists with
full monitoring. 13.17.5 After the completion of case
sheet & before shifting of patient to ward,
13.14 Narcotics in Anesthesia:- anesthesia consultant is signing on
operation theatre deficiency checklist after
13.14.1 Narcotics mainly injectable it is seen by post operative staff,
Fentanyl & Morphine are used. All the
narcotic drugs are stored in a separate 13.18 Monitoring:-
125
13.18.1 Respiratory rate, Heart rate, ECG, 1) Anesthesia Work Station - 2 nos.
B.P. Spo2, temp. & urine output are being
monitored. 2) Anesthesia Machine - 3 nos
13.18.2 Patients are also monitored for 3) Multipara Monitors - 4 nos.

any pain, irritability, sedation, allergic
reactions. 4) Defibrillator - 2 nos.
13.18.3 In the event of any untoward 5) Post Operative Monitors - 10 nos.

event, the anaesthesiologist in the OT. are
informed. 6) Pulse Oximeter - 02 nos.
7) Videolaryngoscope - 03 nos.
13.19 Equipments & Drug’s:-
8) Syringe Pumps - 12 nos.
13.19.1 Post-op is equipped with all
necessary drugs & equipments. 9) Fibreoptic Bronchoscope - 01 set
10) Portable Colour Doppler USG System- 01

13.19.2 Emergency cart is always ready
for emergency intubation.
13.20 Oxygen:-
13.20.1 We have central pipeline supply

of oxygen & air in the post-op & have wall
outlets.
13.20.2 We tend to give oxygen to all

patients as advised by anesthesiologists.
13.21 Environment:-
13.21.1 Quiet, attendants are allowed in

post-op only one at a time with each
patient.
13.22 Scheduling of Surgeries & List of

Major Equipments:-
13.22.1 O.T. list are received one

day prior to date of surgery. Surgeries are
scheduled according to priority, age of
patients & duration of surgery.
13.22.1b List of Major Equipments (One

Anesthesia Work Station & Portable Colour Doppler
USG System procured in the current year 2015) :-
126
13.23 Outcome Monitoring:- This
department continuously monitor and
evaluate the outcome/performance
through Key Performance Indicators
(KPI’s) for continuous quality
improvement. List of KPI’s is as
Follows:-
13.23.1 Sub Arachnoid Failure rate.
13.23.2 Dental Injuries related to

Anesthesia.
13.23.3 Accidental Extubation.
13.23.4 Stay more than 2 hrs in

post-op room.
13.23.5 Equipment Uptime rate.
13.23.6 O.T,Utilization Rate

(Elective OT.
13.23.7 O.T,Utilization Rate (EM-

OT)
13.23.8 Cancellation rate (Elective

OT).
13.23.9 Cancellation rate (EM- OT).
13.23.10 O.T.Utilization rate

(Operating room wise).
13.23.11 Cancellation Rate

Spectrum.
13.24 Inventory Management of Narcotic

drugs:-
13.24.1 As per the narcotic policy of

the hospital strict Inventory (In units) of the
narcotic drugs (i.e. inj. Fentanyl &
Morphine) is being maintained by the
department, Further, fresh ampoule will be
broken for the regional blocks & the same
will be entered in the inventory. All the
broken ampoules to be disposed off as
per hospital narcotic policy.
127
Chacha Nehru Bal Chikitsalaya, g)
Delhi h) Referalls are asked for by the experts like
cardiologists, urologists,nephrologists etc.
Policy No:-CNBC/ANES/PAC/15.a as & if required.

13.26 PAC for Emergency Surgery: -
Revised on: August 2020 a) PAC is done bed side as & when asked for .
b) Pre-anaesthetic orders are different from
Approved Director previous one:-
by c) High risk consent is taken.
d) ICU & VENTILATOR bed is arranged as per
Prepared Dr Geeta kamal requirement. If ventilator is not available &
By the surgery is urgent, then the consent for
AMBU ventilation is required.
e) Prognosis is explained to attendants
f) The patient is kept NPO as per standards, if
13.25 Protocols for Pre-Anesthesia
possible, if not then high risk consent is
Checkup (P.A.C.) Clinic
taken & all due precautions are taken for full
stomach.
13.25.1 PAC for Elective
Surgeries:-
13.25.1.1 PAC Clinic runs from 09:00 AM to 01:00

PM every day.
13.25.1.2 This is run by Anaesthesia senior

residents supervised by Anaesthesia
consultant.
13.25.1.3 This includes detailed history physical

examination & investigations to work up
for fitness for surgery. Records are kept
in register.
13.25.2 Pre-Operative Orders:

a) Order for nil per oral (NPO) as per
standards.
b) Premedication as per individual cases.
c) Informed consent.
d) Arrangement of blood & its products
according to requirements of surgery.
e) Hgm & urine as universal investigation for
elective cases is being done.
f) Special investigation i.e.
KFT’s,LFT’s,S.E.,CXR,ECHO etc. are
advised as required in special cases.
128
Sedation Policy 13.28.2 The ability to independently
maintain ventilatory function is often
impaired. Patients often require assistance
in maintaining a patent airway, and
POLICY positive pressure ventilation may be
required because of depressed
13.26.1.1 Our organization provides spontaneous ventilation or drug-induced
guidelines for monitoring oral or intravenous depression of neuromuscular function.
moderate or deep sedation administered to Cardiovascular function may be impaired.
patients undergoing invasive, manipulative,
or diagnostic procedures. 13.29 Goals
13.27 Definitions Of Sedation 13.29.1 1. To guard the patient’s

safety and welfare
13.27.1 Minimal sedation
(anxiolysis) :- A drug-induced state 13.29.2 2. To minimize physical
during which patients respond normally to discomfort, pain, or anxiety
verbal commands. Although cognitive
function and coordination may be 13.29.3 3. To minimize negative
impaired, ventilatory and cardiovascular psychological responses to treatment by
functions are unaffected providing sedation and analgesia, and to
maximize the potential for amnesia
13.27.2 Moderate
sedation/analgesia (“conscious 13.29.4 4. To control behavior
sedation”):- A drug-induced depression
of consciousness during which patients 13.29.5 5. In some children to
respond purposefully to verbal commands, expedite the conduct of procedures which
either alone or accompanied by tactile are not particularly uncomfortable but
stimulation. No interventions are required which require that the patient not move
to maintain a patent airway, and
spontaneous ventilation is adequate. 13.29.6 To return the patient to a
Cardiovascular function is usually state in which safe discharge, as
maintained. determined by recognized criteria, is
possible for outpatients or to return
13.27.3 Deep sedation/analgesia:- inpatients to pre-sedation status
A drug-induced depression of
consciousness during which patients 13.29.7 This policy does not apply
cannot be easily aroused, but respond to minimal sedation or for sedation used
purposefully following repeated or painful for therapeutic management of pain
stimulation. The ability to independently control, mechanically ventilated patients in
maintain ventilatory function may be the intensive care unit, seizures, or
impaired. Patients may patients under the immediate and direct
management of the Department of
13.28 Anesthesia Anesthesiology.
13.28.1 Consists of general 13.29.8 Responsibility for

anesthesia and conductive anesthesia. It implementation of this policy has been
does not include local anesthesia. General assigned to the all HODs and Nursing
anesthesia is a drug-induced loss of Incharge.
consciousness during which patients are
not arousable, even by painful stimulation.
129
13.30 Indications:- administration of moderate or deep
a) Bone Marrow Aspiration sedation. Children under age 8 may
b) Lumbar Puncture receive only chloral hydrate up to a dose
c) Skin Biopsy of 100 mg/kg or only oral midazolam up to
d) Liver Biopsy a dose of 0.5 mg/kg without an
e) GI Endoscopy intravenous access.
f) Bronchoscopy
g) ICT insertion and 13.32 Pre-procedure Assessment
h) Other Selective Procedures.
13.32.1All patients requiring moderate or deep
13.31 sedation will have a pre-procedure evaluation and
assessment including, but not limited to:
Protocol for Sedation 1. History and physical performed by a
physician/dentist
13.31.1
2. Current medications, including any
LOCATION:- Moderate or deep sedation is allergies
practiced in various departments and locations
within the organization, as listed at the end. 3. Prior history of adverse reaction to
sedation or anesthesia
13.30.1 PROCEDURE
4. NPO status
13.30.1.1 All moderate or deep sedation will be ordered
and supervised by a qualified
5. Proper consent forms signed
physician/dentist. He/she will assume the
responsibility of the patient until patient meets
6. Vital signs: heart rate, blood pressure,
discharge criteria and/or returns to pre-
sedation status. respiratory rate, oxygen saturation, pain
score, level of consciousness, temperature
13.30.1.2 The Professional nurse responsible for when applicable
managing the care of patients receiving
moderate or deep sedation will complete and 13.32.1 The physician will decide
maintain competency in the skill. The person that the patient is a suitable candidate for
administering and monitoring the sedation planned sedation based on assessment.
should be different from person performing
the procedure. 13.32.2 One method of pre-
procedure assessment might be by
13.30.1.3 The head of each department administering
utilizing the ASA
moderate or deep sedation will be
responsible for ensuring that departmental
13.32.3 Physical Status
policies and procedures are applicable and
Classifications as follows:
consistent with this hospital policy.
1. Class I A normal healthy patient
13.30.2 Patient attendant/ Guardian 2. Class II A patient with mild systemic disease
are to be explained about procedural 3. Class III A patient with severe systemic
sedation analgesia and its procedure. disease
4. Class IV A patient with severe systemic
13.30.3 Emergency equipment like disease that is a constant threat to life
laryngoscope, ambu bag, and 5. Class V A moribund patient who is not
endotrachual tube, suction machine must expected to survive without the operation
be immediately available to every location
where moderate or deep sedation is
administered or recovery occurs.
13.30.4 All patients must have an

intravenous access secured prior to
130
13.32.4 In the following situations, c) Respiratory rate
the physician should consider consultation d) Oxygen saturation
with an anesthesiologist prior to sedation: e) level of consciousness
1. Patient does not fulfill NPO criteria and i. prior to initiation of sedation
requires emergency diagnostic exam or ii. reviewed every 5 minutes (minimum)
iii. recorded every 5 minutes (minimum) for
procedure deep sedation and every 10minutes
(minimum) for moderate sedation
2. Severe cardiopulmonary, neurologic, or iv. after completion of procedure
other organ system disease which may f) If maximum drug dosage is exceeded, the
present a significant hazard with the reason should be documented by the
administration of sedation physician.
3. Potential difficult airway management (i.e.

distorted anatomy, obstructive sleep apnea, 13.34 Post-Procedure Assessment
morbid obesity, micrognathia, immobilization
of the head and neck) 13.34.1 Post-procedure documentation must
include:
4. Patient taking medication that may a) Heart rate
adversely react with sedatives or analgesics b) Blood pressure
(i.e. MAO inhibitors) c) Respiratory rate
d) Oxygen saturation
5. Prior history of adverse reaction to sedation or e) Pain score
f) Level of consciousness
anesthesia
13.34.1 Post-procedure observation
13.33 Pre-Medications must occur in a suitable location.
Monitoring and documentation will
13.33.1 Intravenous ondansetron continue every 10 minutes for 1 hour after
and I.V Rantac should be used as the last dose of sedation or until patient
premedication. Oxygen is delivered at rate meets discharge criteria and/or returns to
of 2 liters / Min via face mask. pre-sedation status. Patients receiving
reversal agents will be monitored for a
13.34 Monitoring During Procedure minimum of 2 hours. If discharged, the
patient or responsible person must be
13.34.1 Monitoring of the patient is provided verbal and written instructions
to be performed throughout the procedure regarding diet, medications, activities, and
and will include documentation of vital signs or symptoms of complications with
signs: course of action to take if any complication
a) Heart rate develops.
b) Blood pressure
131
13.35 Pediatric Post-procedure/Post-sedation Recovery Score
Patient Sign Criterion Score
Consciousness Awake (or returned to baseline) 2
Responding to stimuli 1
Not responding 0
Respiratory Breathes easily with adequate volume 3
Slightly decreased rate and/or volume 2
Labored or limited respiration 1
Apnea or inadequate ventilation 0
Circulatory BP and pulse within baseline limits 2
BP and pulse approaching baseline limits 1
Abnormally high or low BP and/or 0
abnormally fast or slow pulse
Activity Moving limbs purposefully (or returned to 2
baseline
Moving limbs nonpurposefully 1
Not moving 0
13.35.1 Pediatric score for discharge is 9 or when released by a physician/dentist.
132
13.36 Qualifications 13.39 NPO Recommendations for Non-
Intubated Patients
13.36.1 Physicians, oral surgeons, Gastric emptying may be influenced by many
and nurses supervising, administering, factors, including anxiety, pain, abnormal
and monitoring moderate or deep sedation autonomic function (e.g., diabetes),
are required to have proficiency in the
pregnancy, and mechanical obstruction.
delivery of sedation. These individuals are
required to: Therefore, the suggestions listed do not
guarantee that complete gastric emptying has
1. be familiar with proper dosages,
occurred. Unless contraindicated, pediatric
administration, adverse reactions, and
patients should be offered clear liquids until 2-
interventions for adverse reactions and
3 hr before sedation to minimize the risk of
overdoses
dehydration. Solids and Nonclear Liquids *
2. Know how to recognize an airway Clear Liquids
obstruction and possess knowledge of
a) Adults 6-8 hr or none after midnight ** 2-
basic life support
3 hr
b) Children older than 36 months 6-8 hr 2-3
3. Assess total patient care requirements or
hr
parameters, including but not limited to c) Children aged 6-36 months 6 hr 2-3 hr
respiratory rate, oxygen saturation, blood d) Children younger than 6 months 4-6 hr 2
pressure, cardiac rate, and level of hr. This includes milk, formula, and
consciousness breast milk (high fat content may delay
gastric emptying).
13.37 Common Complication e) ** There is no data to establish whether a
6-8 hr fast is equivalent to an overnight
13.37.1 Apnea, Hypoxia (Spo2 < fast before sedation/analgesia.
92%), Seizures, Arrythmias, Hypotention,
Rash
13.37.2 Vomiting or Aspiration are

to be recorded in case sheet.
13.38 Dosing Recommendations for Adult

and Pediatric Patients
13.38.1 Minimal Sedation /

Moderate Route
1. Inj. Midazolam .5 – 1mg / Kg I.V
2. Inj Ketamine – 1 -2 mg/ Kg I.V
4-5 MG/Kg I.M
3.Inj Fentanyl 1-2 mg/Kg
13.38.2 Deep Sedation:-

Inj Propofol 1-2 mg/Kg
133
Policy No:- CNBC/ANEST/PAIN/15.c
Revised on: Aug 2020 vide Rev. No.: 1.1
Prepared By Dr .Geeta kamal
13.40 Pain Management Protocol
13.40.1 Acute Pain can be defined as that which is caused by noxious stimulation due to
injury, a disease process, or abnormal function of muscle or viscera.
13.40.2 Peri-operative period is defined as the time when patient is wheeled from ward to
operation Theatre, awaiting surgery in pre-operative hold area, intra-operative period, stay in
post-anaesthesia Care unit (PACU) and up to the time when patient is wheeled back to his/her
ward. The duration of this peri-operative period for pain management would be up to maximum
of 24hrs post operatively. Only in circumstances where patient goes to ward with epidural
catheter in situ, till the time such devices are in place. In circumstance when due to the nature
of surgery and associated co-morbid conditions, it is decided to shift patient to surgical ICU
from PACU for intensive monitoring and elective mechanical ventilation, the peri-operative
period for purpose of pain management may extend beyond 24 hrs.
13.41 Role and Scope
13.41.1 To provide pain management services to patients who come for operative
procedures and for the relief of acute pain arising out of surgical/diagnostic & therapeutic
procedures.
13.42 Goals
13.42.1 Assessment of pain with Documentation of pain score in case sheet
13.42.2 Recommendation for pain relief
13.42.3 Education and training of personnel’s, for achieving above goals.
13.42.4 Referring the patients to respective consultant form anaesthesia/surgery.
13.42.5 Formulating treatment schedule for pain relief in peri-operative period, depending
upon the type of surgery, duration of surgery, nature of surgery and the place where patient is
going to be in post op. period i.e., PACU, SICU or ward.
134
13.43 Procedure
13.43.1 Analgesic advised either Non-narcotics/narcotics or their combinations.
Route of administration of narcotic/non-narcotic

a) Oral route or
b) Intramuscular route or
c) Intravenous route or
d) Transdermal patch or
e) Per-rectal route
f) Epidural Route
Continuous infusion/Intermittent boluses of local anaesthetic/narcotic /or combination of LA and

narcotic, epidurally through catheter
Through catheter inserted after locating the nerve trunk/plexus by nerve locator or under US
guidance (when available).
13.45 Assessment of pain and its documentation to be done which should include--
 Onset ,Description of pain,Site of pain
 Intensity of pain by Visual analogue scale score
 Vital signs like, pulse, BP, SPO2, R/R and associated signs like,
sweating, pallor agitation etc.
 What pain relieving medication received and time of last dose received
to be noted down
13.46 Nursing Care:- The nurse has to initiate the pain management flow sheet/chart
13.46.1 Monitor the vital signs
13.46.2 Administer the prescribed analgesic medication
13.46.3 Titrate medication, dosage, frequency & route, in consultation with the physician
/surgeon /anesthesiologist of that particular patient.
13.46.4 Comforting measures like assuring, covering up the patient if feeling cold with
blanket etc, adjusting the posture or limb of patient to achieve maximum comfort.
13.46.5 Monitor the patient for side effect of analgesics.
135
Policy No:- CNBC/ANEST/Critical incidents/15.c
Revised on: Revised on: Aug 2020 vide Rev. No.: 1.1
Prepared By Dr .Geeta kamal/Dr Aikta Gupta
13.47 Critical incidents during Anaesthesia
13.47.1 Anaesthesia is a complex and dynamic system in which there is interaction between man
(anaesthesiologist, patient), machine (anaesthesia machine and monitors) and the environment
(surgeons, nurses, the operating room and hospital). Failures or errors can occur in any of the
components of this system which could be harmful to the patient, therefore giving rise to adverse
events or critical incidents .Critical incidents indicate that something undesirable happened during
the course of anaesthesia. The severity of the incident affects the outcome of the patient, ranging
from transient damage or increasing length of hospital stay and in worst cases death. Therefore,
reporting of adverse events is an appropriate instrument for quality control in anaesthesia.
13.48 Definition -Adverse Events Or Critical Incident Under Anesthesia

“An event under anaesthesia care which had the potential to lead to an undesirable outcome if left to
progress.” These incidents could be airway, respiratory, cardiac,pharmacological, vascular, allergic or
equipment related problems Anaesthesia is a complex and dynamic system in which there is interaction
between man.
13.49 List of Events

1. Death
2. Cardiac arrest
3. Reintubation
4. Perioperative myocardial infarction
5. Anaphylaxis
6. Malignant hyperthermia
7. Transfusion reaction
8. Operation on incorrect site
9. Operation on incorrect patient
10. Medication error
11. Unplanned ICU admission
12. Unrecognized difficult airway
13. Bronchospasm
14. Larnygospasm
15. Dental trauma
16. Perioperative aspiration
136
17. Vascular access complication, including vascular injury or pneumothorax
18. Pneumothorax following attempted vascular access or regional anesthesia
19. Infection following epidural or spinal anesthesia
20. Epidural hematoma following spinal or epidural anesthesia
21. High spinal
22. Postdural puncture headache
23. Major systemic local anesthetic toxicity
24. Peripheral neurologic deficit following regional anesthesia
25. Infection following peripheral nerve block
13.50 Proposed Variables and Their Definitions
13.50.1 -Death: Death within 24 hours after induction of anesthesia/ in-hospital death
No standard exists for the time frame defining perianesthetic mortality. Deaths within 24hours of
induction of anesthesia should be tracked . The surgery team will report each and every death within 24
hours of surgery to OT committee every month.
13.50.2 Cardiac arrest: Cardiac arrest is broadly defined as the cessation of cardiac mechanical activity
as confirmed by the absence of signs of circulation during anesthesia, surgery and
postoperatively(till 24hr).The definition include the following criteria: (1) use of cardiac
compressions and/or defibrillation and (2)during the first 24 hours after induction of anesthesia.
Hs and Ts: Reversible Causes
Hypovolemia • Tension Pneumothorax
• Hypoxemia • Tamponade (Cardiac)
• Hydrogen ion (acidosis) • Thrombosis
• Hyperkalemia • Toxin (anesthetic, β-blocker)
• Hypoglycemia • Trauma (bleeding outside surgical area)
• Hypothermia
Treatment --
- Give 100% O2- Turn off all anesthetic gases
-Check for reversible causes (Hs and Ts) early and often.
-Follow PALS protocol.
137
13.50.3 Brochospasm-Moderate to severe bronchospasm intraoperatively and post operatively,requiring
prolonged nebulisation by bronchodilator and steroid and accompanied by increased oxygen
requirement and desatuaration episodes.
13.50.4 laryngospasm
13.50.5 Increased oxygen requirement-Required use of supplemental oxygen greater than baseline
requirement for more than 60 minutes after surgery
13.50.6 Negative pressure pulmonary edema-Pulmonary edema developing postoperatively confirmed

by diagnostic criteria =1.Desatuaration,Increased Oxygen requirement,Xray finding suggestive of
Pulmonary edema
Causes -Postextubation Larnygospasm
Endotracheal obstruction
Post tonsillectomy/adenoidectomy
Treatment- Positive end-expiratory pressure and Diuretic ,Controlled mechanical ventilation
13.50.7 Perioperative myocardial infarction: Perioperative myocardial infarction was

Defined by following criteria along with the additionof diagnosis by cardiologist:
Detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least one
value above the 99th percentile of the upper reference limit together with evidence of
myocardial ischemia with at least one of the following:
a. ECG changes indicative of new ischemia (new ST-T changes or new left bundle
branch block)
b. Development of pathological Q waves in the ECG
c. Imaging evidence of new loss of viable myocardium or new regional wall motion
abnormality.
13.50.8 Anaphylaxis: Rash, bronchospasm, hypotension

Anaphylaxis is broadly defined as a severe, systemic allergic reaction characterized by multisystem
involvement including the skin, airway, vascular system ,and gastrointestinal tract, potentially resulting in
obstruction of the airway, cardiovascularcollapse, and death.
1.Increase O2 to 100%
2. Remove suspected trigger(s)
138
3. If latex is suspected, thoroughly wash area
4. Ensure adequate ventilation/oxygenation
5. If hypotensive, turn off anesthetic agents and Treat
13.50.9 Malignant hyperthermia:↑Temp ↑HR ↑CO2 acidosis

(1) Clinical diagnosis of suspected MH during or after exposure to anaesthetic gases or succinylcholine
(2) treatment with dantrolene (3.) increasing end-tidal CO2, trunk or total body rigidity, masseter spasm or
trismus, tachycardia, tachypnea, mixed respiratory and metabolic acidosis, increased temperature, and
myoglobinuria.
Treatment include-
1.Stop volatile anaesthetic, succinylcholine.
2.Turn O2 flow to 10 L/min
3. Hyperventilate patient to reduce EtCO2
4.Give dantrolene2.5 mg/kg IV, rapidly, through large bore IV if possible, every 5 min until symptoms
resolve. May need up to 30 mg/kg
5. Give sodium bicarbonate 1-2 mEq/kg IV for suspected metabolic acidosis
6. Cool patient if temperature > 39C
7. Apply ice externally to axilla, groin and around head
8. Infuse cold saline intravenously
9. NG and open body cavity lavage with cold water
13.50.10 Transfusion reaction: Hemolytic transfusion reaction involving administration of

blood or blood products .
Clinical diagnosis -Definite or suspected transfusion reaction during or following
transfusion of blood products confirmed by Blood bank results possibly because of transfusion with blood
incompatible with patient blood.It can be Hemolytic,Non-hemolytic and Anaphylactic.
Treatment incude-
139
1.Stop transfusion
2. Disconnect donor product and IV tubing
3. Infuse normal saline through clean tubing
4. Examine blood product ID; determine correct pt
5 Send product ,Blood sample and urine sample to Blood Bank
13.50.11 Operation on incorrect site: Surgery or anesthesia (including regional nerve block)
on the wrong body part or wrong side of patient. Wrong site surgery is defined as a
sentinel event ,so needs to be reported to QMD and CAPA needs to be done.
13.50.12 Operation on incorrect patient: Surgery or procedure on the wrong patient.Wrong-patient

surgery is again a sentinel event.
13.50.13 Medication error: Administration of wrong medication or wrong dosing during

anesthesia,surgery and in recovery needs to be reported.
13.50.14 Unplanned ICU admission: Unplanned admission to the intensive care unit within 24 hours of
inductionof anesthesia.
13.50.15 Intraoperative awareness: The definition ofawareness during anesthesia as a scenario in

which a patient becomes consciousduring a procedure performed under general anesthesia and
subsequently has recall ofthese events.
13.50.16 Unrecognized difficult airway: For reporting of unrecognized difficult airway, we

refer to the ASA’s Practice Guidelines for Management of the Difficult Airway:The clinical situation in
which a conventionally trained anesthesiologist experiencesdifficulty with face mask ventilation of the
upper airway, difficulty with tracheal intubation,or both.
Treatment-
Increase to 100% and maintain continuous oxygen flow during airway management
1. Call for help, airway expert and cart, rigid bronchoscope and tracheostomy kit
2. If unable to mask ventilate, ask for 2-handed assistance and:
• Insert oral and/or nasal airway;
• If unsuccessful, insert supraglottic airway (e.g., LMA)
• Decompress stomach with orogastric tube
• Consider reversing neuromuscular blocker
140
• Consider awakening pt if surgery not started
4. Consider alternative approach for intubation-Different blade
• Re-position head • Intubating LMA
• Fiberopticscope Different operator
• Intubating stylet• Blind oral
• Blind nasal• Video-laryngoscope
• Fiberopticscope
• Intubatingstylet
5. If macroglossia(e.g. Beckwith-Wiedemann, Pierre-Robin),
ormediastinal mass, consider prone or lateral position
6. If still unable to ventilate: -• Emergency non-invasive airway rigid bronchoscopy in
younger children, jet ventilation in older children
• Emergency invasive/surgical airway cricothyrotomy or tracheostomy
13.50.17 Reintubation:
Patient requires placement of tracheal tube or other airway devices and mechanical or assisted
ventilation within 6 hours after extubation because of severe respiratory distress, hypoxia, hypercapnia, or
respiratory acidosis.
13.50.18 Dental trauma: unanticipated loss of a tooth should be reported.
13.50.19 Perioperative aspiration:

Clinical diagnosis of aspiration during anaesthesia and postoperatively consistent with radiologic findings
should be reported.
13.50.20 Vascular access complication, including vascular injury :

Complications of central venous cannulation are well known. In an attempt to identify injuries of severity
sufficient to require additional interventional therapy, we agreed on the following definition: Accidental
intraarterial placement of central venous catheter, pneumothorax, thoracic duct injury, or other injuries
requiring either surgical or interventional radiologic management. They all need to be diagnosed , treated
and reported .
141
13.50.21 Pneumothorax following attempted vascular access or regional anaesthesia: ↑HR ↓SpO2 ↓BP,
tracheal deviation, mediastinal shift
The traumatic open or tension pneumothorax , diagnosed on clinical presentation or by imaging study
(e.g. X-ray, CT, ultrasound),should be reported.
Treatment include-
1.Stop N2O;
2. increase O2to 100%
3. Secure airway with endotracheal tube
4 Reduce positive ventilation pressure
5.Administer vasopressors for circulatory collapse
6.Decompression-Needle or chest
13.50.22 Infection following epidural or spinal anaesthesia: Infectious complications associated with
neuraxial anaesthesia and analgesia are of great concern because of their potentially devastating
sequelae – including meningitis, paralysis, and death
Superficial soft tissue infection along the course of an epidural/spinal catheter or needle
placement track – Swelling, local erythema and tenderness in combination with any of
the following:
a. Fever (>38.0 degrees centigrade)
b. Drainage
c. Positive culture from the area
d. Leukocytosis>12/nl or CRP>20 mg/L
Epidural abscess – Radiological evidence of a mass in the epidural space consistent
with an epidural abscess within 30 days following epidural/spinal needle/catheter
placement/catheter removal or attempted epidural/spinal placement in combination with
any of the following:
a. Fever (>38.0 degrees centigrade)
b. Drainage
142
c. Positive culture from surgical exploration or puncture
d. Leukocytosis>12/nl or CRP>20 mg/L
e. Local erythema
f. Local tenderness
g. Focal back pain
h. Neurologic deficit
Meningitis associated with central neuraxial block – Spinal or epidural block (catheter
insertion/removal) in the last 72 hours in combination with
a. New onset of central neurologic symptoms
b. Headache
c. Stiff neck
d. Fever >38.0 degrees centigrade
e. Positive CSF culture
f. Meningitis specific antibiotic therapy started
Epidural infection with sepsis – Diagnostic criteria of Superficial soft tissue infection or
Epidural abscess or Meningitis in combination with positive blood culture with the same
organism isolated from puncture site or abscess or clinical diagnosis of sepsis
13.50.23 Epidural hematoma following spinal or epidural anaesthesia

The epidural hematoma following neuraxial anesthesia, confirmed by imaging (MRI), should be reported.
143
13.50.24 High spinal: The unintentional high spinal as indicated by paralysis higher than T4,
hypotension, bradycardia, respiratory insufficiency, possibly necessitating intubation should be
reported.
13.50.25 Postdural puncture headache: The reporting of PDPH , diagnosed on the basis of a clinical
history of a new onset of headache, worsening in the sitting or upright position, within 72 hours of
intended or unintended dural puncture.
13.50.26 Major systemic local anesthetic toxicity: Local anesthetic toxicity is broadly defined by the
ASRA recommendations on systemic toxicity of local anesthetics
The major systemic effects observed following injection of local anesthetics should be reported, and
should include features to allow reporters to report observed effects, including: seizures, somnolence,
loss of consciousness, respiratory depression/apnea, bradycardia/ asystole ,or ventricular
tachycardia/fibrillation.
13.50.27 Peripheral neurologic deficit following regional anaesthesia:

Clinical diagnosis of residual sensory and/or motor and/or autonomic block 72 hours after last injection of
local anaesthetic without other identifiable etiology when no regional anaesthetic/analgesia related
infection is present.
The diagnoses could be confirmed, where appropriate by:
a. Electrophysiological evidence of new nerve damage (MEP, SEP, nerve
conduction study, electromyography)
b. New loss of deep tendon reflexes
c. New loss of vibration sensation
d. Paraesthesia in affected nerve distribution area
e. Sensory and/or motor and /or autonomic deficit consistent with dermatomes or nerve distribution
affected by the regional anaesthetic technique.
13.50.28 Infection following peripheral nerve block:

Peripheral nerve block associated superficial and deep soft tissue infection within 30 days of block -
Swelling, local erythema, and tenderness along the catheter or needle placement track in combination
with any of the following:
a. Fever (> 38.0 degrees centigrade)
b. Drainage
144
c. Positive culture from the area
13.50.29 Equipment Malfunction/failure

a. Anaesthesia machine malfunction
b. Gas delivery system malfunction
c . Pump mal function

Policy No:- CNBC/ANEST/Management during pandemic/15.c
Revised on: AUGUST 2020 vide Rev. No.: 1.1
Prepared By Dr .Geeta kamal
13.51 Anaesthesia policies for Perioperative management during covid-19 pandemic-
13.51.1 Preanesthetic Check up (PAC)

1.All patients to be screened for temperature at the outpatient clinic entrance and any doubtful case to be
referred to the flu corner.
2.One attendant per patient to prevent crowding and make social distancing easier. Being a pediatric
hospital, one attendant per patient is being followed at our institution.
3.Wearing mask before entering hospital premises is mandatory.
4.The anesthesiologist must wear PPE (gown, gloves, N95 mask, face shield) at all times in the clinic and
practice hand hygiene every time .
5.The reusable medical equipment in the PAC clinic, such as the stethoscope and the blood pressure
apparatus, to be sanitized frequently.
6.Every day, after the pre-anesthesia consultations, the room should be cleaned and disinfected.
7.Mandatory COVID screening with rapid antigen test is must in all cases presenting for surgeries.
8.History of symptoms or contact history in mother is also important and maternal COVID testing is
advised.
13.50.03. Preparation of the Operation Theatre
1. Thermal screening before entering operation theatre
145
2. Dedicated OT with signage “COVID-19 operation theatre” should be posted on the doors to
minimize staff exposure.
3. Face mask is mandatory both for relative and the patient.
4. Intubation can be preferably done in negative pressure OT or in OTs with laminar flow through
HEPA filter with increased air exchanges (>12 cycles/hours).. Our OTs have laminar flow with
HEPA filter with air exchanges up to 14-18 cycles/hour.
5. Limit the number of staff present in the OT during any aerosol generating procedures.
One anesthesiologists, one technician and one Nursing orderly stays inside OT, one standby
anesthetist outside OT door, surgeons and the nursing staff stays out during AGPs and allowed
to enter after 10 minutes of AGPs (both intubation and extubation).
6. A dedicated runner should be donned and wait outside the OT to procure and transport items if
needed.
7. Early preparation of airway equipment and drugs should be done in the OT prior to the case.
Only the drugs to be used are kept on work station.
8. As the PPE which can hamper the voice, clear and loud communication should be made.
9. Use of two high-efficiency particulate air (HEPA) viral filters is recommended. The first one
should be interposed between Y-piece of the breathing circuit and the patient’s mask or ETT. The
second one should be placed between the expiratory limb and anesthesia machine. The gas
sampling tubing should be placed after HEPA filter or should be scavenged.
10. Disposable covers (e.g., plastic sheets for surfaces, long ultrasound probe sheath covers, C-
ARM, covers for anesthesia machine) are used to reduce droplet and contact contamination of
.
equipment
13.51.2 Rationale Use of Personal Protective Equipments in operation theatre (ot)

1. Ensure HCW is not fasting and is well hydrated. They should ideally have used the restroom before
donning. Nonessential items, jewelry, and phones, books not allowed inside Ot.
2. Before donning, proper hand hygiene should be ensured.
3. Centers for disease control (CDC) videos for donning and doffing personal protective N-95 masks
can be used for training the personnel.
146
13.51.3 Transfer of Patients into Operation Theatre
1. Suspected COVID patients, who are otherwise negative on investigation, should not be allowed
to wait in the holding area and should be directly wheeled into the dedicated theater.
2. Whenever logistically possible, separate corridors should be used for transport to OT.
3. Avoid use of that OT for other asymptomatic patients on the same day.
4. A surgical mask must be applied to the patient during transfer and till pre-oxygenation
6. As intubation results in significant exposure to a high-viral load, it is a high-risk procedure. The

goal is to secure the airway without contaminating the environment with aerosols.
7. Avoid AGP, including high-flow nasal oxygen, noninvasive ventilation and awake bronchoscopy.
8. Acrylic aerosol shield box with arm holes for unrestricted arm movement or transparent plastic
sheet should be utilized to cover the face of the patient during intubation to prevent aerosol
transmission. In our institution we use the plastic transparent sheet over the face once the child is
sedated during induction. Similar protocol to be followed during extubation.
9. Two handed ventilation (VE grip) with closed circuit, is preferred to minimize operation theatre
pollution.
10. Modified Rapid Sequence Induction should be preferred.
11. A video laryngoscope should be routinely preferred over direct laryngoscopy as the latter
requires the anesthetist to be near the patient’s airway.
12. The most experienced anesthesiologist in the team should perform intubation, to reduce the
number of intubation attempts.
13. An endotracheal tube (ETT) is preferred over a supraglottic airway because of decreased
aerosolization risk.
14. Airway devices and used laryngoscopes and suction catheters should be carefully placed
separately on a plastic sheet to avoid contaminating other surfaces.
15. Endotracheal tube should be clamped before insertion into the larynx, cuff inflate, attach to circuit
and then remove the clamp. Tube position is confirmed by bilateral chest rise and the presence of
continuous waveform capnography. Unnecessary contamination of stethoscope can be avoided,
which can become a potential source of fomites.
16. When the nasogastric tube is required, it should be inserted under the plastic drape.
17. Use low gas flows and closed circuits throughout the case.
18. Minimize the ventilatory disconnections, and whenever it is required (e.g., during prone
positioning), the ventilator is put on standby mode (to prevent the blast of the gas mixture) and
ETT is clamped distal to HEPA filter at the end-expiratory phase.
19. A closed airway suction system is preferable to decrease viral aerosolization.
147
20. Pharmacological strategies for reduction of bucking on emergence from anesthesia should be
practiced, extubation under deep plane should be considered weighing the risk vs benefit.
21. Administration of prophylactic antiemetic to reduce the risk of vomiting with subsequent
contamination.
22. Patients who are unfit for extubation can be shifted to ICU with a single-use AMBU bag with an
attached HEPA filter at the patient end.
13.51.4 Decontamination of Operation Theatre

1. All unused items on the drug tray should be discarded.
2. Discard disposable equipment safely after single patient use (breathing circuit, mask, tracheal
tube, HEPA filters, gas sampling line, and soda-lime). Water trap must be changed if it becomes
potentially contaminated.
14
3. Decontaminate reusable equipment fully and according to manufacturer’s instructions.
4. Seal all used airway equipment and suction catheter in a double zip-lock bag which must then be
removed for decontamination and disinfection.
5. A one-hour time gap is planned between two cases to give adequate time for thorough
decontamination of OT. So the number of cases posted per OT should be reduced.
6. Cleaning staff to be provided with adequate PPE. All surfaces, screens, keyboard, cables,
monitors, and anesthesia machine to be cleaned with 2 to 3% hydrogen peroxide spray
disinfection, or 2 to 5 g/l chlorine disinfectant, or 75% alcohol wiping of solid surfaces of the
equipment and floor.
13.52 Policies For Implantable Prosthesis And Medical Supplies

Please refer Chapter 29 Pharmacy, clause no 29.16.
148
14 Department of CSSD
Responsibility of Dr Bhumika Kalra,

Updating:
Mo I/c Department of CSSD
Last reviewed/ August, 2020

updated on:
Version (CNBC/CSSD/16/Ver. 3.2)
Replacing version (CNBC/CSSD/16/Ver.

3.1)
149
14 Department of CSSD ...................................................................................................................... 149
14.1 Amendment Record Sheet ........................................................................................................ 151
14.2 Objectives of CSSD: .................................................................................................................. 153
14.3 Scope of services: ..................................................................................................................... 153
14.4 Timing: ....................................................................................................................................... 153
14.5 Staffing: ...................................................................................................................................... 153
14.6 Hierarchy of the CSSD Unit ....................................................................................................... 154
14.7 Cleaning protocols of CSSD ...................................................................................................... 155
14.8 Structure:- .................................................................................................................................. 155
14.9 Packing Area Sterile Storage Area ............................................................................................ 157
14.10 Quality Indicators ( Before use & after use) ............................................................................... 158
14.11 Recall policy: .............................................................................................................................. 159
14.12 Record Maintenance: ................................................................................................................ 159
14.13 Performance Evaluation: ........................................................................................................... 159
14.14 Maintenance of Equipments: .................................................................................................... 159
14.15 Future planning- ......................................................................................................................... 160
14.16 Categorization Of Items ............................................................................................................. 160
14.17 List of items which are Sterilized by Steam Sterilization in CSSD ............................................ 160
14.18 List of items which are Disinfected (HLD) by Chemical Disinfection ....................................... 160
14.19 Note: ........................................................................................................................................... 161
14.20 List of Equipments available in CSSD: ...................................................................................... 161
14.21 Contact Details:-......................................................................................................................... 161
14.22 Tips to Assure Effective Sterilization by Autoclave .................................................................... 161
14.23 Note: Do not autoclave plastic unless it is rated as autoclavable. ............................................. 162
14.24 Trouble Shooting Problems ....................................................................................................... 162
150
S.no Clause Date of Amendment Reasons Sign of QM
. no. Amendmen Made Of
t Amendment
1. 14.2.2 23.03.2013 In point (b) Indicators To remove grammatical

mentioned in place of error
effectiveness
2. 14.2.5 23.03.2013 Point (e) modified To maintain continuity
of the sentence
3. 14.2.7 23.03.2013 Institute word replaced with As CNBC is a hospital
hospital
4 14.14.4 23.03.2013 Timing changed Previous timing was
coinciding with the
changeover of staff
5 14.8 23.03.2013 Font changed in zoning under Typing error corrected
STRUCTURE
6 14.8.3 23.03.2013 A line added in receiving area Previously not
to describe double door window mentioned
7 14.8.4 23.03.2013 Ultrasonic cleaner added in As Ultrasonic cleaner
cleaning area. newly added in our
cleaning protocol.
8 14.8.5 23.03.2013 Timing for immersion of items in Previously not
Cidex added mentioned.
9. 14.8.8 23.03.2013 In Linen processing area first Previously wrongly
line deleted. mentioned.
10. 14.15.1 23.03.2013 In Future plans ETO Machine & We have bought
(c) Ultrasonic Cleaner deleted and Ultrasonic cleaner.
Roll dispenser & cutter added.
11. 14.10.3 23.03.2013 In load control monitoring, the Corrected as per
load containing implant is protocol.
added & In equipment control
frequency of Bowie Dick
changed from once a week to
daily
12. 14.13 23.03.2013 Paragraph PERFORMANCE Grammatical errors
EVALUATION edited
13 14.16 June 2014 Addition of categorization of Previously not
items mentioned
14 14.5.1 29.12.14 TS(OT) instead of TA(OT) As supervision is now
being done by TS(OT)
15 14.6 29.12.14 TS(OT) instead of TA(OT) Now TS(OT) in
hierarchy chart instead
of TA(OT)
16 14.8.3 29.12.14 Primary rinsing of items done at Previously not
user end. mentioned.
17 14.8.4 29.12.14 Concentration of Multienzyme Previously some other
solution mentioned as 1% brand was in supply,
instead 0.8% as per Now we are using 3M
manufacturer brand and
recommendations. concentration used as
per manufacturer
recommendations.
18 14.10.6 29.12.14 Glutraldehyde monitoring strips Previously not
th th
used on 7 & 10 day after the mentioned.
151
day of activation.
19 14.5 19.01.16 Technicians added in staffing Previously not

column mentioned.
20 14.8.2 19.01.16 Zoning A, B & C categorized Previously not
mentioned.
21 14.8.7 19.01.16 Packaging Instruction added Previously not
mentioned.
22 14.15.1 19.01.16 Under Procurement equipments Previously not
added in future plans mentioned.
23 14.20 19.01.16 List of available equipments Previously not
added mentioned.
24 14.21 19.01.16 Contact Details of CSSD Previously not
mentioned.
25 14.22 19.01.16 Tips to assure effective Previously not
sterilization by autoclave mentioned.
26 14.23 19.01.16 Troubleshooting Previously not
mentioned.
27 1.8.4 13.12.17 Washer, Disinfector added Previously not
mentioned.
28 14.3 13/12/17 High Level Disinfection added Previously not
mentioned.
29 14.14.1 13.12.17 Automatic Washer, Disinfector Previously not
& dryer added mentioned.
30 14.15 13.12.17 Future Plans & Development Updation as on date.
updated
31 14.14.3 13.12.17 Note: Plasma sterilizer instead Updation as on date.
of Glutraldehyde solution added
for sterilization of endoscopic
instruments in point no.-2
32 14.20 13.12.17 List of equipments updated with Updation as on date.
Washer, disinfector & dryer
system, RO & UPS and plasma
sterilizer (in OT)
33 14.21 13.12.17 Contact details: Name & Updation as on date.
contact number of HOD (A) and
M.O.I/c (CSSD) updated
34 14.14.6 12.01.19 Details of new procured Previously these
equipment namely Drying equipment’s were
Cabinet & Labeller Gun added mentioned in Plan in
clause no. 1.6.1
35 14.21 12.01.19 Name of Dr. Bhumika Kalra As she is designated as
incorporated as M.O.I/c M.O.I/c (CSSD)
36 14.21 12.01.19 Name of Director, CNBC Dr. B.L. Sherwal taken
updated over the charge of
Director, CNBC.
37. 14.14.8 27.08.20 Replacement of autoclave Updation as on date.
machine mentioned.
38. 14.21 27.08.20 Contact details updated Updation as on date.
39. 14.20 27.08.20 Equipment list updated Updation as on date.
152
14.2 Objectives of CSSD:
14.2.1 To provide supplies of sterile instruments, linen packs, basins and other sterile
items used in patient care units.
14.2.2 To maintain record of indicators of cleaning, disinfection and sterilization

process.
14.2.3 To maintain and enforce controls necessary to prevent cross infection according
to infection control policy.
14.2.4 To maintain an inventory of supplies and equipments.
14.2.5 To stay updated regarding development in the field keeping in view the
efficiency, economy, accuracy and provision of better patient care.
14.2.6 To provide a safe environment for the patients and staff.
14.2.7 In CNBC, CSSD is located in the basement. It is equipped with two autoclaves
and caters to the requirement of the entire hospital.
14.3 Scope of services:
14.3.1 Services are provided round the clock. Unsterile items including heat sensitive
items from various departments of the hospital are received. After sterility and High level
disinfection (HLD) they are issued back to the respective departments. The work is supervised
by an officer who is concerned with the day to day management of the unit and also by a
quality control team.
14.4 Timing:
14.4.1 For routine items:

Morning:- 08:30am to 11:00am ( Receiving and issuing)
Evening:- 02:30pm to 05:00pm (Receiving and issuing)
14.4.2 For Emergency items: 24 hrs.
14.5 Staffing:
14.5.1 There is a team of CSSD Assistants & Technicians posted throughout the day in
the department with CSSD technician posted from 09:00am to 04:00 pm supervised by
T.S.(OT).
153
14.6 Hierarchy of the CSSD Unit
DIRECTOR
MEDICAL
SUPERINTENDENT
HOD(ANESTHESIA)
M.O.I/c (CSSD)
T.S.(OT)
O.T.TECHNICIAN
CSSD
ASSISTANT
NURSING
ORDERLIES
154
14.7 Cleaning protocols of CSSD
14.7.1 Floor is mopped daily with superoxide solution.
14.7.2 - Fumigation of sterile storage room in done once a week.
14.7.3 - Trolleys, shelves and tables are wiped with disinfectant every day
14.8 Structure:-
14.8.1 The various standard Operating procedures in the CSSD are very efficiently
followed. Our CSSD has been divided into 3 zones-
1. Protective zone
2. Clean zone
3. Sterile zone
14.8.2 A) Protective Zone includes:-

1. Receiving Window
2. Cleaning Area
3. Decontamination and HLD Area
4. Drying Area
5. Assembling and Packaging Area
6. Linen processing Area
B) Clean Zone includes:-
 Autoclaving Area
C) Sterile Zone includes:-
a) Sterile storage room
b) Issuing window.
155
14.8.3 Receiving Area: After use of items, primary rinsing done at the user end with
normal tap water to reduce bio burden. Items are brought to CSSD from respective wards,
ICU’s, O.T.’s & casualty by nursing orderly. The CSSD assistant receives them & checks the
status of items. There are two windows at the receiving & issuing area and they are opened
one after another to maintain the sterility of CSSD environment.
14.8.4 Cleaning Area: In this area all instruments are cleaned in ultrasonic
cleaner/Washer disinfector with multienzyme solution to remove dried blood & secretion.
14.8.5 Decontamination Area: In this area, High level disinfection (HLD) of soiled heat
sensitive items like oxytubings, nebulization chamber, airway and other supplies are done with
the help of glutraldehyde 2% for 45 minutes.
14.8.6 Drying Area: In this area all cleaned items are dried with the help of drying
0
cabinet at a temperature of 45 C for 45 minutes. Instrument cleaned in Automatic Washer,
disinfectant & dryer system is dryed in the said system.
14.8.7 Assembling & Packaging Area: Here all the instruments are assembled and
packed for sterilization after cleaning & drying. Labels and autoclave indicator tapes are
pasted on all the packs. To ensure the quality of work, a label ensuring date of packing, date
of expiry, packed by, checked by & content will be provided with each item issued from CSSD.
This label is to be quoted and return back by the user department for any sort of queries later
on.
14.8.7.1 Packaging Instruction: - All the trays/items should be packed in double layer, Inner layer is of
Medical Craft Paper and outer layer to be packed from Linen towel. Pack size should not
exceed 12" x 12" x 20" for proper exposure of steam inside the packs.
14.8.8 Linen processing Area: Various types of dressings like gauge pieces; cotton
pads and bandages etc. are also prepared in this area. Linen processing unit is separated
from instrument assembly area as a lot of fibers are generated in this section.
14.8.9 Autoclaving Area: In this area sterilization process is carried out by autoclaves.
Before that autoclave indicators are pasted on the
packs. Then technician places the packs in the
autoclave machine and starts the machine as per
cycle of appropriate temperature and pressure
recommended by the manufacturer for 30 minutes.
14.8.10 Sterile storage Area: In this area

sterile items are placed in racks after completion of
autoclave before that adequacy of sterilization is
confirmed by indicators.
14.8.11 Issuing Window: All the sterile

instruments and other supplies are distributed to
concerned departments at a separate window after entry of all the items in the appropriate
issuing register.
156
14.9 PACKING AREA STERILE STORAGE AREA
157
14.10 Quality Indicators ( Before use & after use)
14.10.1 Monitoring protocol of CSSD:

1). Temperature, Pressure and time of each cycle is recorded is followed according to
manufacturer’s recommendations.
2). Various quality indicators are used to check the adequacy of sterilization:
3) Air cultures are taken once in a month
4) Wet pack is not accepted as sterile. These are repacked and resterilized (even if the indicators
show the appropriate changes.
5). There are different trolleys for carrying sterile and unsterile instruments White & Red
respectively.
6). No person is allowed to enter in sterile room without Personal Protective Equipments (PPE)
(i.e. Cap, mask, gown, & slippers etc.) Exposure control: Autoclave indicators tape is pasted
on all packs to be kept in autoclave
14.10.2 Load Control: Rapid Biological indicators are used once a week in both
autoclave machines in first load and the load which contains implant. This indicator gives us
rapid results, i.e. positive result in one hour and negative result in 3 hours. If result is positive
means sterilization is not adequate that whole load is recalled & re autoclaved.
14.10.3 Pack control: Class 5 chemical indicators - It is used in every pack.
14.10.4 Equipment control: Bowie-dick test pack - It is used daily in first load in both
machines.
th
14.10.5 Glutraldehyde monitoring Strips: This is to check cidex efficacy. Used on 7 &
th
10 day after the day of activation.
158
14.11 Recall policy:
14.11.1 Actions to be taken if any monitoring indicators fail:
14.11.2 CSSD supervisor should be informed immediately.
14.11.3 CSSD personnel should try and discover the cause of the failure and arrange for
corrective action.
14.11.4 The item should be reprocessed and then supplied after confirmation of sterility.
14.12 Record Maintenance:
1.1.1 Entry of all the items made in CSSD receipt register including date, time, type of
instruments in the pack, name of department, procedure used for, case infected not, name
and signature of person receiving the items.
1.1.2 Inventory of sterile packs is checked so that they are not distributed directly to the user
department.
1.1.3 Record of all the indicators tests and culture report is kept.
14.13 Performance Evaluation:
Performance evaluation is carried out on the basis of appropriate records and quality
indicators noted in the CSSD on routine basis. Internal quality audit is carried out every
month on the basis of performance records and the surprise inspection. The feedback
coming out of such evaluation is recorded and made use of in improving the working of
CSSD.
14.14 Maintenance of Equipments:
14.14.1 - This is done as per AMC/Warranty. All the details are maintained in the register.
14.14.2 - All the equipments are calibrated at periodic intervals.
14.14.3 Plasma Sterilizer for sterilization of endoscopic/laparoscopic & other endoscopy

nd
equipment has been procured and installed in elective operation theatre (2 floor) and the
same is being used for sterilization of all kinds of compatible equipments SOP's of Plasma
sterilizer is mentioned in O.T. Manual.
14.14.4 Automatic Washer Disinfector & Dryer System has been procured and installed
in CSSD for better cleaning & disinfection of the instruments.1.6.2
14.14.5 R.O. Plant & UPS for Autoclave machine has been procured and installed in
CSSD for better functioning of the sterilizer.
14.14.6 One additional Drying Cabinet has been procured and installed in CSSD for
smooth functioning.
14.14.7 One Labeler Gun has been procured in CSSD for proper labeling on items.
14.14.8 One autoclave machine has been procured in replacement of defective machine
and the new machine has been installed in August, 2020.
159
14.15 Future planning-
We are planning to procure the following equipment’s in future to improve the quality and efficacy
of CSSD department.
a)Packing Roll dispenser & Cutter.
b)One Steam Sterilizer.
14.16 CATEGORIZATION OF ITEMS
CATEGORIZATION OF ITEMS
Classification Item Use Appropriate Process
Critical Items Items entering sterile tissue, the body cavity, the Sterilization
vascular system and non intact mucous (By Steam sterilization or any
membranes. other available appropriate
Eg. Surgical Instruments, dressing material etc. method)
Semi-Critical Items that makes contact, directly or indirectly, HLD
Items with intact mucous membranes or non intact (High Level Disinfection)
skin.
Eg. Respiratory therapy equipments, Masks, Thermal disinfection
Temp.probes etc. OR
Chemical Disinfection
Non-Critical Objects that come into contact with intact skin LLD
Items but not mucous membranes. (Low Level Disinfection)
Eg. BP Cuffs, tabletops, ECG Leads, SPO2
probes, bedside tables etc. Cleaning (Manual or mechanical)
14.17 List of items which are Sterilized by Steam Sterilization in CSSD

S.NO. Name of Item Method
1. Surgical Instruments (S.S.) Steam Sterilization
2. S.S. Trays Steam Sterilization
3. Dressing Material & Dressing Drums Steam Sterilization
4. Linen Items Steam Sterilization
5. Reusable silicon Breathing Circuit Steam Sterilization
6. Red Rubber items (like ETT, Airway, Catheter, Drain etc.) Steam Sterilization
7. Borosil bottle Steam Sterilization
8. Etc. (Any other autoclavable item) Steam Sterilization
14.18 List of items which are Disinfected (HLD) by Chemical Disinfection i.e. Glutraldehyde
Solution in CSSD
S.NO. Name of Item Method
1. Oxygen Mask HLD
2. Nebulization Chambers HLD
3. AMBU Bags HLD
4. PVC Breathing circuits HLD
5. Oxygen Tubings HLD
160
6. Suction Jars HLD
7. Humidifier Chambers HLD
8. Etc. (Any other Semi-critical items) HLD
14.19 Note:
1) Non-critical items are treated by Low Level disinfection method & the same is being done in the
user department.
2) All types of Endoscopes (i.e. Cystoscope, Laparoscope, Fibrotic Bronchoscope, Laryngoscope &
other heat sensitive critical items are sterilized with the help of Plasma Sterilizer in Elective O.T.
14.20 List of Equipments available in CSSD:

1) Cylindrical Autoclave Machine (Manually operated) - 01 no
2) Automatic High Speed Steam Sterilizer - 01 no.
3) Ultrasonic Cleaner - 01 no
4) Autoreader Incubator - 01 no.
5) Sealing Machine - 01 no.
6) Fogging Machine - 01 no.
7) Airjet & Waterjet Gun - 01 each
8) Automatic Washer, disinfectant & dryer system - 01 no.
9) RO Plant & UPS for Autoclave Machine - 01 no.
10) Plasma Sterilizer (installed in OT) - 01 no.
11) Autoclave machine cylindrical - 01 no.
14.21 Contact Details:-

S.No. Name Designation Mobile NO.
1 Dr. B.L.Sherwal Director 8595919300
2 Dr. Geeta Kamal HOD(Anesthesia) 8595919329
3 Dr. Bhumika Kalra M.O.I/c (CSSD) 8595919327
4 Dr. Aikta Gupta Link Officer M.O.I/c & Quality 8595919328
Manager
5 Mr. Vineet Kr. Arora Tech. Supervisor 8595919303
6 CUG (On Rotation) CSSD CSSD Deptt. 8595919363
7 CSSD Inetrcom Intercom 143
14.22 Tips to Assure Effective Sterilization by Autoclave
Failure to effectively sterilize an autoclave load can be due to either a mechanical problem with the
equipment or operator error. Report mechanical problems to FM (Facility Manager-CSSD Supervisor).
Operator errors are generally due to insufficient steam circulation and penetration due to:
161
14.22.1 Autoclaving for too short of a time for the size and configuration of load.
14.22.2 Using an autoclave bag that is too large for the autoclave.
14.22.3 Filling bags more than 3/4 full.
14.22.4 Closing bags before autoclaving.
14.22.5 Not having enough liquid in bottom of bag to create steam and force air out.
14.22.6 Placing material in plastic container that does not allow efficient heat transfer.
14.22.7 Placing material in plastic container with high sides that does not allow effective
steam penetration.
14.23 Note: Do not autoclave plastic unless it is rated as autoclavable. Do not exceed the temperature
that the material is rated for. Melted plastic releases fumes, ruins autoclave surfaces and can
clog chamber drain.
14.24 Trouble Shooting Problems
PROBLEM CAUSE CORRECTIONS

Clogged Drain Agar boiled over or other Clean chamber drain strainer, if still clogged call FM.
debris.
Wet Wrappers -Overloaded baskets or racks -Load loosely
-Clogged chamber drain -Remove strainer; free openings of lints, sediment,
strainer not allowing water to etc.
drain
-Clogged chamber drain line. -Clean chamber drain line; mix 2 tbsp. trisodium
phosphate with one quart of hot water, pour into
chamber drain line. Then flush drain with one quart
of hot tap water. If still clogged call FM.
-Excessively large or dense -Reduce pack to 12" x 12" x 20" or less; and 12
packs. pounds or less.
-Placing warm sterilized -Allow packs to cool on rack or in autoclave
packs on cold surfaces
-Sterilized goods removed -Allow goods to remain in autoclave additional 15
from sterilizer too soon minutes with door slightly open.
following completion of cycle.
Improper loading -Place packs on edge; arrange packs to present the
least possible resistance to passage of steam and
air through layers of load
-Combining items in a pack -Wrap separately.
Corroded Instruments -Poor cleaning: residual soil -Improve cleaning. Do not allow soil to dry on
instruments
-Moisture. -Check sterilizer for drying efficiency. Store in a dry
area
-Exposure to harsh -Do not expose instruments to these chemicals. If
chemicals: acids, iodine, exposure occurs, rinse thoroughly after contact
sodium chloride, detergents,
etc
-Inferior instruments -Use only top-quality instruments
162
-Metallic deposition resulting -Keep sterilizer chamber and trays clean. Use
from galvanic reaction with detergent recommended by manufacturer
sterilizer components
Caps "Blow off" of -Exhausting sterilizer too -Use slow exhaust cycle.
Liquid Containers rapidly.
-Maladjusted slow exhaust -Notify FM
valve
Loss of More than 5% -Exhausting sterilizer too -Use slow exhaust cycle
Fluid Volume during rapidly.
Sterilization -Maladjusted slow exhaust -Notify FM
valve.
Cracked or Broken -Cracked before sterilization; -Inspect thoroughly after cleaning; discard chipped
glass Containers poor inspection following or cracked flasks
cleaning.
-Containers not heat-resistant -Use only borosilicate (Type I) containers and
or with screw-caps automatic sealing and venting closures
Solutions Boiling -Door opened too quickly -Do not open door until temperature gauge is below
when Door is Opened 212°F and pressure gauge is at "0". Do not touch or
move a load of boiling solutions
-Maladjusted slow exhaust -Notify FM
valve
Indicator Shows -Load may be too large, too -Size of packs should not exceed 12" x 12" x 20";
Sterilization Not dense, or improperly loaded weight should not exceed 12 pounds. Packs should
Complete in chamber rest on edge; all packs arranged to present the least
possible resistance to passage of steam and air
through layers of load.
-Time not sufficient for load -Increase time
-Sterilizer may be -Notify FM
malfunctioning
Steam Leakage -Worn gasket -Call FM
-Door closed improperly. -Close properly (if problem continues, notify FM)-
Close properly (if problem continues, notify FM).
Chamber Door Won't -Vacuum in chamber -Follow manufacturer's instructions
Open -Door-lock clutch is jammed -Follow manufacturer's instructions
-Gasket sticking to door frame -Notify FM
163
15 OPERATION THEATRE
Date created: August 2008
Responsibility of Operation theatre committee

Updating:

updated on:
Version (CNBC/OT/20/Ver. 1.2)
164
15 OPERATION THEATRE ......................................................................................................................... 164
15.1 Amendment Record Sheet .......................................................................................................... 168
15.2 Departmental procedures ............................................................................................................ 169
15.3 Departmental policies .................................................................................................................. 169
15.4 Forms / Documents ..................................................................................................................... 170
15.5 DAILY OT ROUTINE -ELECTIVE................................................................................................ 171
15.6 List of Major Equipments ............................................................................................................. 172
15.7 Introduction .................................................................................................................................. 172
15.8 Principles To Be Taken Under Consideration; ............................................................................ 173
15.9 Purpose:....................................................................................................................................... 173
15.10 Frequency of Meeting : Quarterly and or as and when required. ................................................ 173
15.11 Responsibilities & Function of OT committee: ............................................................................. 173
15.12 15.9.11 Hierarchy Chart of Operation Theatre ............................................................................ 174
15.13 Structure of OT Committee: ......................................................................................................... 175
15.14 Departmental Procedures ............................................................................................................ 175
15.15 Admission Procedure to Operating Room Procedure ................................................................ 175
15.16 Assessment of Surgical Patients ................................................................................................. 176
15.17 Purpose: The purpose of patient assessment is to determine the need for care, the type of care
to be provided and the need for further assessment. ................................................................................. 176
15.18 Procedure: ................................................................................................................................... 176
15.19 Assessment and Follow up of Post-Surgical Patients in Surgical Area ...................................... 176
15.20 Purpose: The purpose of patient assessment is to determine the need for care & the type of care
to be provided postoperatively. ................................................................................................................. 176
15.21 Procedure: ................................................................................................................................... 176
15.22 Accountability for Sponges, Sharps and Instruments .................................................................. 177
15.23 Purpose: To provide guidelines of accountability for sponges sharps and instruments used during
a surgical procedure. To provide safe practice for the surgical patient, prevent patient injury and adhere to
legal standards. ........................................................................................................................................... 177
15.24 Procedure: ................................................................................................................................... 177
15.25 Close Gowning and Surgical Technique ..................................................................................... 178
15.26 Cardiopulmonary Resuscitation in Operating Room ................................................................... 179
15.27 Purpose: To reinstate cardiopulmonary function on cardiac and/or respiratory arrest victims. .. 179
15.28 Procedure .................................................................................................................................... 179
15.29 Cardiopulmonary Resuscitation Report: ...................................................................................... 180
15.30 Handling of Biohazard Waste Materials ...................................................................................... 180
15.31 Purpose: To provide guidelines for the handling and disposal of all waste in accordance with the
State Health and Safety Code. .................................................................................................................... 180
15.32 Procedure: ................................................................................................................................... 180
15.33 Disposal of Sharps ....................................................................................................................... 180
15.34 Electrical Surgical Cautery Unit Safety ........................................................................................ 181
165
15.35 The Electro surgical Active Electrode (Pencil):............................................................................ 181
15.36 Employee Infection Control.......................................................................................................... 182
15.37 Immediate clinical action: ............................................................................................................. 182
15.38 Reporting: (This is essential in every case) .............................................................................. 182
15.39 Gowning and Gloving Technique ................................................................................................ 182
15.40 Hand Washing ............................................................................................................................. 182
15.41 House Keeping Procedure........................................................................................................... 183
15.42 Infection Control Surveillance ...................................................................................................... 184
15.43 Duration of Informed Consent:..................................................................................................... 185
15.44 Any special circumstances: ......................................................................................................... 185
15.45 Role of Name of Your Institution in the Informed Consent Process: ........................................... 186
15.46 Operating Room Techniques ....................................................................................................... 186
15.47 Procedure for contaminated areas: ............................................................................................. 186
15.48 Pathology Specimen .................................................................................................................... 187
15.49 Patient Positioning during surgery ............................................................................................... 187
15.50 The patient's eyes must be protected from pressure and corneal drying or abrasions. .............. 187
15.51 Variations of the supine position .................................................................................................. 187
15.52 Lithotomy position: ....................................................................................................................... 188
15.53 Prone position - patient is lying with abdomen on the surface of the operating table. ................ 188
15.54 Fracture Table: ............................................................................................................................ 189
15.55 Preparing Case Trolley ................................................................................................................ 189
15.56 Skin Preparation Protocol ............................................................................................................ 189
15.57 Standard Precautions .................................................................................................................. 190
15.58 Patient Care Equipment............................................................................................................... 191
15.59 Environmental Controls ............................................................................................................... 191
15.60 Linen ............................................................................................................................................ 191
15.61 Occupational Health and Blood borne Pathogens ...................................................................... 191
15.62 Patient Placement ........................................................................................................................ 192
15.63 Surgical Hand Scrub .................................................................................................................... 192
15.64 Use of Tourniquet ........................................................................................................................ 192
15.65 Criteria for Admission Prior to Surgery ........................................................................................ 193
15.66 Scheduling Surgical Procedures.................................................................................................. 193
15.67 Protocol for scheduling of operating cases .................................................................................. 193
15.68 Pre-operative tests for inpatients ................................................................................................. 194
15.71 Cardiopulmonary Resuscitation in Operating Room ................................................................... 195
15.72 Handling of Bio-hazardous Materials ........................................................................................... 195
15.73 Electro surgical Cautery Unit Safety ............................................................................................ 196
166
15.74 Collection of Pathology Specimen ............................................................................................... 197
15.75 Patient Positioning during surgery ............................................................................................... 198
15.76 Selection of Barrier Material for surgery procedure ..................................................................... 198
15.77 Packaging Materials: ................................................................................................................... 198
15.78 Skin Preparation Protocol ............................................................................................................ 199
15.79 Standard Precautions .................................................................................................................. 200
15.80 Sterile Storage ............................................................................................................................. 200
15.81 Surgical Hand Scrub .................................................................................................................... 200
15.82 Traffic and Visitor Control ............................................................................................................ 200
15.83 Scheduling of Surgical Procedures ............................................................................................. 201
15.84 After Office hour Surgeries .......................................................................................................... 201
15.85 Criteria ......................................................................................................................................... 201
15.86 Sterilization-Reprocessing single use product............................................................................. 201
15.87 Transferring /Shifting Criteria ....................................................................................................... 201
15.88 Other minimal shifting criteria are:- .............................................................................................. 202
15.89 The anaesthetist can determine the criteria for shifting of patient :-............................................ 203
15.90 Operation theatre washing protocol (weekly) .............................................................................. 204
15.91 Weekly washing protocol for decontamination of instruments .................................................... 205
15.92 Equipment surface disinfection protocol ...................................................................................... 206
15.93 Daily washing protocol-................................................................................................................ 207
15.94 Radiation health hazard in OT ..................................................................................................... 208
15.95 Pest control in OT ........................................................................................................................ 208
15.96 Implant policy in OT ..................................................................................................................... 208
15.97 Plasma sterilization policy: ........................................................................................................... 208
15.98 Day to Day Operation .................................................................................................................. 208
15.99 Chemical indicator tape- .............................................................................................................209
15.100 Chemical indicator strip-Inside each pack-For exposure control ................................................. 209
15.101 Biological indicator-Daily first load is kept at the back of the chamber,on the bottom shelf. ....... 209
15.101.1 Routine maintenance include- ..................................................................................................... 209
15.102 Day Care Policy- .......................................................................................................................... 209
15.103 Preoperative Fasting .................................................................................................................... 210
15.104 Protocol for Operative management in peration theatre during covid-19 pandemic ................... 210
15.105 Forms / Document........................................................................................................................ 215
15.106 Quality Assurance in OT .............................................................................................................. 216
167
S.no. Clause No Date of Amendment Made Reasons Of Amendment
Amendment
1 15.95 20.3.2013 Addition of Pest control policy Not mentioned earlier
2. 15.94 20.3.2013 Radiation health hazards policy in previously Described as
OT per standards
3. 15.58 20.3.2013 Linen in OT Not mentioned previously
4 15.101 20.12.17 Implant policy Not mentioned previously
5 15.102 20.12.17 Plasma sterilization policy Not mentioned previously
6 15.104 20.12.17 Day care surgeries policy Not mentioned previously
7 15.5 20.12.17 New forms and documents added Not mentioned previously
8 15.6 20.12.17 List of major Equipment’s in OT Not mentioned previously
9 15.13 20.12.17 Nomenclature of OT Committee New member added
revised which was not mentioned
before
10 15.14 24.1.2019 Orientation of New Personnel and In- Not mentioned before
Service Training
11 15.15pg 151 24.1.2019 Not mentioned before
Criteria for shifting patient with from
recovery to Ward
12 15. 97.1 pg no 24.1.2019 Not mentioned before
186 Emergency and Disaster
Preparedness Plan for the
Operating Theatre
13 15.105.01- 31.8.20 Anaesthesia policies for Operative Not mentioned before
management during covid-19
pandemic
14 15.106 31.8.20 Was done before but not

Quality Assurance in OT tabulated before
168
15.2 Departmental procedures
15.2.1.1 Admission Procedure to the Operating room
15.2.1.2 Assessment of Surgical Patients
15.2.1.3 Assessment and Follow up of post-surgical patients
15.2.1.4 Accountability For Sponges, Sharps And Instruments
15.2.1.5 Close gowning and Surgical Technique
15.2.1.6 CPR in Operating room
15.2.1.7 Handling of bio hazardous waste materials
15.2.1.8 Disposal of Sharps
15.2.1.9 Electrical Surgery cautery unit safety
15.2.1.10 Employee infection control
15.2.1.11 Gowning and gloving technique
15.2.1.12 Hand washing
15.2.1.13 Housekeeping procedure
15.2.1.14 Infection control surveillance
15.2.1.15 Verification on Infection Control
15.2.1.16 Operating room techniques
15.2.1.17 Pathology Specimen
15.2.1.18 Patient positioning during surgery
15.2.1.19 Preparing Case trolley
15.2.1.20 Skin preparation protocol
15.2.1.21 Standard precautions
15.2.1.22 Surgical Hand scrub
15.2.1.23 Use of tourniquet
15.2.1.24 Criteria for admission prior to surgery
15.2.1.25 Scheduling surgical procedures
15.3 Departmental policies
15.3.1.1 Pre-operative tests for inpatients
15.3.1.2 Accountability for sponges, sharps and instruments
169
15.3.1.3 Attire in Operating room
15.3.1.4 CPR in Operating room
15.3.1.5 Handling of biohazardous materials
15.3.1.6 Electro surgical cautery unit safety
15.3.1.7 High level disinfections of endoscopes
15.3.1.8 Collection of Pathology Specimens
15.3.1.9 Patient positioning during surgery
15.3.1.10 Selection of barrier material for surgery procedure
15.3.1.11 Skin preparation protocol
15.3.1.12 Standard precautions
15.3.1.13 Sterile storage
15.3.1.14 Surgical hand scrub
15.3.1.15 Traffic & visitor control
15.3.1.16 Scheduling of surgical procedures
15.3.1.17 After office hour surgeries
15.3.1.18 Sterilization-reprocessing single use product
15.4 Forms / Documents
15.4.1.1 Pre Anaesthetic Check-up Form
15.4.1.2 Consent form for surgery and anaesthesia
15.4.1.3 Pre-Operative Check list
15.4.1.4 Operative notes
15.4.1.5 Adverse Drug Reaction form
15.4.1.6 Incident /accident reporting form
15.4.1.7 Blood Transfusion consent form.
15.4.1.8 Blood Transfusion reaction form
15.4.1.9 Pain scoring form
15.4.1.10 Sedation assessment policy
15.4.2 Investigation form
170
15.4.2.1 Anaesthesia operative notes
15.4.2.2 Preclosure checklist
15.4.2.3 Operation theatre format
15.4.2.4 Data collection sheet
15.4.2.5 Needle stick injury form
15.4.2.6 Medication error form
15.4.2.7 Cardiopulmonary resuscitation form
15.4.2.8 Key performance indicator form
15.5 DAILY OT ROUTINE -ELECTIVE

S.NO. PROCEDURE TIME
1 Open the OT 08.00 AM
2 Cleaning ,Dusting& Moping 08.10AM
3 Carbolisation 08:30 AM
4 Preparation of OT for Anaesthesia& Surgical 08:45 AM
Procedures
st
5 1 case taken in Operating Room 09:00AM
6 Carbolisation and Moping after each case In between cases
7 Packing of instrument & linen send to CSSD 04:00 PM
for sterilisation;
8 OT closed 06:30PM OR two hours after
the last case
15.5.1.1 DAILY OT ROUTINE (EMERGENCY )

S.NO. PROCEDURE TIME
1 Open the OT 08.00 AM
2 Cleaning ,Dusting& Moping 08.10AM
3 Carbolisation 08:30 AM
4 Preparation of OT for Anaesthesia & Surgical 08:45 AM
Procedures
st
5 1 case taken in Operating Room 09:00AM
6 Carbolisation and Moping after each case In between cases
7 Packing of instrument & linen send to CSSD After the last case in OT
for sterilisation;
8 OT closed 06:30PM OR two hours after
the last case
171
15.7 Introduction
15.6 List of Major Equipments
1.Anesthesia Work Station - 5 nos. 15.7.1 An operation theatre complex is the
heart of any major surgical hospital.
2) Multipara Monitors - 6 nos. The patient is the centre point of a
functioning OT complex. Efforts are
4) Defibrillator - 5 nos. directed to maintain vital function,
prevent infection/promote healing with
5) Post Operative Monitors - 10 nos. safety, comfort and economy.
6) Pulse Oximeter - 02 nos.
15.7.2 OT complexes are designed and built
7) Videolaryngoscope - 03 nos. to carry out investigative, diagnostic,
therapeutic and palliative procedures of
8) Syringe Pumps - 12 nos varying degrees of invasiveness.
9 )Operation theatre light 4+4( mobile) 15.7.3 OT complex divided in to four zones :
1.Protective zone.
 Fibreoptic Bronchoscope - 01set with
2 scope 2.Clean zone; connects protective
zone to aseptic zone.
 Peripheral Nerve Stimulator - 2
3.Aseptic zone.
 Vein Viewing Device -2
4.Disposal zone.
 Patient warming device -2
15.7.4 The division is based on varying
 Transport incubator-1 degree of cleanliness, in which the
bacteriological count progressively
 Pharmaceutical refrigerator -2 diminishes from the outer to the inner
zone [operating area] and is
 Radiant Heat Warmer 2 maintained by a differential decreasing
positive pressure ventilation gradient
 Blood Warmer- 4
from the inner zone to the outer zone.
 Portable Colour Doppler USG System- 01 1. OT Sub-Areas
2. Changing Room for OT
 Hydrogen peroxide based plasma steam Personnel’s
sterilizer-1 3. Preoperative check in area
[reception area]
 Leproscope 4. Induction room.
5. Post anaesthesia care unit
 Cystoscope [PACU]
6. Staff room
 Microscope (EYE+ENT) 7. Sanitary facility for staff.
8. Offices-For staff nurse and
 Endoscope anaesthesia staff.
9. Rest room.
 Cryo unit with 2 probe 10. Store room.
11. Theatre sterile supply unit
 Harmonic cutting/coagulation device 12. Scrub room.
 Surgical cautry
 Arthroscope
 C-arm image intensifier

172
15.8 Principles To Be Taken Under 15.8.7 Three stages of filterationoccure in
Consideration; operation theatre 2nd floor consisting
of pre-filters, microvee& HEPA filters
15.8.1 Zone wise distribution of the area, so upto0.3 micron particle size.
Relative Humidity -50 +/- 5% 15.8.8 Minimum fresh air quantities in air
nd
conditioned( operation theatre 2 floor
Indoor Air Quality - 100% Fresh Air ) is accordance with ASHRAE indoor
air quality standards –100% fresh air.&
as to avoid crisis cross movement of
alternatively re –circulation system
men & machines
having 20-25 air changes per hour(
ACPH)
15.8.2 Adequate & appropriate space allotted
as per utility of the area.
15.8.9 Positive air pressure system in OT [5
cm H2O] from ceiling of OT down ward
15.8.3 Provision for emergency exit
and out ward to push out air from OT.
15.8.4 Provision for ventilation & temperature
15.8.10 Pendent services is present in
control [Laminar flow]
operation theatre. It has oxygen,
nitrous oxide, four bar pressure
15.8.5 Proper ventilation in operation theatre& medical compressed air, medical
the direction of air flow is from the vacuum scavenging terminal out let
operation theatre towards the main and electric sockets.
entrance.
15.8.11 Telephones Intercom and code
15.8.6 Indoor design conditions for centrally warning signals are present in OT
air –conditioned spaces in operation complex. Intercom to connect to control
theatres is (summer,monsoon,winter) desk, pathology and other Ots. A code
:Dry Bulb Temperature-21 +/- 3 degC signal ,when activated, signals an
0
(18-24 C) emergency state such as cardiac arrest
or need for immediate assistance.
15.9 Purpose: To recommend measures to

streamline OT functions in keeping with
the hospital policies & guidelines.
15.10 Frequency of Meeting : Quarterly and or as

and when required.
15.11 Responsibilities & Function of OT

committee:
15.11.1 To advise on smooth functioning of OT.
15.11.2 To evaluate bottlenecks and issues

causing patient delay.
15.11.3 To optimize OT utilization.
15.11.4 To set guidelines for allotment of

theatres.
15.11.5 To set guidelines for appointment for

emergency procedures
173
15.11.6 To decide staff pattern and training
program for staff.
O.T.Technician
15.11.7 To advise upon equipment and
instrument requirement for the use in
theatre.
O.T.Assistant
15.11.8 To monitor critical incident that occurs
in the OT.
15.11.9 To monitor post operative infection rate

to measure sterility rates in theatre.
15.11.10 To minimize cancellation of the

surgeries.
15.12 15.9.11 Hierarchy Chart of Operation

Theatre
Director
HOD(Anesthesia
MO I/C ‘s
Technical MO I/C ‘s Nursing Sister (OT)

Supervisor (OT)
CNBC Manual MO I/C ‘s Version 4.7
174
15.13 Structure of OT Committee: 15.15.9 On admission to the ward:
15.13.1 Chair Person 15.15.10 Nurse to follow instructions for pre-

op preparation.
15.13.2 Consultant Surgeons
15.15.11 Site preparation to be done in the
15.13.3 Consultant Anaesthesia ward (clipping only- no shaving) site
will be specified by surgeon.
15.13.4 ConsultantMicrobiologist
15.15.12 The patient will be brought to the
15.13.5 Purchase and Maintainance officer O.T with the complete patient/pre-op
check list records//folder.
15.13.6 Nursing Sisters In-charge
(Elective+Emergency) 15.15.13 The holding room & the circulating
nurse will check in the patient.
15.13.7 Technical In-charge
15.15.14 Greet the patient with a smile and
15.14 Departmental Procedures provide support and reassurance.
15.15 Admission Procedure to Operating Room 15.15.15 Ask patient's name verbally and
verify name, medical record number
Procedure and surgeon with armband or face
sheet.
15.15.1 Patient will be seen by surgeon at OPD
and decision to admit / or work up as 15.15.16 Check the pre-op check list
an outpatient will be made.
15.15.17 Read operative consent for
15.15.2 If decision is to work up as an completion and accuracy. Verify that
outpatient, then do Investigations as appropriate consent forms are
mentioned in Preoperative tests for completed.
inpatients.
15.15.18 Read physician's order sheet to
15.15.3 Results of investigations to be seen by verify that all preoperative orders have
consultant/doctor on duty been completed. All lab and other test
results must be on the chart at the time
15.15.4 Doctor on duty & nurse to organize pre of surgery.
anaesthetic check up with anaesthetist
15.15.19 Question the patient or attendant,
15.15.5 Following this pre-anestheticcheck up for the following information:
will be done by anesthetist in the
specified area. 15.15.20 Time of last meal/fluid intake
15.15.6 Upon clearance for surgery admit 15.15.21 Allergies

instructions will be given by the
surgeon 15.15.22 Verify surgeon, operative procedure
and operative site & prepare the part.
15.15.7 In the event of an In patient requiring
surgery the consultant shall request for 15.15.23 Check for the presence of prosthetic
pre anestheticcheck up after due work or loose teeth, contact lenses or
up. intraocular lens implants; prosthesis
(arm, leg, eye), hairpins or clips,
15.15.8 Pre anesthetic will be done at the bed jewellery or personal clothing items.
side & patient will be scheduled for
surgery.
175
15.15.24 If the patient arrives in the Surgical 15.18 Procedure:
Services Department with any of
therefore mentioned items, the 15.18.1 Upon admission to the pre-op area, a
following procedure is to be brief initial assessment is performed by
implemented: a qualified registered Nurse. The data
obtained includes, but is not limited to:
15.15.25 Removable item to be removed and
placed in the appropriate container, 15.18.2 Proper identification of the patient;
marked with the patient's name.
15.18.3 The patient's procedure to be
15.15.26 Call the appropriate floor and ask performed as, per the surgeon’s written
the nurse caring for the patient to come order, appropriate consent obtained
to the operating room and pick up the and the patient's understanding of the
item. Document the disposition of the procedure to be performed;
item in the nurse's notes.
15.18.4 The patient's known allergies;
15.15.27 The patient's pre-operative nursing
assessment shall include physiological 15.18.5 Baseline vital signs and cardiac rhythm
and psychological status, social strip according to age requirement;
concerns, immediate and emerging
needs of the patient. Report any 15.18.6 The patient's functional status and
abnormal findings to the mobility;
anesthesiologist or surgeon and
document abnormal findings on the 15.18.7 The patient's psychological and
Intraoperative Nursing Record. emotional status;
15.15.28 Any abnormalities in lab results 15.18.8 Any diagnostic test results relevant to
must be reported to the the determination and treatment needs
anesthesiologist for evaluation. of the patient available on the medical
record;
15.15.29 The patient may be taken to the
assigned operating room when: 15.18.9 The patient's history and physical
examination are completed and placed
15.15.30 The chart is complete; on the medical record.
15.15.31 The patient is identified and

prepared; 15.19 Assessment and Follow up of Post-
Surgical Patients in Surgical Area
15.15.32 Anaesthesiologist, if required
surgeon and assistant are present.
15.15.33 If there is a delay, the patient will be 15.20 Purpose: The purpose of patient
kept in the holding room. Make the assessment is to determine the need for
patient as comfortable as possible by care & the type of care to be provided
offering a warm blanket and postoperatively.
reassurance. The patient will remain
under constant observation during the
delay. 15.21 Procedure:
15.16 Assessment of Surgical Patients 15.21.1 Upon transfer to the recovery area, the
patient is seen by anaesthetist
15.17 Purpose: The purpose of patient
assessment is to determine the need for 15.21.2 Once the patient is stable and fulfils the
care, the type of care to be provided and discharge criteria, anaesthetist
the need for further assessment.
176
authorizes the shifting of patient to 15.22 Accountability for Sponges, Sharps and
room / ICU. Instruments
15.21.3 In the ICU patient is seen by 15.23 Purpose: To provide guidelines of

Anaesthetist& ICU doctor on duty. accountability for sponges sharps and
instruments used during a surgical
15.21.4 ICU Doctor on duty to carry out procedure. To provide safe practice for the
standard postoperative round, assess surgical patient, prevent patient injury and
& notify the surgeon. adhere to legal standards.
15.21.5 Consultant to see the patient 15.24 Procedure:

immediately if deviations or as a
standard practice within 4hrs post 15.24.1 Two (2) people, one (1) of whom is an
operatively. NURSE, will perform all counts.
15.24.2 Counts shall always begin at the

surgical field and surrounding area,
then to the Mayo stand, then to back
table and last the sponges, sharps or
instruments discarded from the field.
15.24.3 Sponges shall be counted on all

procedures.
15.24.4 Sponges shall be counted in the OT

prior to; during, as needed and at
closure by the scrub person and the
circulating nurse together. Additional
sponge counts are taken before any
part of a cavity or a cavity within a
cavity is closed .
15.24.5 All sponges inserted into the wound

shall be x-ray detectable.
15.24.6 Counted sponges shall not be taken

from the operating room during a
procedure.
15.24.7 X-ray detectable sponges shall not be

used as dressings.
15.24.8 Sponges shall be contained to ensure

appropriate infection control technique,
ease in counting and proper safe
disposal.
15.24.9 Sharps shall be counted on all

procedures.
15.24.10 Sharps include but are not limited to

suture needles, scalpel blades,
hypodermic needles, cautery blades
and safety pins.
177
15.24.11 The scrub person together with the 15.25.1 Set out enough sterile gowns, gloves
circulating nurse on the procedure shall and towels for all members of the scrub
count sharps in the OT prior to, during team.
and at closure.
15.25.2 Place a sterile unfolded towel in the
15.24.12 Suture needles shall be handed to hand of each person.
the surgeon on an exchange basis
only. 15.25.3 The scrub nurse will assist each person
put on his/her gown as follows:
15.24.13 Counted sharps shall not be taken
from the operating room during a 15.25.4 Grasp the top of the gown at shoulder
procedure. seams to armholes.
15.24.14 Sharps broken during a procedure 15.25.5 Insert gloved hands along shoulder
shall be accounted for in their entirety. seams to armholes.
15.24.15 Sharps are disposed of in the rigid 15.25.6 Slide gown over surgeon’s arms,
sharps container. avoiding touching the surgeon with
gloved hands.
15.24.16 Instruments shall be counted on all
procedures: 15.25.7 The circulating nurse will assist the
surgeon as follows:
15.24.17 Standardization of instrument sets
with the number and types of 15.25.8 Bring left flap of gown over so it
instruments are established for ease in completely covers his back.
counting.
15.25.9 Tie the neckline and waistline strings.
15.24.18 Instruments are counted as they are
assembled and a count sheet is 15.25.10 The back of the gown is now
inserted in the instrument tray prior to contaminated. Scrub nurse will assist
sterilization. surgeon with his/her sterile gloves as
follows:
15.24.19 The scrub person together with the
circulating nurse on procedure counts 15.25.11 Insert fingers of both hands under
instruments in the OR prior to the cuff of right glove, either keeping
surgical procedure and again during thumbs away from cuff or tucked under
closure. cuff. Spread glove to form a circular
opening with thumb of glove facing the
15.24.20 Instruments are not to be taken from surgeon.
the OT during a procedure.
15.25.12 As surgeon inserts his hand into
15.24.21 Instruments broken or disassembled glove, bring the cuff up over the wrist
during a procedure shall be accounted cuff of the gown and releases glove
for in their entirety. gently.
15.24.22 Instruments are contained to ensure 15.25.13 The surgeon now will unhook the
appropriate infection control technique, waist strings at the front of the gown
ease in counting and proper and hands the right string with the
processing. paper tab to either the scrub nurse or
the circulating nurse.
15.25 Close Gowning and Surgical Technique
15.25.14 The nurse will hold the paper tab
while the surgeon pivots to the left. The
surgeon then pulls the string to release
178
it from the paper tab and ties the waist 15.28.11 Patient's condition and/or activities
string. prior to arrest;
15.25.15 Note: All Surgical Services 15.28.12 Time of arrest;

Department nursing personnel must be
capable of gowning and gloving 15.28.13 Patient responds to the treatment
members of the surgical team. since during the resuscitation;
15.26 Cardiopulmonary Resuscitation in 15.28.14 Sample of ECG tracing;

Operating Room
15.28.15 Nurse's signature.
15.27 Purpose: To reinstate cardiopulmonary
function on cardiac and/or respiratory
arrest victims.
15.28 Procedure
15.28.1 Prepare and administer medications,

as ordered by Anaesthetist in charge.
15.28.2 Other drugs requested and not in the

crash cart drawer may be obtained
from the auxiliary emergency drug box,
located on top of crash cart.
15.28.3 Connect patient to monitor if not

already done.
15.28.4 ACLS protocol will be followed, per

Anaesthetist order.
15.28.5 Connect ECG machine for recording

electrocardiography and turn on "Lead
II." Run tracing continuously throughout
procedure.
15.28.6 Charting: Throughout cardiopulmonary

resuscitation measures, Anesthetist will
document:
15.28.7 Medications being administered, with

dosage and time;
15.28.8 Defibrillation, including the number and

strength; Other procedures being
performed (i.e., intubations, arterial
blood gases, cut down);
15.28.9 Patient's response (i.e., state of

consciousness, respiration, pulse,
blood pressure, skin color).
15.28.10 Record on Nurse's Notes:
179
15.29 Cardiopulmonary Resuscitation Report: disposing of needles, sharps and blood
specimens.
15.29.1 Cardiopulmonary Resuscitation Report
form is to be filled out by the NURSE 15.32.6 Used needles, syringes, lancets, and
and Anesthetist, immediately following scalpels should be used only disposed
an arrest. Report will be distributed as biohazard container.
follows:
15.32.7 Never recap a contaminated needle or
15.29.2 One copy on patient chart. reach inside the container. Drop used
syringes, scalpels, lancets into the
15.29.3 One copy sent to Manager of Nursing container. Snap on or tape the lid every
Services. 48 hrs container, prior to discarding.
15.29.4 One copy to Pharmacy. At the same 15.32.8 Never dispose of syringes are needles
time, request a new auxiliary drug box in a general trash receptacle.
and drug tray.
Follow needle stick policy, if injured by
15.29.5 Cardiopulmonary Resuscitation Follow- contaminated needle.
up is to be filled out by an Anesthetist
immediately following arrest: 15.33 Disposal of Sharps
15.29.6 Form can be found on crash cart. 15.33.1 Purpose: To prevent injury and
exposure, to blood borne infections, for
15.29.7 Completed form is kept in patient’s file. personnel handling sharps including
needles, syringes, knife blades and
15.30 Handling of Biohazard Waste Materials opened ampoules of medication.
15.31 Purpose: To provide guidelines for the 15.33.2 Procedure:

handling and disposal of all waste in
accordance with the State Health and 15.33.2.1 All sharps, including hypodermic needles
Safety Code. and syringes, suture needles, knife blades,
trocars from drains and opened glass
15.32 Procedure: ampoules of medicine will be disposed of
into plastic sharps containers.
15.32.1 Biohazardous waste shall be
segregated from other non- 15.33.2.2 After syringe/needle use DO NOT RECAP.
biohazardous medical waste at any
15.33.2.3 The sharps will be placed into
point of origin, in plastic bags located in
contaminated sharps container at
designated-covered waste containers.
completion of procedure.
15.32.2 Containers used for bio hazardous 15.33.2.4 Opened glass ampoules from anaesthesia
waste shall be so secured as to deny use will be handled carefully. All
access to unauthorized persons. medication shall be removed from an
ampule and the ampule placed into
15.32.3 Bio hazardous waste shall be single- contaminated sharps container. If
bagged prior to disposal and should not unopened, ampoules can be saved. They
be stored for more than one (1) day, shall be wiped with approved germicide
other than needles and sharps. and placed in the appropriate area. If the
medication is not to be used elsewhere,
15.32.4 Disposal of Sharps: the ampule shall be carefully opened and
the medication discarded, prior to disposal
15.32.5 Bio hazardous sharps waste disposal in the contaminated sharps container.
containers should be of hard plastic
containing with a small opening for 15.33.3 PRECAUTIONARY MEASURES:
180
15.33.3.1 Under no circumstances shall sharps be 15.35 The Electro surgical Active Electrode
discarded into waste or trash containers. (Pencil):
15.33.3.2 Bare needles will not be left on IV poles, 15.35.1 Only electro surgical active electrodes
instrument trays or any place that may approved by the hospital Biomedical
pose a hazard to personnel, patients or Engineer are to be used in the Surgical
visitors. Services Department.
15.33.3.3 DO NOT RECAP NEEDLES. This is the 15.35.2 The active electrode shall be inspected
single most important cause of needle at the field for damage before each
puncture injury. use.
15.35.3 The active electrode shall fasten

15.34 Electrical Surgical Cautery Unit Safety directly into a labeled, stress-resistant
receptacle on the electro surgical unit.
15.34.1 Purpose: To provide for the safe
operation of electro surgical units, used 15.35.4 The active electrode cord shall be long
for the purpose ofcutting and enough and flexible enough to reach
coagulation of body tissue with a high the operative site.
frequency electrical current during
surgical procedures. 15.35.5 The active electrode cord shall be free
of loops, twists and metal clamps that
15.34.2 Procedure: can deviate current flow.
15.34.2.1 The depressive electrode pad shall be
15.35.6 The active electrode and cord shall be
placed on the patient, on clean dry skin
impervious to fluids/secure and free of
over a large muscle mass, as close to the
charred tissue/must be placed in a
operative site as possible. Bony
holster at all times.
prominences, hairy surfaces and scar
tissue shall be avoided.
15.35.7 Other Precautionary measures:
15.34.2.2 All depressive pads shall maintain uniform
body contact. Potential problems include 15.35.8 Patient’s skins are not in contact with
tenting, gaping and liquids interfering with any metal.
adhesion.
15.35.9 Metal jewellery must be removed or if
15.34.2.3 The pad placement area shall be charted the patients do not allow their jewellers
on the Intraoperative Nursing Record and to be removed, it must be taped with
Nurses Notes. adhesive tapes or placed such that the
jewellery/mangal sutra do not contact
the skin.
181
15.36 Employee Infection Control 15.39 Gowning and Gloving Technique
15.39.1 Procedure:
15.36.1 Purpose: To establish the mechanism 1. Set out enough sterile gowns, gloves and
for reporting an employee injury from towels for all members of the scrub team.
needle puncture. And /or accidental 2. Place a sterile unfolded towel in the hand of
blood or body fluid exposure. each person.
3. The scrub nurse will assist each person put
15.36.2 Procedure: on his/her gown as follows:
4. Grasp the top of the gown at shoulder
15.36.2.1 All personnel shall take precautions to seams to armholes.
prevent needle punctures or injuries. 5. Insert gloved hands along shoulder seams
Should they occur; the following to armholes.
procedures shall be strictly adhered to. 6. Slide gown over surgeon's arms, avoiding
touching the surgeon with gloved hands.
15.36.2.2 If a glove is torn or a needle stick or other 7. The circulating nurse will assist the surgeon
injury occurs, the following shall be done: as follows:
8. Bring left flap of gown over so it completely
15.36.2.3 Remove the damaged glove as promptly covers his back.
as possible. 9. Tie the neckline and waistline strings.
10. The back of the gown is now contaminated.
15.36.2.4 Wash hands thoroughly.
11. Scrub nurse will assist surgeon with his/her
15.36.2.5 The appropriate employee injury form shall sterile gloves as follows:
be submitted, with copies routed as 12. Insert fingers of both hands under cuff of
indicated to Personnel and Nurse right glove, either keeping thumbs away
Manager. from cuff or tucked under cuff.
13. Spread glove to form a circular opening with
15.37 Immediate clinical action: thumb of glove facing the surgeon.
14. As surgeon inserts his hand into glove, bring
the cuff up over the wrist cuff of the gown
15.37.1 Encourage bleeding, washes with soap
and releases glove gently.
water, then clean with spirit
15. The surgeon now will unhook the waist
strings at the front of the gown and hands
15.37.2 Splashes of blood or body fluids in the
the right string with the paper tab to either
mouth should be washed thoroughly
the scrub nurse or the circulating nurse.
with copious amounts of Water.
16. The nurse will hold the paper tab while the
surgeon pivots to the left.
15.37.3 Splashes of blood or body fluids into
17. The surgeon then pulls the string to release
the eyes should be irrigated well with it from the paper tab and ties the waist string
normal saline
15.40 Hand Washing
15.38 Reporting: (This is essential in every
case) Purpose: To provide guidelines for effective
hand washing, in order to prevent or reduce the
15.38.1 All Incidents should be reported to the occurrences of cross infections.
Incharge infection control committee .
15.40.1 Procedure:
15.38.2 Subsequent action will depend on 1. Keep clothing away from sink and splashes.
the nature of the exposure and 2. Wear minimal jewellery; clean fingernail
the likelihood of “Source” area (bacteria may be harboured beneath
fingernails).
3. Turn on water and adjust temperature for
your comfort.
182
4. Wet hands and apply approximately 1 by Surgical Services Department personnel,
teaspoon of soap to hands. Lather well are placed on the dirty cart and removed to
(soap reduces surface tension enabling the the soiled utility room for transport to Central
removal of bacteria). Service. Suction containers are sealed and
5. Wash hands thoroughly, using rigorous sent out for disposal.
scrubbing action for at least 15 seconds. 10. The floor is cleaned with approved detergent
Work lather around fingernails, top of hands, germicide and a clean mop head. Ensuring
etc. (to facilitate eradication of all bacteria). that all floor areas are mopped.
6. Rinse hands and wrists under running water. 11. The circulating nurse disconnects the
7. Repeat hand washing technique, if suction. Sealed the container and place it on
necessary (to prevent recontamination of the Central Service cart.
hands). 12. All linen is placed in plastic bags and sealed.
8. Dry hands with clean paper towel. Scrub nurse's gown is placed in the bag last,
9. Turn off faucets with used paper towel and after all cleaning is completed.
discard. 13. Trash is placed in plastic bags, sealed and
placed on the Central Service cart.
15.41 House Keeping Procedure 14. As much as possible, instruments are to be
kept clean during the procedure. At the end
15.41.1 Purpose: To provide, through of each the procedure, all instruments are
established practices, policies and placed in the perforated tray, in a sealed
schedules, relevant cleaning measures plastic bag to be sent to Central Service for
for the control and prevention of processing. A separate plastic bag may be
infection. used for basins and other autoclavable
items.
15.41.2 Procedure: 15. A suction container is cleaned, disinfected
1. Housekeeping procedures include cleaning and kept ready for the next procedure.
and disinfections/disposal of soiled linen and 16. Surgical lights and racks are cleaned.
solid wastes. These procedures are 17. All wall-mounted equipment, view boxes,
performed by Housekeeping Services etc., are cleaned with a detergent germicide
personnel assigned to the Surgical Services solution and disposable wipes.
Department. 18. Kick buckets are thoroughly cleaned with
2. Adequate time must be allowed between detergent germicide; Walls are cleaned as
surgical procedures for the proper cleaning necessary.
and disinfections of the operating room. 19. Cabinet doors and handles are cleaned;
3. Damp dust all flat surfaces and overhead Entire floor space is mopped with detergent
lights every morning prior to the first surgical germicide.
procedure. Use a germicide-dampened 20. Scrub sinks, faucets, soap dispensers and
disposable wipes. surrounding walls are cleaned.
4. Spraying approved detergent germicide 21. Instruments and other reusable autoclavable
solution onto the surface and wiping it off equipment will be decontaminated before
with dry disposable wipes clean all flat washing.
surfaces. 22. Nonautoclavable items will be placed in
5. The cleaning sequence is from the periphery yellow bags for decontamination in Central
of the room to the center of the room. Service.
6. Flat table surfaces are cleaned first; OT
table is cleaned last and a clean sheet is
placed on the mattress.
7. Kick buckets are cleaned as necessary;
rolling the wheels over floor cleaning
solution cleans Table wheels.
8. Anaesthesia disposable suction containers
are removed, if used, discarded and
replaced.
9. Trash, used linen and instruments, which
have been previously sealed in plastic bags
183
15.42 Infection Control Surveillance 15.42.2.15 Maintenance of effective ventilation
and air conditioning systems;
15.42.1 Purpose: To minimize infection in
the surgical patient; to improve 15.42.2.16 Adherence to OT "Traffic and Visitors
wound healing; to Control" policy.
minimizedisability, morbidity and
15.42.2.17 Protective Eye Shields: Eye shields
mortality; to reduce cost of
must be worn during the direct care of
hospitalization.
all patients.
15.42.2 Procedures:
15.42.3 Verification of informed consent
15.42.2.1 Barriers for isolating the operative
15.42.3.1 Check for validity of the informed
wound from infectious contaminants
consent against the following criteria:
are as follows:
15.42.3.2 Information has been provided to the
15.42.2.2 Skin Barriers: Preoperative skin
patient prior to the anesthesia or
preparation of the patient and
procedure;
operating team;
15.42.3.3 Has been explained to the patient s
15.42.2.3 Special OT attire; Sterile drapes to
relatives by the anesthesiologist
cover the patient and sterile field;
and/or the surgeon;
15.42.2.4 Occlusion of incised skin edges from
15.42.3.4 The blanks have been filled in with the
the operative wound;
necessary information; and all the
15.42.2.5 Adherence to operative aseptic signatures required have been
technique. obtained.
15.42.2.6 Barriers to Nasopharyngeal Flora and 15.42.3.5 Name of Your Institution personnel
Hair: must assure that the patient s relatives
has been informed and can:
15.42.2.7 Wearing of masks and hoods;
Removal of hair from operative site; 15.42.3.6 State the name of the surgeon or other
practitioner who has primary
15.42.2.8 Exclusion from the OT of personnel responsibility for the patient's care;
with an acute infection or skin lesion;
15.42.3.7 Identify the professional status of
15.42.2.9 Use of an anesthesia screen to individuals responsible for authorizing
separate anesthesia area from sterile and performing treatments and
area. procedures.
15.42.2.10 Barrier to Fomites: Dust covers to be 15.42.3.8 The patient will be informed about any
used over sterile items in storage professional relationship the
responsible surgeon, healthcare
15.42.2.11 Proper packaging of supplies and practitioner, Name of Your Institution
sterilization procedure staff or Name of Your Institution has to
another healthcare provider or
15.42.2.12 Enclosed cabinets or carts for institution, which might suggest a
storage of sterile supplies; conflict of interest, and
15.42.2.13 Clean preoperative bed linen; 15.42.3.9 Any relationship to educational

Barriers to Airborne Contamination: institutions involved in the care of the
patient, or
15.42.2.14 Disinfections of OT surface following
every surgical procedure.
184
15.42.3.10 Any business relationships between 15.44.4 The original copy of the informed
individuals treating the patient or consent must be placed in the
between the organization and any medical record before the
other healthcare, service or anesthesia or procedure is
educational institutions involved in the performed.
care of the patient.
15.43 Duration of Informed Consent:
15.43.1 Has continuing force and effect

until the patient revokes the
consent;
15.43.2 Circumstances have changed

which would affect the nature of, or
the risks of the procedure and/or
the alternatives to the procedure
for which the patient gave the
consent.
15.43.3 Informed consent form is prepared

by the attending physician or
operating surgeon and is discussed
with the patient by the
physician/surgeon.
15.43.4 Supplemented with verbal

discussion;
15.43.5 Supplemented through written

additions that give further
information relevant to the patient's
condition Consent.
15.44 Any special circumstances:
15.44.1 The patient signs where indicated

and receives a copy of the
informed consent. The
anesthesiologist and/or surgeon
obtaining the consent signs in the
appropriate location.
15.44.2 The nurse witnessing the signature

of the patient signs as a witness
stating date and time of witnessing
the signature.
15.44.3 Third party consent for an

incompetent or minor patient is to
be obtained following the same
procedure. An informed consent for
anesthesia and/or any procedure
must be obtained from the third
party.
185
15.45 Role of Name of Your Institution in the 15.46.2.2 Foreign substances must be removed
Informed Consent Process: from the skin before the area is
mechanically cleansed with the
15.45.1 Limited to obtaining verification that antiseptic solution.
consent has been obtained by the
anesthesiologist and/or surgeon 15.46.2.3 Skin marking by the surgeon is usually
before the surgeon is permitted to done prior to skin prep. If the skin is to
administer anesthesia and/or be marked after the prep, a sterile
perform the procedure. marking pen is utilized.
15.45.2 Name of Your Institution personnel

may not answer patient's questions 15.46.2.4 Procedure for clean areas:
about the nature of the anesthesia
15.46.2.5 Expose the skin area to be prepared
or procedure and its benefits or
by folding back the blanket and gown
risks or alternatives.
as necessary.
15.45.3 Hospital personnel will refer all 15.46.2.6 A sterile disposable skin prep tray is
questions of significant nature to opened on a small table.
the anesthesiologist or surgeon to
enable him/her to provide informed 15.46.2.7 Put on sterile gloves. Place sterile
consent: towels above and below area to be
cleansed.
15.45.4 Verifies that a witness was present
during the time that the patient 15.46.2.8 Scrub the skin, starting at the site of
received the information incision, with circular motion to the
constituting an informed consent; periphery. Use enough pressure and
friction to remove dirt and
15.45.5 Verifies that a witness was present microorganisms from the skin and
during the time that the patient pores.
signed the informed consent.
15.46.2.9 Discard the sponge after reaching the
15.46 Operating Room Techniques periphery. Never bring a soiled sponge
back toward the center of the area.
15.46.1 Purpose: To render the
operative site as free as 15.46.2.10 Repeat the scrub with a separate
possible from transient and sponge for each round.
resident microorganisms. To
15.46.2.11 Document the preoperative skin
ensure that, a minimal source of
preparation on the operative nursing
infection at the site of the skin
note, noting the area prepped, the
incision.
antimicrobial agents used and
development of any skin sensitivity.
15.46.2 Procedure:
15.46.2.1 After the patient has been 15.47 Procedure for contaminated areas:
anesthetized and positioned on the a) The following areas within the operative
operating table and immediately prior area are considered contaminated:
to draping, the skin of the operative I. Umbilicus
site, and the extensive area II. Stoma
surrounding it, is mechanically III. Draining of sinuses
cleansed with an approved antiseptic IV. Skin ulcers
agent. V. Vagina
VI. Anus
VII. Traumatic wounds
186
15.47.1 Skin preparation for contaminated b) Supine position - this is the most
area differs. If possible, common position used. Patients are
contaminated areas are sealed off usually anesthetized in this position and
with a towel or sponge, while the modifications are made after the
remaining skin areas are scrubbed. induction of anesthesia.
The most contaminated area is c) The position of the head shall place the
scrubbed last with separate cervical, thoracic and lumbar vertebrae
sponges, which are discarded after in a straight, horizontal line.
one-time use. d) A pillow may be placed under the small
of the back to prevent strain on the
15.47.2 Procedure for Graft areas: back, to prevent strain on the back
muscles and ligaments.
15.47.3 Separate skin prep tray setups are e) A small pad or pillow placed under the
necessary for skin preparation of head allows the muscles to relax and
the donor and recipient sites. prevent neck strain.
f) Hips shall be parallel.
15.47.4 The donor site is scrubbed first. g) Legs are placed parallel and uncrossed
Microorganisms on the skin of the to prevent compromised circulation and
donor site must not be transferred nerve damage. The legs shall be slightly
to the denuded recipient site. separated so that skin surfaces are not
in contact.
15.47.5 The recipient site, following a burn h) The safety strap is placed across the
or injury, is usually considered thighs so that the patient is secured,
contaminated. Items used in ensuring that superficial venous return is
preparation of the recipient site not impaired.
must not be permitted to i) The heels may need to be padded with
contaminate the donor site. foam protectors, if the procedure is
expected to be lengthy.
15.48 Pathology Specimen j) Arms are usually placed on arm boards,
at less than a 90 degree angle to the
15.48.1 Procedure: body. The palms shall be turned
upwards to diminish the pressure on the
a) Document pathology specimens on the brachial and ulnar nerve. Foam
Intraoperative Nursing Record and protectors may be used to pad the
include all pertinent information. elbows if necessary. Table pads and
b) The surgeon has the responsibility for arm board pads should be of the same
identifying the specimen properly to the height.
circulating nurse. k) If the head is turned to one side, the
c) The circulating nurse is responsible for bony prominences of the skull and the
correctly completing the required ears must be padded, to prevent
paperwork and identifying the containers pressure on nerves or blood vessels.
with the proper labels.
d) The scrub nurse must properly handle 15.50 The patient's eyes must be protected
the specimen from the time of removal from pressure and corneal drying or
until the circulating nurse receives it. abrasions.
15.51 Variations of the supine position

15.49 Patient Positioning during surgery include Trendelenburg, Reverse
Trendelenburg and Fowler's positions.
In all of the variations, the principles
remain the same. Bony prominences
15.49.1 Procedure:
must be well padded and circulation
a) Proper positioning for a number of must not be impeded.
different procedures is outlined.
187
15.52 Lithotomy position: 15.52.4 The patient's position must be
symmetrical. The perineum is in
15.52.1 With the patient in the supine line with the longitudinal axis of the
position, the legs are raised table: The pelvis is level and the
simultaneously and abducted to head and trunk are in a straight
expose the perineal area. Each leg line.
is raised by grasping the sole of the
foot in one hand and supporting the 15.52.5 The arms are placed on the arm
leg near the knee in the other boards, using the previously
hand. The leg is raised and the described precautions.
knee flexed slowly.
15.52.6 The patient is released from
15.52.2 The foot is secured in the holder by lithotomy position slowly to allow
loops of the canvas slings. One gradual adjustment to the change.
loop of the canvas sling is placed The legs are brought down
around the sole at the metatarsals simultaneously to prevent strain on
and the other loop placed around the lumbosacral muscles.
the ankle. The lower part of the leg
shall be free from pressure against 15.53 Prone position - patient is lying with
the leg holders. Foam padding may abdomen on the surface of the
be needed to protect areas of the operating table.
leg or foot from excess pressure.
15.53.1 In preparation for placing a patient
15.52.3 The leg stirrups must be level and in prone position, two (2) chest rolls
the height adjusted to the length of must be made by rolling two (2)
the patient's legs. By placing the bath blankets lengthwise together
patient's anterior iliac spine on a to form a firm roll. Two pillows must
line with the leg holder and the be available for placement under
buttocks level and on a line with the patient's feet. The patient is
the edge of the table pad, a good placed supine on a stretcher rather
position can be achieved with a than surgi-lift.
minimum of effort.
15.53.2 Four (4) people are required to
safely place a patient in prone
position. The anesthesiologist
supports the head and neck. One
person stands at the side of the
stretcher, with hands at the
patient's shoulders and buttocks, to
initiate the roll of the patient. A
second person stands opposite, at
the side of the operating table, with
arms extended to support the chest
and lower abdomen on
outstretched arms, as the patient is
rolled forward and over. The third
person stands at the foot of the
stretcher to support and turn the
legs. At the completion of the turn,
the stretcher is removed.
15.53.3 The anesthesiologist to ensure

maintenance of the airway must
coordinate all movements.
188
15.53.4 An arm board is provided on each requires. The unaffected leg rests
side of the table and the patient's in a padded foot holder.
arms are brought down and
forward to rest with elbows flexed 15.54.3 A center post is placed at the
and hands pronated at either side perineum and is well padded.
of the head.
15.54.4 The surgeon will be in the
15.53.5 The head is positioned on a foam operating room during the
pillow or doughnut, keeping the positioning of the patient for the
neck in alignment with the spinal fracture table.
column. The eyes are protected
from the pillow and the drapes. 15.55 Preparing Case Trolley
15.53.6 Chest rolls should extend from the 15.55.1 Purpose: To supply the
acromioclavicular joint to the iliac Operating Room with all
crests to allow movement of the instruments, equipment and
chest for respiration. sutures needed to complete a
specific procedure (case).
15.53.7 One or two pillows are placed
under the ankles, to prevent
pressure on the toes and feet. 15.55.2 Procedure:
15.53.8 The restraint is placed across the a) Identify case to be operated.
thighs to secure the patient and b) Begin with the first item listed under the
allow unimpaired venous return. procedure. Remove it from the sterile
store and place it on the trolley. Check
15.53.9 While a patient is in prone position, off each item selected.
a firm stretcher must be readily c) Repeat, until all items for the procedure
available outside of the room in are on the trolley. If notification is
event of an emergency. received from the Surgical Ward that the
patient is obese, include extra clamps,
15.53.10 The patient is returned to the large retractors and long instruments.
supine position by reversing the d) Cover the trolley.
four-man roll described above. e) Place the prepared trolley in the
Operating Room
15.53.11 The operating room table is
flexed to bring the patient's chest 15.56 Skin Preparation Protocol
and legs down and flex the
patient's flank.
15.56.1 Procedure:
1. Explain the procedure to the
15.54 Fracture Table:
patients relatives and ensure
privacy
15.54.1 The Operating fracture table allows
2. Lower extremities: Fractured femur:
the patient to be positioned for hip
Any upper leg or thigh surgery
nailing and other orthopedic
3. Lower Leg or Foot/ Open reduction
procedures, requiring C-arm or
of the tibia and fibula/Ankle Surgery
fluoroscopy.
: Clean and trim the toenails and
remove nail polish
15.54.2 The patient rests with the injured
4. Abdomen and Leg/ Femoral
leg restrained in a boot-like device.
popliteal artery surgery/Common
The leg may be rotated, pulled into
iliac artery surgery
traction or released, as the surgery
5. Prepare the entire abdomen to the
bedline on the patient's sides and
189
from the axillae margins extending 20. Prepare from the nipple line of the
down the affected side to below the opposite breast over the affected
knee and on the other leg to the breast to the midline of the back,
midthigh. On the back include the from the shoulder to the umbilicus,
buttocks, backs of the legs as far and the whole arm from the
down as on the fronts and a shoulder to finger &Include an axilla
complete perineal preparation. preparation.
6. Abdomen/ 21. Neck/ Thyroid surgery/Excision of
Cholecystectomy/Gastrectomy/Bow cyst
el resection: 22. Prepare from the chin to the nipple
7. Incision above the umbilicus - line and from the right shoulder to
Prepare the entire abdomen from the left shoulder.
the axillae margins to the tops of the 23. Nasal Area/ Submucous
thighs. resection/Removal of polyp/Plastic
8. Back/ Nephrectomy/Removal of surgery
kidney stones/ Cervical Spine 24. Mastoid and Ear/ Myringotomy
9. Prepare from above the external /Mastoidectomy/ Stapedectomy
occipital protuberance to the 25. Clip all visible hair around the
midlumbar area of the back and to external auditory meatus. Comb
the bedline on both sides. lacquer into long hair to the midline
10. Posterior Thoracic and Lumbar on the operative side; hold the hair
Spine/ Thoracic spine away from the area with bobby pins.
surgery/Lumbar spine surgery Repeat on the morning of surgery
Prepare from the hairline to the and remove the pins.
bottom of the buttocks and to the 26. Skin/ Skin graft/Bone graft
bedline on both sides. 27. Check with the surgeon about the
11. Spinal Surgery/ Intractable exact area to be prepared.
pain/Spinal tumor/Spina bifida 28. Eye/ Retinal detachment/Cataract -
12. Prepare the back from the axillary Check with the surgeon regarding
line to the midthigh and to the their preference.
bedline on each side.
13. Lower arm - Remove rings, clean
and trim nails and remove nail
polish. Check that the identification
bracelet is on the unaffected arm.
Prepare the whole affected hand
and arm up to the shoulder.
14. Upper Arm/ Forearm surgery/Hand
surgery/ Shoulder surgery 15.57 Standard Precautions
15. Prepare from past the midline on the
back to past the midline of the
chest. Include the shoulder, axilla
15.57.1 Procedure
and arm below the elbow.
16. Elbow surgery/ Fracture of the
humerus 15.57.2 Standard Precautions include the
17. Prepare from the shoulder to and following:
including the hand. Include an
axilla preparation.
18. Upper Extremity (Entire) past the 15.57.2.1 Hand washing
midline on the chest. Include the 1) Hands are to be washed after touching
complete shoulder, axilla, arm and blood, body fluids, secretions,
hand. excretions or other contaminated items,
19. Chest: / Breast surgery/Lung whether or not gloves have been worn.
surgery/Closed heart surgery 2) Hands must be washed immediately
after removal of gloves, between any
190
patient contact and when otherwise appropriately, prior to use on
indicated. This will help prevent another patient.
transmission of microorganisms.
3) To prevent cross contamination of 15.59 Environmental Controls
different body sites on the same patient,
it may be necessary to wash hands 15.59.1 Make sure that Name of Your
between tasks and procedures. Institution has adequate
procedures and that they are
15.57.2.2 Gloves followed for the routine cleaning of
1) Gloves are to be worn when touching all surfaces, including beds,
blood, body fluids, secretions, bedrails, bedside equipment and
excretions and other contaminated other frequently touched surfaces.
items. Clean, non-sterile gloves will be
adequate. 15.60 Linen
2) Gloves shall be changed between tasks
and procedures on the same patient 15.60.1 Used linen soiled with blood, body
after contact with material that may fluids, secretions and excretions
contain a high concentration of will be handled with care ,must be
microorganisms. begged in red color bag with label,
never shaken or allowed to touch
15.57.2.3 Mask, Eye Protection, Face Shields the floor is transported and
1) When performing procedures that may be processed in a way that prevents
likely to generate splashes or sprays of skin and mucous membrane
blood, body fluids, secretions or excretions, exposure, contamination of clothing
wear a mask and eye protection or a face and the transfer of microorganisms
shield. This will protect the mucous to other patients and the
membranes of the eyes, nose and mouth. environment.
15.61 Occupational Health and Blood borne

15.57.2.4 Gowns Pathogens
15.61.1 Avoid injuries if at all possible when

1) When performing procedures that may using needles, scalpels and other
be likely to generate splashes or sprays sharp instruments.
of blood, body fluids, secretions or
excretions, wear a gown to protect the 15.61.2 Never recap needles; use a one-
skin and to prevent soiling of clothing. handed scoop technique or a
2) Always remove the soiled gown as soon mechanical device for holding the
as possible and wash hands. needle sheath.
15.58 Patient Care Equipment
15.58.1 All patient care equipment that is

soiled with blood, body fluids,
secretions or excretions shall be
handled in a manner that will
prevent skin and mucous
membrane exposures.
15.58.2 Single use, disposable items must

be disposed of properly.
15.58.3 Make sure that reusable equipment

has been cleaned and reprocessed
191
15.61.3 Place all contaminated needles, 15) Scrub arm #1 from wrist to forearm.
syringes, scalpel blades and other 16) Scrub arm #2 from wrist to forearm.
sharp items in designated 17) Scrub arm #1 from forearm to elbow.
puncture-resistant containers. 18) Scrub arm #2 from forearm to elbow.
These containers should be 19) Rinse hands and arms thoroughly,
located as close as possible to the keeping hands raised.
area where the items are used. 20) Turn off water, using foot control.
21) Proceed to OR, keeping hands above
15.61.4 Instead of doing mouth-to-mouth the elbows and out from scrub clothes.
resuscitation, use mouthpieces,
resuscitation bags or other
ventilation devices when the need 15.64 Use of Tourniquet
for resuscitation is anticipated.
15.64.1 Procedure:
15.62 Patient Placement
15.62.1 Ensure that patients, who may 1) Select proper size tourniquet cuff. An
contaminate the environment or overlap of three (3) inches is
who do not (or cannot be expected recommended but should not exceed 6
to) assist in maintaining inches. Failure to select the proper size
appropriate hygiene, are placed in cuff may result in rolling or wrinkling on
a private room. Consult with your the limb, causing hazardous, localized,
infection control professionals on excessive pressure areas.
patient placement, if a private room 2) Apply a soft, wrinkle-free padding
is not available. (i.e.sofroll) on the area, which the
tourniquet will be applied.
15.63 Surgical Hand Scrub
3) Apply the tourniquet cuff evenly. Smooth
the underlying skin and padding so that
15.63.1 Procedure
no wrinkles are allowed to form. The cuff
15.63.1.1 Preparation: shall be placed with its hose stem on the
1) Adjust water temperature. lateral side of the limb. Tie the
2) Keep arms level and well away from tourniquet strings to secure the cuff.
body and hands up above elbows for Attach the tourniquet cuff to the
duration of scrub. tourniquet tubing securely to prevent
3) Prewash: leakage.
4) Wet hands and forearms. 4) With the inflating valve in "OFF"
5) Apply sufficient water and work up position, slowly turn tourniquet pressure
lather. adjustment knob clockwise until the
6) Wash from fingertips to three inches desired cuff pressure is reached. The
above elbows. surgeon will designate the pressure to
7) Clean nails and subungual areas. be used.
8) Rinse hands and forearms thoroughly. 5) Open the inflating valve and the cuff will
9) Surgical Scrub: inflate to the present pressure on the
10) Scrub hands and forearms, to two (2) tourniquet pressure gauge. Occasionally
inches above elbow. the pressure may fluctuate from the
11) Fingernails of hand #1 - using 15 preset pressure. This may be adjusted
strokes. by turning the pressure adjustment knob
12) Begin with palm of hand #1 - apply 9 clockwise until the desired cuff pressure
strokes to each of 3 areas of fingers and is reached. The gauge must be checked
hand. and pressure readjusted approximately
13) Repeat above steps for hand #2. five (5) minutes after the cuff is inflated
14) Scrub backsides of hand #1 - apply 9 to get an exact pressure setting.
strokes to each of 3 areas of fingers and 6) Increased cuff pressure may be
hand. obtained at any time by slowly turning
192
the regulator pressure adjustment knob perform a diagnostic study or operative
in a clockwise direction. procedure.
7) To expose bleeding areas and/or to
aerate the site, the inflating valve may 15.66 Scheduling Surgical Procedures
be turned to "OFF" and then back to
"ON." When the valve is turned back on, 15.66.1 Procedure
the tourniquet cuff will automatically 1. The routine theatre can function from 9-
return to the pre-set tourniquet gauge 4 pm on from Monday to Friday and 9
pressure. am to 1 pm on Saturday except
8) The surgeon shall be notified of the gazetted holidays and national holidays.
duration of tourniquet use at frequent, Elective cases should be scheduled as
pre-established time frames. far in advance as possible. If there are
9) For quick deflation of the tourniquet cuff, any questions about the surgical
turn the inflating valve to the "OFF" procedure time, the person scheduling
position. the procedure will verify the time with
the surgeon. In the case of cancellations
or changes in the schedule, the surgeon
15.65 Criteria for Admission Prior to Surgery must notify the Operating Room or
Nursing Supervisor as early as possible.
2. Emergency theater will function 24
hours on all days. The surgeon with an
15.65.1 Inpatient Admission Prior To
emergency situation will notify the
Surgery (Pre-Op Days)
Operating Room incharge or designee
15.65.1.1 Procedure and the emergency will be
accommodated at the earliest. Any
1) Unless indicated otherwise above, this question regarding the urgency of the
policy applies to all patients undergoing
procedure will be referred to the
surgery at CNBC
surgeon involved. In the case of a
2) Inpatient hospital admissions on days disagreement, the anesthetist will be
prior to surgery are medically necessary notified to assist with the decision.
and allowed when any of the following 3. The scheduling personnel are
criteria are met: responsible to schedule cases as
3) The patient has a concurrent medical accurately as they can, taking into
problem that requires specific inpatient consideration time, personnel and
treatment prior to major surgery (defined equipment requirements. Every effort
as craniotomy, median sternotomy, should be made to accommodate
thoracotomy, or laparotomy) to reduce surgeons’ requests, if possible.
the operative risk or assure a more
favorable outcome; OR
4) A planned surgical procedure on 15.67 Protocol for scheduling of operating
partially obstructed bowel, which cases
requires a slow but extensive bowel
preparation (multiple enemas, laxatives) An emergency list will be on first come first
in a patient with a co – morbidity (e.g. serve basis, depending on the degree of
chronic renal failure ,poor nutritional urgency.
status resulting in a significant weight
loss > 10%) whose condition places the 15.67.1 Local cases
patient at high risk for electrolyte and 1. Local cases will be booked under
fluid imbalances; OR individual consultant’s time slot.
5) The patient requires intravenous steroid 2. Added cases will be done on a first
preparation for protection against a come first serve basis, depending on the
previously documented allergic reaction availability of the operating room time.
to dye prior to intravascular 3. Operating theatre booking slip has to
administration of dye necessary to state ward staying or day care case.
193
15.68 Pre-operative tests for inpatients 15.69.1.7 If the count is incorrect, the surgeon is
notified, a recount is taken, a search is
15.68.1 Policy: made for the missing item and, if not
found, an x-ray of the patient is taken.
15.68.1.1 It is the policy of Hospital that the If the item is not found on x-ray,
following are suggested diagnostic documentation of x-ray results is
tests to be considered, at the recorded on the operative record. If x-
discretion of the surgeon and ray indicated item is in the patient,
anesthesia provider, for inpatients document this fact and the course of
undergoing surgery with any type of action taken.
anesthesia except local.
15.69.1.8 Patients are not to leave the OT until
15.68.1.2 Complete blood count with differential missing items are accounted for.
leukocyte count
15.69.1.9 All counts shall be taken before the
15.68.1.3 Urinalysis-routine/ microscopic. procedure, when additional sponges
are added to the sterile field, prior to
15.68.1.4 Other investigations as per the type of closure of a cavity within a cavity, prior
the procedure and illness will be to wound closure and when permanent
carried out. relief of the scrub person and/or
circulating nurse occurs.
15.68.1.5 All patients with co morbid conditions
will require work up & clearance from 15.70 Accountability for Sponges, Sharps
consultants of respective specialties. and Instruments
15.69 Accountability for Sponges, Sharps 15.70.1 Policy:
and Instruments
15.70.1.1 Surgical attire provides a barrier
15.69.1 Policy: between personnel and between
patient and patient and personnel,
15.69.1.1 To provide safe practice for the through which contamination may
surgical patient, prevent patient injury pass. Surgical attire also provides
and adhere to legal standards. protection for personnel against
exposure to infectious microorganisms
15.69.1.2 All counts shall be audibly and visually
and hazardous materials.
performed according to procedure.
15.70.1.2 All personnel entering semi-restricted
15.69.1.3 Incorrectly numbered packages of
and restricted areas of the surgical
sponges and sharps shall be isolated
suite shall be in operating room attire.
and not used during the procedure.
15.70.1.3 Operating room attire consists of
15.69.1.4 The circulating nurse and scrub
standard multi-use fabric or limited-use
person shall document and sign the
non-woven pantsuits and a low-lint
operative record with the results of the
surgical hat or hood. OT attire, which
counts.
is soiled or wet, shall be changed. All
15.69.1.5 The count form shall list the type and reusable attire shall be laundered after
number of each instrument. For each use, by a laundry facility
instruments having more than one approved and monitored by Name of
part, the total number of parts shall be Your Institution. OT attire shall be
accounted for. stored in open shelves.
15.69.1.6 Counts not done due to patient 15.70.1.4 All head and facial hair is to be
emergency shall be documented on covered while in the restricted areas of
the operative record and incident the surgical suite.
report filed.
194
15.70.1.5 The surgical hat or hood is to be clean, 15.71.4 The nurse and Anesthetist
free of lint and confine the hair. The following each arrest must
surgical hat or hood is changed daily. complete a cardiopulmonary
All personnel entering the restricted resuscitation report.
area of the surgical suite, are to wash
hands and enter in proper O T attire. 15.72 Handling of Bio-hazardous Materials
15.70.1.6 Shoe covers shall be worn if it is 15.72.1 General

anticipated that splashes or spills will
occur. 15.72.1.1 YELLOW bags, labelled "Bio-
hazardous Waste” are used to collect
15.70.1.7 Masks shall be worn at all times in the body part/ organ.
surgical suites and other areas where
open sterile supplies or scrubbed 15.72.1.2 Hampers lined with plastic marked
personnel are located. Masks shall "Bio hazardous Waste" are placed in
cover the nose and mouth and shall be certain isolation rooms, according to
discarded whenever removed. protocol.
15.70.1.8 Personal jewelry worn in the surgical 15.72.1.3 Collecting barrels, marked "Bio
suites shall be limited to the following: hazardous Waste", are placed in
designated storage areas.
15.70.1.9 Watch
15.72.1.4 Only items that fit the definition are to
15.70.1.10 Bracelets - None be placed in the yellow bags by
personnel in the use areas (no
15.70.1.11 Necklace - One small single chain newspapers, IV bottles, etc.).
15.70.1.12 Earrings - Small studs. All other 15.72.1.5 Trolleys/Room are decontaminated
earrings worn are to be contained whenever soiled or at least weekly.
within a cap at all times.
15.72.2 Anatomical Remains/Pathological
15.70.1.13 Rings - Wedding set only or one ring
Specimens
per hand.
15.72.2.1 Anatomical remains (recognizable
15.70.1.14 All jewelry (rings and watches) is to
body parts, such as amputations) are
be removed prior to hand washing. All
transported from the operating room
other jewelry shall be totally confined
wrapped in plastic until disposal.
within scrub attire or removed.
15.72.2.2 Pathological specimens (all specimens
15.70.1.15 Fingernails shall be kept short and
other than anatomical remains above)
well maintained.
are all delivered fresh or in10%
formalin to Pathology lab (Is available
15.71 Cardiopulmonary Resuscitation in
in Lab) Relatives of patients are
Operating Room
advised to collect anatomical remains
for burial whenever convenient.
15.71.1 Anesthetists will initiate CPR in O.T
15.71.2 Nursing personnel currently 15.74 Orientation of New Personnel and In-
certified in BCLS/ACLS may initiate
CPR when appropriate. Service Training
15.74.1. Purpose
15.71.3 Emergency crash cart, supplies
and defibrillator must be checked
To ensure that the new personnel are well
by O.T nursing staff every shift for
completeness and function. oriented with the hospital wide policies and keep
up with all the latest developments in their
195
occupation, so as to provide qualityhealth care shock-resistant and designed to
services. minimize unintentional activation.
Footswitch cord shall be long enough to
15.74.2 All new staff members are introduced reach the user without stress.
with the specific operation theatre guidelines in 7. The electro surgical unit generator shall
not be used in the presence of high
CNBC.
concentrations of O2 or flammable
agents, such as alcohol or tincture-
15.74.3During orientation, the SISTER IN
based agents.
CHARGE must inform the new staff members 8. Before each use, the electrical cord,
about the policy of the institution, work connections, plug and foot switch cord
schedules, hand hygiene and vaccination. shall be inspected for damage. The unit
shall be removed from service if
15.74.4 In operation theatre must have regular damaged.
in-service training programme-induction classes, 9. Power settings for coagulation and/or
Nursing procedure demonstration classes, cutting shall be as low as possible for
Public education pre and post operatively for the each procedure, confirmed orally with
the surgeon before activation and
relatives, equipment maintenance training for determined according to manufacturer
the staff and technician. recommendation.
10. The dispersive electrode shall be
15.74.5 In-service -training in the form of inspected before each use for wire
discussions, demonstrations with regard to breaking/fraying and shall be long
procedures and methods can be done by the enough to be placed on the patient
more senior staff members. without stress. All connections shall be
intact and clean.
15.74.6 It is important that everyone participate 11. Plasma Sterilization High Level
in the in-service training activities. Disinfection ofInstruments sterilized in
Sterrad 100
12. Arthroscopes
15.73 Electro surgical Cautery Unit Safety
13. Laparoscopes
1. To provide for the safe operation of 14. Cystoscopes
electro surgical units, used for the 15. Nasal endoscope
purpose of cutting and coagulation of 16. cautery instruments
body tissue with a high frequency 17. laryngoscope blades if used in infected
electrical current during surgical patients
procedures. 18. LMA
2. Equipment: Electro surgical Generator
Grounding Pad (Depressive Electrode)/ Day to Day Operation
Active Pencil.
3. All electro surgical generators shall
meet the performance and safety 1.Instruments to be sterilized are cleaned, dried
standards of the hospital. thoroughly.
4. Biomedical Department personnel are
provided with detailed instructions from 2. Instruments are loaded in the trays provided
the electro surgical unit's manufacturer. with it and packed in packing paper
Operational directions are attached to
each electro surgical unit. 3. Sealed packet is put in the machine.
5. The electro surgical unit is properly
grounded, mounted on a stand, easily 4.Power on -warming time-20 minutes.
cleaned and movable and generator
shall be kept clean and protected from
5. After pressing start button select cycle(Short
spills.
or Long).
6. The electro surgical unit foot switch shall
be designed for easy cleaning, shall be
196
6. Now the sterilization process moves through have to the recommendation of the
following phases- manufacturers guideline
vaccum(15min)/Injection(6min),Diffusion(2min),
Plasma(5 15.73.3 All endoscopes shall receive
min),Injection(6min),Diffusion(2min),Plasma(5mi mechanical cleaning prior to
n) and Vent(<1min). disinfections. Flexible endoscopes
shall be cleaned with a
Short Cycle (54minutes)-This cycle is selected manufacturer-approved enzymatic
for all instruments except flexible instruments. cleaner immediately following use.
Long cycle(72min)-This is selected for Flexible 15.73.4 The channels will be irrigated and
endoscopes with longer lumen. brushed if accessible. Immiscible
surfaces, both internal and
external, shall be in contact with
7. Completing the cycle-It is signalled as - a long
the sterile/disinfectant from EPA
beep
registered agent for a minimum of
20 minutes.
-Process Complete is displayed
15.73.5 All non-immiscible parts shall be
-Paper printout shows process shows process cleaned with water and detergent
parameters(in black ink only;red in indicates and wiped with 70% alcohol.
problem)
15.73.6 Following chemical disinfections,
8.After completion sterilization chamber remains rinse the endoscopes with sterile or
closed until you press ''open door'. tap water.
Quality control for plasma sterilization 15.73.7 Thoroughly air-dry the endoscopes.
15.73.8 Do not store the endoscopes

1. Chemical indicator tape-above the
coiled. Store endoscopes in a
pack- For exposure control(colour
manner, which will protect the
change grom red to gold)
endoscopes.
2. Chemical indicator strip-Inside each
pack-For exposure control
15.73.9 All reusable accessories (i.e.,
3. Biological indicator-Daily first load. In
cytology brushes, biopsy forceps),
this bacilliusatrophaeus spores
which penetrate mucosal barriers,
areused.Bi is kept at the back of the
will be mechanically cleaned and
chamber, on the bottom shelf.
sterilized between each patient or
discarded.
Routine maintenance include-
15.73.10 Use freshly filled water bottle for
1. Changing cassette collection box each patient.
2. Replacing injector valve vaporizer plate
3. Replacing printer rolls 15.74 Collection of Pathology Specimen
4. Resetting time and date display
5. Setting pressure units 15.74.1 All specimens removed from
6. Cleaning patients in the operating room must
be sent to Lab for further action.
15.73.1 To prevent cross contamination of This includes all tissue, foreign
patients when using the bodies, etc.
endoscopes for multiple patients.
15.74.2 Specimens should be placed in the
15.73.2 The cleaning and disinfecting of the appropriate sized containers. All
flexible endoscopes should and tissues shall be placed in 10%
197
formalin, unless otherwise microorganisms between sterile
specified by surgeon or pathologist. and nonsterile areas.
15.74.3 Each specimen must be tagged 15.76.2 Packages, containing sterile

with a label,seal, stamped with the medical items, shall remain sterile
addressograph plate. The up to the time the package is
individual specimen must be intentionally opened.
identified on this label. The
designation of left and right must 15.76.3 Drapes and Gowns: The materials,
be made when applicable. The selected for use during the
words "right" and "left" should be procedure, shall be resistant to
written; not R and L. blood and liquid penetration.
15.74.4 The pathology request form must 15.76.4 Unused disposable items will not
be completed with all of the be resterilized for use, unless the
requested information. manufacturer provides written
instructions for processing and they
15.74.5 Multiple specimens must be can be followed.
numbered and listed individually.
Use two (2) sets of the request 15.76.5 Materials shall be resistant to tears
form if necessary. and punctures and shall be as lint
free as possible to reduce
dissemination of particles into the
15.75 Patient Positioning during surgery wound or environment.
15.75.1 The patient's position shall provide 15.76.6 Materials shall maintain an
optimum exposure and access to isothermic environment that is
the operative site, shall sustain appropriate to body temperature/
circulatory and respiratory function, shall be nonabrasive, free from
shall not compromise toxic ingredients and non-colorfast
neuromuscular structures and, dyes.
shall afford as much comfort to the
patient as possible. The patient 15.76.7 Materials shall be non-glazed and
shall be assessed prior to the be of a color that minimizes
procedure for the following: distortion from reflective light.
1) Age
15.77 Packaging Materials:
2) Height
3) Weight
4) Skin condition 15.77.1 Materials used for in-facility
5) Nutritional status packaging and wrapping of sterile
6) Physical limitations supplies, shall be compatible with
7) Neuropathies the sterilization process and remain
8) Pre-existing disease and sterile until they are intentionally
conditions opened.
9) Type of procedure
15.77.2 When the steam process is used,
15.76 Selection of Barrier Material for materials should allow adequate air
surgery procedure removal and steam penetration.
15.76.1 Surgical drapes, gowns and 15.77.3 When gas sterilization is used,
packaging materials, used for and materials should allow adequate
during the surgical procedure, will penetration and release of gaseous
establish an effective barrier, sterilant and moisture.
minimizing the passage of
198
15.77.4 Materials, used for in-facility 15.78.3 The patient's surgical site shall be
wrapping and packaging, will assessed for moles, warts, rashes
provide a seal of proven integrity, or other conditions prior to skin
resist tears and be free of pin preparation and documented.
holes.
15.78.4 Only personnel trained and skilled
15.77.5 Materials shall allow for suitable in skin preparation techniques shall
printing or labeling per package prepare the surgical site.
identification and sterilization
process.
15.77.6 Documentation shall be available

to validate that the material is an
effective barrier to microorganisms,
under prescribed storage and use
conditions.
15.77.7 Materials, used for in-facility

wrapping and packaging, shall
allow for ease in aseptic
presentation.
15.77.8 All sterilized packages shall allow

opening without significant risk of
product contamination, damage or
personnel injury.
15.77.9 Packages that serve as a sterile

drape upon opening should drape
easily and be memory free.
15.77.10 Materials shall not peel,

delaminate or flake off / shall be
free of toxic ingredients and non-
fast dy.
15.77.11 Chemicals and laundry

processing shall not have
deteriorating effects on woven
reusable materials.
15.77.12
15.78 Skin Preparation Protocol
15.78.1 Prior to surgery, the patient shall

clean the area by showering,
shampooing or washing the
surgical site area.
15.78.2 Hair removal shall be completed as

close to the surgery time as
possible.
199
15.79 Standard Precautions recall purposes .Each item will
have the following documentation:
15.79.1 Standard Precautions combine the
features of universal precautions 15.80.10 Department name ,Item
and body substance isolation. description; Date of sterilization;
Sterilizer number; Sterilizer load
15.79.2 Standard Precautions apply to all number; Assembler initials, Expiry
patients regardless of their date.
diagnosis or suspected infection
status. 15.81 Surgical Hand Scrub
15.79.3 Standard Precautions apply to the 15.81.1 All members of the sterile surgical
following: team must properly complete the
surgical hand scrub.
15.79.4 Blood/all body fluids, secretions
and excretions except sweat 15.81.2 Remove all jewelleries from hands
whether or not they contain visible and forearms; Fingernails should
blood; be kept short and well maintained.
15.79.5 Non-intact skin/Mucous 15.81.3 Hands and forearms must be free

membranes. of open lesions and breaks in skin
integrity.
15.79.6 Details are covered in infection
control manual. 15.81.4 Be wearing complete operating
room attire.
15.80 Sterile Storage
15.81.5 Key Point - Antimicrobial soap or
15.80.1 Sterility of items will be date- detergent must be rapid acting /
related. have broad spectrum of activity in
reduction of transient micro flora
15.80.2 All items sterilized by Sterile and have minimal harsh effects on
Processing will be considered skin;
sterile unless the
package/pack/tray/container is 15.82 Traffic and Visitor Control
damaged or wet. Damage includes:
15.82.1 To outline policy for visitors in the
15.80.3 Holes or torn wrappers; Surgical Services Department
15.80.4 Securing tapes or locks have been 15.82.2 All patient and relatives name
tampered with or removed; should be registered in register
prier entry to the OT One attendant
15.80.5 Broken seals in peel pouches or is allowed in preoperative and
sterility maintenance covers; post operative room per
patient;The attendant should wear
15.80.6 Exposure to any type of moisture. OT slippers, mask and disposable
gowns.
15.80.7 Items dropped that are wrapped or
in peel pouches; 15.82.3 Only visitors and personnel in
proper surgical attire will be
15.80.8 Exposure to a contaminated or allowed into the department past
unsafe environment; the red floor line marking after OT
list is over.
15.80.9 Load identification labels are
applied to all items sterilized for
200
15.82.4 This policy will be strictly enforced 15.83.8 Emergency – Patient in unstable
at all times. There are no condition with life threatening,
exceptions. which need urgent surgical
intervention should be done
15.82.5 Proper surgical attire includes all of immediately.
the following:
15.84 After Office hour Surgeries
15.82.6 Surgical scrubs pants and shirts;
15.84.1 At present there is no after hour
15.82.7 Surgical cap surgeries. Plan under processes.
Policy are sameas follows-
15.82.8 Surgical mask.
15.84.2 To enable the call team to have
15.82.9 Cover gowns will not be worn enough of rest because the same
inside the red line area of the set of staff will continue work
operating room. during office hour.
15.83 Scheduling of Surgical Procedures 15.84.3 To provide priorities to

emergencies those are life
15.83.1 To establish the most effective threatening in nature.
method for the scheduling of
surgical procedures. 15.85 Criteria
15.83.2 The admitting department must be 15.85.1 Life saving.

notified of all scheduled procedures
so that pre-admission can be 15.85.2 Minimize further complications due
completed and the patients given to delay of surgery.
preoperative instructions.
15.85.3 To serve unfinished scheduled
15.83.3 Addition of cases during the day cases planned for the same day.
must be coordinated with the OT
Manager to determine optimal time 15.86 Sterilization-Reprocessing single use
for the procedure. product
15.83.4 Special Implants, equipment or 15.86.1 To establish guidelines for

supplies must be requested at the reprocessing of “single use” item.
time of surgery scheduling.
15.86.2 Single use item will not be
15.83.5 The responsibility for scheduling of reprocessed unless manufacturer
surgery lies with the hospital’s provides written instructions
OT/surgeons a. Scheduling supporting re-sterilization.
Priorities
15.87 Transferring /Shifting Criteria
15.83.6 Elective – Patient with stable
condition will be done mutually 15.87.1 Criteria for shifting patient with ASA
agreeable time slot. grade 1 & 2 from operation theatre
to Ward:-
15.83.7 Urgent – Patient in stable condition
but would become unstable. To be 15.87.2 All the patients must be evaluated
scheduled in first available time by an anaesthesiologist prior to
slot. Where time is a factor, the shifting the patient from operation
surgeon will indicate. theatre to Ward. The criteria for
transferring patient from operation
theatre to Ward are established by
201
the department of 15.87.10 Established criteria are used to
anaesthesiologist and the hospital make decisions regarding the
medical staff. patient's discharge from the
recovery room
15.87.3 Criteria can vary according to age,
patient condition whether the 15.87.11 The decision to discharge the
patient is going to be shifted to an patient is recorded in register.
intensive care unit and ward .
15.87.12 Recovery area arrival and
15.87.4 Before shifting all the patients in discharge times are recorded
recovery room must be observed
for minimum 30 minutes and 15.87.13 The signatures of those
maximum 2 hrs. handing over and those
receiving the patient are.
15.87.5 Before shifting the patient should
be observed by the anesthetist/ 15.88 Other minimal shifting criteria are:-
Nurse for respiratory depression for
at least 20-30 minutes after the last 15.88.1 Easy arousability.
dose of parental narcotic
15.88.2 Full Orientation.
15.87.6 Criteria for shifting patient with from
recovery to Ward:- 15.88.3 Ability to maintain and protect the
airway.
15.87.7 Standardised criteria developed by
anaesthesiologist are used to make 15.88.4 Stable vital sign for at least 15-30
discharge minutes.
15.87.8 During the post-anaesthetic 15.88.5 Ability to call for help if necessary.
recovery period, patients must
receive monitoring appropriate to 15.88.6 No obvious surgical complication.
their condition.
15.88.7 Controlling post operative pain,
15.87.9 Monitoring findings are entered in nausea vomiting and normothermia
the patient's record prior to discharge highly desirable.
202
15.89 The anaesthetist can determine the criteria for shifting of patient as per aldrete scoring
table:-
ORIGINAL CRITERIA MODIFIED CRITERIA Point
value
COLOUR: OXYGENATION:
Pink SpO2 > 92% on room air 2
Pale or dusky SpO2 > 90% on oxygen 1
Cyanotic SpO2 <90% on oxygen 0
RESPIRATION:
Can breath deeply and cough Breaths deeply and cough freely 2
Shallow but adequate exchange Dyspneic, Shallow or limited breathing 1
Apnoea or obstruction Apnoea 0
CIRCULATION:
Blood pressure within 20% of normal Blood pressure ± 20mmHg of normal 2
Blood pressure ± 20-50 mmHg of normal 1

Blood pressure within 20-50% of normal Blood pressure more than ± 50 mmHg of normal 0
Blood pressure deviating > 50% of normal
CONCIOUSNESS:
Awake, alert, oriented Fully awake 2
Arousable but readialy drift back to Arousable on calling 1
Sleep Not responsive 0
No response
ACTIVITY:
Moves all extremities Same 2
Moves two extremities Same 1
No movements Same 0
203
15.89.1 In addition to the above criteria patient receiving regional anaesthesia should also show
signs of resolution of both sensory motor block.
15.89.2 All the patient of ASA grade1 & 2 should be shifted with the nursing orderly with Complete
case sheet and Input and output charting and all investigation accompanied with patient
attendants.
15.89.3 Criteria for shifting patient with ASA grade 3 & 4 from PACU/ot to Intensive care unit:-
15.89.4 Before shifting of patients a Prior intimation must be given to doctor posted in Intensive care
unit.
15.89.5 Vitals should be stable.
15.89.6 Patient must be transferred under monitoring of vital signs on monitor and under the
observation of an anaesthetist, Surgeon, Staff Nurse, Technician and nursing orderly.
15.89.7 All life saving drugs and equipments( i.e. oxygen cylinder, AMBU, masks, laryngoscope etc.)
must be accompanied with the patient during shifting. Complete case sheet and
investigation must be carried with patient.
15.89.8 Complete shifting notes with accompanied accessories should be mentioned by the staff
nurse in patient transfer register with date & time.
15.89.9 Hand over and taking over notes must be documented in the patient transfer register.
15.89.10 All neonates/Infants must be transferred in incubator with temperature monitoring.
15.90 Operation theatre washing protocol (weekly)
15.90.1 Remove all equipments and accessories outside the operation theatre in corridor.
15.90.2 Wet the floor with plain water for 15-20 minutes.
15.90.3 Scrub the floor with soap solution 20% (200 ml liquid soap in 800ml of plain water) by using
scrubbing machine.
15.90.4 Wipe out remaining water with wiping machine.
15.90.5 Mop the floor with sterisol solution (disinfectant solution) activated H2O2
15.90.6 Dis-infect the equipments and accessories with 2% bacillocid solution (1,6 Dihydroxy2,5-
dioxyhexane-11.2, glutaraldehyde-5.0) 20ml/liter
15.90.7 Keep the equipment and accessories back to the operation theatre
15.90.8 Fogging with ecoshield solution (20% = 200ml/liter) for one hour by using automatic fogger.
15.90.9 Close the operation theatre; open the theatre on next day.
204
15.91 Weekly washing protocol for decontamination of instruments
Step -1.wear the PPE
Step-2. Dip the instruments in diluted savlon soln. for ½ hour
Step -3. Scrub the instrument with brush
Step- 4. Rinse the instruments
Step -5. lubricating the instrument with silicon spray for ½ hour
Step -6. Dry and send for a autoclaving after packing Sharp instrument put in cidex 2% - activated
glutarldehyde
205
15.92 Equipment surface disinfection protocol
15.92.1 Wear PPE
15.92.2 Clean the surface thoroughly with wet duster.
15.92.3 Remove dust stain, blood or other body fluid using detergent solution.
15.92.4 Use soft cloth dipped in 2% bacillocid solution.
15.92.5 Change the solution for next equipment.
15.92.6 Repeat every day or before use the equipment.
15.92.7 Kindly dip the mop/cloth in disinfectant solution for 5 minutes prior to use.
206
15.93 Daily washing protocol-
STEP-1 Wear PPE , dip the
instruments with
multienzyme 1%
(10ml/liter) for 10 minutes
STEP-2 Scrub and brushing the
instrument with soap
water solution
STEP-3 Rinse the instruments with
plain water
STEP-4 Dry and send for
autoclaving after packing
sharp instrument, put in
Cidex 2%
207
15.96 Implant policy in OT
15.94 Radiation health hazard in OT
15.96.1 Implants are used OT: intraocular
15.94.1 The radiation safety programme lens, Gromet ,K Nail, K wire, screw
applied to operation theatre where plates
C –ARM/ Mobile Image intensifier)/
is used . 15.96.2 All implants are approved and
proceed by our tender process
15.94.2 The department supervisor shall after the technical evaluation.
provide safety rules to each
individual operating X-ray 15.96.3 Approvedproduct is received in
equipment including any store.
restrictions as to the operating
technique required for the safe 15.96.4 After receiving the concerned
operation of the particular x-ray MOIC in charge again approve and
apparatus. check the product received
15.94.3 We use personal protective 15.96.5 The sister in charge OT receive

equipment- them and store in OT store as per
manufacture guide lines.
15.94.4 Lead apron
15.96.6 Patient and relatives are
15.94.5 Thyroid shield counselled before use of implants.
15.94.6 Safety goggles. 15.96.7 The implant are identified as type,

batch no, of procurement,
15.94.7 TLD Shall be worn by all staff
during radiation exposure in 15.96.8 Implant is recorded in patient
operating room. Badges will be medical record and log book, and
processed and recorded Quarterly. operation theatre book.
15.95 Pest control in OT 15.97 Plasma sterilization policy:
15.95.1 We follow the same policy as 15.97.1 Plasma sterilization (vaporized

mention in hospital manual. hydrogen peroxide)-Instruments
sterilized are
15.95.2 15.97.1 Emergency and Disaster
Preparedness Plan for the 15.97.2 ArthroscopesLaparoscopesCystosc
Operating Theatre ope,Nasal endoscope
15.95.3 Purpose- To provide an 15.97.3 Cautery instruments,Laryngoscope

emergency plan for internal blades if used in infected
emergencies that will ensure the patientsLaryngeal mask airway
safety of all staff, patients and
visitors. 15.98 Day to Day Operation
15.95.4 Disaster Committee 15.98.1 Instruments to be sterilized are
cleaned,dried thoroughly.
15.95.5 All internal and external disasters
will be coordinated by the Disaster 15.98.2 Instruments are loaded in the trays
Committee and OT follows all the provided with it and packed in
instruction written in disaster packing paper
manual.
15.98.3 Sealed packet is put in the
machine.
208
15.98.4 Power on -warming time-20 15.101.1.2 Replacing printer rolls
minutes.
15.101.1.3 Resetting time and date display
15.98.5 After pressing start button select
cycle(Short or Long). 15.101.1.4 Setting pressure units
15.101.1.5 Cleaning
15.98.6 Now the sterilization process
moves through following phases-
15.102 DAY CARE POLICY-
15.98.7 Vaccum(15min)/Injection(6min),Diff
15.102.1 Commonly performed procedures:
usion(2min),Plasma(5
min),Injection(6min),Diffusion(2min
),Plasma(5min) and Vent(<1min). 15.102.2 Paediatric surgery-
Circumscism,InguinalHernia,
15.98.8 Short Cycle(54minutes)-This cycle Orchidopexy ,
is selected is selected for all
instruments except flexible 15.102.3 Cystoscopy and other
instruments. Diagniosticscopies,Examination
under GA,Dermoid sebaceous cyst,
Lipoma excision ,Umblical and
15.98.9 Long cycle(72min)-This is selected
for Flexible endoscopes with longer Epigastric hernia,Polydactyly(without
lumen. bone correction)Tongue tie release,
Rectal polypectomy,Branchial cyst
,Sinus excision Minilap, Diagnostic
15.98.10 Completing the cycle-It is
Leprotomy
signalled as - a long beep
15.102.4 Orthopaedic –Percutaneous
15.98.11 Process Complete is displayed
Tenotomy,Closed reduction of
fractures
15.98.12 Paper printout shows process
shows process parameters(in black
15.102.5 ENT-Myringotomy, Grommet
ink only;red in indicates problem)
insertion
15.98.13 After completion sterilization
15.102.6 EYE- EUA,Syringing and Probing
chamber remains closed until you
,Chalazion Excision
press ''open door'.
15.102.7 DAY CARE SURGERIES
15.98.14 Quality control for plasma
LIMITATION: Long distance between
sterilization
home and hospital and Illiteracy
15.99 Chemical indicator tape-above the
15.102.8 PROCEDURE SHOULD NOT
pack- For exposure control(color
INVOLVE:
change grom red to gold)
1. Any major fluid and blood loss
15.100 Chemical indicator strip-Inside each 2. Minimal risk of anaesthetic and surgical
pack-For exposure control complication.
3. Minimal investigation required:
15.101 Biological indicator-Daily first load is Complete blood count
kept at the back of the chamber,on the 4. Urinalysis
bottom shelf. 5. Investigations appropriate to clinical
complaint examination finding are done
15.101.1 Routine maintenance include- additionally
Changing cassette collection box
15.101.1.1 Replacing injector valve vaporizer

plate
209
15.103 PREOPERATIVE FASTING 15.104 Protocol for Operative management
in peration theatre during covid-19
15.103.1 Clear fluid-2hrs pandemic
Chacha Nehru BalChikitsalya Hospital is NON
15.103.2 Breast milk-4hrs
COVID designated hospital.Initially It was
15.103.3 Formula milk -6hrs decided by the Govt of NCT Delhi elective
15.103.4 Meals- 6-8 hrs surgeries will be put on hold to reduce the strain
on the health care system as well as to
15.103.5 SPECIAL POINTS EXCLUSION
decrease the risk of spread of the disease to
CRITERIA-
both the patient, attendant, and health care
15.103.6 Premature infant<60 WKS
worker to decrease the viral load in hospital and
15.103.7 H/O sudden death syndrome in for optimum and preferential allocation and
family
utilization of available medical resources to
15.103.8 URTI upper resp infection combat the surge of positive cases.
15.103.9 LFT/KFT-not in within normal 15.105.02- Policies for education and training
limit
of all health care worker and anaesthesia
15.103.10 PATIENT SELECTION personnelregarding the use and disposal of PPE
CRITERIA
by the HICC team, simulation session ,(focussed
15.103.11 age>1month on intubation and extubation protocols, hand
15.103.12 15.97.25 ASA Grade 1and 2 hygine,PPE,) webinar.
15.103.13 PREOPERATIVE
INSTRUCTION :
15.103.14 Detailed written instruction must

be givenregarding fasting
15.103.15 WHEN TO REPORT ON THE

DAY OF SURGERY
15.103.16 Who should be called for further

instruction if child develop
URI/COLD/FEVER/UNEXPCTED
ILLNESS
15.103.17 PAC ONE WEEK BEFORE

INCLUDE- 15.105.03Policies for testing for COVID19 in
children coming for emergency/elective
15.103.18 Acute illness I day prior
surgeries- Testing is required for appropriate
15.103.19 On the day of surgery check list risk stratification-advisable to have covid test
15.103.20 NPO and Acute illness (rapid antigen test)for every patient one day
prior to surgery. And real -time polymerase
15.103.21 Any preoperative treatment.
chain reaction (RT-PCR) testing of nose and
210
throat swab for detection of the virus is 15.105.05 -Preparation of the Operation
recommended as the confirmatory test for Theatre -
COVID 19.
1.All the personnel involved with the procedure
15.105.04- Preoperative assessment should don the PPE in the donnig area before
entering the OT. PPE includes cap well fitted
All patients to be screened for temperature at
medical protective mask(N95 or equivalent)
the operation theatre entrance and any doubtful
medical goggles or face shield, medical
case to be referred to the flu corner.
protective clothes,boot covers and latex gloves.
1.One attendant per patient to prevent crowding Face mask is mandatory both for relative and
and make social distancing easier. Being a the patient.
paediatric hospital, one attendant per patient is

2. Intubation can be preferably done in negative
being allowed at operation theatre
pressure OT (our hospital is NON COVID
1. Wearing mask before entering into centre) or in OTs with laminar flow through
operation theatre complex is HEPA filter with increased air exchanges (>12
mandatory. cycles/hours).. Our OTs have laminar flow with
2. The anesthesiologist must wear HEPA filter with air exchanges up to 14-18
PPE (gown, gloves, N95 mask, face cycles/hour.
shield) in preoperative area in and
3.Limit the number of staff present in the OT
practice hand hygiene every time
during any aerosol generating procedures.
3. Mandatory COVID screening with
rapid antigen test is must in all 4.One anaesthesiologists, one technician and
cases presenting for surgeries. one Nursing orderly stays inside OT, one
4. History of symptoms or contact standby anesthetist outside OT door, surgeons
history in mother is also important and the nursing staff stays out during AGPs and
and maternal COVID testing is allowed to enter after 10 minutes of AGPs (both
advised. intubation and extubation).
5. A dedicated runner should be donned and

wait outside the OT to procure and transport
items if needed.
6. Early preparation of airway equipment and

drugs should be done in the OT prior to the
case. Only the drugs to be used are kept on
work station.
5.
211
15.105.06Rationale Use of Personal
Protective Equipments in operation theatre
(OT)
1. Ensure HCW is not fasting and

is well hydrated. They should
ideally have used the restroom
before donning. Nonessential
items, jewellery, and phones,
books not allowed inside Ot.
2. Before donning, proper hand
6. As the PPE which can hamper the hygiene should be ensured.
voice, clear and loud communication 3. Centres for disease control
should be made. (CDC) videos for donning and
doffing personal protective N-95
masks can be used for training
the personnel.
15.105.07- Transfer of Patients into Operation
Theatre
1. Suspected COVID patients, who are

otherwise negative on investigation, should
not be allowed to wait in the holding area
8. Use of two high-efficiency particulate air and should be directly wheeled into the
(HEPA) viral filters is recommended. The first dedicated theatre.
one should be interposed between Y-piece of
the breathing circuit and the patient’s mask or 2. Whenever logistically possible, separate
ETT. The second one should be placed between corridors should be used for transport to OT.
the expiratory limb and anesthesia machine. The

3. Avoid use of that OT for other asymptomatic
gas sampling tubing should be placed after
patients on the same day.
HEPA filter or should be scavenged.
4. A surgical mask must be applied to the
9.Disposable covers (e.g., plastic sheets for
patient during transfer and till pre-
surfaces, long ultrasound probe sheath covers,
oxygenation
C-ARM, covers for anaesthesia machine) are
used to reduce droplet and contact
.
contamination of equipment
212
10. Modified Rapid Sequence Induction should
be preferred.
11. A video laryngoscope should be routinely

preferred over direct laryngoscopy as the
latter requires the anaesthetist to be near
the patient’s airway.
12. The most experienced anaesthesiologist in

the team should perform intubation, to
reduce the number of intubation attempts.
13. An endotracheal tube (ETT) is preferred

over a supraglottic airway because of
decreased aerosolization risk.
5. As intubation results in significant exposure
to a high-viral load, it is a high-risk 14. Airway devices and used laryngoscopes and
procedure.The goal is to secure the airway suction catheters should be carefully placed
without contaminating the environment with separately on a plastic sheet to avoid
aerosols. contaminating other surfaces.
6. 6. Avoid AGP, including high-flow nasal 15. A Plastic drape or sheet can be placed over
oxygen, noninvasive ventilation and awake the airway device and patient`s head to trap
bronchoscopy. any aerosolized virus,
7. Acrylic aerosol shield box with arm holes for

unrestricted arm movement or transparent
plastic sheet should be utilized to cover the
face of the patient during intubation to
prevent aerosol transmission.In our
institution we use the plastic transparent
sheet over the face once the child is sedated
during induction.
8. Similar protocol to be followed during

extubation.
9. Two handed ventilation (VE grip) with closed

circuit, is preferred to minimize operation
theatre pollution.
213
20. Minimize the ventilatory disconnections, and
whenever it is required (e.g., during prone
positioning), the ventilator is put on standby
mode (to prevent the blast of the gas
mixture) and ETT is clamped distal to HEPA
filter at the end-expiratory phase.
21. A closed airway suction system is preferable

to decrease viral aerosolization.
22. Pharmacological strategies for reduction of

bucking on emergence from anesthesia
should be practiced, extubation under deep
plane should be considered weighing the
risk vs benefit.
23. Administration of prophylactic antiemetic to

reduce the risk of vomiting with subsequent
contamination.
24. Patients who are unfit for extubation can be

shifted to ICU with a single-use AMBU bag
with an attached HEPA filter at the patient
end.
16. Endotracheal tube should be clamped 25. Employ lung protective mechanical
before insertion into the larynx, cuff inflate, ventilation strategies (low tidal volume 5-6
attach to circuit and then remove the clamp. ml/kg ,RR less to maintain the adequate
Tube position is confirmed by bilateral chest MV)Maintain peak airway pressure below
rise and the presence of continuous 30mmhg.
waveform capnography.
26. Doffing of PPE to be done in the designated
17. Unnecessary contamination of stethoscope area of the Operation theatre and discarded
can be avoided, which can become a in the respective colour coded bag
potential source of fomites.
15.105.08-Policies for surgeries in OT
18. When the nasogastric tube is required, it
1.Surgery should be carried out with an
should be inserted under the plastic drape.
experienced surgeon in attendance.
19. Use low gas flows and closed circuits
throughout the case.
214
2. Use a smoke evacuator when 7. anaesthesia machine to be cleaned with
electrocautery is used. 2 to 3% hydrogen peroxide spray
disinfection, or 2 to 5 g/l chlorine
3. Consider avoiding laparoscopic
disinfectant, or 75% alcohol wiping of
procedures, as the risk of generating virus-
solid surfaces of the equipment and
carrying aerosol is supposedly higher.
floor.
Special precautions should be taken during

tracheostomy and airway endoscopic
15.105 Forms / Document
procedures because of the high risk for
aerosolization. 15.105.1 Pre Anaesthetic Check-up Form
15.105.2 Consent form for surgery and

Anaesthesia.
15.105.09- Decontamination of Operation 15.105.3 Pre-Operative Check list

Theatre
15.105.4 Operative notes
1. All unused items on the drug tray should 15.105.5 Adverse Drug Reaction form
be discarded.
15.105.6 Incident reporting form
2. Discard disposable equipment safely
after single patient use (breathing 15.105.7 Blood Transfusion consent form.
circuit, mask, tracheal tube, HEPA
15.105.8 Blood Transfusion reaction
filters, gas sampling line, and soda- form.
lime). Water trap must be changed if it
15.105.9 Pain Scoring form.
becomes potentially contaminated.
3. Decontaminate reusable equipment fully 15.105.10 Investigation form
and according to manufacturer’s 15.105.11 O.T.Format

14
instructions.
15.105.12 Registers
4. Seal all used airway equipment and
suction catheter in a double zip-lock bag 15.105.13 Case Posting Register (OR
Schedule)
which must then be removed for
decontamination and disinfection. 15.105.14 OT Register (Statistics)
5. A one hour time gap is planned between 15.105.15 Billing Register (Consumables)
two cases to give adequate time for
15.105.16 KPI Register
thorough decontamination of OT. So the
number of cases posted per OT should
be reduced.
6. Cleaning staff to be provided with
adequate PPE. All surfaces, screens,
keyboard, cables, monitors, and
215
15.106 Quality Assurance in OT
Quality Assurance program of OT include surveillance activities like-
1.Daily monitoring of humidity, Temperature,pressure,pressure differential
2.Six monthly changing of Hepa filter.
3.Ot culture once a month
4.OT cleaning /Fogging record kept
5. Care related Outcomes –KPI measured by both surgery/Anesthesia/QMD department—
1.Re exploration rate
2.Intraoperative mishaps-like cautery burns,patient fall etc
3.Percentage of unplanned return to OT
4.Percentage of surgeries where organisation procedure to prevent wrong site,wrong surgery and wrong
procedure has been adhered to
5.Surgical site infection rate
6.Percentage of rescheduling of surgeries
7.Percentage of cases who received prophylactic antibiotics within specified time frame
8.Percentage of medical records having incomplete consent
9.Percentage of transfusion reactions
10.Percentage of Anesthesia adverse events
11.Percentage of unplanned ventilation after anesthesia
12.Percentage of modification of anesthesia plan
13.Air changes report
14.Purity of air checked at outlet in OT once a year.
216
16 Nursing Manual
Responsibility of Department of Nursing,

updating:

Updated on:
Version (CNBC/Nursing/16/Ver.1.3)
217
Updated by Quality Management Division.
16 Nursing Manual ...................................................................................................................................................... 217
16.1 Amendment Record Sheet .......................................................................................................................... 219
16.2 Job responsibilities of all post hierarchy of nurses. ..................................................................................... 219
16.3 Purpose: ................................................................................................................................................. 198
16.4 Scope: It covers all in patients receiving treatment in the hospital ............................................................. 198
16.5 Responsibility: Additional Nursing Superintendent .................................................................................... 198
16.6 General Instructions for Nurses .................................................................................................................. 198
16.7 Discipline .................................................................................................................................................... 198
16.8 Orientation to patients and their attendants at the time of admission. ...................................................... 198
16.9 Courtesy ..................................................................................................................................................... 198
16.10 Procedures /Investigations ......................................................................................................................... 199
16.11 Medicines & I.V. Fluids ............................................................................................................................... 199
16.12 Infection Control/ Waste Management ...................................................................................................... 200
16.13 Discharge Process ....................................................................................................................................... 201
16.14 Job responsibilities of all post hierarchy of nurses. ..................................................................................... 201
16.15 Nursing Services:- ....................................................................................................................................... 201
16.16 Oral Care..................................................................................................................................................... 202
16.17 Bed / Sponge Bath ...................................................................................................................................... 199
16.18 Back Care .................................................................................................................................................... 202
16.19 Oral Medication .......................................................................................................................................... 205
16.20 Intramuscular Injection ............................................................................................................................... 207
16.21 Subcutaneous Injection .............................................................................................................................. 209
16.22 Assisting In Intravenous Infusions ............................................................................................................... 212
16.23 artificial feeding .......................................................................................................................................... 216
16.24 Gastrostomy/ jejunostomy feeding ........................................................................................................... 220
16.25 Oxygen Administration ............................................................................................................................... 223
16.26 Urinary Catheterization (Done by Doctor – Sister Only Assist the Doctor) .................................................. 226
16.27 Surgical Dressing ......................................................................................................................................... 229
16.28 Oral Suctioning ........................................................................................................................................... 235
16.29 Nebulization ............................................................................................................................................... 238
16.30 Offering Urinal ............................................................................................................................................ 241
16.31 Departmental Manual. ............................................................................................................................... 243
16.32 Nursing Clinical practice Guidelines for the prevention of peripheral thrombophlebitis. ............................ 244
16.33 Practice Guidelines for the prevention the prevention of fall. .................................................................... 246
16.34 Nursing care plan (NCP) .............................................................................................................................. 248
218
S. Date of Amendment Reasons Of Sign of QM

No. Amendment Amendment
Made
1 January’2012 Keep main calling bell at Nursing At present CNBC does

Counter always “ON” not have the facility
Switch off the call bell switch first

at the patient’s bed side when you
attend patient call.
2. January’2012 Nursing protocol of Oral To upgrade the nursing

suctioning, Nebulization & offering protocols
urinal have been incorporated.
3 January’2012 Nursing protocol for CPR has As the same has been
been deleted. mentioned in Hospital
wide policies.
4 January=2014 Artificial feeding To upgrade nursing

procedure
Gastrostomy / jejunostomy
5 Dec 2015 Previously was not

16.2 Job responsibilities of all mentioned.
post hierarchy of nurses.
6 Dec 2016 16.6 Nursing services Previously was not

mentioned.
7 Dec 2017 16.32 Department Manual To upgrade nursing

procedure
8 Jan 2019 16.18 Back care (addition of steps To upgrade nursing

of back care procedure
219
16.3 Purpose: To provide guideline 16.8.1.3 Make sure nurses are always available at
instructions for General Nursing care with the time of call.
the aims that needs and expectations of
patients are established, Patient satisfaction 16.8.1.4 Show the lists of the items available in the
is enhanced on continual basis. room(private ward)
16.8.1.5 Make sure that the hospital properties are

16.4 Scope: It covers all in patients receiving
intact when the patient gets discharged.
treatment in the hospital
16.8.1.6 Inform the patients attendants about
16.5 Responsibility: Additional Nursing
Superintendent 16.8.1.7 Visiting hours and regulations
16.6 General Instructions for Nurses 16.8.1.8 Location of R.O. water
16.7 Discipline 16.8.1.9 Provision of water supply
16.7.1 DO’s 16.8.1.10 Food timings
16.7.1.1 Report in proper uniform 10 minutes before 16.8.1.11 Record activities like sponge bath, back
duty time. care and mouth care after giving to needy
patients/ or educate the attendants and
16.7.1.2 Always display Identity Card. supervise them.
16.7.1.3 Be in possession of pocket articles. 16.8.1.12 Inform the patient well in advance about
various procedures like
16.7.1.4 Take over inventory articles by counting operation/investigations etc.
each item.
16.8.1.13 Make sure the patient is seen by the
16.7.1.5 Take over each patient from previous staff doctor soon after admission and whenever
with minute details. there is a complaint.
16.7.1.6 Fill up initial/re-assessment sheet . 16.8.1.14 Inform Consultant –in-charge on the spot
in case the doctor on duty doesn’t respond
16.7.1.7 Check crash cart in every shift to make sure to call/ message.
all required articles are intact.
16.9 Courtesy
16.7.2 DON’TS
16.9.1 DO’s
16.7.2.1 Come late for duty
16.9.1.1 Be polite and courteous to the
16.7.2.2 Use nail polish, have long nails or wear patients/attendants/visitors.
ornaments.
16.9.1.2 Attend to the patient on one call.
16.7.2.3 Accept gifts/ money from
patients/attendants. 16.9.1.3 Speak only in English or Hindi while at work.
16.7.2.4 Use mobile phones on duty. 16.9.2 DON’Ts
16.8 Orientation to patients and their attendants 16.9.2.1 Talk improperly/ rudely to the
at the time of admission. patients/attendants
16.8.1 DO’s 16.9.2.2 Argue with patients/ attendants/ Visitors/ Co-

workers/ Supervisors
16.8.1.1 Address the patients by their names.
16.9.2.3 Ignore any problem mentioned by the
16.8.1.2 Accompany the patient to room. patient/ attendants
198
16.9.2.4 Allow smoking or drinking in the premises 16.10.2 DONT’s
16.9.2.5 Allow eatables and flowers into the hospital. 16.10.3 Allow valuables and money with the patient
16.9.2.6 Engage in lengthy talks over telephone. 16.10.4 Allow attendants to sit or sleep on patient’s
bed
16.10 Procedures /Investigations
16.10.5 Allow the patient to leave hospital without
16.10.1 DO’s written permission from the doctor
16.10.1.1 Send patients to other departments or for
16.10.6 Leave the medical record in patient’s
investigations with Nursing orderly only.
room/bed
16.10.1.2 Send the blood sample to Blood Storage
Centre through Nursing orderly (along with a 16.10.7 Allow the patient/attendants to carry the
relative) medical record to any place.
16.10.1.3 Collect blood from Blood Storage Centre 16.10.8 Fill investigation forms by nursing staff
through Nursing orderly.
16.10.9 Shift the patients without rails or safety belt on
16.10.1.4 Start blood transfusion with the knowledge of and cover with sheets/blankets
patient/relative only.
16.10.10 Allow the Nursing Orderly &Sanitary
16.10.1.5 Switch off electrical appliances when not in attendants to leave the ward/department
use (needle destroyers, hot plates, fans,Air without information.
Conditioners etc.)
16.10.11 Allow the Nursing Orderly &Sanitary
16.10.1.6 Always get vacant rooms locked after getting attendants to leave the ward/ department
thoroughly cleaned up. before handing over the responsibility to next
shift person.
199
16.11 Medicines & I.V. Fluids 16.11.1.3 Make sure the patient takes the medicine
in your presence
16.11.1 DO’s
16.11.1.4 Check blood sugar before the food
16.11.1.1 Start medications immediately after reaches the patient if needed.
admission/orders
16.11.1.5 Give insulin injection, if required, in time.
16.11.1.2 Remember 6 “R” before administering any Make a loop and fix the I.V. tube to
medication prevent cannula from coming out.
1. Right Drugs
2. Right Dose 16.11.1.6 Put date to I.V. Cannula site (72hrs), I.V.
tubings(24hrs), urinary catheters(7days),
3. Right Route
Ryle’s Tubes(),chest tubes() etc.
4. Right Time
5. Right Patient 16.11.1.7 Regular care of I.V. sites always (after
6. Right documentation. removing cannula also)
16.11.1.8 Observe for any in duration, local

temperature, blister or swelling at site.
16.11.1.9 Check the balance of medicines before

indenting
16.11.1.10 Inform Nursing Sister / Consultant –in-

charge on the spot about medicines not
available.
16.11.1.11 Check portable O2 Cylinders in each shift,

note down reading in register.
16.11.1.12 Ensure enough sterile water in O2

humidifiers and put date.
16.11.1.13 Keep oxygen humidifier dry when not in

use.
16.11.1.14 Sign the medicine record soon after

administration.
16.11.2 DON’T’s
16.11.2.1 Record before giving medicine/injections.
16.12 Infection Control/ Waste Management
16.12.1 DO’s
16.12.1.1 Hand wash in before doing any

procedures to avoid spread of infection.
16.12.1.2 Ensure waste segregation, burning of

needles, cutting the tips of syringes,
cutting tubing after each use and keep
them in 0.5% Bleaching solution.
200
16.12.1.3 Change bleaching solution in every shift 16.12.2.7 Hand over the original discharge summary
or if 2/3 of the bucket filled before that and to patients/relatives with instructions.
the content had to be emptied. Attach photocopy of discharge summary
to the case sheet. Cut the id band and
16.12.1.4 Use color coded bags for proper disposal hand over to patient relatives/ parents to
of the waste as per the CNBC’s Bio- further handover to the security guard at
medical waste management policy. exit gate.
16.12.1.5 Ensure cleaning and decontamination of 16.12.2.8 Nursing Sisters responsibilities remain as
suction jars after every use. per the hospital authority’s instructions.
16.12.1.6 Ensure barrier nursing universal 16.12.3 DO’s

precautions to infectious patients
16.12.3.1 Remove I.V. cannula at the time of
16.12.1.7 Ensure decontamination of the beds and discharge
the unit after a patient is discharged to
keep the ICU Bed ready for next patient. 16.12.3.2 Check medications and advise them the
proper drug administration at home.
16.12.2 DONT’s
16.13 Discharge Process
16.12.2.1 Wear ICU /OT dress/ slippers out of the
department 16.13.1.1 Explain them about the emergency
conditions when they have to contact the
16.12.2.2 Keep infected dressing materials in doctor on the telephone number printed
dressing trolley on the discharge slip.
16.12.2.3 Keep sterile gauze drum for more than 72 16.13.1.2 Explain them about feedback form and
hours. help the relatives to fill it
16.12.2.4 Keep the decontaminated and packed 16.14 Job responsibilities of all post hierarchy of
tubings from CSSD for more than 14 days nurses.
16.12.2.5 Prick more than once during venue Please refer CNBC Human Resource Philosophy
puncture
16.15 Nursing Services:- nursing services are
16.12.2.6 Touch the area of I.V. site after cleaning provided to the patient as per the current
and before inserting the cannula. standards of nursing ie, Nursing care plan, ,
Nurse patient assignment.
Nurses are empowered to take nursing-related
decisions to ensure the timely care of patients
with nursing care plan.
201
16.16 Oral Care 9. Pick up the tooth brush, wet it with water,
spread tooth paste on it and hand it over to the
16.16.1 Definition: Care of the Oral cavity including patient.
teeth, gums, lips and cheeks. 10. Instruct the patient to brush all sides of the
teeth extending from the gum to the enamel.
16.16.2 Purpose 11. Once brushing finishes help him to wash the
1. To give a feeling of freshness. brush into kidney tray, clean brush thoroughly
2. To prevent infection. and put it back.
3. To give a sense of well-being. 12. Help the patient to rinse his mouth thoroughly.
4. For aesthetic sense. 13. Let the patient hold kidney tray as per his
5. To maintain cleanliness. convenience for return flow.
6. To prevent bad odour (Halitosis) 14. Help the patient to wash his face and hands.
7. To stimulate appetite. Wipe with the towel.
16.16.3 Articles Required 16.16.5 Procedure 2 (For an unconscious patient –

ICU)
A clean tray containing
1. Small mackintosh and towel 1) Arrange the articles and take to the bedside.
2. Face towel 2) Explain procedure to patient’s attendant (if
3. Small jugs – 2 (one with hot water, one with present)
tepid water) 3) Provide privacy
4. Empty jug to mix water 4) Place patient in lateral position with face at
5. Tooth paste edge at end of pillow
6. Glass of water 5) Place the mackintosh and face towel on the
7. Artery forceps – 1 pillow
8. Dissecting forceps – 1 6) Wash hands and put on clean gloves.
9. Gauze pieces (in a bowl) 7) Prepare the mouth wash by mixing hot and cold
10. Dentifrice (in container) water and one crystal of KMnO4in 1ltr water.
11. Solution for mouth wash 8) Make a paste with Soda bicarbonate or salt or
12. Emollient any available dentifrice.
13. Crystal of KMnO4 9) Place the kidney tray close to the cheek.
14. Salt. 10) Take a gauze piece; wrap it around artery
15. Swab sticks in a bottle forceps and lock it, covering the tips completely
16. Tongue depressor (in case of unconscious to prevent the vocal cavity injury.
patient) 11) Moisten the gauze and dip it in the cleansing
17. Boro- glycerin agent.
18. Kidney tray and paper bag 12) Swab each tooth gently but firmly
19. Screen for privacy cleaning all sides of the teeth.
13) The used gauze can be removed from
16.16.4 Procedure 1 (For the patient who is able to artery forceps with the help of a
care for himself) dissecting forceps and discard in the
paper bag.
1. Arrange the articles and take to the 14) Clean the inner and chewing surface of
bedside. teeth and tongue by using wet gauze
2. Explain the procedure to the patient/ covered artery forceps.
relatives. 15) Wipe the face with towel.
3. Provide privacy 16) Apply Boro- glycerine on lips and
4. Give a comfortable position to the patient tongue with swab sticks.
(sitting or Fowler’s position with cardiac table in 17) Remove the kidney tray, mackintosh
front or lateral with face at the edge of pillow) and towel.
5. Place the mackintosh and face towel across the 18) Make the patient comfortable, tidy up
chest (if patient is sitting / on the pillow if patient the unit.
is in lateral position) 19) Discard the paper bag in the red bag.
6. Place kidney tray close to the cheek 20) Clean the articles with soap and water.
7. Wash hands and put on clean gloves. 21) Send forceps for autoclaving.
8. Help the patient to rinse his mouth.
202
22) Wash hands. a) KMnO4 solution(1:1000)
23) Record the time, solution used for mouth b) Sodium chloride (1tablespoon to a pint of
cleaning and condition of the mouth on water)
the nurse’s record. 26) Common emollients
24) Any undue findings to be reported to sister a) Olive oil
i/c b) White Vaseline
Note: c) Boro- glycerine
25) Common Mouthwash Solutions d) Liquid paraffin
16.16.6 Nursing Protocol : Checklist for Oral Care – ( Used For Monitoring)
S. Checklist Yes No Remarks
No.
Procedure I: (For the patient who is able to care for himself)
1. Explain the procedure to the patient.
2. Provide privacy.
4. Arrange the articles.
5. Wash hands and put on gloves.
6. Wet tooth brush, apply tooth paste.
7. Instruct the patient to brush all sides of the teeth extending from the gum to the enamel.
8 Help patient to hold kidney tray as per own convenience and rinse mouth.
9 Wash face and rub with towel.
Procedure II: (For an unconscious patient)
1. Explain the procedure to the patient attendant.
2. Provide privacy.
3. Position the patient
4. Place the mackintosh and face towel across the chest (on the pillow if patient is in lateral
position).
6. Arrange the articles.
7. Wash hands and put on gloves.
8. Prepare the mouth wash by mixing hot and cold water and one crystal of KMnO4.
9. Make a paste with Soda bicarbonate or salt or any available dentifrice.
10. Place the kidney tray close to the cheek.
11. Take a gauze piece; wrap it around artery forceps covering the tips completely and lock it.
12. Moisten the gauze and dip it in the cleansing agent. Swab each tooth gently but firmly
cleaning all sides of the teeth. The used gauze can be removed from artery forceps with
the help of a dissecting forceps and discard in paper bag.
13. Clean the inner and chewing surface of teeth and tongue by using gauze covered artery
forceps.
14. Wipe the face with towel.
15. Apply Boro-glycerine on lips and tongue with swab sticks.
16. Remove the kidney tray, mackintosh and towel.
17. Make the patient comfortable, tidy up the unit.
18. Discard waste and clean articles with soap and water.
19. Wash hands.
20. Record the time, solution used for mouth wash and condition of the mouth on the nurse’s
record.
198
16.17 Bed / Sponge Bath
16.17.1 Definition
16.17.1.1 Sponge bath is defined as bathing a patient who is confined to bed and who does not have the physical or
mental capability of self bathing.
16.17.2 Purpose
1) To make the patient comfortable and fresh.
2) To improve circulation.
3) To observe skin for redness, injuries, swelling, rashes or other infections and bony prominences for bed sores.
4) To prevent pressure sores.
16.17.3 Articles Required

1) A screen for privacy and top sheet.
2) Wash / Sponge cloths – 2
3) Bath towel – 2
4) Face towel – 1
5) A fresh set of clothing
6) Container with hot and cold water.
7) Moisturizing tissue/coconut oil & talcum powder
8) Bath basin.
9) A tray containing soap, hair oil, comb, nail cutter, kidney tray, paper bag, duster to clean the locker.
10) Laundry drum.
16.17.4 Procedure
1) Assemble all the articles at bedsides, wash hands and put on clean gloves.
2) Patient is to be asked to pass urine before beginning the procedure.
3) Explain the procedure to the patient, if conscious.
4) Screen the patient.
5) Cover the patient with top sheet. Fanfold other top clothes at foot end.
6) Mix cold and hot water in basin from containers and check the temperature on the back of your hand. (Already
mixed warm water can also be brought in a basin).
7) Remove clothing and put in laundry bag.
8) Place the towel on chest of the patient or under the head.
9) Fold the sponge cloth in your hand to make a mitten, wet it, and apply soap on it and clean face, neck, behind
the ears thoroughly.
10) Rinse, sponge cloth and clean face with fresh water and dry face, neck etc. with face towel.
11) Expose farther hand, spread bath towel underneath, fold sponge cloth around hand, wet, and apply soap and
clean hand, axilla, thoroughly using long, firm strokes from distal to proximal end.
12) Wipe with plain water and dry. (Patient’s hands can be immersed in basin for 3-5 minutes).
13) Repeat the same on other arm.
14) Expose patient upto waist, spread towel on chest, clean chest thoroughly with soap and then water from under
the bath towel dry and cover again with top sheet.
15) Expose patient upto pubic region, place bath towel over chest and abdomen, wash, rinse and dry abdomen
lifting edge of the bath towel, in side to side strokes.
16) Turn the patient to left lateral position with back towards you. Spread bath towel under back, expose back and
clean with soap and fresh water in circular motion and dry with bath towel.
17) Massage back in circular motion, with talcum powder.
18) Expose farther leg, spread bath towel under the leg, flex the knee clean with soap and water using long, firm
strokes, dry and cover (foot can be allowed to soak while you wash leg).
19) Do the same on other leg.
20) Offer a bedpan and clean private parts or ask patient to do it himself/ herself
21) Remove top sheet, cover with top cloths Put on clean clothes, comb hair, and cut nails.
22) Leave patient comfortable and unit tidy.
23) Remove and replace articles.
24) Record the procedure in register.
199
25) If any abnormal changes have been observed in skin is to be brought to the notice of ward sister.
26) Any sign of bedsore/ pressure sore shall be reported in Incident reporting form to Quality Management Division.
16.17.5 Nursing Protocol IIA: Checklist for Bed / Sponge Bath- (used for monitoring)
S. Checklist Yes No Remarks
No.
1. Assemble all the articles at bedside, wash hands and put on clean gloves.
2. Patient should empty bowel and bladder before beginning the procedure.
3. Explain the procedure to the patient, if conscious
4. Screen the patient.
5. Cover the patient with top sheet. Fanfold other top clothes at foot end.
6. Mix cold and hot water in basin from containers and check the temperature on the
back of your hand. (Already mixed warm water can also be brought in a basin).
7. Remove clothing and put in laundry drum.
8. Place the towel on chest of the patient or under the head.
9. Fold the sponge cloth in your hand to make a mitten, wet it, and apply soap on it and
clean face, neck, behind the ears thoroughly.
10. Rinse, sponge cloth and clean face with fresh water and dry face, neck etc. with face
towel.
11. Expose farther arm, spread bath towel underneath, fold sponge cloth around hand,
wet, apply soap and clean hand, axilla, thoroughly using long, firm stokes from distal to
proximal end.
12. Wipe with clean with water and dry. (Patient’s hands can be immersed in basin for 3-5
minutes).
13. Repeat the same on other arm.
14. Expose patient up to waist, spread towel on chest, clean chest thoroughly with soap
and then water from under the bath towel dry and cover again with top sheet.
15. Expose patient up to pubic region, place bath towel over chest and abdomen, wash,
rinse and dry abdomen lifting edge of the bath towel, in side to side strokes.
16. Turn the patient to left lateral position with back towards you. Spread
bath towel under back, expose back and clean with soap and fresh water
in circular motion and dry with bath towel.
17. Massage back in circular motion with, talcum powder.
18. Expose farther leg, spread bath towel under the leg, flex the knee clean
with soap and water using long, firm strokes, dry and cover (foot can be
allowed to soak while you wash leg).
19. Do the same on other leg.
20. Offer a bedpan and clean the private part or ask patient to do it herself.
21. Put on clean clothes, comb hair, cut nails.
22. Leave patient comfortable and unit tidy.
23. Remove and replace articles.
24. Record the procedure in the register.
If any abnormal changes have been observed in skin is to be to the
notice of ward sister.
200
5) Provide privacy by means of curtains.
16.18 Back Care 6) Bring the patient to the edge of the bed and
back facing towards the nurse to prevent
16.18.1 Back Care means cleaning and massaging overreaching.
back by paying special attention to pressure
points especially sacral area to neck. 16.18.6 Procedure
1) Assemble articles and bring to the bed side.
16.18.2 Objectives of Purposes 2) Explain the procedure to the patient if
 Back care is given to - conscious, or else to the relatives.
1) Cleanse the skin 3) Wash hands and put on clean gloves.
2) Promote circulation by stimulating the skin’s 4) Mix hot and cold water in the basin and check
nerve endings and underlying tissues. the temperature on the back of the hand. Fill the
3) Help to prevent bedsore and keep the skin basin half full.
intact. 5) Assist the patient to turn to a prone or side-lying
4) Dilate superficial arterioles, which bring more position by back facing the staff. Position the
blood and nourishment to the skin. sheet to expose only the back till buttocks.
5) Eliminate waste products from the body through Make sure that the patient will not fall.
the skin. 6) Fold back the sheet from the shoulder to the
6) Promote comfort through muscle relaxation and buttocks, and tuck the edges secularly around..
skin stimulation. Place the towel over the bed, close to the back,
7) Give the nurse an excellent opportunity to lengthwise.
strengthen the nurse-patient relationship. 7) Wet back & apply soap in a circular motion from
the shoulders to the buttocks.
16.18.3 General Instructions: 8) Clean with plain water and dry.
1) Check the physician’s orders to see the specific 9) After drying the back give a though back rub in
precautions if any, regarding positioning and circular motion with coconut oil followed by
movement of patient. talcum powder.
2) Assess the patient’s need for back care. 10) Massage is an activity done by pressing the
3) Assess the patient’s mental state to cooperate body / muscle gently to make someone more
and to follow directions. comfortable.follow following steps:-
4) Assess the cardiac respiratory functioning. 1. STROKING (EFFLEURAGE) is an activity
Check T.P.R. and B.P. use surface hand, this move follow vena
circulation.
16.18.4 Preparation of articles 2. KNEADING (PETRISSAGE) is a
squeezing movement by holding the tissue
1) Clean Gloves between the fingers.
2) Bath basin - 1 3. TAPPING (TAPOTEMENT) is movement
3) Small bowl - 1 by using the edge of the hand to stimulate
4) Soap with dish circulation ulnar
5) Washed clothes - 2 4. FRICTION is circular motion using the
6) Bath towels - 2 palm of the hand, carried out in the direction of
7) Moistening tissue /coconut oil & talcum powder. the vena circulation to the heart
8) Kidney tray and paper bag. 5. VIBRASI is an activity using the palm of
9) Jug - 2 the hand to provide vibration
10) Bucket - 1
11) Clean linen 11) Pay particular attention to the pressure points
12) Laundry drum and cleansing between gluteal folds.
12) And observe for any indication of redness or
16.18.5 Preparation of patient and unit skin breakdown in the sacral area.
1) Explain the procedure to the patient. 13) Put on the clean gown / patient clothes.
2) Remove unnecessary items from the work area 14) Wash hands.
and place the articles needed conveniently on 15) Record the observation in the nurse’s daily
the bedside table. notes with date, time, and condition of skin like
3) Check the room temperature and warm it if redness, breaking skin, etc.
necessary. 16) Any sign of bedsore/ pressure sore shall be
4) Close the windows if necessary and put off the reported in Incident reporting form to Quality
fan to prevent draughts. Management Division.
201
16.18.7 After care of the patient and articles
1) Replace the patient’s personal clothing.
2) Straighten the bed linen.
3) Remove the sheet and put it for laundry.
4) Change the bed linen if needed.
5) Position the patient for comfort and proper
alignment.
6) Take all articles to the utility room. Disinfect the
bath basin and the wash clothes.
7) Put back all the articles in the proper places
after cleaning. Personal articles are replaced
into the bedside table.
8) Take the opportunity to teach the patient on his
relatives about the personal hygiene
9) Wash hands
202
16.18.8 Nursing Protocol IIIA: checklist for back care (used for monitoring)
S. Check List Yes No Remarks
No.
1 Preparation of patient and unit:
2. Explain the procedure to the patient.
3. Remove unnecessary items from the work area and place the articles
needed conveniently on the bedside table, wash hands and put on
clean gloves.
4 Bring the patient to the edge of the bed and back towards the nurse to
prevent overreaching.
5 Check the room temperature and warm it if necessary.
7 Close the windows if necessary and put off the fan to prevent draughts.
9 Provide privacy by means of curtains.
10 Keep patient prone or on side according to the patient’s condition.
11 Expose back from neck to buttocks.
Procedure
1 Mix hot and cold water in the basin and check the temperature on the
back of the hand. Fill the basin half full.
2 Wet back &apply soap from the shoulders to the buttocks with brisk
circular movements.
3 Clean with plain water &dry.
4 After drying the back give a thorough back rub with
moisturizer/coconut oil and talcum powder.
5 Pay particular attention to the pressure points and cleansing between
gluteal folds.
6 Observe for any indication of redness or skin breakdown in the sacral
area and bony prominences.
7 Put on clean gown / patient clothes.
8 Wash hands.
9 Record the observations on the Nurse’s Daily Record with date and
time.
10 Any sign of bedsore/ pressure sore shall be reported in Incident
reporting form to Quality Management Division.
After care of the patient and articles:
1 Replace the patient’s personal clothing.
2 Straighten the bed linen.
3 Change the bed linen if needed.

4 Position the patient for comfort and proper alignment.
5 Take all articles to the utility room. Disinfect the bath basin and the
wash clothes. Put the dirty linen into the laundry drum.
6 Put back all the articles in the proper places after cleaning. Personal
articles are replaced into the bedside table.
7 Take the opportunity to teach the patient on his relatives about the
personal hygiene.
203
16.19 Oral Medication
16.19.1 Definition: To administer drugs by oral route (mouth).
16.19.2 Purposes:
1) For therapeutic & symptomatic treatment of diseases.
2) For prophylactic measures.
3) For building up general health & supplementing diet.
16.19.3 General Instructions

1. Check the diagnosis and the age of the patient .
2. Check the identification of the patient
3. Always give medicines from a written order signed by doctor.
4. Medicine bottle should be clearly labeled. Never give medicine from unlabelled bottles. Don’t keep
poison drugs on the medicine trolley.
5. Never give medicine on empty stomach unless ordered.
6. Medications should not be mixed with large quantities of food (e.g. milk).
7. Keep 6 R’s in mind, i.e. right patient, right time, right drug, right dose , right route& Right documentation.
8. The nurse should know about each medication she is administering, common usage & dosages
contraindications, side effects & toxic effects.
9. Always check the label of medicine thrice; i.e. before taking out from the storage; before pouring out in
the glass; before replacing the bottle and administering.
10. Pour liquid medicine away from label to avoid spilling on the label.
11. Never give the medicine, which is prepared by others.
12. Record the time of the medicine given & put the signature.
13. .Don’t handle tablets, pills & capsules with bare hands.
14. If any time, one dose is missed by the patient due to some investigation etc., don’t give the missed dose
without consulting the doctor.
16.19.4 Articles Required

1) A tray containing
2) Motor piston
3) ounce glass
4) water in a glass
5) containers for keeping tablets
6) Treatment Book
7) paper bag
8) Small towel,
9) Droppers in a bowl of water.
16.19.5 Procedures
1) Wash hands ..
2) Check the orders twice in the medicine book & write down the order in the treatment book.
3) Take out the required medicines after checking the Treatment Book &rechecking the label of the
container, dosage, expiry date once again before you keep back the bottle in place.
4) Set up the trolley.& Carry with treatment chart to the patient..
5) check the label before taking out from storage
6) Open the lid and label the bottle by keeping multi dose vial policy in mind. Check the label before pouring
out in the glass
204
7) For liquids, shake the bottle well before pouring Hold the medicine glass in your left hand at eye level.
8) Pour the exact amount of medicine in the medicine glass, keeping away from the label.
9) Wipe the mouth of the bottle, check the label once again & replace the bottle.
10) Call the patient by full name and check CR no. to ensure that you are giving medicines to the right
patient.
11) Explain the procedure to the patient/ relatives.
12) Give the medicine to the patient one by one with water.
13) In case patient refuse to accept prescribed medicine, that is to be endorsed in file and guardian has to
sign. The concerned physician is to be informed in time for any alternative measures if possible.
14) Record the time, dosage, and medicine on the nurse’s notes with signature.
15) All the articles(glasses, containers etc.) are washed, dried & replaced.
16) Observe patient for 15 minutes for any adverse drug reaction (in case of adverse drug reaction follow
ADR policy).
16.19.6 Nursing Protocol IV : checklist for oral medication (used for monitoring)
S. No. Check List Yes No Remarks
1. Wash hands
2. Set up the trolley.
3. Check the orders twice in the medicine
book & write down the order in the
treatment book.
4. Take out the required medicines after
checking the Treatment Book & rechecking
the label of the container, dosage, expiry
date once again before keeping back the
bottle in place.
5. For liquids, shake the bottle well before
pouring.
- Removes the lid, holds the medicine in
the right hand & checks the label again.
- Holds the medicine caps in left hand at
eye level.
- Pour the exact amount of medicine in the
medicine glass, keeping away from the
label.(Dropper is used for this purpose)
- Wipe the mouth of the bottle, checks the
label once again & replaces the bottle.
6. Carry the tray with Treatment Book to the
patient.
7. Call the patient by full name and check CR
no. to ensure the right patient, explain the
procedure to the patient.
8. Give the medicine to the patient one by
one with water.
9. Record the time, dosage, and medicine on
the nurse’s note with signature.
10. All the articles (glasses, container etc.),
are to be washed dried y & replaced.
205
16.20 Intramuscular Injection
16.20.1 Definition:- It is the introduction of fluid 16.20.5 Articles required Tray containing
medication in to the muscle tissue of the 1) File to break the ampoule.
body with the help of a syringe& needle.. 2) Distilled water to dissolve the medication.
3) Spirit swabs in a container. Disposable
16.20.2 Purpose
needles with syringes.
1) To obtain a rapid systematic effect of the
4) Sterile dissecting forceps.
drug.
5) Kidney tray & paper bag.
2) To administer the drug when it can’t be
given orally.
16.20.6 Procedure
3) To prevent the irritation of the lining of the
1) Check the medicine order.
digestive tract by irritating drugs.
2) Confirm the right patient
4) To list the patient’s sensitivity to
3) Explain procedure to the patient.
drugs(Eg.Inj.Inferan).
4) Wash hands.
5) To prevent the drug from being destroyed or
5) Check label on vial or ampoule.
rendered ineffectual by the action of
6) Check again the name, dose, time & mode
digestive juices.
of injection from the prescription.
7) Tap the ampoule to bring drug down ceil
over the constricted part with file.
1) Check the prescription of the physician
8) Clean the rubber cork of vial with spirit and
before administering injection.
2) Check for expiry of the drug. allow drying before inserting needle.
3) Be sure that patient is not sensitive to 9) Dissolve injection thoroughly by using the
drug.Read the label and check the strength suitable dissolvent.Withdraw the prescribed
of the medication. dose of medicine into the syringe.
4) Keep 2 needles- One for drawing fluid from 10) Select the site for injection.
vial(<22G) / ampoule & one for
11) Expel if any air bubbles in the syringe.
administering medication.
5) Administer drug by following 6 “R”, - right 12) Clean the area with spirit swab.
drug, right route, right patient, right dose 13) Stretch the muscle and insert the needle at
right time&Right documentation 90º angle with quick thrust.
6) Select the right needle for thin & obese 14) Inject medicine slowly.
patients. 15) Withdraw the needle quickly & press the site
7) Alternate the site of injection each time to with spirit swab gently for a while.make the
prevent irritation & allowing complete
patient comfortable.
absorption.
8) Ensure multi dose vial policy is strictly 16) Discard the needle after destroying the tip
followed. into sharp container.
.Observe patient for 15 minutes for any
16.20.4 Sites for injection adverse drug reaction (in case of adverse drug
1) Dorso Gluteal- Upper & outer quadrant of reaction follow ADR policy).
gluteal muscle. } commonly
2) Deltoid- three finger below the acromion
process } used
16.20.7 After care
3) Thighs – Vastus lateralis- lateral aspect of
the thigh. 1) Replace all the articles as soon as
4) Ventro gluteal procedure is over.
2) Leave the unit clean & tidy.
3) Wash hands after replacing articles.
206
16.20.8 Nursing Protocol va: checklist for intramuscular injection (used for monitoring)
1. Check the medicine order.
2. Explain procedure to the patient / relatives.
3. Wash hands.
4. Check label on vial or ampoule.
5. Check again the name, dose, time & mode of
injection from the prescription.
6. Taps the ampoule to bring drug down, cut over
the constricted part with file.
7. Clean the rubber cork of vial with spirit and
allow to dry before inserting needle.
8. Dissolve injection thoroughly with prescribed
dissolvent..
9. Ensure multi dose vial policy is strictly
followed.
10. Withdraw medicine into the syringe.
11. Select the site for injection.
12. Change the needle with the help of dissecting
forceps.
13 Clean the area with spirit swab.
14. Stretch the muscle, at 90º angle insert needle
with quick thrust.
15. Inject medicine slowly.
16. Withdraw the needle quickly & press the site
with spirit swab gently for a while.
17. Discard the needle after destroying in sharp
container syringes into separate container.
18. Makes the patient comfortable.
19. Charts in the nurse’s notes.
20. Observe patient for 15 minutes for any
adverse drug reaction (in case of adverse drug
reaction follow ADR policy).
AFTER CARE
1. Replace all the articles as soon as procedure
is over.
2. Leave the unit clean & tidy.
3. Wash hands after replacing articles.
207
16.21 Subcutaneous Injection
2) Withdraw the prescribed dose of medicine
16.21.1 Definition:- It is an introduction of medicine into the syringe.
into subcutaneous connective tissue with the 3) Expel if any air bubbles in the syringe.
help of a syringe & needle. 4) Select the site for injection.
5) Clean the area with spirit swab.
16.21.2 Purpose 6) Grasp the area surrounding the site of the
1) To achieve a slow absorption & action rate injection & hold it in a cushion fashion.
compared to intramuscular & intravenous 7) Inject the needle quickly at 45º to 60º angle.
injections. 8) Release the grasp on the tissue & inject the
2) All general purposes of injection. medication slowly.
9) Withdraw the needle quickly & press the site
16.21.3 General Instruction with spirit swab gently for a while
1) Follow instructions of I.M. injections 10) Make the patient comfortable.
2) Select hypodermic syringe, which has ml& 11) Chart in the nurse’s notes.
C. C. marking for more accuracy and needle
of No. 26 gauge.
12) Observe patient for 15 minutes for any
16.21.4 Sites adverse drug reaction (in case of adverse
drug reaction follow ADR policy).
1) Anterior aspects of thigh.
2) Fore arm 16.21.7 After care of articles
3) Abdominal (pectoralis major)
4) Lateral aspects upper arm. 1) Replace all the articles after the procedure is
over.
16.21.5 Articles required 2) Leave the unit clean & tidy.
3) Wash hands after replacing articles.
Tray containing
1) File to break the ampoule.

2) Distilled water to dissolve the medication.
3) Spirit swabs in a container.
4) Disposable needles with syringes.(needles
of no. 26 gauge.)
5) Sterile dissecting forceps.
6) Kidney tray & paper bag
7) Hypodermic / insulin syringe.
16.21.6 Procedures
1) Check the medicine order.
2) Confirm the right patient
3) Explain procedure to the patient.
4) Wash hands.
5) Check label on vial or ampoule.
6) Check again the name, dose, time & mode
7) Tap the ampoule to bring drug down ceil
8) Clean the rubber cork of vial with spirit and
allow drying before inserting needle.
1) Dissolve injection thoroughly by using the
suitable dissolvent.
208
16.21.8 Nursing Protocol VIa: checklist for subcutaneous injection (used for monitoring)
1. Check the medicine order.
2. Explain procedure to the patient / relatives.
3. Wash hands.
4. Check label on vial or ampoule.
5. Check again the name, dose, time & mode
6. Tap the ampoule to bring drug down, cut
7. Clean the rubber cork of vial with spirit and
allow to dry before inserting needle.
8. Withdraw medicine into the syringe.
9. Ensure multi dose vial policy is strictly
followed.
10. Select the site for injection.
11 Grasp the area surrounding the site of the
injection & hold it in a cushion fashion.
12 Inject the needle quickly at 45º to 60º angle.
13. Release the grasp on the tissue & injects the
medication slowly.
14. Withdraw the needle quickly & press the site
with spirit swab gently for a while
15. Make the patient comfortable.
16. Chart in the nurse’s notes.
17 Observe patient for 15 minutes for any
adverse drug reaction (in case of adverse
AFTER CARE
18. Replace all the articles after the procedure is
over.
19 Leave the unit clean & tidy.
20 Wash hands after replacing articles
209
16.21.9
210
16.22 Assisting In Intravenous Infusions 16.22.5 Veins Frequently Used
1) Veins of the cubital fossa
2) Median Cephalic Vein
16.22.1 Definition:- The introduction of a large 3) Basilic Vein
amount of fluid, electrolytes or other 4) Ante brachial
nutrients into the body via veins/artery 5) Venous network on back of the hand
. 6) Dorsalispedis
7) Saphenous veins
16.22.2 Purpose 8) Scalp vein (infants)
1) To supply fluid & electrolytes,blood & blood
components, nutrients & drugs to the body 16.22.6 Articles Required
when patient is unable to take orally. 1) A tray containing Spirit
2) To dilute poisons & flush the kidneys. 2) Mackintosh with towel
3) To prevent & treat shock. 3) Kidney tray & paper bag
4) To alter vascular pressure. 4) Adhesive plaster & scissors I V Stand
5) To supply & meet the patient’s basic 5) Proper size sterile gloves
requirements of calories, water, minerals & 6) Dissecting forceps
vitamins. 7) I.V solution
8) Sterile I.V. tubing with drip chamber &
16.22.3 General Instructions clamp.
1) Check the infusion pump for working 9) Proper size sterile cannula
condition. 10) Sterile syringes
2) Maintain strict aseptic techniques. 11) Sterile cotton swabs
3) Be sure of solution’s type, strength, and
amount.
4) Avoid entry of air. 16.22.7 Procedure
5) Observe the site for swelling (tissue 1) Explain the procedure to the patient/
infiltration leaking & bleeding) relatives.
6) Observe the patient for unfavorable 2) Wash hands and put on sterile gloves.
symptoms. 3) Remove the bottle seal from top, clean the
7) Regulate the flow of fluid. top with spirit swab, holding the bottle
upright, insert the drip set into the bottle.
a) Drop/minute= Total fluid amount X drops in 4) Close the clamp & hang the bottle on the I/V
1ml. Total time in minutes stand about 18’.25” high, along with a closed
sterile needle attached on the tip of the set.
16.22.4 Note: 5) Remove needle and de clamp to expel any
air columns into a kidney tray from the IV
 Pediadrip 1ml= 60 drops (approx.)
set.
 BT set 1ml= 15 drops (approx.)
6) Clamp the tubing again, and fix a fresh
 IV fluid set 1ml = 20 drops (approx.) needle with cap into it.
7) Prepare few strips of adhesive tapes.
8) Site preparation – apply a tourniquet firmly 6
1) Flow and the amount depend upon condition to 8” proximal to the site.
& need of patient, disease nature of fluid. 9) Encourage the patient to clench & unclench
2) Fluid should be at room temperature. the fist rapidly lightly tap the vein with finger
3) Clamp before the whole amount of fluid tip.
finishes. 10) Clean the area with a spirit swab.
4) Ensure any IV Set is changed after 24 11) Physician inserts needle into the vein at 15º
hrs.(label with date every day when iv set/ to 30º angle & once it enters the vein,
micro set is changed) makes it parallel with the skin & back flow
occurs to the cannula.
211
12) Physician inserts the needle further up into 16.22.8 After Care
the vein about ¾ to 1”. 1) Disconnect IV set from the cannula, and put
13) Release the tourniquet. cannula cap.
14) By pressing the tip of the cannula with left 2) Remove cannula if not further required.
hand, physician takes out the stylet which 3) Dispose the IV set & used cotton into the
prevents bleeding while connecting the IV kidney tray & ensure that Hospital’s Bio-
set to the cannula and open the clamp to let medical waste management policy is being
fluid flow. followed.
15) Adjust drops according to requirement of the 4) Remove IV Stand & tray from patient’s
patient. bedside.
16) Secure needle & tubing by adhesive tapes / 5) Clean & replace all equipments in proper
strips. place.
17) Immobilize with split if required. 6) Watch for edema, discoloration or
18) Label the iv fluid bottle mentioning pateint’s hematoma formation.
name,CR no. date ,type of fluid, 7) Incase of hematoma formation, it shall be
drops/minutes,if any medicine added in to it reported in an Incident reporting form to the
19) IV set is to labeled for the date. QMD.
20) Record in nurse’s notes & I/O chart. 8) Hand over to the shift nurse.
21) Time of starting infusion
22) Amount & drops/ minute
23) Type of fluid
24) Observe patient for 15 minutes for any
adverse drug reaction (in case of adverse
25) Change the bottle whenever it finishes with ______
prescribed IV fluid.
212
16.22.9
213
16.22.10 Nursing Protocol VIIa: checklist for assisting in intravenous infusions (UseD for Monitoring)

1. Wash hands and put on sterile gloves. Remove the bottle seal from top,
clean the top with spirit swab, holding the bottle upright, insert the drip
set.
2. Close the camp & hang the bottle on the I/V stand about 18’- 25” high.
3. Close the clamp & hang the bottle on the I/V stand about 18’.25” high,
along with a sterile&capped needle attached on the tip of the set.
4. Remove needle clamp to expel any air columns into a kidney tray from
the IV set.
Clamp the tubing again, and fix a fresh needle with cap into it.
5. Prepares few strips of adhesive tapes.
6. Site preparation – applies a tourniquet firmly 6 to 8” proximal to the site.
7. Encourages the patient to clench & unclench the fist rapidly, lightly taps
the vein with fingertip.
8. Cleans the area with a spirit swab.
9. Physician inserts needle into the vein at 15º to 30º angle & once it enters
the vein, makes it parallel with the skin & backflow occurs to the cannula.
10. Physician inserts the needle further up into the vein about ¾ to 1”.
11. Releases the tourniquet
12. By pressing the tip of the cannula with left hand, physician takes out the
stylet which prevents bleeding while attaching the IV set to the cannula
and open the clamp to let fluid flow.
13 Adjust drops according to requirement of the patient.
14. Secure needle & tubing by adhesive tapes / strips.
15. Immobilize with split if required.
Labeling done for both iv fluid& iv set
16. Record in nurse’s notes & I/O chart.

- Time of starting infusion.
- Amount & rate of flow.
- Type of fluid.
17. Change the bottle whenever it finishe with prescribed IV fluid.
AFTER CARE
1. Disconnect IV set from the cannula, and put cannula cap.
2. Remove cannula if not further required.
3. Dispose the IV set & used cotton into the kidney tray & ensure that
Hospital’s Bio-medical waste management policy is being followed.
4. Remove I V Stands tray from patient’s bedside.
5. Clean & replaces all equipments in proper place.
5 Watch for edema, discoloration or hematoma formation. Incase of
hematoma formation, it shall be reported in an Incident reporting form to
the QMD.
6 Hand over to the shift nurse.
214
16.23 artificial feeding
16.23.1 a)aRyle’s Tube Feeding
a) Gastrostomy& jejunostomy feeding
.
16.23.2 Ryle’s Tube Feeding
16.23.3 Definition:- It is an artificial method of giving fluids ,nutrients& medications through a tube that has been
passed into stomach through the nose & mouth, when oral intake is inadequate or impossible
.
16.23.4 Indications
1) When patient is unable to take food by mouth e.g. unconscious, semi-conscious & delirious patient.
2) Patient who refuses food.
3) Patient with dysphagia, fracture jaw, cleft palate, cleft lips, oral surgery, esophageal or throat surgery etc.
4) When patient is too weak to swallow food.
16.23.5 Articles required

A tray containing
16.23.6 Clean Gloves
16.23.7 Gauze pieces in a bowl.
16.23.8 Paper bag & kidney tray.
16.23.9 10ml clean syringe (for testing location)
16.23.10 20ml-50ml clean syringe for feeding the patient.
16.23.11 Glass of feed in a bowl of warm water.
16.23.12 Empty glass.1
16.23.13 Ounce glass (to measure the feed)

5) A bowl with water.
6) Mackintosh with towel.
7) Stethoscope.
8) Face towel and hand towel.
215
16.23.15 Give only after Doctor’s orders
16.23.16 Explain procedure to patient & gain cooperation.
16.23.17 Don’t push feed till it is made sure that tip of ryle’s tube is in the stomach.
16.23.18 Don’t change amount or time frame which is advised by the doctor.
16.23.19 Record intake & output accurately.
16.23.20 Watch for complications e.g. nausea, vomiting, diarrhoea, breathing problem etc.
16.23.21 Don’t force the feed.
16.23.22 Prevent air entry through Ryle’s tube while feeding.
16.23.23 Keep suction apparatus ready & handy.
16.23.24 Procedure
16.23.25 Explain procedure to patient relatives.
16.23.26 Bring all articles at bedside
16.23.27 Give fowler’s position or raise head with extra pillows.
16.23.28 Place mackintosh & towel under patient’s head.
16.23.29 Place hand towel under patient’s chin to protect linen & garments.
16.23.30 Wash hands and wear clean gloves.
16.23.31 Check the tube for placement in stomach by aspirating gastric contents or ausculting while pushing
air through ryle’s tube.
16.23.32 Measure the feed with ounce glass and pour in to the empty glass,
16.23.33 The feed can be given by syringe method by gravity: Give feed through barrel of syringe; while
giving the
216
16.23.34 feed don’t let the air enter the tube. Before the air can enter either pour more feed or pinch the tube
& lower the barrel, below shoulder level of patient.
16.23.35 After completing feed clamp the tube to prevent any leakage of feed.
16.23.36 Clean face with face towel.
16.23.37 Remove mackintosh & towel.
16.23.38 Make the patient comfortable in bed.
16.23.39 Discard the waste, clean articles with soap & water, dry and replace for further use.
16.23.40 Wash hands & record the procedure: in nurse’s record,In intake & output chart:
a. Record the time & date.

b. Record amount & type of feed.
c. The reaction of patient after feed, if any.
217
16.23.41 - Nursing Protocol iXa: checklist for ryle’s tube feeding (used for monitoring)
1. Explain procedure to patient’s attendant.
2. Collect all articles at bedside.
3. Give fowler’s position or raise head with extra pillows.
4. Place mackintosh & towel under patient’s head.
5. Place hand towel under patient’s chin to protect linen & garments.
6. Wash hands and put on clean gloves.
7. Check the tube for placement in stomach by aspirating gastric

contents or by ausculting.
8. Measure the feed in ounce glass, the feed can be given by syringe
method by gravity: Give feed through barrel of syringe; while giving
the feed don’t let the air enter the tube. Before the air can enter either
pour more feed or pinch the tube & lower the barrel, below shoulder
level of patient.
9. After completing feed clamp the tube to prevent any leakage of feed.
10. Clean the face with face towel.
11. Remove mackintosh & towel.
12. Make the patient comfortable in bed.
13. Discard the waste, clean articles with soap & water, dry and replace
for further use.
14. Wash hands & record the procedure:
In nurse’s notes / In intake & output chart:
- Records the time & date.
- Records amount & type of feed.
- The reaction of patient after feed, if any.
- Date & time.
218
16.24 Gastrostomy/ jejunostomy feeding
16.24.1 Definition:- Gastrostomy / jejunostomy feeding is artificial method of feeding through a tube , introduced
into the stomach through the abdominal wall by a surgical procedure, temporarily or permanently.
16.24.2 Indications
1) When patient is unable to take food by mouth due to
2) GIT injury
3) Carcinoma in GIT
4) Intestinal obstruction due to congenital malformation
5) In comatose patients where regurgitation takes place after NG tube feeding
16.24.3 Purpose
1) To maintain nutritional, fluid & electrolyte balance.
2) Where artificial feeding is required to be continued for more than 4 weeks

Dressing Tray
A tray containing:
1) Clean Gloves
2) Gauze pieces in a bowl.
3) Paper bag & kidney tray.
4) 20ml-50ml clean syringe for feeding the patient.
5) Glass of feed in a bowl of warm water.
6) Empty glass.1
7) Ounce glass (to measure the feed)A bowl with water.
8) Mackintosh with towel.

1) Give only as per doctor’s order.
2) Always check the tube placement before administering feeding and medication.
3) Assess for the presence of bowel sound before administering feeds
4) Don’t force the feed.
5) Explain procedure to patient & gain cooperation.
6) Don’t change amount or time frame which is advised by the doctor.
7) Record intake & output accurately.
8) Watch for complications e.g. nausea, vomiting, diarrhea, breathing problem etc.
9) Prevent air entry through tube while feeding.
16.24.6 Procedure
1) Bring all articles at bedside
2) Explain procedure to patient’s relatives.
3) Place mackintosh & towel below tube inserted site to protect patient’s linen as well as wound.
4) Wash hands and wear clean gloves.
5) Measure the feed with ounce glass and pour in to the empty glass.
6) While pinching the tube, attach barrel of a syringe (20ml/50ml).
7) Pour feed in to it by making sure not to spill.
Slowly lift the barrel for a free flow of feed by gravity.
8) Before the air can enter either pour more feed or pinch the tube & lower the barrel, below shoulder level
of patient.
219
9) After completing feed clamp the tube to prevent any leakage of feed.
10) Make the patient comfortable in bed. Remove mackintosh & towel. Check wound, do dressing if required.
11) It is essential that the area of the skin around the tube be kept clean and dry .A water proof ointment such
as zinc oxide may be applied around the tube to protect the skin from the irritation of the hydrochloric
acid.
12) Discard the waste, remove gloves.
13) Wash hands & record the procedure in nurse’s record, in intake & output chart:
14) Time , date, type of feed, amount .Report to doctor in case patient had any discomfort.
15) Clean articles with soap & water, dry and replace for further use.
16.24.7 Potential Problems with G-Tubes
Dislodgement of feeding tubes
Feeling of fullness
Nausea/Vomiting
Abdominal Distension
Aspiration
Depressed Gag or cough reflex
Alterations in normal swallowing
220
16.24.7 Nursing Protocol Xa: checklist for GASTROSTOMY /JEJUNOSTOMY FEEDING (used for
monitoring)
1. Explain procedure to patient’s attendant.
Collect all articles at bedside.(Dressing
2. Tray Ready)
Place mackintosh & towel below the wound
3.
to protect optd site& linen.
4. Wash hands and put on clean gloves.
Measure the feed with ounce glass& keep
5.
ready in an empty glass.
Pinch feeding tube to prevent air entry and
6.
attach barrel of a 20/50ml syringe.
Pour feed in to the barrel without spilling.
7.
Give feed through syringe by gravity.
Before the air can enter either pour more
8. feed or pinch the tube & lower the barrel,
below shoulder level of patient.
After completing feed clamp the tube to
9.
prevent any leakage of feed.
10. Make patient comfortable
11. Remove mackintosh & towel.
12. Discard the waste, wash hands.
Record the procedure, time, date , amount
13 and type of feed in nurse’s notes and in
intake & output chart.
Report to doctor in case patient had any
14 discomfort.
Clean articles with soap & water, dry and
15.
replace for further use.
16 Potential problems with G-Tubes
221
16.25 Oxygen Administration
16.25.1 Definition:- It is the administration of oxygen to the patient by means of a clean mask & tubing to prevent
or relieve Hypoxia or Hypoxemia. (Hypoxia is a condition in which sufficient amount of O2 is not available
to meet the metabolic needs of the tissues. Hypoxemia is deficiency of O2 in the arterial blood).
16.25.2 Indications
1) Breathlessness
2) Cyanosis.
3) Atlectasis
4) Thoracoplasty
5) Poisoning
6) Hemorrhage and air hunger.
7) Shock and circulatory failure.
8) Critically ill patients
9) In certain post operative patients.
10) Anemia
11) Patients under anesthesia
12) Asphyxia
16.25.3 Oxygen Delivery Systems
1) Nasal Cannula
2) Simple Mask
3) Partial Re-Breather Mask
4) Non-Re Breather Mask
5)Venturi Mask
6) Oxygen Hood
7) Oxygen Tent
8) AMBU Bag
9) Tracheostomy Collar
10) T-piece
Methods of Oxygen Adiministration
222
Nasal cannula (Prongs):-Used for low-medium concentrations of oxygen .Flow of 1-6 litre /mts oxygen will be
sufficient to maintain the concentration of 24-44% oxygen
Simple Mask:-It delivers 35-60% oxygen .A flow rate of 6 to 10 liters per minute.
Partial Re-Breather Mask:- It is used to deliver oxygen concentrations up to 80%.A flow rate of 6 L/min .
Non-Re Breather Mask :- Provides the highest concentration of oxygen (95-100%) at a flow rate 6-15 L/min.
Venturi Mask:-It is high flow oxygen delivery device.Oxygen from 40-50% .At litres flow of 4-15 L/min
Oxygen Hood:- An oxygen hood is used for babies who can breathe on their own but still need extra oxygen .
Oxygen Tent :- An oxygen tent consists of a canopy placed over the head and shoulders ,or over the entire
body of a patient to provide oxygen at a higher level than normal.AMBU BAG:-Artificial Manual Breathing Unit
or Bag Valve Mask Ventilation is a hand –held device commonly used to provide positive pressure ventilation
to patients who are not breathing or not breathing adequately.
Tracheostomy Collar/Mask:-Inserted directly int to trachea.It is indicated for chronic oxygen therapy
need.Oxygen flow rate 8-10 L.
T-PIECE:-Used on end of ET tube when weaning from ventilator.

1) Oxygen cylinder or central supply with its accessories(Regulator,flowmeter,humidifier with sterile watetr
,connecting tube)
2) Water soluble lubricating jelly
3) Adhesive Tapes
4) Bowel of water
5) Cotton applicators and normal saline in a container
6) Kidney Tray and Paper bag
7) Mackintosh and Towel
8) Rag pieces or gauze pieces in a container
9) Clean Oxygen Mask and tubing
10) Oxygen hood

1) Check doctor’s order
2) Review safety measures (No leaking of O2)
3) Never adjust oxygen flow while patient is on therapy
4) Keep O2 cylinder in secure upright position
5) Check that cylinder is full with O2 with all its attachments
6) Never discontinue O2 abruptly but gradually by reducing dosage, watch for any signs of toxicity
7) All articles collected at bed side

8) Adjust the flow as prescribed
9) Assess patient’s condition 14) Keep a watch that the oxygen cylinder
10) Assess the level of conscioucness doesn’t get emptied while patient is on
11) Never leave the patient alone. Oxygen therapy.
12) Always label the O2 cylinder filled or empty. 15) Assess the patient for response of the
13) Check for fire precautions as O2 supports therapy.
combustion. 16) Do the charting
223
3) When the oxygen is to be discontinued, do it
16.25.3 Procedure gradually.
(Administering oxygen by Oxygen Mask/ prongs) 4) Watch the patient for any untoward
symptoms like dysponea, cyanosis etc.
1) Explain the procedure to the patient relative. 5) Sent tubings& mask for decontamination to
2) Bring all the articles to the bed side. CSSD once in 24hrs if it used for the same
3) Assess the condition of the patient. patient or after every use.
4) Review safety precautions; make him 6) Change the nasal catheyers atleast every 8
comfortable in proped up position or lying hours or more often.
down if very sick.
5) Wash your hands. 16.25.4 Complications/ Hazards
6) Connect the Oxygen Mask to the oxygen 1) Infection
setup with humidification. Adjust the flow 2) Combustion
rate as ordered by doctor.Check that oxygen 3) Oxygen toxicity
is flowing. 4) Oxygen induced apnoea.
7) Adjust the headband or plastic slide until 5) Retrolental fibroplasia.
mask fits comfortably. 6) Asphyxia.
8) Encourage patient to breath through nose 7) Oxygen Toxicity
with mouth closed.
9) Assess the patient for response of the After
care of the patient and articles
1) Keep the patient warm and comfortable.
2) Evaluate the patient’s progress by observing
the vital signs and colour.
16.25.5 Nursing Protocol Xa: checklist for oxygen administration by Oxygen Mask (Used for monitoring)
S. Check List Yes No Remarks
No.
1. Wash hands
2. Setup the /tray
3 Check the orders for dose of oxygen, rate of
flow, methods of administering.
4 Check the tubing for any kinks and obstruction
5 Explain the procedure to the patients relatives
and assess his condition
6 Give Comfortable position
7 Oxygen delivery systems
8 Methods of oxygen administration
9 Administer oxygen by means of Hood / Mask
10 Take the vitals (respiration & O2
concentration) of patient and observe the
response of oxygen therapy.
11 Record the date, time, and effect of the O2
therapy
12 Replace Oxygen hood after washing with soap
and water and drying.
13 Sent tubings& mask for decontamination to
CSSD once in 24hrs if it used for the same
patient or after every use.
14 Complications of oxygen therapy
224
16.26 : Urinary Catheterization (Done by Doctor – Sister Only Assist the Doctor)
16.26.1 Definition:- Urinary catheterization is the Sterile Tray containing:
introduction of a tube ( a catheter) through
the urethra into the urinary bladder to drain 1. Sterile sheet
the bladder. 2. Gloves
3. Lubricant with applicator/swab/ gauze
16.26.2 Purpose pieces
4. Foley's Catheter 6 - 14 French
1) To relieve distension e.g. urinary retention,
5. 10ml/ 5ml disposable syringe
2) In case of incontinence. 6. Labeled container to collect samples if any.
3) As an aid in diagnosis e.g. obtaining sterile 7. Urinary bag with tubing
sample 8. Normal Saline/distilled water
4) For diagnostic purposes, e.g. urethral 9. Sticking plaster.
cystogram. 10. Kidney tray.
5) To empty the urinary bladder before
16.26.5 Steps of procedure
operation on pelvic organs.
6) To introduce medications into the bladder. 1) Wash your hands, collect the articles & carry
it to bedside
7) To induce voiding.
2) Explain the purposes & procedure to the
8) To monitor accurate urinary output. patient/ relative.
9) To provide for intermittent or continuous 3) provide privacy with the help of screen
bladder drainage and irrigation. 4) Provide proper light, fold the top linen to foot
10) To measure the amount of residual urine end and drape the patient with extra sheets
when the bladder is incompletely emptied. 5) Place the patient (Female: Position patient
11) To prevent urine from passing over a wound in a supine position with knees flexed and
thighs abducted Male: Position patient in a
e.g., after repair of the perineum.
supine position with legs extended and flat
on bed) position.
16.26.3 Preliminary Assessment 6) Wash hands and put on sterile gloves
1) Check the physician’s order. 7) Place sterile sheet under the patient's
2) Identify the patient and check the purpose buttocks & place the sterile articles on it.
for the catheterization. 8) Expose patient perineum.
3) Check the consciousness of the patient and 9) Clean perineum with anti septic wet swabs,
ability to follow the instructions. by applying single swipe on either labia
4) Condition of the perineum for cleanliness. majora &the way both the labia minora, and
5) Availability of adequate lighting in the room. the vulva the fifth swab could be used to
clean meatus.
16.26.4 Articles Required 10) Take help, to get the appropriate size
1) Screen. catheter opened without touching the
2) Spot light catheter.
3) Extra Sheets for draping. 11) Lubricate the catheter tip with jelly.
4) Articles for protecting bed linen & for 12) After separating labia minora with non
patient’s comfort. dominant hand, insert catheter gently into
5) Mackintosh & draw sheets. the urethra until the urine flows into kidney
Articles for perineal care tray or any obstruction while inserting.
13) Collect sample if any required, directly from
A Sterile Tray containing: catheter.
14) Secure the catheter by inflating bulb with
1. Sterile gloves pair N.S. or distilled water as required.
2. Bowl of cotton swabs with antiseptic solution 15) Use a nonirritant adhesive to stick catheter
3. Bowl of sterile dry cotton swabs to patient’s body to prevent pulling of the
4. Kidney tray tube.
5. Paper bag 16) Attach catheter to urobag if continuous
Articles for Catheterization drainage is recommended.
225
17) Place all the articles on tray & cover it. 6. Wash the equipments with soap and water.
7. Reset the tray & complete it & send it to
16.26.6 After care of the patient and equipment CSSD for sterilization
8. Wash hands and maintain intake output
chart.
1. Dry the perineum and remove the drapes. 9. Check & label the specimen & send it for
2. Make the patient comfortable. investigation to the laboratory.
3. Take all articles to the utility room. 10. Record the procedure on the nurse’s note
4. Measure the urine & note the characteristics (date, time, characteristics, amount,
of the urine and discard safely. problems encounter if any).
5. Dispose off the waste as per the Hospital’s 11. Observe the patient for any discomfort or
Bio-medical waste management policy. complication ( oligemic shock).
226
16.26.7 Nursing Protocol Xia: checklist for urinary catheterization (Used for monitoring)
1 Wash hands, collect the articles & carry it to bedside
2 Explains the procedure and its purposes.
3 Provide good light and privacy.
4. Protect bed clothing from soiling.
5. Place the patient in Dorsal recumbent position
6. Wash hands, wear sterile gloves.
7. Clean perineum under aseptic technique.
8 Take help to get the sterile catheter opened without touching it.
9. Lubricate the catheter before inserting gently in to urethra.
10. Collect the specimen according to instructions.
11. Secure the catheter by inflating the bulb with normal saline /
distilled water according to manufacturer recommendation.
12 Use a nonirritant adhesive to stick catheter to patient’s body to
prevent pulling of the tube.
13. Attach the catheter to the urobag and fix it to the bed frame.
14. Remove the article and make the patient comfortable.
15 Measure the amount of urine and observe its characteristics and
discard it.
AFTER CARE
1. Take equipments to the utility room. Wash and replace them.
2. Check & label the specimen & send it for investigation to the
laboratory.
3. Wash hands and document the procedure and maintain the
output chart.
4 Assess the patient for any discomfort or complication
227
16.27 Surgical Dressing
16.27.4 Assessment
16.27.1 Definition:- Dressing is a protective covering 1) Check the diagnosis & the general condition
applied to the wound. of the patient.
2) Check the purpose for which the dressing is
16.27.2 Purpose to be done.
1) To control bleeding 3) Check the condition of the wound, type of
2) To prevent infection. wound and type of suturing applied.
4) Check the physician’s order for the type of
3) To prevent tissue damage.
dressing to be applied & specific
4) To promote healing instructions.
5) To absorb inflammatory exudates and to 5) Check the articles available in the unit.heck
promote drainage. the patient’s full name & CR no.
6) To convert the contaminated wound into a 6) Check the nurse’s record to find out the
clean wound. general condition of the wound.
7) To prevent skin excoriation. 7) Check the consciousness of the patient &
the ability to follow instructions.
8) To apply the medication.
9) To prevent flies from infesting. 16.27.5 Articles required
A sterile tray containing:
16.27.3 General Instruction
1) Practice strict aseptic technique. 1) Artery forceps – 1
2) Wash hands thoroughly before & after the 2) Dissecting forceps – 2
procedure. 3) Scissors – 1
3) Instruments used for one dressing cannot be 4) Sinus forceps – 1
used for another until they have been re- 5) Probe – 1
sterilized. 6) Small bowl – 1
4) Use mask sterile gloves & gowns for large 7) Safety pin – 1
dressings to minimize the wound 8) Gowns for large dressings to minimize the
contamination. wound contamination.
5) Create a sterile field around the wound by 9) Cotton balls, gauze pieces, cotton pad etc
spreading sterile towels. as necessary
6) Avoid talking, coughing & sneezing when 10) Slit dressing towel.
the wound is opened. 11) Kidney tray
7) Cleaning of the wound should be done from
the cleanest area to the less clean area.
8) Always place a dressing directly on to a Clean tray containing:
wound never slide it on from the side.
9) When drains are in place, anticipate 1) Sterile Gloves & mask
drainage & re-enforce the dressing 2) Mackintosh & towel
accordingly. The dressing over the drain
should not be combined with the dressing on
the wound line. 3) Disinfectant solution.
10) The amount of discharge from the wound 4) Normal Saline
should be accurately measured. 5) Cheatle forceps in a sterile container
11) Before doing the dressing, inspect the (optional).
wound for any complications such as
dehiscence (gaping) If present, report it
immediately to the surgeon & immediate 6) Ointments and powders as ordered.
steps are to be taken. 7) Vaseline gauze if required.
8) Sterile ribbon gauze.
9) sterile swabs sticks
228
10) Bandages, binders, adhesive plaster and
scissors.
11) Kidney tray.
12) paper bag
12) Discard the forceps in the kidney tray.
13) Apply medications if ordered.
16.27.6 Preparation of the patient and environment 14) Apply the sterile dressings. Apply the gauze
1) Identify the patient & explain the procedure. pieces first & then the cotton pads.
2) Provide privacy with curtains & drapes. 15) Reinforce the dressing on the dependant
3) As far as possible avoid meal timings. parts where the drainage tube is attached
4) Offer bedpan or urinal prior to the dressing. 16) Remove the gloves and discard it into the
5) If the patient is in pain. Consult doctor give separate kidney tray to further dispose off in
some analgesics after his advise 0.5% bleaching solution.
6) Place the patient in a comfortable & relaxed 17) Secure the dressing with bandage or
position. adhesive tapes.
7) Close doors & windows to prevent draughts. a. N.B.: Removal of the drains or
Put off fans. sutures should be done after the
8) Call for assistance if necessary e.g. to do cleaning of the wound area.
the unsterile procedures, to transfer sterile
supplies etc.
9) Protect the bed with a mackintosh and 16.27.8 Aftercare of the patient and articles
towel. 1) Remove the mackintosh and towel.
10) Turn the head of the patient to one side, so 2) Help the patient to dress up and to take a
that the patient may not see the wound & comfortable position in the bed. Change the
get worried about it. garment if soiled with drainage.
3) Replace the bed linen if required.
4) Take all articles to the utility room.
16.27.7 Procedure 5) Discard the soiled dressings to red bagged
a. Tie the mask. dust bin as per the Hospitals Bio-medical
2) Wash hands thoroughly. waste management policy.
3) Put on gown, sterile gloves etc. as 6) Reset the tray and send to CSSD
necessary. sterilization.
4) Open the sterile tray spread the sterile towel 7) Replace all articles to their proper places.
around the wound. 8) Tidy up the bed & the unit of the patient.
5) Pick up a dissecting forceps and remove the
dressings and put it in the paper bag.
Discard the dissecting forceps in the kidney 9) Send the soiled linen in a separate red bag
tray. which is sealed and labeled, to the laundry.
6) Note the type and the amount of drainage 10) Dispatch pus swab to laboratory for culture.
present. 11) Wash hands.
7) A sample for pus is to be collected for 12) Record the procedure on the nurse’s record
culture if pus/serous fluid present, before with date & time, the condition of the wound,
cleaning the wound. type and amount of drainage and condition
8) Ask the assistant to pour small amount of of the sutures etc.
cleansing solution into the bowl. 13) Report to the surgeon and initiate surgical
9) Clean the wound from the centre to site infection reporting form to Infection
periphery discarding the used swabs after Control Nurse if any abnormalities found.
each stroke. 14) Return to the bedside to assess the comfort
10) In case any slough present, remove gently of the patient. Special instructions in case of
with the help of artery forceps/dissecting the wound are to be communicated to the
forceps. patient.
11) If the wound is deep, asinus forceps could
be used to clean.
229
16.27.9 Nursing Protocol Xiia: checklist for surgical dressing (Used for monitoring)
1 Check the orders for dressing.
2 Wash hands
3 Collect the articles- sterile and clean and
take it to the bedside.
4 Explain the procedure & assess the
condition of the patient.
5 Provide privacy & give comfortable position.
6 Protect the bed linen with mackintosh and
towel.
7 Wash hands, we0ar gloves and assess the
condition of the wound after removing the
previous dressing.
8 Discarded the dissecting forceps after
removing the dressing in a kidney tray
9 A sample for pus is to be collected for
culture if pus/serous fluid present, before
cleaning the wound.
10 In case any slough present, remove gently

with the help of artery forceps/dissecting
forceps.
11 If the wound is deep, asinus forceps could

be used to clean.
12 Clean the wound from centre to periphery in

each stroke.
13 Secure the wound with adequate sterile
dressing and make the patient comfortable.
After Care of patient and Articles
1 Assist the patient to dress up.
2 Change the linen if soiled.
3 Take all the articles to the utility room and
discard the soiled dressing in to red bag.
4 Reset the tray and send to CSSD for
sterilization.
5 Wash hands and document the procedure
with date, time, type of dressing and
amount of drainage etc.
6 Report to the surgeon and initiate Surgical
site infection reporting form to Infection
Control Nurse if any abnormalities found.
7 Assess the comfort of the patient again.
230
16.27.10 Nursing Protocol XiiiA: for casualty / emergency (Used for monitoring)
1. Reception of the patient:
Received by Nursing staff
Patient is wheeled to Emergency Room
Identify the patient by full name
Initial assessment of the condition of patient.
Patient seen by SR
Carry out the immediate treatment as ordered and record.
2. If the patient is critical:
Wheel the patient to Resuscitation Room
Assist doctor in resuscitation of the patient.
Carry out the treatment as ordered and record.
Observe and monitor the condition of the patient,
Record the vitals.
Coordinate with other support services e.g. Lab./
Radiology etc. for investigations.
Follow institutional policies regarding legal issues.
Decision for Admission by MO
SR informs the MO I/c ICU (PICU/NICU) regarding patient’s condition.
SR from ICU reviews the patient and assess whether he requires ICU care. If yes, ICU sister/
Nursing staff is informed about the patient.
Enters all details regarding patient in the emergency register.
As per the availability of bed/warmer/ ventilator the patient is transferred to ICU along with
JR, Nursing Orderly.
Hand over the patient to ICU.
Nursing orderly decontaminate the unit, nurse takes care of the resuscitation equipment as
per the hospital policy and keep ready for next use.
3. If a patient is MLC:
MO informs the police
4. If patient not critical and is to be admitted:
Carries out the treatment as ordered and records.
Observes and monitors the condition of the patient.
Initial assessment done by nursing staff and doctors.
Follows institutional policies regarding legal issues.
Sends the patient to the allotted room/ward along with nursing orderly twice a day(6-
30am to8-30pm&6-30pm to8-30pm) or in case, emergency ward requires empty bed ,any
time patient could be shifted to concerned ward after confirming that the ward has space
to occupy the patient.
5 Patient who is not admitted:
Assess the condition of the patient.
Carries out the treatment as ordered and records.
Patient may be kept for observation.
Observes and monitors the condition of the patient and record the vitals.
Gives necessary instructions for compliance of treatment and follow up at the time of
release.
231
16.27.11 Nursing Protocol XivA: checklist for pre-operative patient (Used for monitoring)
Nursing staff are requested to complete the following checklist before sending the patient to operation
theatre for any surgery.
S.No. Check List Yes No Remarks
1 Informed consent taken
2 PAC done
3 Part preparation done
4 Prepared part checked by Nursing Sister/Nursing staff
5 All investigation report including X-ray, CT Scan, MRI etc. are attached
with file.
6 Blood grouping & cross matching and arrangement of blood done
7 Patient instructed on deep breathing, coughing and post-operative

exercises.
8 Patient fasting for ordered period of time,
9 Jwellery removed
10 Prosthesis removed like dentures
(false teeth) hearing aid, eye-glasses, contact lenses etc.
11 Enema given with good result
12 Voided/catheterized
13 Thorough bath & patient dressed in hospital clothes
14 Hair combed and tied
15 Information about drug allergy /vital signs checked &recorded on case

file
16 Any medication which was advised by Anesthetist during PAC is given.
232
16.27.12 Nursing Protocol XvA: checklist for post-operative patient (Used for monitoring)
S.No. Check List Yes No Remarks
1 Receive the patient with smile and concern
2 Identify the patient by asking full name & checking CR no. with file
3 Transfer the patient safely from trolley to the post-operative bed
4 Cover the patient with sheet/blanket
5 Give comfortable position
6 Connect oxygen if ordered
7 Check the drainage for any loose connection, bleeding, blockage etc&
report accordingly.
8 Check the I/V line to ascertain that it is functioning as per the doctors
order
9 Check the vital signs, record the same & report if needed
10 Observe the wound for any bleeding
11 Give moral support to patient & family
12 Explain to the relatives to maintain silence
13 Administer antibiotics or any other drugs as per order
14 Continue recording vital signs as per the anesthetist’s instruction / as

necessary as per the patient’s condition
15 Maintain intake and output chart
16 Aspirate as indicated , record and report if needed
17 Maintain records legibly and correctly
18 Report / call the doctor when required
233
16.28 Oral Suctioning
Definition:- Oral suctioning is removal of secretion 0-28 days 80-100
from oral cavity with vacuum pressure by using a
clean catheter, in an unconscious, semiconscious or 29 days -12years 100
sedated patients.
In case secretion is 100-200
16.28.1 Indications thick
1) Change in respiratory pattern/ difficulty in
breathing.
2) Noisy gargling sound. 16.28.5 Special Precautions
3) Excessive secretion found in Oral cavity.
1) Provide steam inhalation to patient before
suctioning to soften the sputum, if required.
16.28.2 Purpose of suctioning Provide oxygen to patient before & after
1) To maintain airway suctioning if required.
2) To improve ventilation
3) To prevent aspiration
4) To Collect Sample for any Diagnostic 2) During suctioning if any obstruction felt, pull
the catheter back, to prevent mucosal
Purpose trauma.
5) To prevent infection& bad odor
16.28.6 Assessment
1) Assess the patient for need of suctioning by
performing visual or auditory assessment
16.28.3 Size of Suction catheter as per age 2) .Observe Level of Consciousness to assess
hypoxia.
AGE Size of Suction
catheter 16.28.7 Articles required
1) Suction Machine with connecting tubes/ Wall
Newborn/ 6-8
mounted suction apparatus
Infant
2) A Clean Tray containing:
2yrs 8-10 3) Suction catheter of appropriate size
4) A pair of Clean Gloves
2-8 yrs 10-12 5) Gauze pieces
6) Small mackintosh & towel
8-12 yrs 13-14 7) A sterile scissors to cut normal saline bottle
8) Normal saline
9) Kidney tray
10) Paper bag
16.28.8 General instructions

1) Check doctor’s order
2) Review safety measures (No leaking of O2,
No Smoking zone)
3) Check Suction Machine for working
16.28.4 Accepted Pressure as per age.
condition with all its attachments
Age Pressure in mm of
4) Adjust the pressure as per the patient’s age
Hg.
or condition of secretion.
234
16.28.9 Procedure 20) Repeat suctioning if required
1) Collect articles 21) Disconnect catheter from suction machine
2) Bring all the articles to the bed side & discard in kidney tray
3) Explain the procedure to the patient 22) Remove gloves& discard in paper bag.
relatives, if any present with patient. 23) Turn off the suction machine
4) Assess the condition of the patient
5) Wash Hands/ Hand hygiene 16.28.10 After care of the patient and articles
6) Wear clean gloves 1) Provide comfortable position to the patient
7) Provide position, with head turn to lateral 2) Assess the Respiratory status & Compare it
side. with previous data
3) Watch the patient for any untoward
8) Open new suction catheter symptoms like dysponea, cyanosis etc
9) Connect catheter to suction tubing 4) Remove articles from bedside & take to
10) Switch on the Suction Machine utility room.
11) Check vacuum pressure by:- 5) After wearing gloves. discard waste as per
12) Inserting suction catheter in a vac of waste management policy.
Normal Saline, Vacuum is generated by 6) Clean all the equipments ,,decontaminate&
replace them properly for further use.
suction machine.
13) Lock the end of the ‘ y‘connection with
thumb,Insert Catheter in a rotating 7) Wash hands.
movement into oral cavity with the 8) Document the procedure in procedure book.
dominant hand 9) Document the color & amount of secretion in
14) Apply intermittent suction during nurses notes
Suctioning, rotate & withdraw catheter from 10) Report any abnormalities, to the treating
doctor.
oral cavity.
11) Reassess the patient. Remove suction bottle
15) Suction should not be more than 10 & replace with decontaminated one..
Seconds in a same stroke
16) Wipe the catheter with gauze piece while
pulling out of mouth, then rinse in Normal 16.28.11 Complications/ Hazards
Saline. 1) Infection
17) Discard gauze piece in paper bag. 2) Mucosal Trauma
18) Make the patient comfortable, ask patient 3) Dyspnoea
to take deep breathe. 4) Hemorrhage
19) Administer oxygen, if required
235
16.28.12 Nursing Protocol XVAI: oral SUCTIONING CHECK LIST (Used for Monitoring)
S. no Check List Yes No Remarks

1. Explain the procedure to relatives if anyone present .
2. Collect equipments.
3. Check oxygen supply.
4. Check suction machine/ wall mounted device.
5. Wash hands & wear clean gloves.
6. Provide O2 to patient if required.
7. Cover patient chest wall with towel.
9. Normal saline is to be kept opened for use.
10. Open the new suction catheter packet with appropriate size.
11. Attach catheter to suctioning tubing.
12. Encourage patient to take deep breath before starting procedure (if
patient is co-operative).
13. Lubricate the catheter with Normal saline.
14. Switch-on suction machine.
15. Kink the catheter at its proximal end/or block Yconnector
16. Gently and quickly insert catheter in to nose/mouth with dominant
hand (separate catheter must be used for nose& mouth).
17. Releasing the kink by swirling the catheter in your thumb & index
finger.
18. Swirl gently & remove catheter out.
19. Suction not more than 10 sec in one stroke.
20 Wipe the catheter with gauze piece while swirling, then suck a little
normal saline to flush the tube.
21. Repeat the suction if needed.
22. Disconnect catheter from suction tube and discard in blue bucket,
before dispose off in a red bag.
23. Turn off the suction machine.
AFTER CARE OF PATIENT & ARTICLES
24. Provide comfortable position.
25. Assess the respiratory status and compare with previous data.
26. Observe secretion and note abnormalities.
27. Wash hands & document procedure.
28. Remove all articles from bedside and take to utility room.
29. Remove suction bottle & replace with decontaminated one.
30. Clean all articles.
31. Keep them at proper place.
Reassess the patient
236
16.29 Nebulization
16.29.1 Definition:- Nebulisation (aerosol therapy) is 6) Explain the procedure to the patient/patient’s
the administration of drugs in aerosol form relatives
directly into the respiratory tract. 7) Collect all articles to the bedside
8) Provide comfortable position
16.29.2 Indications 9) Wash hands
1) Patients requiring Emergency or High doses
16.29.7 Drugs which are commonly nebulise
of bronchodilators.
2) Patients unable to use inhalers. 1) Broncho dilators
3) Patient with severe chronic airways disease. 2) Steroids
4) Tightness of chest 3) Mucolytics
5) Increased or thick secretion
6) Pneumonia 16.29.8 Procedure
7) Atelactasis 1) Check Doctor’s Order.
8) Bronchial Asthma 2) Identify patient.
3) Bring all the articles to the bed side
16.29.3 Contraindication 4) Explain the procedure to the patient/Patients
1) Increased Blood pressure rela
2) Tachicardia 5) Assess the condition of the patient for
3) History of adverse reaction to the medication awareness, ability to cooperate & level of
4) Purpose of Nebulisation consciousness.
5) To maintain airway 6) Check Oxygen supply & suction apparatus.
6) To improve ventilation 7) Provide sitting or semifowler’s position to the
7) To administer medication patient
8) To soften the secretion/sputum 8) Wash Hands
9) Prepare prescribed dose of medication in a
16.29.4 Assessment sterile syringe
10) Remove the nebulizer cap from the
1) Assess the patient for need of Nebulisation.
nebulization chamber
2) Assess Patient’s awareness & ability to co-
11) Put the prepared medicine in the
operation.
nebulisation chamber(ideal volume-2 to
3) Observe Level of Consciousness.
4ml).
12) Attach the nebulisantion cap.
13) Set the Oxygen flow rate 6-8Lt/min.
1) Clean gloves 14) Connect the nebulisation chamber to the
2) Compressor o2 cylinder / Wall connection compressor by means of the tube.
3) Respiratory medication 15) Attach mouth piece or mask with the
4) Syringe & needle to measure the dose of nebulisation chamber.
drug 16) Switch on the compressor & check whether
5) Gauze pieces mist is forming.
6) Nebulisation Kit /Hood 17) Position the mask around the face.
7) Towel 18) Encourage patient to inhale & Exhale as
8) Normal saline slowly & deeply as possible.
9) Kidney tray 19) Continue to breathe for a duration
10) Paper bag recommended by physician or 10-
15minutes.
16.29.6 General Instructions 20) Switch off the compressor
1) Check doctor’s written order 21) Remove mask from face.
2) Follow 6 ‘R’s of medication 22) Use suction if required
3) Check nebuliser for working condition with 23) Observe the patient for any complication
all its attachments 24) Follow any other advise if given by the
4) Confirm the patient’s identity by asking doctor
his/her fullname ,I.D band, ,C R no. etc. 25) Provide comfortable position
5) Assess the condition of patient 26) Disconnect the tubing from compressor
237
27) Assess the respiratory status and compare
with previous data
28) Report any abnormalities to the treating 5) Send tubes & mask etc. to CSSD for
doctor. decontamination.
6) Keep them at proper place.
16.29.9 After care of the patient and articles
1) Wash hands. 16.29.10 Complications/ Hazards
2) Document the procedure in procedure book. Infection
& administer of the medication,
3) Remove articles from bedside.& take to 1) Over dose
utility room.
4) Clean all articles.
238
Nursing Protocol XVIIA: Nebulization CHECK LIST
(Used for Monitoring)

A. SAFE AND QUALITY NURSING CARE
1. Check doctor’s order.
2. Identify the patient.
3. Assess the condition of patient for awareness, ability to co-operate & level of
consciousness
4. Review medical orders and obtain information on drugs,dosages,specifics of
administration,responses to previous treatments and other medical and nursing history.
5. Wash hands and wear clean gloves.
B. PREPARES INSTRUMENT AND EQUIPMENTS NEEDED
1. Prepare prescribed dose of medication with a sterile syringe.
2. Patient’s medical record/chart
3.. Air compressor and nebulizer
4. Oxygen supply and suction apparatus
C. PERFORMS SAFELY NURSING PROCEDURES
1. Explain the procedure to patient/ relatives
2. Monitor the heart rate before and after the treatment for patient using bronchodilator
drugs.
3. Place the patient in a comfortable sitting or a semi fowler’s position.
4. Add the prescribed amount of medication and saline to the nebulizer.
5. Connect the tubing to the compressor and turn it on.
6. Instruct the patient to exhale.
7. Tell the patient to take deep breath from the mouthpiece and hold breathe briefly then
exhale
8. Observe expansion of chest to ascertain that patient is taking deep breaths.
9. Instruct the patient to breathe slowly and deeply until all the medication is nebulized.
10. Encourage patient to expectorate if possible.
11. Observe for adverse effects during administration.
12. Assess need for percussion vibration postural drainage and suctioning.
13. Provide comfortable position.
14. Assess the respiratory status and compare with previous data.
D AFTER CARE OF PATIENT & ARTICLES
1. Wash hands
2. Record medication used and description of secretion.
3. Remove all articles from bedside and take to utility room.
4. Clean all articles and sent to CSSD for decontamination.
5. Disassemble and clean nebulizer after each use.
6. Reassess the patient for any respiratory distress
239
16.30 Offering Urinal 16.30.7 Procedure
1) Identify the needy patient.
16.30.1 Definition 2) Bring all the articles to the bed side
Introduction of plastic or metallic liquid receptacle to 3) Explain the procedure to the patient/Patients
a fully/ partially bedridden patient in order to fulfill relatives
basic need have urged to void. 4) Assess the condition of the patient
5) Provide privacy
6) Wash Hands & Wear clean gloves
16.30.2 Purpose
7) Spread mackintosh & disposable sheet
1) To prevent bedwetting. under the sacral region.
2) To have an accurate urine measurement. 8) Position the patient, to ease comfortably to
3) To properly observe the color & consistency the urinal.
of urine. 9) Untie the lower clothing & expose the
4) To give bed rest to patients where their required part.
movements are to be restricted. 10) Hand urinal to patient, if he/she is able to
5) To avoid catheterization. handle it. Otherwise position the urinal
properly to avoid soiling of linen.
16.30.3 Indications 11) Never leave the patient alone.
1) Patient with impaired physical mobility due 12) Encourage patient to void
to surgery, fracture & head injury. 13) Collect sample if any
2) Patient’s mobility restricted due to prolonged 14) When the patient has voided, remove urinal
treatment on the bed.eg: Dialysis, carefully to avoid spilling.
Chemotherapy etc. 15) Clean the perineal area with wet swabs &
Dry swab.
16.30.4 Contraindication 16) Check the bottom sheet for any spill and
1) Patient has retention of urine due to any change if needed.
obstruction in the urethra or neck of urinary 17) Observe color & consistency of urine
bladder. 18) Measure the amount accurately.
2) Unconscious patient. 19) Report in case of dysuria, discoloration,
3) Patient who are mobile and can use the disproportionate quantity of urine etc. to the
toilet. treating physician.
16.30.5 Assessment
20) After care of the patient and articles.
1) Assess the physical /psychological status of 21) Put the patient back to comfortable position.
the patient. 22) Remove all articles & dispose urine into
2) Assess Patient’s normal elimination habits. toilet and flush.
3) Assess for incontinence or distended urinary 23) Dispose rest of the items in appropriate bins.
bladder. 24) Wash urinal and keep ready for next use.
4) Assess patient’s knowledge regarding urinal 25) Remove gloves & wash hands.
use 26) Document the date, time ,color, consistency
and amount of urine.
1) Urinal (Plastic/Metallic) Designed for
Male/Female as per the requirement 16.30.8 Complications/ Hazards.
2) A pair of Clean gloves
1) Infection
3) Wet Swabs & Dry swabs
2) Tissue injury
4) Mackintosh & Disposable sheet
3) Olygmic Shock
5) Pint Measure
____
6) Sample collection Container
7) Kidney tray
8) Paper bag
240
16.30.9 Nursing Protocol XVIIIA: OFFERING URINAL CHECKLIST (Used for Monitoring)
1. Identify the patient
2. Explain the Procedure to the patient.
3. Wash hands and wear clean gloves.

4. Provide Privacy.
5. Untie the lower garments and expose the needed area.(Avoid
unnecessary exposure)
6. Place mackintosh and towel under sacral area.
7. If the patient is female: - Position urinal close to urethra.
If the patient is male:-place penis in opening of urinal.
8. Position the patient, to ease comfortably to the urinal.
9. Encourage patient to void.
10. Collect sample if any
11. When the patient has voided remove urinal carefully to avoid spilling.
12. Clean the perineal area with wet swabs.
13. Check the bottom sheet for any spill and change if needed.
14. Observe color & consistency of urine.
15. Measure the amount accurately.
16. Report in case of any abnormalities
AFTER CARE OF PATIENT & ARTICLES
17. Put the patient back to comfortable position.
18. Remove all articles & dispose urine into toilet and flush.
19. Dispose rest of the items in appropriate bins.
20 Wash urinal and keep ready for next use.
21. Remove gloves & wash hands.
22. Document the color, consistency and amount.
241
16.31 Departmental Manual.
16.31.1 Separate manuals are available for different departments. A departmental manual gives full
details about the working of a department. It includes introduction to the department, its scope of
services, services available in the department. Relationship among various persons in the
department including their authority and responsibility, rules and procedures followed for
undertaking various tasks, inter-departmental relationship, etc can be included in department
manual. All employees working in the hospital are supposed to be aware about their concerned
department manual for the smooth working of a department.
16.31.2 CHECKLIST FOR DEPARTMENTAL MANUAL.
1. Introduction of the department
2. Scope of services
3. Resources available
4. Departmental policies
5. Hospital wide policies
6. Nursing Documentation
6a Registers
6b Forms available
242
16.32 Nursing Clinical practice Guidelines for the
prevention of peripheral thrombophlebitis.
VISUAL INFUSION PHLEBITIS SCORE
16.32.1.1 Policy Statement:-

All patients with an intravenous access device in place must have the IV
site checked at least daily for signs of infusion phlebitis.
The subsequent score AND action(s) taken (if any) must be documented.
The cannula site must also be observed when:
1. Bolus injections are administered,
2. IV flow rates are checked or altered or
3. Solution containers are changed.
4. Hyper-osmolarity or high risk drugs are infused.
The incidence of infusion phlebitis varies. The following ‘Good Practice

Points’ may assist in reducing the incidence of infusion phlebitis:
1. Observe cannula site at least daily
2. Secure cannula with a proven intravenous dressing
3. Replace loose, contaminated dressings
4. Cannula must be inserted away from the joints whenever possible
5. Aseptic technique must be followed
6. Consider your policy position on resiting of the cannula
7. Plan and document continuing care
8. Use the smallest gauge cannula most suitable for the patient’s needs
9. Replace the cannula at the first indication of infusion phlebitis (Stage
2 on the VIP score)
10. Report the incident to Quality Management Division through
incident reporting form as earliest and follow incident policy.
243
VISUAL INFUSION PHLEBITIS SCORE
Site Observation Score Stage/Action

IV site appears healthy No signs of phlebitis
0
OBSERVE CANNULA
One of the following signs is evident: Possibly first signs of
1
phlebitis
 Slight pain near the IV site OR OBSERVE CANNULA
 Slight redness near IV site
TWO of the following are evident: Early stage of phlebitis
2
RESITE CANNULA
 Pain at IV site
 Redness
ALL of the following are evident: Medium stage of phlebitis
3
RESITE CANNULA
 Pain along path of cannula CONSIDER TREATMENT
 Redness around site
 Swelling
ALL of the following signs are evident and Advanced stage of phlebitis
4
extensive: Or the start of
thrombophlebitis
 Pain along path of cannula RESITE CANNULA
 Redness around site CONSIDER TREATMENT
 Swelling
 palpable venous cord
ALL of the following signs are evident and Advanced stage
5
extensive: thrombophlebitis
INITIATE TREATMENT
 Pain along path of cannula RESITE CANNULA
 Redness around site
 Swelling
 palpable venous cord
244
16.33 Practice Guidelines for the prevention the
prevention of fall.
1. Children are in a process of constant development, and it is common for them to fall. People
may not regard falls as accidents if injury does not occur. However, with hospitalized
children, falls without injury should be regarded as an accident. There are many risk
factors of falls, such as an unfamiliar environment, a painful procedure, and the first
treatment given to a patient. Falls in children are usually not problematic if they are
healthy. However, falls in children can be life‐threatening after an operation and in those
with a hemorrhagic tendency. Falls are the most common type of accident in pediatric
wards, fall prevention measures must be taken to decrease pediatric falls.
2. Bed side rails must be used while patient is on bed and unattended.
3. All patient with deteriorated consciousness level, case of seizures, physically or mentally
handicapped prone to fall must be allotted the bed with side rails only.
4. Patient must be shifted either on patient shifting trolley or wheel chair with safety belts.
5. Patient’s relative education is given in wards and through central announcement system
for the prevention of fall from bed.
6. Appropriate light must be available all the time in patient care units.
7. Floor must be antiskid.
8. Washrooms must be cleaned and dried frequently (at least 3 hourly) by sanitation staff to
prevent fall.
9. Patent safety audits can be used by validated tool , example attached.
245
246
16.34 Nursing care plan (NCP)
is a formal process that includes correctly identifying existing needs, as well as recognizing potential
needs or risks. Care plans also provide a means of communication among nurses, their patients, and
other healthcare providers to achieve health care outcomes.
Components of Nursing care plan includes:-
Nursing Diagnosis
Goals/objectives
Intervention
Nursing Goals/object Nursing Evaluation

Diagnosis ives Intervention
Evaluation
IN CNBC, Nursing care plan is implemented in PICU.
247
17 Laboratory Division
Date created: April 2008
Responsibility of updating: Dr. Karnika
Dr. Sikha
Dr.Lavleen Singh
Last Reviewed/ Updated on: August 2020
Version (CNBC/Lab/17/VER.1.2)
252
17 Laboratory Division ............................................................................................................. 252
17.1 Amendment Sheet ................................................................................................... 255
17.2 Scope ....................................................................................................................... 256
17.3 Definition .................................................................................................................. 257
17.4 Abbreviations: .......................................................................................................... 258
17.5 Hierarchy chart ........................................................................................................ 259
17.6 Collection of specimen ............................................................................................. 260
17.7 Flow chart ................................................................................................................ 260
17.8 Policy: Sample Collection – Labeling and Handling ................................................ 261
17.9 Labeling ................................................................................................................... 262
17.10 Specimen Collection ................................................................................................ 262
17.11 Policy: Blood Collection ........................................................................................... 262
17.12 Policy: Processing haematology specimens ........................................................... 266
17.13 Policy: Processing histopathology specimens: ........................................................ 266
17.14 Biochemistry Specimens ......................................................................................... 267
17.15 Microbiology Cultures .............................................................................................. 268
17.16 Serology ................................................................................................................... 269
17.17 Clinical Pathology Specimens ................................................................................. 270
17.18 Policy: Reporting System ......................................................................................... 271
17.19 Policy: Standard Precautions................................................................................... 271
17.20 Policy: Correcting Erroneous reports ....................................................................... 272
17.21 Policy: Laboratory critical/panic values .................................................................... 272
17.22 Handling and disposal of biohazard waste .............................................................. 277
17.23 Time frame for dispatch of reports ........................................................................... 277
17.24 Emergency samples reporting ................................................................................. 278
17.25 Appendix 1: Details of laboratory tests available and TAT. ..................................... 280
17.26 Pathology ................................................................................................................. 293
17.27 Laboratory Documentation Retention Policy ........................................................... 295
17.28 Standard Operating Procedure for Antigen Testing ................................................ 296
17A Laboratory Safety Manual .................................................................................................... 299
17A.1 Safety and Health Policy Statement ............................................................................. 301
17A.2 Emergency Response .................................................................................................. 301
17A.3 Hazard Identification and Communication .................................................................... 301
17A.4 Safety program ............................................................................................................. 302
17A.5 General Safety .............................................................................................................. 303
17A. 6 Electrical Safety ........................................................................................................... 304
17A.7 Personnel Protective Equipment .................................................................................. 305
17A.8 Fire Hazards and Fire Safety ........................................................................................ 306
253
17A. 9 Chemical Hazards, Hygiene and Spill Management ................................................... 307
17A.10 Biological Hazards and Spills Management ............................................................... 310
17A.11 Hazards from Compressed Gases ............................................................................. 313
17A.12 Medical Emergencies ................................................................................................. 314
17A.13 Accident Reporting...................................................................................................... 315
17A.14 General Laboratory techniques .................................................................................. 316
17A.15 Handling glassware and safety practices for disposal of broken glassware .............. 318
17A.16 Centrifuge Safety ........................................................................................................ 319
17A.18 Biological Safety ......................................................................................................... 319
17A.19 Housekeeping ............................................................................................................. 321
17A.20 Bio-Safety Levels ........................................................................................................ 322
17A.22 Effective Use of Biological Safety Cabinets ................................................................ 325
17A. 23 Administrative ............................................................................................................ 328
17A. 24 Safety Education And Training Program ................................................................... 329
17A.25 Safety Surveys ............................................................................................................ 329
17B Laboratory Quality Assurance Programme .......................................................................... 335
254
S. Date of Clause Amendment made Remarks
No. Amendment no.
1 ____ 17.7.4 Addition of phlebotomists and research Addition of

Staff (Hierarchy) research project
staff
2 ____ 17.27 Addition of document retention Policy As per Policy
3 ____ ____ Modification of available tests As per patient
requirement
4 Nov 2014 17B Addition of details of ongoing quality Previously was

assurance programs not mentioned.
5 Dec 2014 17.25.3.5 Serological tests – CRP test omitted from Test shifted to
the list Biochemistry
Lab
6 Dec 2014 17.25.3.5 ANA Latex test replaced with ANA (IFA) test More sensitive
test
7 Dec 2014 17.25.3.4 PCR assay for bacterial meningitis, viral Expansion of
meningitis, viral encephalitis, respiratory services
pathogens and TB added
8 Dec 2014 17.25.3.2 Catheter culture and chest tube culture No clinical
omitted significance of
tests
9 Dec 2014 17.21.5 Addition of parameters As per patient
requirement
10 Dec 2014 17.25.5 Mycobacterium Laboratory tests added Expansion of
services
11 July 2015 17.27.1 Addition of Quality and technical records Previously it was
retention period not mentioned
12 July 2015 17.21.6 Addition of critical values of biochemistry Expansion of
department services
13 December 18. Redo and Recall policy
2018
14 Feb 2020 17.5 Serum CPK MB report to be generated Earlier was
within 1 hour within 24 hours,
corrected as
needed.
15 July 2020 17.28 Standard Operating Covid19
Procedure for Antigen pandemic
Testing
255
17.2 Scope
Stations / counter / area Process
Laboratory The laboratory aids in management of various diseases by detecting

the level of constituents by using state of the art equipments like
random access fully automatic biochemistry analyzer, fully automatic
biochemistry immunoassay system, blood cell counter, coagulation
analyzer and rapid culture system. It consists of various sections of
different departments like clinical pathology, haematology,
histopathology, cytology, Routine biochemistry, Immunoassay, clinical
microbiology, rapid serology, ELISA laboratory, Molecular diagnosis of
infectious Diseases, Integrated Counseling and testing center for HIV
testing under one roof to cater to the needs of customers in an efficient
and systematic way.
Laboratory Tests As per Appendix No. 1
Limitations Biopsy specimens are processed and reported at Departments of

Pathology, Maulana Azad Medical College and GB Pant Hospital
Futuristic vision Biochemistry Lab – Screening for disorders of Porphyrin Metabolism,

Biochemistry Section for urinary screening of Inborn errors of
metabolism. HbA1c measurement and therapeutic drugs for
antiepileptics.
Microbiology Lab - Expansion of parameters for molecular diagnosis

of infectious Diseases, To develop molecular typing techniques for
clonality of strains for suspected outbreaks, To be developed as
referral center for laboratory diagnosis of childhood infectious diseases
for other Government Hospitals
Pathology Lab - Thrombotic tendency evaluation,

Immunohistochemistry on cytology and histopathology cases for
accurate diagnosis
256
17.3 Definition
17.3.1 Critical (‘Panic’) Value: The result value which needs immediate attention by the doctor/
nurse failing which there is a danger of harm to the patient.
17.3.2 Phlebotomy: The procedure by which Blood is collected through veni-puncture.
257
17.4 Abbreviations:
17.4.1 QA = Quality Assurance
17.4.2 OP = Out patient
17.4.3 IP = In Patient
17.4.4 MS9 = Hematology cell counting analyzer
17.4.5 PT= Prothrombin Time
17.4.6 APTT= Activated partial thromboplastin time
17.4.7 RA = Rheumatoid Arthritis
17.4.8 CRP= C - reactive protein
17.4.9 ASLO = Anti - streptolysin O titer
17.4.10 RPR = Rapid plasma reagin
17.4.11 HIV = Human immuno deficiency virus
17.4.12 HbsAg = Hepatitis B virus surface antigen
17.4.13 HCV= Hepatitis C virus
17.4.14 FNAC = Fine needle aspiration cytology
17.4.15 VDRL = Venereal disease research laboratory
17.4.16 CCA = Customer care assistant
17.4.17 MO = Medical officer
17.4.18 MRN = Medical record number
17.4.19 FUS = fasting urine sugar
17.4.20 FDP = Fibrin degradation products
17.4.21 EDTA = Ethylene diamine tetra-acetic acid
17.4.22 TRF = Test requisition form
17.4.23 ER = Emergency room
258
17.5 Hierarchy chart
Consultants
Residents
Laboratory
Research Staff
Technical Staff
Lab
Technicians
Lab Assistants
Orderlies
259
17.6 Collection of specimen
17.6.1 Blood Collection Out patient
17.7 Flow chart
Receive patient in Blood Collection area
Is request available? Resend the patient to treating

No doctor
Yes
Check whether fasting is required
Ye
No s No
Is the patient Instruct to come
fasting? fasting
Register patient and Generated bar code

labels
Label the containers with stickers and draw blood
samples
Is patient
giddy?
Ye No
s
Take the patient to the
room
Ask attendant to escort the
Confirm that patient is to required place
patient
stable
260
17.7.1 Once patient enter the collection center a dedicated lab worker/data entry operator will
scrutinize the forms and give lab numbers/bar codes.
17.7.2 Then with labeled forms, patient enters the bleeding area and other lab worker bleeds the
patient after explaining the procedure of bleeding to the attendant and how to restrain the
child while drawing blood sample.
17.7.3 After phlebotomy, samples are dispensed in the labeled vials and needle is destroyed by
needle destroyer and syringe is discarded in freshly prepared hypochlorite solution (1%).
261
17.7.4 Blood Collection-In patient
1. In patient blood Collection is carried out in the wards and it is usually done by nurses and
residents.
In patient blood collection
Phlebotomists/SR/ JR/ Nurses collect samples in their respective wards
Labeled samples with requisition are sent to the lab registration counters
17.8 Policy: Sample Collection – Labeling and Handling
17.8.1 FOR OPD PATIENTS

1. Samples are collected from 8:30AM to 11:30 AM (8:30 AM to 10:30 AM on Saturday/ Half
day working days)
2. Stool samples to be collected only till 10:30AM
17.8.2 FOR IPD PATIENTS

1. All samples are collected and sent by ward nurses/ residents/ Phlebotomists/Laboratory
staff.
2. Requisition for various tests is brought to the lab from IPD Patients
3. In- patient’s samples are received in lab area room no. 145.
4. No samples from patient or attendant are admissible.
5. All samples are to be submitted by nursing orderlies or doctors.
6. Samples are collected from 8:30 AM to 2:30 PM
7. Microbiology specimens collected round the clock on all days.
8. Emergency samples may be sent from 2:30PM onwards to emergency lab in room no.
41.
9. In the sample receiving area, lab worker will scrutinize the lab form and suitability of
samples and will sign the lab registers of the respective in-patient units.
10. Lab worker will label the samples and their forms giving lab numbers and enter them in
ward entry register and disperse the samples in respective processing units.
262
17.9 Labeling
1. Empty labeled vials are sent to all the wards and sample with request forms comes from
wards duly labeled with ward name
2. Investigation required in OPD as the work sheet is received a number is given on the vial
and on the form for blood/urine/stool or other samples
17.10 Specimen Collection
1. 2 ml blood is collected in EDTA Vial for CBC with ESR and Blood Grouping
2. Blood is mixed to prevent clotting and is processed within 24 hours
3. 3 – 5 ml is collected in serum vial for biochemical analysis/ serological investigations
4. The specimen of urine and stool are sent to the respective laboratory sections with the
requisition, after they are given lab numbers and same numbers is given on the
investigation form
5. Amount of sample to be collected and precautions are summarized in Appendix 1.
17.11 Policy: Blood Collection
17.11.1 Materials Required

1. Spirit Swabs
2. Disposable gloves
3. Tourniquet
4. Disposable needles and syringes
5. Cotton Balls
6. EDTA /fluoride/citrated/ Plain Vials
7. Tubes with Racks
8. Needle Shredder
9. Freshly prepared hypochlorite (2%), prepared every day in morning.
17.11.2 Steps of Phlebotomy

1. The patient comes with the requisition for the desired test; the qualified hospital staff
bleed the patient after briefing the child’s attendant about the procedure and explaining
how to restrain the child while bleeding.
2. The antecubital vein of both the hands is visualized whichever is prominent is selected for
puncture. Other veins may be selected depending on the patient condition/ availability of
prominent vein to bled from.
3. The tourniquet is tied
4. The site is cleaned with sprit cotton swab rolling the swab inside out
5. After cleaning care should be taken not to touch the area of venipuncture
6. Disposable syringe is unpacked and needles cover removed
7. After informing the attendant bleeding is done and after removal of needle attendant is
ask to make it sure that the swab is kept press on venipuncture site for few minutes.
8. Patient is also asked to keep the hands folded with swabs for few minutes.
9. The blood is transferred to the desired vials after needle is removed by needle shredder.
10. Empty syringe is discarded in blue bucket with freshly prepared hypochlorite solution.
263
17.11.3 Adverse reactions:-During venipuncture and finger prick syncopal attacks may occur
patient have giddiness nausea, sweating and fainting attacks, in such a case following
steps are taken
1. Patient is made to lie down
2. Foot end is raised
3. Tight clothes collar are loosened
4. BP is recorded
5. Patient is given glucose syrups to drink
6. Physician is informed immediately patient is shifted to ICU if he doesn’t respond
17.11.4 Transportation and Handling
1. In the sample receiving area, lab worker will scrutinize the lab form and suitability of
samples and will sign the lab registers of the respective in-patient units.
2. Lab worker will label the samples and their forms, giving lab numbers and enter then in
ward entry register and disperse the samples in respective processing units.
3. No sample is handled without gloves.
17.11.5 Criteria for rejecting laboratory specimen

1. Samples with incomplete forms or illegible writing are summarily rejected.
2. Any leaking containers or inappropriate samples to the requested investigations are
rejected.
3. Un-labeled specimens are rejected.
4. Haemolysed specimens are rejected.
5. Samples with insufficient quantity of specimens are rejected.
6. Bone marrow slides without EDTA blood are not acceptable.
7. Bone marrow aspiration request without clinical details are not accepted.
8. All Bactec CSF /body fluids samples should be sending along with the sample in sterile
container.
9. Histopathology specimens which are not in adequate fixative are sent back.
10. HPLC requisition forms without the consultant's signature and stamp are not accepted.
11. All special request forms should accompany the specimen as informed by laboratory from
time-to-time.
12. All notifieable diseases tests namely Tuberculosis, Dengue, Malaria, Chikungunya,
Japanese encephalitis and cholera must accompany patient’s complete address and
mobile number.
13. All long line cathters must accompany blood cultures.
14. All CSF cultures must accompany blood cultures.
15. Specimens like catheter tip, ET tube are not clinically relavent and will be summarily
rejected.
264
17.11.6 Transportation of samples
1. Only take samples from Nursing orderlies and NOT from attendants of admitted children
2. Never accept blood smeared vial/form
3. Blood tubes must be placed in proper racks and these racks in a tray
4. Urine /stool/ other containers must be placed in a tray
5. No sample transportation without gloved hand
6. No investigation slip / register to be put in tray
7. Never wrap/place any sample on the request form
8. Transportation of any blood cavity fluid should be as soon as possible to the lab.
9. Histopathology specimens should be immersed in 10% buffered formalin before being
transported to lab.
265
17.11.7 Hematology Samples
Check labeling, and

distribute as below
Sample in EDTA tube

Make slides for comment on peripheral smear
and malarial parasite. Perform ESR &
reticulocyte count estimation if requested
CBC
Store specimen for next

24hrs for future/follow up
tests
Enter Patient Data to
cell counter
Generate counter report
Examination of peripheral smear

by senior resident
Report blood
Transfer matches
The sample is re-tested for
with
tube counter
to blood
confirmation
homogenizer
report for
Yes
Yes Release the report
266
17.12 Policy: Processing haematology specimens
1. The specimens are collected and labeled and name entered in the OPD register or IPD
registers. For OPD and IPD, separate entries are made accordingly.
2. The specimens are sent to haematology lab for processing e.g. performance of CBC on
haematology cell analyzer, staining of peripheral blood films and ESR/ Retic count, if
requisitioned.
3. The CBC report is cross-checked with the peripheral smear by senior residents and
consultant, if required.
4. The results are recorded by the technician and entered in the register and the request
form.
5. Panic values are immediately informed to the ward and concerned doctors and entry
made in the corresponding register.
6. HPLC sample is run on the analyzer and the form and CBC report is kept in the file. The
sample is preserved in the refrigerator for batch processing.
7. Samples for coagulation (PT/APTT) are checked for level of the sample, centrifuged for
separation of plasma and test performed on the semi-automated coagulation analyzer.
The results are recorded on the request form. Panic values are informed to the ward and
entry made in the register.
8. Bone marrow aspiration smears are stained by Giemsa stain and submitted for reporting
by the consultant along with the peripheral smear and CBC report.
17.13 Policy: Processing histopathology specimens:
1. The histopathology requisition form is checked for completion of patients’ demographic

data and relevant clinical details and matched with the label on the specimen
container.
2. The specimen is given a lab accession number (CN-).
3. The specimen with the requisition form is sent to Department of Pathology, Maulana
Azad Medical College or GB Pant Hospital for processing and reporting.
4. The reports are collected by the nursing orderly and brought to CNBC for despatch to
patients’ attendants.
267
17.14 Biochemistry Specimens
17.14.1 Policy: Processing Biochemistry Specimens

1. All specimens are collected,
2. Samples are checked for haemolysis, icterus, lipemia, condition is mentioned on the
request form.
3. Serum is separated and various tests are done accordingly to the request form.
4. The results are recorded by the biochemist.
5. Panic values are immediately informed to the wards and concerned doctor.
Cross check the sample label

against requisition
And separate serum
Check for hemolysis, Make a note

Yes
gross lipemia, & of the same
hyperbilirubinemia on worksheet
No
Put the serum separated tubes in

analyser rack after feeding patient
details and tests requested in
computer
No Check for panic

Is it values. Repeat if
Normal? needed
Yes
Send sample to the next section for

analysis
Report the result
268
17.15 Microbiology Cultures
Check for the specimen approriateness and

the requested investigation
Obtain clarification,
Is it get fresh sample if
correct? necessary
Plate the sample on proper media

and incubate
No
Is growth
present?
Yes
Do Gram Stain
Do capsule stain/ motility test /

Coagulase / catalase other test
as required
Identify and do Antibiotic

sensitivity pattern
Report the result (AST only first line if all

drugs are sensitive otherwise report all
three lines)
Dispatch the results
269
17.16 Serology
Check the TRF and sample label
For HBsAg, Rapid test done RPR, ASLO, RA factor, are done by
HCV by rapid test rapid card method. Widal tube test
is performed.
No
If Positive?
Yes
Repeat by
ELISA/ELFA
Report the result
270
17.17 Clinical Pathology Specimens
Urine
Analysis
Check the sample for correct

labeling and test required
Physical Chemical Microscopic

examination examination examination
No
R/E
Pour urine into Sugar Present Put

Take
Colour and appearance test tube, dip a test for Ketone
Centrifuged
multistix 10 SG bodies
deposit, stain &
strip, blot and
examine under
read
microscope,
report the
findings
Compile the report with other parameters
Enter the report
271
17.18 Policy: Reporting System
1. All OPD and IPD reports of samples received in routine hours are approved the same
day.
2. Reporting of investigations requiring more than 24 hrs is done next day
3. Special investigations, like HPLC, PTH estimation are performed once a week.
4. Critical/ panic reports are communicated immediately to the concerned doctor on phone
or personally (panic value reporting). And marked on the HIMS system also
17.19 Policy: Standard Precautions

(Should be read in conjunction with the Hospital infection control manual)
1. Only disposable needles and syringes used for collection purpose

2. Staff should wear all protective clothes apron and gloves
3. Used needles are never be recapped
4. Spillage of samples is avoided. In case of spillage, surface is cleaned with 1% sodium
hypochlorite (See hospital infection control manual for details)
5. Mouth pipetting should never be done
6. Exterior of the blood container wiped for any trace of blood with disinfectant
7. All specimen are labeled carefully before sampling
8. In case of needle stick injury, wound is washed with soap and water and blood allowed to
flow freely
9. Needles are shredded with the help of needle shredder
10. All fluids are discarded after treating with sodium hypochlorite (2%) /autoclaved/phenol
(5%)
11. Microbial cultures are immersed in phenol (5%) overnight and the liquid is disposed in
washing room sink under running tap water. Solid waste resulted must be put in red bag.
12. Staff is instructed to wash hands with soap and water liberally before every episode of
direct patient contact/ bench work.
13. All the staff has been advised to immunize themselves for hepatitis B.
272
17.20 Policy: Correcting Erroneous reports
17.20.1 The false information or misinformation presented to a physician is corrected in a manner

that does not compromise patient care. Clerical discrepancy test reported Vs test
requested and reporting erroneous test reports are areas which need correction.
17.20.2 As soon as an erroneous result is discovered, the physician is informed of the error.
17.20.3 After an error is identified a new request form with correct results is made indicating the
date and time.
17.20.4 On reports “corrected reports of specimen X" is written.
17.20.5 Corrected report is sent to the wards
17.20.6 Error is crossed out by drawing a single line.
17.20.7 Initial report is also attached to the correct report.
17.20.8 It is recorded as reporting error in the register
17.21 Policy: Laboratory critical/panic values
1. The results is rechecked and it is ensured that it is a true panic

2. Immediately notify the requesting ward or physician, documented each call.
17.21.1 Haematology
Analyte Age Range Panic Values Units Policy
Hb Any age Less than 5 gm% Immediately
WBC Any age Below 2000 or Per cumm Immediately
≥50,000 Per cumm Immediately
Platelet Count Any age Below 20000 Per cumm Immediately
Peripheral smear Any age Blast cells - Immediately
PT Any age ≥30 seconds Immediately
APTT Any age ≥70 seconds Immediately
17.21.2 Biochemistry
PANIC VALUES
PARAMETER LESS THAN MORE THAN

ELECTROLYTES
SODIUM 120 mmol/L 155 mmol/L
POTASSIUM 3 mmol/L 6 mmol/L
273
IONIZED CALCIUM 0.75 mmol/L 1.6mmol/L
CHLORIDE 75 mmol/L 125 mmol/L
SERUM GLUCOSE(NEW 30 mg/dL 325 mg/dl
BORN)
SERUM 46mg/dL 445 mg/dL
GLUCOSE(CHILDREN)
GLUCOSE (CSF) 30 mg/dL
PROTEIN (CSF) 188mg/dL
SERUM UREA 115 mg/dL

SERUM CREATININE 3.8 mg/dL
URIC ACID 12 mg/dL
TOT BIL 15 mg/dL
BLOOD GAS (ARTERIAL)
pH 7.2 7.6
Pco2 20 mm Hg 70 mmHg
Po2 40 mm/ Hg
INORGANIC PHOSPHATE 1 mg/dL 10mg/dL
TOTAL CALCIUM 6.5 mg/dL 12.7 mg/dL
TOT PROTEIN 3.4 mg/dL 9.5 mg/dL
ALBUMIN 1.7 mg/dL 6.8 mg/dL
MAGNESIUM 1 mg/ dL 4.7 mg/dl
Serum glucose Any age <40 - >400 mg% Immediately
Total Bilirubin Any age >18 mg % Immediately
Serum urea Any age >80 mg % Immediately
Serum Creatinine Any age >8 mg % Immediately
Serum sodium Any age <125 mmol/L Immediately
Serum potassium Any age >6.5 mmol/L Immediately
Serum calcium Any age <5.5 mg % Immediately
17.21.3 Urine analysis

Acetone Any age Present - Immediately
Sugar Any age 3+glucose Mgm% Between 8 am – 8 pm
274
17.21.4 CSF Analysis
CSF Cell Count Any age WBC Count >300 Immediately
17.21.5 Microbiology
Analyte Age Panic Values Policy
Range
CSF Any age All positives in direct microscopy, Latex agglutination, Immediately
culture and PCR
Blood Any age  Yeast isolated Immediately

 All positive cultures
 Any Dengue Reactive Sample
Stool Any age Vibrio cholerae isolated/ darting Motility Immediately
Any Specimen Any age  Any Multi –drug resistant bacteria e.g. MRSA Immediately
e.g. Blood,  Any unusal pathogen isolated
pleural fluid  Any fastidious pathogen isolated
etc.  Positive PCR results
 Diagnosed mycobacterial infection
(Microscopy, NAATs, Culture, DST
17.21.6 Pathology
Critical Value
Sample Reference
Test Gender Age
Vial range Low High
3/
EDTA WBC M/F 0-2 months 5.0-20.0 x 10
2 months-5 years µL <<1.0 x >30.0 x
3/ 3 3
5-11 years 4.5-17.0 x 10 10 / µL Aall 10 / µL (all
>11 years µL ages) ages)
3/
4.5-13.0 x 10
µL
3/
4.0-10.0 x 10
EDTA RBC M/F
NONE
275
6
MALE 0 - 6 months 3.90-5.90 x 10 /
FEMALE 6 months - 11 µL
6
years 3.80-5.40 x 10 /
>11 years µL
6
>11 years 4.31-6.40 x 10 /
µL
6
3.85-5.20 x 10 /
µL
EDTA Hemoglobin M/F
0 - 2 months 14.0-18.0 gm/dL <10.0
2 months - 11 11.0-14.0 gm/dL gm/dL
MALE years 13.6-18.0 gm/dL <6.0
>11 years 11.5-16.0 gm/dL gm/dL NONE
FEMALE
>11 years <6.0
gm/dL
<6.0
gm/dL
EDTA Hematocrit M/F
0 - 2 weeks 42.0-68.0% <30.0%
2 weeks - 2 35.0-50.0% <18.0%
months 3 30.0-40.0% <18.0% NONE
2 months - 1 year 3 2.0-42.0% <18.0%
1 - 5 years 39.8-52.0% <18.0%
>5 years 34.7-46.0% <18.0%
>5 years
EDTA MCV M/F
0 - 2 weeks 88.0-114.0 fl
2 week - 6 85.0-97.0 fl
months 72.0-86.6 fl NONE
6 months - 11 80.0-97.0 fl
years
>11 years
EDTA MCH M/F
0 - 2 weeks 34.0-37.0 pg
2 weeks - 6 31.0-36.0 pg
months 25.0-31.0 pg
6 months - 5 26.0-34.0 pg NONE
years
>5 years
EDTA MCHC M/F

0 - 2 weeks 31.0-35.0 gm/dL NONE
2 weeks - 6 32.0-35.0 gm/dL
months 32.0-36.0 gm/dL
>6 months
EDTA RDW M/F
0 - 2 days 14.9-18.7 % NONE
>2 days 11.5-15.0 %
EDTA Platelet M/F
3
0 - 2 months 140-440 x 10 / < 100 x >1,000 x
3 3
>2 months µL 10 /µL 10 / µL
3 3
140-440 x 10 / <25 x 10 / >1,000 x
3
µL µL 10 / µL
EDTA MPV M/F NONE
276
6.5-12.4 fl
All Ages
EDTA Neutrophils,ab M/F
3
solute 0 - 6 days 1.5-16.0 x 10 / <0.50 x
3
6 days - 2 µL 10 / µL (all
3
months 0.8-9.0 x 10 / ages)
2 months - 1 µL
3
year 0.7-7.6 x 10 /
1 - 5 years µL NONE
3
5 - 11 years 1.5-11.0 x 10 /
>11 years µL
3
1.5-8.5 x 10 /
µL
3
1.5-8.0 x 10 /
µL
3
EDTA Eosinophis,Ab M/F 0.0-1.4 x 10 /
solute 0 - 2 months µL
2 months - 5 3
0.0-1.2 x 10 /
years µL
5 - 11 years 3 NONE
0.0-0.9 x 10 /
>11 years
µL
3
0.0-0.3 x 10 /
µL
EDTA ESR MALE All Ages 0-15 mm/hr
FEMALE 0-20 mm/hr NONE
EDTA Reticulocyte M/F All Ages 2.5-6.5%

percent 0.5-2.0% NONE
CITRATE PT M/F All Ages 12.8 ± 3 INR > 6

VIAL
CITRATE APTT M/F All Ages 31 ± 5 ≥100 sec
VIAL
EDTA Malaria M/F All Ages POSITIVE
17.21.6.1 Body Fluids
Fluid Gender Age WBC RBC Critical Value

CSF M/F < 1 Month ≤30 / µL No Cells WBC > 30/ µL
Mononuclear
Cells
CSF M/F >1 Month ≤5/ µL No Cells WBC > 10/ µL
Mononuclear
Cells
277
17.22 Handling and disposal of biohazard waste
(To be followed in conjunction with Hospital infection control manual)
1. The purpose of disposing biohazard waste e.g. sharp, laboratory waste and
microbiological specimen is to avoid contamination with infectious waste agents, which
are infectious to human beings.
2. Sharps:-Needles are shredded in needle shredder
3. Liquid waste:-All the liquid waste is collected in a container having sodium hypochlorite
treated and allowed to flow in the drain in running tap water
4. Cultures of microbiology are put in red bag after disinfection at source using 5% Phenol
or 1% Sodium Hypochlorite.
17.23 Time frame for dispatch of reports
1. All routine reports should be dispatched to the inpatient units after investigations are
over as per turn around time defined.
2. All out-patient reports are segregated as per source rooms in OPD and are collected
by respective nursing orderly.
3. All routine reports received are dispatched by 4 pm.
4. All the abnormal results are conveyed immediately on phone to the treating
physician/concern inpatient unit.
5. All reports are verified and approved by the senior residents and /or consultants.
6. All reports of FNAC, bone marrow aspirate and biopsies are to be collected by the
patients’ attendants from Room No. 145.
278
17.24 Emergency samples reporting
S.No Samples Time Frame
1. Hemoglobin 2 hrs
2. TLC 2 hrs
3. DLC 2 hrs
4. Blood Gas Analysis Within 30 mts
5. Serum Electrolytes 1 hr
6. CSF Microscopy 1hr
7. Rapid Malaria Antigen 30 – 40 min
8. Blood grouping /cross matching for 1 hr

emergency transfusions only
9. Serum Urea 2 hrs
10. Serum Creatinine 2 hrs
11. Serum Bilirubin 2 hrs
12. Serum C-reactive protein (CRP) 2 hrs
13. Serum Total Protein 2 hrs
14. Serum Total Calcium 2 hrs
15. Serum Blood Sugar (GOD-POD) 2 hrs
16. CSF Sugar/Protein 2 hrs
17. Cholera – Hanging Drop Within 30 min
18. Rapid culture (CSF) After microbiological processing
19. Dengue NS1/IgM/IgG (Rapid) Within 2 hrs
20. HIV (Rapid) Only for needle stick/sharp injuries after proper filling of
reporting forms
21. HBsAg (Rapid) Only for needle stick/sharp injuries after proper filling of
reporting forms
22. Gram staining of CSF and other body Smear preparation and heat fixed slide to be prepared
fluids within one hour. Reporting may be delayed to next
morning.
279
23. All Microbiology cultures Should be received and processed. Slides may be
processed as described above
24. All Microbiology serum based Should be received. Serum should be separated and
investigations stored in refrigerator. The specimens should be handed
over to the next day morning technical staff.
280
17.25 Appendix 1: Details of laboratory tests available and their expected turnaround time
(TAT).
Test Availability Of Report Submission

Test
Serum Sugar Daily With In 24 Hrs
Serum Urea Daily With In 24 Hrs
Serum Creatinine Daily With In 24 Hrs
Serum Uric Acid Daily With In 24 Hrs
Serum SGOT Daily With In 24 Hrs
Serum SGPT Daily With In 24 Hrs
Serum Bilirubin Daily With In 24 Hrs
Serum Total Protein Daily With In 24 Hrs
Serum Albumin Daily With In 24 Hrs
Serum Globulin Daily With In 24 Hrs
Serum Calcium Daily With In 24 Hrs
Serum Phosphorus Daily With In 24 Hrs
Serum Alkaline Phosphatase Daily With In 24 Hrs
Serum GGT Daily With In 24 Hrs
Serum CRP Daily With In 24 Hrs
Serum Sodium Daily With In 24 Hrs
Peritoneal Fl. Biochem. Daily With In 24 Hrs
Pleural Fl.Biochem. Daily With In 24 Hrs
Urine Electrolytes Daily With In 24 Hrs
Urine Pro/Creat Daily With In 24 Hrs
Urinary Phos Daily With In 24 Hrs
Serum Lactate Daily With In 24 Hrs
Urinary UA Daily With In 24 Hrs
Serum Potassium Daily With In 24 Hrs
281
Serum Chloride Daily With In 24 Hrs
Serum Total Cholesterol Daily With In 24 Hrs
Serum HDL Cholesterol Daily With In 24 Hrs
Serum LDL Cholesterol Daily With In 24 Hrs
Serum Triglyceride Daily With In 24 Hrs
Serum VLDL Cholesterol Daily With In 24 Hrs
Serum Amylase Daily With In 24 Hrs
Serum LDH Daily With In 24 Hrs
Serum Magnesium Daily With In 24 Hrs
Serum Total CPK Daily With In 24 Hrs
Serum CPK MB Daily With In 1 hour
Serum LDH Daily With In 24 Hrs
Serum Lipase Daily With In 24 Hrs
Serum Total Iron Daily With In 24 Hrs
Serum Total Iron Binding Daily With In 24 Hrs

Capacity (TIBC)
Serum Tranferrin Saturation Daily With In 24 Hrs
24 Hr Urinary Creatinine Daily With In 24 Hrs
24 Hr Urinary Calcium Daily With In 24 Hrs
24 Hr Urinary Protein Daily With In 24 Hrs
Spot Urine Calcium Creatinine Daily With In 24 Hrs

Ratio
CSF-Sugar Daily With In 24 Hrs
CSF-Protein Daily With In 24 Hrs
Urine/Stool Reducing Sugar Daily With In 24 Hrs

(semiquantitative tests)
17.25.1.1 Biochemistry Immunoassay Tests Lab

Serum FT3 Daily With In 7 Days
Serum FT4 Daily With In 7 Days
282
Serum TSH Daily With In 7 Days
Serum Folate Daily With In 7 Days
Serum Vit B12 Daily With In 7 Days
Serum PTH Daily With In 7 Days
Serum Ferritin Daily With In 7 Days
Serum Total IgE Daily With In 7 Days
17.25.1.2 Biochemistry Special Tests Lab

Serum Vitamin D (Elisa Method) Daily With In 7 Days
Serum Osmolality Daily With In 24 Hrs
Urine Osmolality Daily With In 24 Hrs
17.25.2 PS: For routine biochemistry tests expected TAT is 6hrs for In-patients and 24hrs for
Out-patients
283
17.25.3 MICROBIOLOGY
17.25.3.1 Bacteriology Lab

S.NO.
TEST SAMPLE AVAILABILITY OF TEST REPORT SUBMISSION
1 Bld C/S Blood 0.5-5ml in bld c/s bottle DAILY 48hrs - 96hrs
2 Rapid Blood Culture Whole blood 0.5-3ml in Bactec Bottle DAILY 6hrs –5 days
3 Urine C/S 0.5ml-2ml in Sterile Collection Container DAILY 24hrs - 48hrs
4 Stool R/M Pea size feaces in dry clean container DAILY Same Evening
5 Wound c/s Sterile swab or syringe - needle assembly DAILY 24hrs - 72hrs
properly covered/bent needle or sterile
container
6 AFB staining Sterile Collection Container DAILY Same Evening
7 Stool C/S Pea size fecal material - Clean dry DAILY 48hrs - 96hrs
container /spoon container assembly
8 Stool for occult blood Pea size fecal material - Clean dry DAILY Same Evening
container /spoon container assembly
9 CSF culture 0.5ml-1ml in Sterile Container DAILY 24hrs - 72hrs
10 Throat swab Sterile swab , one for culture only, 2 in DAILY 24hrs - 72hrs
nos. for Albert staining
284
11 Pleural effusion culture 0.5ml-2ml in Sterile Collection Container DAILY 24hrs - 48hrs
12 Pus C/S Sterile swab or syringe - needle assembly DAILY 24hrs - 72hrs
properly covered/bent needle or sterile
container
13 Ascitic fluid culture 0.5ml-1ml in Sterile Container DAILY 24hrs - 48hrs
14 Synovial fluid culture 0.5ml-1ml in Sterile Container DAILY 24hrs - 48hrs
17.25.3.2 BACTERIOLOGY LAB (…CONTD)

S.NO. TEST SAMPLE AVAILABILITY OF TEST REPORT SUBMISSION
15 Conjuctival swabs culture Sterile swab , one for culture only, 2 in DAILY 24hrs - 48hrs
nos. for Microscopy is also requested
16 Vaginal swabs culture Sterile swab , one for culture only, 2 in DAILY 24hrs - 72hrs
nos. for Microscopy is also requested
17 Petechial fluid -Gram Stain At least two slides, properly labelled DAILY 2hrs
18 Direct Gram Depends on the site of sampling DAILY Same Evening

stain/microscopy
19 ET aspirate culture 0.5ml-1ml in Sterile Container DAILY 24hrs - 72hrs
20 BAL Culture 0.5ml-1ml in Sterile Container DAILY 24hrs - 72hrs
21 Central line Catheter Tip 0.5-1cm in Sterile Container DAILY 24hrs - 72hrs
Culture (only when
accompanied with
peripheral blood culture
285
specimen)
22 Lung/Pleural Aspirates 0.5-1cm in Sterile Container, 0.5ml DAILY 24hrs - 72hrs

drainage material from tube and NOT
from bag. Direct specimen from fresh tap
is preferred specimen
23 Peritoneal Fluid 0.5ml-1ml in Sterile Container DAILY 24hrs - 72hrs
24 Latex agglutination test for Serum/plasma -3ml, CSF-1ml DAILY Same Evening
diagnosis of meningitis due
to Grp B Streptococcus, E.
coli K12, S. pneumoniae,
H. influenzae and N.
meningitides
286
17.25.3.3 Parasitology Tests
S.NO. TEST SAMPLE AVAILABILITY OF TEST REPORT SUBMISSION
1. Stool- Ova/Cysts Pea size fecal material - Clean dry DAILY Same Evening
container /spoon container
assembly
2. Stool- Ova/Cysts, conc. Technique Pea size fecal material - Clean dry DAILY Same Evening
assembly
3. Stool- Ova/Cysts, Permanent Pea size fecal material - Clean dry DAILY Same Evening
staining (Trichrome) container /spoon container
assembly
4. Stool - Modified Acid Fast Staining Pea size fecal material - Clean dry DAILY Same Evening
assembly
5. Stool - Antigen test - Cryptosporidium Pea size fecal material - Clean dry DAILY One week
assembly
6. Plasma - Rapid malaria antigen Whole Blood in EDTA vial - 2ml DAILY Same Evening
7. Serum - Leishmania Antigen for Kala Whole Blood in yellow vial - 3ml DAILY Same Evening
Azar
8. Serum - antibodies - see under Whole Blood in yellow vial - 3ml DAILY See under immunology lab
immunology lab
287
17.25.3.4 Mycology Tests
S.No. TEST AVAILABILITY OF TEST REPORT SUBMISSION
1 Bactec Fungal C/S DAILY 6hrs - 7days
2 Fungal KOH DAILY with 1hr
3 Fungal culture DAILY 3 days to 6 weeks
17.25.3.5 Serological Tests

S.No. TEST Sample AVAILABILITY OF TEST REPORT SUBMISSION
1 Hbs Ag (Rapid Test) Serum/plasma -3ml DAILY Same Evening

(PROVISIONAL)
Final Report after ELISA next
day
2 HCV (Rapid Test) Serum/plasma -3ml DAILY Same Evening

(PROVISIONAL)
Final Report after ELISA next
day
3 HIV antibodies Serum/plasma -3ml DAILY Same Evening
4 Anti-treponemal antibodies Serum/plasma -3ml DAILY Same Evening

(RPR/VDRL)
5 ASO (Latex Agglutination Test) Serum/plasma -3ml DAILY Same Evening
288
6 RA (Latex Agglutination Test) Serum/plasma -3ml DAILY Same Evening
9 ANA (IFA) Serum/plasma -3ml DAILY Same Evening
10 Widal test (Slide Test) Serum/plasma -3ml DAILY Same Evening
11 ANA (LIA) for specific antibodies Serum/plasma -3ml DAILY Next evening
12 Leishmania Ag detection test for Serum/plasma -3ml DAILY Same Evening

Kala Azar
13 Japanese Encephalitis Serum/plasma -3ml and CSF DAILY Same Evening

1ml
17.25.3.6 ELISA Tests

S.No. Tests Sample Availability Of Test Day of reporting
1 Anti-dsDNA ELISA Serum/plasma -3ml DAILY 7 days
2 Combo detection of viral Serum/plasma -3ml** DAILY 7 days

pneumonia- Influenza A,
InfluenzaB, Mycoplasma
pneumoniae, RSV ELISA
4 Cytomegalovirus IgG ELISA Serum -3ml** DAILY 48 hours
5 Cytomegalovirus IgG avidity Serum -3ml** DAILY 48 hours

ELISA
6 Cytomegalovirus IgM ELISA Serum/plasma -3ml DAILY 48 hours
7 Echinococcus serum antibody Serum/plasma -3ml DAILY 15 days
289
8 Entamoeba histolytica serum Serum/plasma -3ml DAILY 7 days
antibody
9 Herpes Simplex Virus IgM ELISA Serum/plasma -3ml DAILY 7 days
10 Measles IgG ELISA Serum/plasma -3ml** DAILY 15 days
11 Mycoplasma pneumoniae IgA Serum/plasma -3ml DAILY 15 days

ELISA
12 Mycoplasma pneumoniae IgG Serum/plasma -3ml** DAILY 15 days

ELISA
13 Mycoplasma pneumoniae IgM Serum/plasma -3ml DAILY 15 days

ELISA
14 Rubella IgG ELISA Serum/plasma -3ml** DAILY 48 hours
15 Rubella IgG avidity ELISA Serum/plasma -3ml** DAILY 48 hours
16 Rubella IgM ELISA Serum/plasma -3ml DAILY 48 hours
17 Toxoplasma IgM ELISA Serum/plasma -3ml DAILY 48 hours
18 Toxoplasma IgG ELISA Serum/plasma -3ml DAILY 48 hours
19 Toxoplasma IgG avidity ELISA Serum/plasma -3ml DAILY 48 hours
20 T. solium serum antibody Serum/plasma -3ml DAILY Parasitology reports on 4th

detection ELISA Friday in Month
21 Tissue transglutaminase IgA Serum/plasma -3ml DAILY 7 days

ELISA
290
22 Dengue IgM ELISA Serum/plasma -3ml DAILY 72 hours
23 Diagnosis of Infectious Serum/plasma -3ml DAILY Same Day

mononucleosis/ EBV antigen
detection
24 Chlamydophila pneumoniae IgM Serum/plasma -3ml DAILY Same day
25 Chlamydophila pneumoniae IgG Serum/plasma -3ml** DAILY Same Day
** Paired sample is useful 2nd sample after 2 weeks
17.25.4 Molecular Laboratory

S. No. Assay Sample Availability Of Test Day of reporting
1. PCR assay for S. pneumoniae Blood/ CSF/ Effusion fluid – Daily Specimens received before
detection 1ml 11:30AM, same day reporting.
Rest specimens next day
2. PCR assay for H. influenzae Blood/ CSF/ Effusion fluid – Daily Specimens received before
3. PCR assay for N.meningitidis Blood/ CSF/ Effusion fluid – Daily Specimens received before
4. PCR assay for Tuberculosis Sputum/ GA/CSF/ Effusion Daily Specimens received before
(Genexpert) detection fluid – 1ml 11:30AM, same day reporting.
5. PCR assay for CMV detection and Blood/ CSF/ Urine – 1ml Daily Specimens received before
11:30AM, same day reporting.
291
quantification Rest specimens next day
6. PCR assay for Bordetella Nasopharygeal aspirate – 1ml/ Daily Specimens received before
pertussis Throat swab 11:30AM, same day reporting.
7. PCR assay for bacterial meningitis CSF/Blood – 1ml Daily Specimens received before
8. PCR assay for viral meningitis CSF/Blood – 1ml Daily Specimens received before
9. PCR assay for viral encephalitis CSF/Blood – 1ml Daily Specimens received before
10. PCR assay for respiratory Nasopharyngeal aspirate/BAL Daily Specimens received before
pathogens – 1ml 11:30AM, same day reporting.
11. PCR assay for NDM-1 detection Stool specimen/ Bacterial For Infection Prevention -
cells/ Swabs Surveillance only
12. PCR assay for CTX-M detection Stool specimen/ Bacterial For Infection Prevention -
13. PCR assay for KPC detection Stool specimen/ Bacterial For Infection Prevention -
14. PCR assay for HSV detection Blood/CSF (1ml) Under Standardisation -
292
15. PCR assay for MRSA detection Blood/CSF/Body Fluids/Swab Under Standardisation -
16. PCR assay for Typhoidal Blood/CSF/Urine (1ml) Under Standardisation -

Salmonella detection
17.25.5 Mycobacteria Laboratory
1. Microscopy - ZN Staining Fluids, aspirates and tissues Daily Same evening
2. Mycobacterial Culture Fluids, aspirates and tissues Daily Maximum 6 weeks. Average
Conventional reporting time for positive
cultures – 3 weeks
3. Mycobacterial Culture- Rapid Fluids, aspirates and tissues Daily Maximum 6 weeks. Average
(MGIT) reporting time for positive
cultures – 9-14 days
4. Mycobacterium drug susceptibility Daily 2-3 weeks after culture

testing – 1 line (Culture Based)
st
positivity
5. Mycobacterium drug susceptibility Daily 2-3 days after culture positivity

testing – MDR Detection
(Resistance Gene detection
based)
6. Mycobacterium NAATs Fluids, aspirates and tissues Daily 2-3 days
293
17.26 PATHOLOGY
17.26.1 Haematology Tests

Test Availability Of Test Report Submission
Hemogram (Hb, Tlc, Dlc, Rbc Indices, Daily Same Day

Platelets)
ESR Daily Same Day
Reticulocyte Count Daily Same Day
Rapid Malarial Antigen Daily Same Day
Sickling Test Daily Within 2 days
Bone Marrow Aspiration Cytology Daily Within 3 Days
Bone Marrow Biopsy With Edta Daily One Week

Sample
Bleeding Time Daily Same Day
Clotting Time Daily Same Day
Coagulation Profile (Pt, Aptt) Daily Same Day
High Performance Liquid Daily Within 10 Days

Chromatography (Hplc)/ Thalassemia
Screening
17.26.2 Cytopathology Tests

Fine Needle Aspiration Cytology Daily Within 4 Days
CSF Cytology Daily Same Day
Pleural Fluid Cytology Daily Within 48 Hours
Peritoneal Fluid Cytology Daily Within 48 Hours
Peritoneal dialysis Fluid Cytology Daily Within 48 Hours
Synovial Fluid Cytology Daily Within 48 Hours
Bal Cytology Daily Within 48 Hours
Splenic Tap Cytology Daily Within 48 Hours
Ultrasound-Guided FNAC Daily Within 4 Days
294
17.26.3 Histopathology Tests
Tissue Biopsy Specimen Daily 7-10 Days
17.26.4 Clinical Pathology Laboratory
Urine Microscopy With Albumin, Daily Same Day

Sugar, Specific Gravity
Urine For Ketone Bodies/ Albumin/ Daily Within 1 Hour

Bile Pigments
Urine For Hemosiderin Daily Within 48 hours
295
17.27 Laboratory Documentation Retention Policy
S. No. Type of Data Period
1. Computer generated analyser’s data 6 months

Biochemistry Analyser
Immunoassay Analyser
Haematology Analyser
Bacterial ID/AST system
2. Molecular Tests Data Five years
3. Temperature Charts for Refrigerators Six months
4. Laboratory Reporting Registers Three years
5. Quality Control Data One Year
6. Laboratory Inventory Records Five Years
7. Histopathology slides 10 years
8. Histopathology tissue blocks 10 years
9. Histopathology reports 10 years
10. FNAC slides 10 years
11. FNAC reports 10 years
12. BMA slides 10 years
13. BMA reports 10 years
14. HPLC database 10 years
17.27.1 Quality and technical records

The laboratory shall decide the retention time of records as per the national,regional and local
regulations.However,NABL requires following minimum retention time for ensuring the quality
service and patient care
S.No. Particulars of Records Retention period
1. Particle cell counter data 1 Week
2. Molecular diagnostic gel pictures 5 Years
3. Flow cytometry /Immunophenotyping data 6 Months (Values only)
4. Electrophoretogram 1 Year
5. Hemoglobin HPLC data 1 Year
6. Coagulation calliberation/standard graph 1 Week
7. Table/chart of daily values of internal quality control 1 Year
8. LAB Reports 1 Year
9. Requisition 1Year
10. Test registers 1 Year
11. Histopath records 5 Year
296
17.28 Standard Operating Procedure for Antigen Testing
17.28.1 Scope:
Antigen Testing for SARS-CoV-2 diagnosis
17.28.2 Place of Testing:

i) Flu Corner (Ground Floor)
ii) HICC Room (First Floor)
iii) IPD areas
17.28.3 Target Population:

Use of Standard Q COVID-19 Ag a point of care diagnostic assay is recommended in the following
settings in combination with the gold standard RT-PCR test
i) All symptomatic ILI patients presenting in a healthcare setting and are suspected of having
COVID19 infection.
ii) Asymptomatic patients who are hospitalized or seeking hospitalization, in the following high- risk
groups:
- Patients undergoing chemotherapy
- Immunosuppressed patients including those who are HIV+;
- Patients diagnosed with malignant disease;
- Transplant patients;
- Elderly patients (>65 yrs of age) with co-morbidities (lung disease, heart disease, liver
disease, kidney disease, diabetes, neurological disorders, blood disorders)
iii) Asymptomatic patients undergoing aerosol generating surgical / non-surgical interventions:
- Elective/emergency surgical procedures like neurosurgery, ENT surgery, dental
procedures etc.
- Non-surgical interventions like bronchoscopy, upper GI endoscopy and dialysis etc.
*ILI case is defined as one with acute respiratory infection with fever ≥ 38◦C AND
cough.
17.28.4 Procedure of Testing:

Sample Collection and Preparation:
1. To collect a nasopharyngeal swab specimen, insert a sterile swab into the nostril of the patient,
reaching the surface of the posterior nasopharynx.
2. Using gentle rotation, push the swab until resistance is met at the level of the turbinate.
3. Rotate the swab a few times against the pharyngeal wall.
4. Remove the swab from the nostril carefully.
5. Specimen should be tested as soon as possible after collection.
Do not use transport media, use the collected specimen and extracted buffer immediately. Be careful of
contamination.
o / o
Specimens may be stored at room temperature for up to 1 hours or at 2-8 C 36-46 F for up to 4 hours
prior to testing.
297
Test Procedure:
1. Insert the swab into an extraction buffer tube. While squeezing the buffer tube, stir the swab more
than 5 times.
2. Remove the swab while squeezing the sides of the tube to extract the liquid from the swab.
3. Press the nozzle tightly onto the tube.
4. Apply 3 drops of extracted specimen to the specimen well of the test device.
5. Read the test result in 15-30 minutes.
Interpretation of Result:
1. A coloured band will appear in the top section of the result window to show that the test is
working properly. This band is control line (C).
2. A coloured band will appear in the lower section of the result window. This band is test line of
SARS-CoV-2 antigen (T).
298
3. Even if the control line is faint, or the test line isn’t uniform, the test should be considered to be
performed properly and the test result should be interpreted as a positive result.
Reporting of Results:
Symptomatic individuals:
Test Result Reported as
Negative negative for COVID-19 by rapid antigen test should be definitely tested
sequentially by RT-PCR to rule out infection
Positive a true positive and does not need reconfirmation by RT-PCR test.
Biomedical Waste Management:
Testing is being done at two locations in the hospital which will have different strategies of waste
disposal:
IPD patients Swabs collected come for testing to laboratory and are discarded along with
testing cards and buffer tubes and followed by autoclaving and disposal.
OPD patients Swabs collected from patients on spot and tested. All swabs, buffer tubes and
test cards disposed in 1% hypochlorite and then put in red bag which is picked by
 Flu Corner outsource agency.
 HICC Room
299
CNBC
Manual for Operations
17A Laboratory Safety Manual
18
Date created: April 2008
Responsibility of updating: Dr. Shikha
Dr. Karnika Saigal
Dr. Lavleen Singh
Last Reviewed/ Updated on: Dec 16
(CNBC/Lab safety/17A/Ver.1.1)
300
Amendment Sheet
Page No. Addition/Deletion Reason of modification Remarks
17 Added Point no. 10 Improved management None

of large chemical spills
Use absorbents to collect substances. Reduce
vapor concentrations by covering the surface of a
liquid spill with absorbent. Control enlargement of
the spill area by diking with absorbent.
17 Maintain Material Safety Data Sheets (MSDS) To improve None

understanding of
Chemical Safety
21-22 Biological Spills - Management for large spills (volume To enhance uniform Nones
>30 ml) and small spills response to biological
spills
301
17A.1 Safety and Health Policy Statement
We at CNBC are committed to provide a healthy environment for employees and patients, protecting the
public, and preserving our institution’s assets and property.
17A.2 Emergency Response

During the course of normal laboratory operations there is always the potential for an emergency situation
to arise. These emergencies can be the result of a chemical spill, fire, or the need for medical assistance.
In the event of an emergency, an emergency response plan should be implemented. This plan would
include evacuation of the facility if such action is deemed appropriate. Internal communication is very
important during any emergency situation. It is essential that all employees know how to act and react
during the emergency. To accomplish this, it is necessary that a written Emergency Response Plan be
developed and that all employees are trained and participate in drills. All accidents, regardless of
severity, should be reported on incident reporting form. Key elements of an emergency procedure plan
are summarized by the acronym NEAR:
Notify
Evacuate
Assemble
Report
17A.3 Hazard Identification and Communication
17A.3.1 Hazards in the Laboratory

Various types of hazards are encountered in the operation of a clinical laboratory. Types of hazards may
include, biological, chemical, electrical, and fire.
17A.3.2 Identification of hazards

1. Clinical laboratories deal with each of the eight classes of hazardous materials , which are
classified by the United Nations (UN) as:
a. Explosives
b. Compressed gas
c. Flammable liquids
d. Flammable solids
e. Oxidizer materials
f. Toxic materials
g. Corrosive materials
h. Miscellaneous materials not otherwise classified
2. Warning labels aid in the identification of chemical hazards. All hazardous chemical containers
will be suitably labeled. Our clinical laboratories also deal with most of the above classes of
hazardous materials.
302
17A.4 Safety program
1. Although safety is each individual’s responsibility, a specific Individual has been assigned the title
of safety officer. This individual will provide guidance to management officials and supervisors
whose responsibility it is to provide a Safe Work Place for all employees. Each new employee
shall receive a copy of the general laboratory safety manual as part of orientation. Each
employee shall know the location of available evacuation routes and firefighting equipment, as
well as the manner in which the equipment is used. The laboratory‘s continuing education
program will include periodic talks on safety.
2. Ensuring that the laboratory environment meets accepted safety standards is the second part of
the safety program. This effort includes, but is not limited to, attention to proper labeling of
chemicals, types and locations of fire extinguisher, maintenance of hoods in good working order,
proper grounding of electrical equipment, and provision of means for proper handling and
disposal of biohazardous materials , including all patient specimens.
3. A safety inspection team shall be constituted from the laboratory staff and shall be responsible for
conducting periodic and scheduled safety inspections.
17A.4.1 Safety checklist
Purpose: Safety in our laboratory is of prime importance. A review of safety policies and procedures for
our staff helps ensure that safe practices are followed.
17A.4.1.1.General Safety:
a) Location of the sink or basin for eye wash
b) Demonstration of eye wash
c) Demonstration of operation of mechanical pipettes
d) Location of circuit breakers
e) Procedures used in the event of electrical shock injury.
f) State the location of compressed gas cylinders and describe the procedures regarding their use.
17A.4.1.2 Fire safety:

a) State the location of the fire extinguishers and demonstrate or describe their use.
b) State the location of the fire alarm boxes.
c) Identify the location of the posted evacuation routes in the laboratory.
d) Describe the procedures to follow in the event of fire.
e) Participate in a mock fire drill.
303
17A.4.1.3 Chemical safety:
a) Look up a hazardous chemical with which you work
b) Discuss the symptoms of over exposure
c) Identify the protective equipment and ventilation that is required
d) Locate the protective equipment area
e) Describe the special precautions needed if the chemical is carcinogenic.
f) State the emergency first aid for this chemical
g) Describe the appropriate spill cleanup for this chemical
h) State the location of the chemical spill kit and its proper use.
i) Describe how a chemical spill of a pint or less is cleaned up.
17A.4.1.4 Blood borne pathogen safety:

a) State the location of the exposure control plan
b) State the percent of risk of infection with Hepatitis B from exposure to blood and body fluids.
c) List four modes of transmission for HIV
d) Point out a Bio Hazard symbol
e) State the infectious waste and regular trash & identify the proper container for disposal
17A.4.1.5 Personal Protective Equipment:

a. Describe the location of personal protective equipment
b. Demonstrate the aseptic removal of glove.
17A.5 General Safety

People who work in scientific laboratories are exposed to many kinds of hazards. This can be said of
most workplaces; in some, the hazards are well recognized (those of ordinary fire, for example) and the
precautions to be taken are obvious. Laboratories, however, involve a greater variety of possible hazards
than do most workplaces, and some of those hazards call for precautions not ordinary encountered
elsewhere. Therefore, this manual has been provided to inform and guide the laboratory worker in safe
practices which should help to avoid injury.
GENERAL SAFETY AND OPERATIONAL RULES
17A.5.1 General Rules of Safety

a) No running, jumping, or horseplay in laboratory areas shall be permitted.
b) No employee shall work alone in a laboratory or chemical storage area when performing a task
that is considered unusually hazardous by the laboratory supervisor or safety officer.
c) Spills shall be cleaned immediately. Water spills can create a hazard because of the slip
potential and flooding of instruments (particularly on the floor below.) Small spills of liquids and
solids on bench tops shall be cleaned immediately to prevent contact with skin or clothing.
d) Lifting of heavy items must be performed in the proper fashion, using the legs to lift, and not the
back.
e) It is the responsibility of everyone working in the laboratory to make certain that the laboratory is
left clean after work is performed.
304
17A.5.2 Personal Hygiene
a) Wash promptly whenever a chemical has contacted the skin. Know what you are working with
and have the necessary cleaning/neutralization material on hand and readily available.
b) No sandals, open toed shoes or clogs shall be worn by laboratory personnel.
c) Clothing worn in the laboratory should offer protection from splashes and spills, should be easily
removable in case of accident, and should be at least fire resistant. Nonflammable, nonporous
aprons offer the most satisfactory and the least expensive protection. Lab jackets or coats should
have snap fasteners rather than buttons so that they can be readily removed. These coats are to
be fastened closed while working and removed prior to exit from the laboratory.
d) Laboratory clothing should be kept clean and replaced when necessary. Clothing should be
replaced or laundered using appropriate decontamination procedures whenever contamination is
suspected.
e) Lab coats are not to be worn outside the laboratory, especially in rest room or break facilities.
Any lab coats, respirators, or other protective gear must be left in the lab areas. Employees
must, as a matter of routine, be responsible for washing, cleaning, and any other decontamination
required when passing between the lab and the other areas. Washing should be done with soap
and water; do not wash with solvents.
f) Inhalation is one of the four modes of entry for chemical exposure. "Sniff-testing" should not be
done.
g) Never pipette by mouth. Always use a bulb to pipette.
h) Do not drink, eat, smoke, or apply cosmetics in the laboratory or chemical storage areas.
i) Do not use ice from laboratory ice machines for beverages.
j) No food, beverage, tobacco, or cosmetics products are allowed in the laboratory or chemical
storage areas at any time. Cross contamination between these items and chemicals or samples
is an obvious hazard and should be avoided.
17A. 6 Electrical Safety
a. The typical laboratory requires a large quantity of electrical power. This increases the likelihood
of electrically-related problems and hazards. One must address both the electrical shock hazard
to the facility occupants and the fire hazard potential.Whenever electrical wires or connections
exist, the potential for shock or fire hazard also exists. Worn wires on all electrical equipment
should be replaced immediately; all equipment should be grounded through use of three prong
plugs.
b. Electrical equipment and connections should not be handled with wet hands, nor should they be
used after liquid has been spilled on it. The equipment should be turned off immediately and dried
thoroughly; in case a wet or malfunctioning electrical instrument is used by several individuals,
the plug should be pulled and a note cautioning all employees against its use should be placed
prominently on the instrument.
1. The following recommendations are basic to a sound electrical safety program in the
laboratory.
a) All electrical equipment shall be properly grounded.
b) Sufficient room for work must be present in the area of breaker boxes. All the circuit breakers
and the fuses shall be labeled to indicate whether they are in the "on" or "off" position, and what
appliance or room area is served. Fuses must be properly rated.
c) Equipment, appliance and extension cords shall be in good condition.
d) Extension cords shall not be used as a substitute for permanent wiring.
e) Electrical cords or other lines shall not be suspended unsupported across rooms or
passageways. Do not route cords over metal objects such as emergency showers, overhead
305
pipes or frames, metal racks, etc. Do not run cords through holes in walls or ceilings or through
doorways or windows. Do not place under carpet, rugs, or heavy objects. Do not place cords on
pathways or other areas where repeated abuse can cause deterioration of insulation.
f) Multi-outlet plugs shall not be used unless they have a built-in circuit breaker. This causes
overloading on electrical wiring, which will cause damage and possible overheating.
g) Most of the portable multiple outlets are rated at 15 amps. Employees shall check when all
connections are made to determine that the total input average will never exceed 15 amps. (the
amperage on electrical equipment is usually stamped on the manufacturer's plate).
h) All building electrical repairs, splices, and wiring shall be performed by the physical plant
electrical department.
17A.7 Personnel Protective Equipment

a) Hand gloves
b) Protective clothing like: Aprons, Masks, Hair caps.
c) Eye protection : Goggles
d) Consideration for the health and safety of employees now is accepted as an obligation of all
employers and laboratory directors.
e) Safe operation of a clinical laboratory encompasses many aspects, including a formal safety
program, and identification of various hazards, such as chemical, fire, electrical, and biological.
306
17A.8 Fire Hazards and Fire Safety
The ideal solution to the problem of fires and indeed to all laboratory accidents is prevention. However, all
fires cannot be prevented, so provisions must be made for those that do occur.
17A.8.1 Classification of fire and fire extinguisher requirements.
Type of hazard Class of fire Recommended extinguisher

agents
Ordinary Combustibles A Water, dry chemical foam,

loaded steam.
Wood, Cloth, Paper
Flammable Liquids and B Dry chemical, carbon

gases dioxide, loaded system,
halon 1211 or 1301 foam
Solvents & greases, natural
or manufactured gases.
Electrical equipment C Dry chemical, Carbon

dioxide, halon 1211 or 1301
Any energized electrical foam
equipment, if electricity is
turned off at the source ,
equipments reverts to a class
A to B
Combinations of hazards
Ordinary combustibles and A&B Dry chemical, loaded steam,

flammable liquids and gases. foam.
Ordinary combustibles and

electrical equipment.
Dry chemical
A&C
Flammable liquids and

gases and electrical
equipment
Dry chemical, Carbon
B&C dioxide, halon 1211 or 1301
foam
Ordinary combustibles and
flammable liquids and gases,
307
& electrical equipment, Triplex dry chemical.
A,B & C
1. Various types of fire extinguishers are available for use in various types of fires. Because every
area practically cannot contain several types of fire extinguishers, dry chemical fire extinguishers
are among the best all purpose extinguishers. An extinguisher should be located near each
laboratory door and also at the end of the room opposite the door. Every individual in the
laboratory should be instructed in the use of these extinguishers and other available firefighting
equipment. All fire extinguishers should be tested by qualified personnel at intervals specified by
the manufacturer. Each fire extinguisher is labeled based on the type of fire it should be used to
extinguish.
17A.8.2 Steps in an event of Fire

(should be dealt with in conjunction to hospital – wide fire safety policy)
A In the event of a fire, do the following things:
1. Assist any person in immediate danger to safety, if it can be accomplished without risk to
yourself.
2. Immediately activate the building fire alarm system.
3. If the fire is small enough, use a nearby fire extinguisher to control and extinguish the fire. Don't
fight the fire if these conditions exist:
4. The fire is too large or out of control.
5. If the atmosphere is toxic.
6. If the first attempts to put out the fire do not succeed, evacuate the building immediately.
7. Doors, and if possible, windows, should be closed as the last person leaves a room or area of a
lab.
8. Do not use elevators; use building stairwells.
9. When they hear the fire alarm sound, all personnel in the affected areas shall evacuate the
building immediately.
10. Upon evacuating the building, personnel shall proceed to the designated meeting area (at least
150 feet from the affected building) where the supervisors are responsible for taking a head count
and accounting for all personnel.
11. No personnel will be allowed to re-enter the building without permission of laboratory incharge.
17A. 9 Chemical Hazards, Hygiene and Spill Management
a) The proper storage and use of chemicals is necessary to avoid dangers such as burns,
explosions, fires and toxic fumes. Thus knowledge of the properties of the chemicals in use and
proper handling procedures greatly reduces dangerous situations.
b) Bottles of chemicals and solutions should be handled carefully, and a cart should be used to
transport a heavy container or multiple numbers of containers from one area to another.
c) Glass containers of chemicals should be transported in rubber or plastic containers that protect
them from breakage and contain the spill if breakage does occur.
d) Spattering from acids, caustic materials, and strong oxidizing agents probably represents the
greatest hazard to clothing and eyes and is a potential source of chemical burns.
308
e) A bottle should never be held by its neck, but instead firmly around its body with one or both
hands, depending on size of the bottle.
f) Acids must be diluted through slow addition to water; water should never be added to
concentrated acid.
g) During work with acid or alkali solution, safety glasses should be worn.
h) Acids, alkalis, strong oxidizing agents should be mixed in the sink, which provides water for
cooling, as well as for confinement of the reagent in case the flask or bottles breaks.
i) All bottles containing reagents must be labeled properly. A good practice is to label the container
before adding the reagent, thus avoiding the possibility of an unlabeled reagent. The label should
bear the name and concentration of reagent, the initial of the individual who made up the reagent,
and the date on which the reagent was prepared. When appropriate the expiration date also
should be included. The labels should be color coded or an additional label added to designate
specific storage instructions, such as the need for refrigeration or special storage related to
potential hazard.
j) Special care is needed with mercury.
k) Although it is policy of hospital to keep the hospital mercury free, however mercurial compounds
may be in use in some tests. Even small drops of mercury on bench-tops and floors can poison
the atmosphere in a poorly ventilated room. Mercury’s ability to amalgamate with a number of
metals is well known. After an accidental spillage of mercury, the spill area should be cleaned
carefully until no droplets remain. All containers of mercury should be kept stoppered.
17A.9.1 Chemical hygiene

The laboratory will have a complete chemical inventory updated annually. The chemical manufacturer’s
information as supplied on the MSDS will be used to ascertain whether a certain chemical is hazardous.
Each MSDS must provide the product’s identity as it appears on the container label, as well as the
chemical and common names of its hazardous components. The MSDS also provides physical data on
the product, such as boiling point, vapor pressure, and specific gravity, and lists easily recognized
characteristics, such as appearance and odor. Information about hazardous properties is given in detail
on the MSDS: This data details fire and explosion hazards and health – related information, including the
threshold limit value, exposure limit, and toxicity values. The threshold limit value is the allowable
exposure for a given employee during an 8-hour day. The MSDS also notes the effects of over exposure
and provides information on first-aid, spill, and disposal procedures and protective personnel gear and
equipment requirements.
17A.9.2 Chemical Spills
17A.9.2.1 Emergency Spills

A chemical spill is classified as an emergency spill whenever it:
a) Causes personal injury or chemical exposure that requires medical attention;

b) Causes a fire hazard or uncontrollable volatility;
c) Requires a need for breathing apparatus of the supplied air or self-contained type to handle the
material involved;
d) Involves or contaminates a public area;
e) Causes airborne contamination that requires local or building evacuation;
f) Causes a spill that cannot be controlled or isolated by laboratory personnel;
g) Causes damage to university property that will require repairs;
309
h) Involves any quantity of metallic mercury;
i) Cannot be properly handled due to lack of local trained personnel and/or equipment to perform a
safe, effective cleanup;
j) Requires prolonged or overnight cleanup; or
k) Involves an unknown substance
17A.9.2.2 Steps to follow in major chemical spillage
1. Things to do when there is a major chemical spill

a) Don't panic! Always send for help first, if possible.
b) Remove contaminated clothing. Flush skin/eyes with water using eye wash bottle for at least 15
minutes to 30; use soap for intermediate and final cleaning of skin areas.
c) Protect yourself, then remove injured person(s) to fresh air, if safe to do so.
d) Notify nearby persons and evacuate as necessary. Prevent entry, as necessary, by posting a
guard in a safe area and/or shutting doors.
e) If flammable vapors are involved, do not operate electrical switches unless to turn off motorized
equipment. Try to turn off or remove heat sources, where safe to do so.
f) Do not touch the spill without protective clothing.
g) Where the spill does not present immediate personal danger, try to control the spread or volume
of the spill. This could mean shutting a door, moving nearby equipment to prevent further
contamination, repositioning an overturned container or one that has a hole in the bottom or side,
creating a dike by putting an absorbent around a spill or opening the sashes on the fume hoods
to facilitate removal of vapors.
h) Never assume gases or vapors do not exist or are harmless because of lack of smell.
i) Increase ventilation by opening closed fume hood sashes to the 12 inch or full open position.
Exterior doors may be opened to ventilate non-toxic vapors.
j) Use absorbents to collect substances. Reduce vapor concentrations by covering the surface of a
liquid spill with absorbent. Control enlargement of the spill area by diking with absorbent.
2. Steps of spill management:
a) Cordon off the area

b) Open windows
c) Wear PPE (acid resistant) gloves, plastic apron, mask & goggles
d) Sprinkle sodium bicarbonate covering the spill
e) Cover the area with absorbent paper
f) Discard in black bag plastic
310
17A.9.2.3 Steps to follow in minor chemical spillage
Minor spills are those spills which do not fit the requirements for emergency spills.
1. The following general procedures should be used for all minor spills:
a) Attend to any persons who may have been contaminated. If these persons require medical
attention this is an Emergency Spill (See above).
b) Notify persons in the immediate area about the spill.
c) Evacuate all nonessential personnel from the spill area.
d) If the spilled material is flammable, turn off ignition and heat sources.
e) Avoid breathing vapors of the spilled material. If respiratory protection is necessary this is an
Emergency Spill (See above).
f) Leave on or establish exhaust ventilation if it is safe to do so.
g) Secure supplies to effect cleanup.
h) Don appropriate personnel protective equipment and follow the steps of spill management as
mentioned above.
17A.9.2.4 Material Safety Data Sheets

Maintain Material Safety Data Sheets (MSDS): A technical document provided by chemical suppliers
that describes the specific properties of a chemical. Every staff of laboratory should know where it has
been kept.
17A.10 Biological Hazards and Spills Management
a) Prevention of laboratory employee exposure to infectious agents, such as the hepatitis virus and
HIV, is essential. Exposure to infectious agents results from:
b) Accidental puncture with needles.
c) Spraying of infectious material by a syringe or spilling or splattering of these materials on bench
tops or floors including procedures leading to aerosol formation while handling biological material.
d) Centrifuge accidents.
e) Cuts or scratches from contaminated vessels. Any unfixed tissue, including blood slides, also
must be treated as potentially infectious material.
17A.10.1 Standard Precautions in Laboratory
All Lab employees will strictly adhere to Standard Precautions as under:
a) Never perform mouth pipetting and never blow out pipettes that contain potentially infectious
material.
b) Do not mix potentially infectious material by bubbling air through the liquid.
c) Use barrier protection, such as gloves, masks, and protective eye wear and gowns, when
drawing blood from a patient and handling all patient specimens, including when removing
stoppers from tubes. Disposable, non sterile latex or vinyl gloves provide adequate barrier
311
protection. Phlebotomists should clean their gloved hands with skin antiseptic hand rub between
patients.
d) Wash hands whenever gloves are changed.
e) Use facial barrier protection if a significant potential exists for the spattering of blood or body
fluids.
f) Avoid using syringes whenever possible and dispose of needles in rigid containers without
handling them.
g) Dispose of all sharps appropriately.
h) Wear protective clothing, which is an effective barrier against potentially infective materials. When
leaving the lab, remove the protective clothing.
i) Try to prevent accidental injuries.
j) Encourage frequent hand washing in the lab; employees must wash their hands whenever they
leave the lab.
k) Make a habit of keeping your hands from your mouth, nose, eyes and other mucous membranes
to reduce the possibility of self-inoculation.
l) Minimize spills and spatters.
m) Decontaminate all the surfaces and reusable devices after use with appropriate hospital
disinfectants.
n) Do not use warning labels on patient specimens.
o) Before centrifuging tubes, inspect them for cracks. Inspect the inside of the trunnion cup for signs
of erosion or adhering matter. Ensure that rubber cushions are free from all bits of glass.
p) Use bio hazard disposal techniques.
q) Never leave a discarded tube or infected material unattended or unlabeled.
r) Periodically clean the freezer and dry-ice chests to remove broken ampoules and tubes of
biological specimens. Use rubber gloves and respiratory protection during cleaning
s) HBV vaccine will be offered to all employees.
17A.10.2 Biohazard spills and their management
17A.10.2.1 Biological Spills

Biological spills outside biological safety cabinets will generate aerosols that can be dispersed in
the air throughout the laboratory. These spills can be very serious if they involve microorganisms that
require Biosafety Level 3 containment, since most of these agents have the potential for transmitting
disease by infectious aerosols. To reduce the risk of inhalation exposure in such an accident, occupants
should leave the laboratory immediately. The laboratory should not be reentered to decontaminate or
clean up the spill for at least 30 minutes. During this time the aerosol may be removed from the
laboratory via the exhaust ventilation systems, such as biological safety cabinets or chemical fume hoods,
if present.
17A.10.2.1.1 Spills on the Body

a) Remove contaminated clothing.
b) Vigorously wash exposed area with soap and water for one minute.
c) Obtain medical attention (if necessary).
d) Report the incident to the laboratory supervisor.
17A.10.2.1.2 Biosafety Level 1 Organism Spill

a) Wear disposable gloves.
b) Soak paper towels in disinfectant and place over sill.
c) Place towels in a plastic bag for disposal.
d) Clean up spill area with fresh towels soaked in disinfectant.
312
a) Alert people in immediate area of spill.
b) Put on protective equipment. This may include a laboratory coat with long sleeves, back-
fastening gown or jumpsuit, disposable gloves, disposable shoe covers, safety goggles,
mask or full-face shield.
c) Cover spill with paper towels or other absorbent materials.
d) Carefully pour a freshly prepared 1 to 10 dilution of household bleach around the edges of
the spill and then into the spill. Avoid splashing.
e) Allow a 20-minute contact period.
f) After the spill has been absorbed, clean up the spill area with fresh towels soaked in
disinfectant.
g) Place towels in a plastic bag and decontaminate in an autoclave.

a) Attend to injured or contaminated persons and remove them from exposure.
b) Alert people in the laboratory to evacuate.
c) Close doors to affected area.
d) Report the incident to laboratory incharge immediately.
17A.10.2.2 Blood Spills

Should be managed in conjunction with the procedure described in HIC manual
17A.10.2.2.1 General Information

a) Universal precautions must be observed.
b) Only disposable towels should /tissue papers be used to avoid the difficulties involved in
laundering.
c) If a spill involves broken glassware, the glass should never be picked up directly with the hands.
It must be cleaned up using mechanical means, such as a brush and dustpan.
17A.10.2.2.2 Personal Protective Equipment

a) Persons who clean blood spills should wear disposable gloves of sufficient strength so they will
not tear during cleaning activities. If the gloves develop holes, tears, or splits, remove them,
wash hands immediately, and put on fresh gloves. Disposable gloves must never be washed or
reused. Remove gloves one at a time by grasping the wrist opening and pulling toward the
fingers so that the gloves come off as inside out. Double-bag gloves with other contaminated
biomedical waste (such as towels).
b) If enough blood has been spilled to expect splashing during cleaning additional protective
equipment may be required. Face-shield and other protective clothing may have to be used.
17A.10.2.2.3 Disinfectants
a) Read and follow all manufacturers’ handling instructions.
b) All spills of blood and blood-contaminated fluids should be properly cleaned using any of the
suitable disinfectants.
313
17A.10.2.3 Cleaning Blood Spills on Hard Surfaces
To assure the effectiveness of any sterilization or disinfection process, surfaces must first be thoroughly
cleaned of all visible blood or soil before a germicidal chemical is applied for disinfection.
17A.10.3 Management for large spills (volume >30 ml)
a) Cordon off the area and make the people aware about the spill
b) Put on the PPE
c) If there any sharp material is present along with the spill, then first remove it with the help of
plastic scoop or with x-ray film
d) Put large size gauze pad over the spill to soak large amount of spill and discard the pads in red
bag
e) Put soaking paper over the rest amount of spill
f) Make fresh bleaching solution by adding 7.5 gm of bleaching powder in 1 litre of water and shake
it well
g) Put this bleaching solution over the spill and wait for the contact time (20 min.)
h) Take another paper and with the help of this paper remove the paper which already put on the
spill
i) Discard the whole papers in red bag
j) Wash the area with soap and water
k) Remove the PPE and discard in red bag
l) Do hand washing
m) Fill the incident form and send it to HIC department
17A.10.4 Management for small spills

a) Cordon off the area and make the people aware about the spill
b) Wear gloves
c) Put absorbent paper over the spill
d) Make fresh bleaching solution by adding 0.75 gm of bleaching powder in 100 ml of water and
shake it well
e) Put this prepared solution over the absorbent paper and wait for the contact time (20 min.)
f) Discard this papers in red bag
g) Wash the area with soap and water
h) Remove gloves and do hand washing
i) Fill the incident form and send it to HIC department
17A.11 Hazards from Compressed Gases
General rules for handling large cylinders of compressed gas include the following.
a) Always transport cylinders with a hand truck to which the cylinder is secured.
314
b) Leave the valve cap on a cylinder until the cylinder is ready for use, before which time the
cylinder should be secured by a support around the upper one third of its body. Disconnect the
regulator, shut off the valve, and replace the cap before the cylinder is completely empty to avoid
the possibility of the development of a negative pressure. Place a sign or label that reads empty
on the container.
c) Chain or secure cylinders at all times, even when they are empty.
d) Always check cylinders for the composition of their contents before connection to the regulator.
e) Never force threads; if a regulator does not thread readily onto the tank, some thing is wrong.
f) The precautions cited for large refillable gas cylinders also apply to small disposable cylinders,
such as propane cylinders of the type frequently secured to flame photometers and cylinders of
calibrating gases for blood gas equipment. Cylinders in floor-standing base supports require the
additional security of a chain or strap attached to a wall or fixed piece of furniture.
17A.12 Medical Emergencies
b) Personal injury is not uncommon in laboratories. These injuries are usually minor cuts or burns
but can be as severe as acute effects of chemical exposure or incidents such as heart attacks or
strokes.
c) The initial responsibility for first aid rests with the first person(s) at the scene, who should react
quickly but in a calm and reassuring manner. The person assuming responsibility should
immediately summon medical help (be explicit in reporting suspected types of injury or illness,
location of victim, and type of assistance required). The injured person should not be moved
except where necessary to prevent further injury.
d) Inform laboratory incharge so that necessary steps can be undertaken.
e) Prevention of injuries should be a major emphasis of any laboratory safety program. Proper
training will help prevent injuries from glassware, toxic chemicals, burns and electrical shock.
17A.12.1 General
a) First aid is defined as any one-time treatment and any follow up visit for the purpose of observation,
treatment of minor scratches, cuts, burns, splinters, and so forth, which do not ordinarily require
medical care.
b) First aid equipment should be readily available in each laboratory.
17A.12.2 Personal Protection During First Aid

a. Adherence to "Universal Precautions" when employees respond to emergencies which provide
potential exposure to blood and other potentially infectious materials. "Universal Precautions"
stresses that all patients should be assumed to be infectious for HIV and other bloodborne
pathogens.
b. Persons responding to a medical emergency should be protected from exposure to blood and other
potentially infectious materials. Protection can be achieved through adherence to work practices
designed to minimize or eliminate exposure and through the use of personal protective equipment
(i.e., gloves, masks, and protective clothing), which provide a barrier between the worker and the
exposure source. For most situations in which first aid is given, the following guidelines should be
adequate.
i. For bleeding control with minimal bleeding and for handling and cleaning instruments with
microbial contamination, disposable gloves alone should be sufficient.
ii. For bleeding control with spurting blood, disposable gloves, a gown, a mask, and protective
eye wear are recommended.
315
iii. For measuring temperature or measuring blood pressure, no protection is required.
c. After emergency care has been administered, hands and other skin surfaces should be washed
immediately and thoroughly with warm water and soap if contaminated with blood, other body fluids
to which universal precautions apply, or potentially contaminated articles. Hands should always be
washed after gloves are removed, even if the gloves appear to be intact.
17A.13 Accident Reporting
a) ALL injuries shall be reported to laboratory management. Minor injuries many times are not
reported because they are perceived to be embarrassing or that "careless actions" lead to the
accident. However, minor injuries can sometimes lead to more serious complications that only
become evident at a later time. Liability will be handled more effectively if initial accident
documentation exists. In addition, all minor accidents should be investigated by safety and
management personnel. Taking corrective action as a result of a minor accident may keep a
major incident from happening. Without knowledge of all minor accidents, the desirable
investigation is circumvented.
b) Employees should understand that the purpose of reporting and documenting accidents is not to
affix blame, but instead to determine the cause of the accident so that similar incidents may be
prevented in the future.
316
17A.14 General Laboratory techniques
Human error, poor laboratory techniques and misuse of equipment cause the majority of laboratory
injuries and work-related infections.
17A.14.1 Safe handling of specimens in the laboratory

Improper collection, transport and handling of specimens in the laboratory carry a risk of infection to the
personnel involved.
17A.14.2 Specimen containers

Specimen containers may be of glass or preferably plastic. They should be robust and should not leak
when the cap or stopper is correctly applied. No material should remain on the outside of the container.
Containers should be correctly labelled to facilitate identification. Specimen request or specification forms
should not be wrapped around the containers but placed in separate, preferably waterproof envelopes.
17A.14.3 Transport of specimens within the facility

To avoid accidental leakage or spillage, secondary containers, such as boxes, should be used, fitted with
racks so that the specimen containers remain upright. The secondary containers may be of metal or
plastic, should be autoclavable or resistant to the action of chemical disinfectants. They should be
regularly decontaminated.
17A.14.4 Receipt of specimens

A particular room or area must be designated for receipt of specimen.
17A.14.5 Opening packages

Personnel who receive and unpack specimens should be aware of the potential health hazards involved,
and should be trained to adopt standard precautions, particularly when dealing with broken or leaking
containers. Primary specimen containers should be opened in a biological safety cabinet. Disinfectants
should be available.
17A.14.6 Use of pipettes and pipetting aids

1. A pipetting aid must always be used. Pipetting by mouth must be prohibited.
2. All pipettes should have cotton plugs to reduce contamination of pipetting devices.
3. Air should never be blown through a liquid containing infectious agents.
4. Infectious materials should not be mixed by alternate suction and expulsion through a pipette.
5. Liquids should not be forcibly expelled from pipettes.
317
6. Mark-to-mark pipettes are preferable to other types as they do not require expulsion of the last
drop.
7. Contaminated pipettes should be completely submerged in a suitable disinfectant contained in an
unbreakable container. They should be left in the disinfectant for the appropriate length of time
before disposal.
8. A discard container for pipettes should be placed within the biological safety cabinet, not outside it.
9. To avoid dispersion of infectious material dropped from a pipette, an absorbent material should be
placed on the working surface; this should be disposed of as infectious waste after use.
17A.14.7 Avoiding the dispersal of infectious materials

1. In order to avoid the premature shedding of their loads, microbiological transfer loops should have
a diameter of 2–3 mm and be completely closed. The shanks should be not more than 6 cm in
length to minimize vibration.
2. The risk of spatter of infectious material in an open Bunsen burner flame should be avoided by
using an enclosed electric microincinerator to sterilize transfer loops. Disposable transfer loops,
which do not need to be resterilized, are preferable.
3. Care should be taken when drying sputum samples, to avoid creating aerosols.
4. Discarded specimens and cultures for autoclaving and/or disposal should be placed in leakproof
containers, e.g. laboratory discard bags. Tops should be secured (e.g. with autoclave tape) prior to
disposal into waste containers.
5. Working areas must be decontaminated with a suitable disinfectant at the end of each work period.
6. Avoiding ingestion of infectious materials and contact with skin and eyes
7. Large particles and droplets (> 5 mm in diameter) released during microbiological manipulations
settle rapidly on bench surfaces and on the hands of the operator. Disposable gloves should be
worn. Laboratory workers should avoid touching their mouth, eyes and face.
8. Food and drink must not be consumed or stored in the laboratory.
9. No articles should be placed in the mouth – pens, pencils, chewing gum – in the laboratory.
10. Cosmetics should not be applied in the laboratory.
11. The face, eyes and mouth should be shielded or otherwise protected during any operation that may
result in the splashing of potentially infectious materials.
17A.14.8 Avoiding injection of infectious materials

1. Accidental inoculation resulting from injury with broken or chipped glassware can be avoided
through careful practices and procedures. Glassware should be replaced with plastic ware
whenever possible.
2. Accidental injection may result from sharps injuries e.g. with hypodermic needles (needle-sticks),
glass Pasteur pipettes, or broken glass.
3. Needles should never be recapped. Disposable articles should be discarded into
4. puncture-proof/puncture-resistant containers fitted with covers.
318
17A.14.9 Separation of serum
1. Only properly trained staff should be employed for this work.
2. Gloves and eye and mucous membrane protection should be worn.
3. Splashes and aerosols can only be avoided or minimized by good laboratory technique. Blood and
serum should be pipetted carefully, not poured. Pipetting by mouth must be forbidden.
4. After use, pipettes should be completely submerged in suitable disinfectant. They should remain in
the disinfectant for the appropriate time before disposal or washing and sterilization for reuse.
5. Discarded specimen tubes containing blood clots, etc. (with caps replaced) should be placed in
suitable leakproof containers for autoclaving and/or incineration.
17A.15 Handling glassware and safety practices for disposal of broken glassware
17A.15.1 Handling Glassware

a) Glass breakage is a common cause of injuries in laboratories. Only glass in good condition
should be used.
b) Discard or send for repair all broken, chipped, starred or badly scratched glassware. Hand
protection should be used when picking up broken glass.
c) Clean all glassware before sending for repair.
d) When using glass tubing, all ends should be fire polished. Lubricate tubing with glycerin or water
before inserting into rubber stoppers or rubber tubing.
e) Protect hands with leather gloves when inserting glass tubing. Hold elbows close to the body to
limit movement when handling tubing.
f) Do not store glassware near the edge of shelves.
g) Store large or heavier glassware on lower shelves.
h) Use glassware of the proper size. Allow at least 20% free space. Grasp a three-neck flask by the
middle neck, not a side neck.
i) Do not attempt to catch glassware if it is dropped or knocked over.
j) Conventional laboratory glassware must never be pressurized.
17A.15.2 Handling and Disposal of Broken Glassware

a) Inspect all glassware before use. Do not use broken, chipped, starred or badly scratched
glassware. If it cannot be repaired, discard it in containers specifically designated for broken
glass. All broken glass requires special handling and disposal procedures to prevent injury not
only to lab personnel, but members of the sanitorial staff as well.
b) All broken glass shall be disposed in rigid, puncture proof containers such as a cardboard box
with taped seams, or a plastic bucket or metal can with a sealing lid. All broken glass disposal
containers shall be clearly marked "DANGER - BROKEN GLASS" Limit quantities to no more
than approximately 15 to 20 pounds so that lifting of the container will not create a situation that
could cause back injury.
c) Food, beverage, and uncontaminated glassware: dispose in a rigid, puncture proof container
such as a box with sealed or taped edges or a metal or thick plastic can or bucket with a sealing
lid. Label container "danger - broken glass".
d) Glassware with biological contamination: glassware that has been in contact with infectious
agents may include: used slides, cover slips, test tubes, beakers, pipettes, etc. Contaminated
glassware shall be disinfected before disposal. Dispose in a rigid, puncture proof container such
as a box with sealed or taped edges or a metal or thick plastic can or bucket with a sealing lid.
Label container "danger - broken glass". Contact the biological safety officer if you require further
information.
e) Glassware with chemical contamination: empty the contents of the glassware into a suitable
container if safe to do so.
319
17A.16 Centrifuge Safety
17A.16.1 Steps for centrifugation safety:

Suggested steps to follow BEFORE starting the centrifuge:
1. Insure centrifuge bowl and tubes are dry.

2. Is the centrifuge spindle clean?
3. Avoid overfilling of tubes and bottles
4. Insure rotor is properly seated on drive hub.
5. Make sure tubes are properly balanced in rotor
6. Has the rotor been properly secured to drive?
7. Is the centrifuge lid shut properly?
a. After the above steps are taken and the centrifuge has started, make sure the run is proceeding
normally before you leave the area.
b. Once the centrifuge run is complete, make sure the rotor has STOPPED completely before you
open the centrifuge lid; then check for spills. If infectious material was placed in the centrifuge,
WAIT 10 minutes before opening the centrifuge lid. If leak or damage has occurred, close the lid
and plan proper decontamination and cleanup.
17A.16.2 Maintenance/Cleaning:
1. Keep rotors clean and dry. If spills occur, make sure rotor has been cleaned/decontaminated. If
salts or corrosive materials were used, ensure they have been removed form the rotor.
2. Avoid mechanical scratches. The smallest, scarcely visible scratch allows etching to enlarge the
fracture, which is subject to enormous rupturing forces at high G's--a vicious cycle leading to rotor
explosion.
3. Avoid bottle brushes with sharp metal ends and harsh detergents when cleaning aluminum rotor
heads.
4. After proper clean-up, rinse the rotor with de-ionized water.
17A.16.3 Inspections:
1. Check the rotor for rough spots, pitting, and discoloration. If discovered, check with the
manufacturer before using.
2. Use professional rotor inspection services frequently.
3. Consult the centrifuge manufacturer and centrifuge log for the derating schedule for the rotor.
17A.18 Biological Safety
Microbiological and biohazard laboratories are special, often unique, work environments that may pose
special infectious disease risks to persons in or near them. Personnel have contracted infections in the
320
laboratory throughout the history of microbiological and biohazard research. A number of cases have
been attributed to carelessness or poor technique in the handling of infectious materials.
17A.18.1 Containment
1. The term "containment" is used in describing safe methods for managing infectious agents in the
laboratory environment where they are being handled or maintained. Primary containment, the
protection of personnel and the immediate laboratory environment from exposure to infectious
agents, is provided by good microbiological technique and the use of appropriate safety
equipment. The use of vaccines may provide an increased level of personal protection.
Secondary containment, the protection of the environment external to the laboratory from
exposure to infectious materials, is provided by a combination of facility design and operational
practices. The purpose of containment is to reduce exposure of laboratory workers and other
persons, and to prevent escape into the outside environment of potentially hazardous agents.
2. The three elements of containment include laboratory practice and technique, safety equipment,
and facility design.
17A.18.2 Laboratory practice and technique
1. Employees shall wash their hands immediately or as soon as possible after removal of gloves or
other personal protective equipment and after hand contact with blood or other potentially
infectious materials.
2. All personal protective equipment shall be removed immediately upon leaving the work area or as
soon as possible if overtly contaminated and placed in an appropriately designated area or
container for storage, washing, decontamination or disposal.
3. Used needles and other sharps shall not be sheared, bent, broken, recapped, or resheathed by
hand. Used needles shall not be removed from disposable syringes.
4. Eating, drinking, smoking, applying cosmetics, and handling contact lenses are prohibited in work
areas where there is a potential for occupational exposure.
5. Food and drink shall not be stored in refrigerators, freezers, or cabinets where blood or other
potentially infectious materials are stored or in other areas of possible contamination.
6. All procedures involving blood or other potentially infectious materials shall be performed in such
a manner as to minimize splashing, spraying, and aerosolization of these substances.
7. Gloves shall be worn when the employee has the potential for the hands to have the direct skin
contact with blood, other potentially infectious materials, mucous membranes, non-intact skin,
and when handling items or surfaces soiled with blood or other potentially infectious material.
a) Disposable (single-use) gloves such as surgical or examination gloves shall be replaced
as soon as possible when visibly soiled, torn, punctured or when their ability to function
as a barrier is compromised. They shall not be washed or disinfected for re-use.
b) Utility gloves may be disinfected for re-use if the integrity of the glove is not compromised,
however, they must be discarded if they are cracked, peeling, discolored, torn, punctured,
or exhibit other signs of deterioration.
8. Masks and eye protection or chin-length face shields shall be worn whenever splashes, spray,
spatter, droplets, or aerosols of blood or other potentially infectious materials may be generated
and there is a potential for eye, nose, or mouth contamination.
9. Appropriate protective clothing shall be worn when the employee has potential for occupational
exposure.
10. The type and characteristics will depend upon the task and degree of exposure anticipated.
a) Gowns, lab coats, aprons or similar clothing shall be worn if there is a potential for soiling
of clothes with blood or other potentially infectious materials.
321
b) Fluid resistant clothing, surgical caps or hoods shall be worn if there is a potential for
splashing or spraying of blood or other potentially infectious materials.
c) Fluid-proof shoe covers shall be worn if there is a potential for shoes to become
contaminated and/or soaked with blood or other potentially infectious materials.
17A.19 Housekeeping
17A.19.1 The following listing of good housekeeping practices indicates common sense activities which
should be implemented as a matter of course in the laboratory.
17A.19.2 These recommendations are designed for accident prevention.
1. The area must be kept as clean as the work allows.

2. Each laboratory employee shall be responsible for maintaining the cleanliness of his/her area.
3. Reagents and equipment items should be returned to their proper place after use. This also
applies to samples in progress. Contaminated or dirty glassware should be placed in specific
cleaning areas and not allowed to accumulate.
4. Chemicals, especially liquids, should never be stored on the floor, except in closed door cabinets
suitable for the material to be stored. Nor should large bottles (2.5l or larger) be stored above the
bench top.
5. Reagents, solutions, glassware, or other apparatus shall not be stored in hoods. Besides
reducing the available work space, they may interfere with the proper air flow pattern and reduce
the effectiveness of the hood as a safety device.
6. Counter tops should be kept neat and clean. Bench tops and fume hoods shall not be used for
chemical storage. All work done in fume hoods shall be performed in the "safety zone", (6"
minimum from the sash).
7. Stored items, equipment, and glass tubing shall not project beyond the front of shelf or counter
limits.
8. Stored items or equipment shall not block access to the fire extinguisher(s), safety equipment, or
other emergency items.
9. Stairways, hallways, passageways/aisles and access to emergency equipment and/or exits must
be kept dry and not be obstructed in any fashion, including storage, equipment, phone or other
wiring.
10. No combustible material such as paper, wooden boxes, pallets, etc., shall be stored under
stairwells or in hallways. Hallways shall be kept free of boxes and materials so that exits or
normal paths of travel will not be blocked.
11. Materials stored near aisles shall be restrained to prevent their falling.
12. Mats and carpeting shall be kept in good condition.
13. All working surfaces and floors should be cleaned regularly.
14. All containers must be labeled with at least the identity of the contents and the hazards those
chemicals present to users. If the contents of all containers are known we will no longer have an
unknown waste disposal problem.
15. Aim of working in synchrony with housekeeping department and the work site shall be maintained
in a clean and sanitary condition. All equipment, environmental enclosures and working surfaces
shall be properly cleaned and disinfected after contact with blood or other potentially infectious
materials.
16. Work surfaces shall be decontaminated with an appropriate disinfectant after completion of
procedures; when surfaces are overtly contaminated; immediately after the spill of blood or other
potentially infectious materials; and at the end of the work shift.
17. Protective coverings such as plastic wrap, aluminum foil, or imperviously-backed absorbent paper
may be used to cover equipment and environmental surfaces. These coverings shall be removed
and replaced at the end of the work shift or when they become overtly contaminated.
322
18. Equipment which may become contaminated with blood or other potentially infectious materials
shall be checked routinely and prior to servicing or shipping and shall be decontaminated as
necessary.
19. All bins, pails, cans, and similar receptacles intended for re-use which have a potential for
becoming contaminated with blood or other potentially infectious materials shall be inspected,
cleaned, and disinfected on a regularly scheduled basis and cleaned and disinfected immediately
or as soon as possible upon visible contamination.
20. Broken glassware which may be contaminated shall not be picked up directly with the hands. It
shall be cleaned up using mechanical means such as a brush and dust pan, tongs, cotton swabs
or forceps.
21. Specimens of blood or other potentially infectious materials shall be placed in a closable, leak-
proof container labeled or color-coded bag prior to being stored or transported. If outside
contamination of the primary container is likely, then a second leak-proof container that is labeled
or color-coded shall be placed over the outside of the first container and closed to prevent
leakage during handling, storage, or transport. If puncture of the primary container is likely, it
shall be placed in a leak-proof puncture-resistant secondary container.
22. Reusable items contaminated with blood or other potentially infectious materials shall be
decontaminated prior to washing and/or reprocessing.
17A.20 Bio-Safety Levels
17A.20.1. Four bio-safety levels are described which consist of combinations of laboratory practices and
techniques, safety equipment, and laboratory facilities appropriate for the operations performed and the
hazard posed by the infectious agents and for the laboratory function or activity.
17A.20.2. Bio-safety level 1: practices, safety equipment, and facilities are appropriate for facilities in
which work is done with defined and characterized strains of viable microorganisms not known to cause
disease in healthy adult humans. Bacillus subtilis, Naegleria gruberi, and infectious canine hepatitis virus
are representative of those microorganisms meeting these criteria. Many agents not ordinarily associated
with disease processes in humans are, however, opportunistic pathogens and may cause infection in the
young, the aged, immunodeficient or immunosuppressed individuals. Vaccine strains which have
undergone multiple in-vivo passages should not be considered avirulent simply because they are vaccine
strains.
17A.20.3 Bio-safety level 2: practices, equipment, and facilities are applicable to clinical facilities in which
work is done with the broad spectrum of indigenous moderate-risk agents present in the community and
associated with human disease of varying severity. With good microbiological techniques, these agents
can be used safely in activities conducted on the open bench, provided the potential for producing
aerosols is low. Hepatitis b virus, the salmonellae, and toxoplasma spp. Are representative of
microorganism assignment to this containment level. Primary hazards to personnel working with these
agents may include accidental autoinnoculation, ingestion, and skin or mucous membrane exposure to
infectious materials. Procedures with high aerosol potential that may increase the risk of exposure to
personnel, must be conducted in primary containment equipment or devices.
17A.20.4 Bio-safety level 3: practices, safety equipment, and facilities are applicable to facilities in which
work is done with indigenous or exotic agents where the potential for infection by aerosols is real and the
disease may have serious or lethal consequences. Autoinnoculation and ingestion also represent
primary hazards to personnel working with these agents. Examples of such agents for which bio-safety
level 3 safeguards are generally recommended include mycobacterium tuberculosis, st. Louis
encephalitis virus and coxiella burnetti.
323
17A.20.5 Bio-safety level 4: practices, safety equipment, and facilities are applicable to work with
dangerous and exotic agents which pose a high individual risk of life threatening disease. All
manipulations of potentially infectious diagnostic materials, isolates, and naturally or experimentally
infected animals pose a high risk of exposure and infection to laboratory personnel. Lassa fever virus is
representative of the microorganisms assigned to level 4.
17A.20.6 Biological safety cabinets (class I or II) should be used for the initial processing of clinical
specimens when the nature of the test is requested or other information is suggestive that an agent
readily transmissible by infectious aerosols is likely to be present. Class II biological safety cabinets are
also used to protect the integrity of the specimens or cultures by preventing contamination from the
laboratory environment.Segregating clinical laboratory functions and limiting or restricting access to
laboratory areas are the responsibility of the laboratory supervisor.
17A.20.7 Handling potentially infectious material
Additional procedures for working with human blood or other potentially infectious material.
1. Universal precautions shall be observed at all times. Universal precautions apply to blood, any
other body fluid containing visible blood, and other potentially infectious material.
I. Under circumstances in which differentiation between body fluid types is difficult or
impossible, all body fluids shall be considered potentially infectious materials.
II. Universal precautions do not apply to feces, nasal secretions, sputum, saliva, sweat, tears,
urine, or vomitus unless they contain visible blood.
2. Other potentially infectious material means the following human body fluids:Vaginal secretions,
Pericardial fluid, Cerebrospinal fluid, Synovial fluid, Pleural fluid, Peritoneal fluid, Amniotic fluid,
Saliva in dental procedures, Any body fluid that is visibly contaminated with blood and all body
fluids in situations where it is difficult or impossible to differentiate between body fluids, Any
unfixed tissue or organ (other than intact skin) from a human, living or dead,Human
immunodeficiency virus (HIV)-containing cell or tissue cultures, organ cultures, and HIV or
hepatitis b virus (HBV)-containing culture medium or other solutions, and Blood, organs, or other
tissues from experimental animals infected with HIV, HBV, or other diseases infectious to
humans.
3. Employees must wash their hands immediately or as soon as feasible after removal of gloves or
other personal protective equipment, and following contact with blood or other potentially
infectious materials.
4. Contaminated needles or other contaminated sharps must not be recapped, sheared, bent,
broken or resheathed by hand. Contaminated sharps must be placed in appropriate containers
until properly reprocessed or disposed. These containers shall be:
I. Puncture resistant,
II. Labeled or color-coded, and
III. Leak-proof on the sides and bottom.
5. Specimens of blood or other potentially infectious materials should be placed in a labeled or
color-coded container which prevents leakage during collection, storage, transport, or shipping. A
secondary container must be used if the primary container is contaminated, punctured or leaking.
6. Equipment which has been in contact with blood or other potentially infected material must be
examined and decontaminated by laboratory personnel as necessary prior to servicing or
shipping.
324
7. If the equipment cannot be completely decontaminated, a readily observable label must be
attached to the contaminated equipment and all persons who will be in contact with the
equipment should be notified.
8. Gloves must be worn when there is potential for contact with blood, or other potentially infectious
materials. Disposable (single use) gloves such as surgical or examination gloves must be
replaced as soon as possible when visibly soiled, torn, and punctured or when their ability to
function as a barrier is compromised.
9. Additional appropriate protective clothing should be selected and worn based upon the task and
degree of exposure anticipated.
I. Gowns, laboratory coats, aprons or similar clothing should be worn if there is a
potential for soiling of clothes with blood or other potentially infectious materials.
II. Fluid-resistant clothing should be worn if there is a potential for splashing or
spraying of blood or other potentially infectious materials.
III. Surgical caps or hoods should be worn if there is a potential for splashing or
spraying of blood or other potentially infectious materials.
IV. Fluid-proof shoe covers should be worn if there is a potential for shoes to
become contaminated and/or soaked with blood or other potentially infectious
materials.
10. Work surfaces must be decontaminated with an appropriate disinfectant after completion of
procedures; when surfaces are overtly contaminated; immediately after the spill of blood or other
potentially infectious materials; and at the end of the work shift.
I. Appropriate germicidals include:
1. EPA-registered "hospital disinfectant" chemical germicides that have a
label claim for tuberculocidal activity, and
2. Commercially available hard-surface germicides or solutions containing
at least 500 parts per million free available chlorine (a 1:100 dilution of
common household bleach - approximately ¼ cup of bleach per gallon of
tap water).
II. For routine housekeeping or removal of soiling in the absence of visible blood
contamination, EPA-registered "hospital disinfectants" (no label claim for
tuberculocidal activity required) can be used.
III. Environmental surfaces such as floors, woodwork, or countertops which have
become soiled should be cleaned and disinfected using any cleaner or
disinfectant agent that is intended for environmental use.
11. All bins, pails, cans, and similar receptacles intended for reuse that have a potential for becoming
contaminated with blood or other potentially infectious materials should be inspected, cleaned,
and disinfected on a regularly scheduled basis and cleaned and disinfected immediately or as
soon as possible upon visible contamination.
12. Broken glassware which may be contaminated must not be picked up directly with the hands. It
shall be cleaned up using mechanical means such as a brush and dust pan, a vacuum cleaner,
tongs, cotton swabs or forceps.
325
17A.22 Effective Use of Biological Safety Cabinets
1. Exposure to airborne microorganisms can result in infection of laboratory workers or

contamination of research materials. Biomedical engineering and technology have provided
safeguards, but these safeguards do not prevent mistakes or human errors. Danger to personnel
and to the success of scientific investigation from carelessly or improperly used equipment cannot
be overly emphasized.
2. The Laminar Flow Biological Safety Cabinet, designed to prevent escape of pathogens into the
workers' environment and to bar contaminants from the research work zone, is a key element to
safe, successful experimentation with biological materials. Escape of pathogens into the workers'
area is prevented by an air barrier at the front opening and the cleaning action of the exhaust air
filter. Inward flow of room air into the front air intake grill creates the air barrier. The amount of
air drawn into the air intake grill and the amount of air exhausted through the exhaust filter are
equal. The exhaust filter removes airborne biological contaminants which may be released in the
cabinet. It does not remove chemical or radiological contaminants.
3. Contamination of the work area inside the cabinet is prevented by the cleaning action of the
supply filters. Air flows through the cabinet work area in a downward direction at a uniform
velocity. The air continues to be recirculated by the fan through the air flow plenum. Airborne
biological contaminants are removed by the filters as the air is returned to the cabinet work area.
4. Certification and advance planning are of prime importance to safe operation. Only qualified
personnel using approved test methods and equipment should provide performance certification
at initial installation, after maintenance, and on an annual basis thereafter. Certification is also
necessary after the cabinet has been moved and after filters have been replaced. Many cabinets
have gauges to indicate pressure differential across the supply filters. If the filters must be
replaced, the cabinet MUST be decontaminated first. This is the responsibility of the researcher
to do or have done by a qualified contractor. After decontamination, only qualified Site Support
personnel should replace filters. Fan speed must also be readjusted by qualified maintenance
technicians.
5. It is the responsibility of individual researchers and/or departments to insure this process is
accomplished at least annually.
6. Maximum safety and full use of the cabinet can be best achieved by adequate advanced
planning. Ideally, advanced planning should follow a procedural check list to anticipate
equipment, apparatus, media, order of events and the many other details necessary for the
completion of the assignment.
7. When planning is completed, start-up procedures may be initiated. There are three start-up
steps:
i. Turn on the lights
II. Check the air intake and exhaust grill to make sure they are unobstructed
III. Turn on the fan
8. Allow the fan to operate a minimum of five minutes before manipulations are begun in the
cabinet. In addition, the following points should be considered:
9. Some cabinets are equipped with ultraviolet light. These must be turned off during the day while
laboratory personnel are occupying the room.
10. Hands and arms should be washed well with germicidal soap before and after work in the
cabinet.
11. Technicians are encouraged to wear long-sleeve gowns with knit cuffs and rubber gloves. This
minimizes the shedding of skin flora into the work area and protects the hands and arms from
contamination by viable agents.
12. Interior surfaces of the work area should be disinfected by wiping them thoroughly with 70%
alcohol.
326
13. The cabinets should not be overloaded. Everything needed for the complete procedure should
be placed in the cabinet before starting so that nothing passes in or out through the air barrier
until the procedure is completed.
14. Do not place anything over the front intake or rear exhaust grill in units having a solid work
surface. As a general rule, keep equipment at least four inches inside the cabinet window and
perform transfer of viable materials as deeply into the cabinet as possible.
15. After all materials have been placed in the cabinet, wait 2-3 minutes before beginning work. This
will allow sufficient time for the cabinet air to purge airborne contamination from the work area.
16. Hold the activity in the room to a minimum. Unnecessary activity may create disruptive air
currents. The ideal location for a cabinet is in a quiet end of the laboratory, removed from
doorways, air conditioning and heating vents. Opening and closing laboratory doors can cause
disruptive drafts that allow microorganisms to penetrate the air barrier.
17. Schedule uninterrupted work periods. The movement of objects including hands and arms
causes turbulent air currents which disrupt the air barrier and allow escape and entrance of
airborne contaminants.
18. Air turbulence caused by rotating laboratory equipment, such as a small clinical centrifuge,
disrupt air flow within the cabinet and at the work opening. This is sufficient for contaminated air
to escape to the laboratory environment. If a centrifuge must be used in the cabinet, do not
perform other research activities in the cabinet while the centrifuge is operating.
19. Normal laboratory contamination control procedures and aseptic techniques are still necessary
while working in the biological safety cabinet.
20. Equipment in direct contact with the biological agent should not be removed from the cabinet until
enclosed or until the surface is decontaminated. Trays of discarded pipettes and glassware must
be covered before removal from the cabinets.
21. If an accident occurs which spills or splatters the biological agent in the work area, all surfaces in
the cabinet must be surface decontaminated before being removed.
22. Do not use a bunsen burner in a biological safety cabinet. The flame causes turbulence in the air
stream and the heat generated may damage the hepa filter. If a procedure requires the use of a
flame, a burner with a pilot light should be used. It should be placed to the rear of the work space
where resulting air turbulence will have a minimal effect.
23. Do not mouth pipette.
24. Following completion of the work, the following steps must be performed:
25. Allow the cabinet to run 2-3 minutes with no activity. This will allow sufficient time for cabinet air
flow to purge airborne contaminants from the work area;
26. Decontamination of the interior surfaces should be repeated after removal of all materials,
cultures, apparatus, etc. A careful check of the work area should be made for spilled or splashed
nutrients. They may support fungus growth and result in spore liberation that contaminates the
protected work environment; and
27. Shut down by turning off the fan and lights. Use UV lights according to manufacturer's
recommendations. Do not use the cabinet to store excess laboratory equipment.
MYTHS, LIES, AND GOBBLEDYGOOK*
a) "I've got to use a Bunsen burner in my biohazard cabinet..."

Using a Bunsen burner in a biohazard cabinet compromises the performance of the unit and may
be dangerous. During operation, the flame of a burner is very disruptive to the air flow patterns of
the cabinet, and may actually increase the dispersion of aerosols in the work area. In addition, if
the flame of the burner is too large, the excessive heat may melt in adhesive holding the HEPA
filter together or literally burn holes in the filter media. (yes, it does happen on a regular basis.)
Finally, a Bunsen burner in a biological safety cabinet is just plain dangerous. An unattended
burner may blow out. If in a type a or a/b3 cabinet, the recirculating gas may reach explosive
concentrations (that has also happened on several occasions). Labconco recommends using
alternative methods such as electric incinerators, or disposable inoculating hoops, for instance.
327
The practice of flaming bottle mouths is unnecessary, as the work area of a biohazard cabinet
should be a sterile environment, if used properly.
b) "I can use a biological safety cabinet just as if it were a fume hood..."
No. The biohazard cabinet and the chemical fume hood are two distinctly different pieces of
equipment and must be used differently. The fume hood is designed to remove noxious or toxic
fumes and aerosols away from the operator. It should be constructed of materials that are inert to
a wide variety of chemical agents. The biohazard cabinet's primary purpose is to protect the
operator, environment, and often the product from biohazardous contaminants. The biohazard
cabinet and its hepa filters are constructed of materials that are inert to the chemicals used in
connection with biological research, but may be damaged by some of the more corrosive
chemicals commonly used in fume hoods. Don't try to use a biohazard cabinet as a fume hood!
c) "If I work in a biohazard cabinet, i don't have to be as careful with my technique..."
Wrong. The biohazard cabinet will provide personal and product protection only if used properly.
Aseptic technique must be practiced at all times while working in a biohazard cabinet.
d) "I use the cabinet's uv light, so i don't need to decontaminate the work area..."
Wrong. The uv light is only good as an adjunct, to minimize contamination of the work areawhen the
cabinet is not in use. Ultraviolet light has virtually no penetrating power, and as such, will not kill
microbes protected by dust, dirt, or organic material. The best method to prevent contamination in the
cabinet is regular decontamination of the work area surfaces, before and after the cabinet is used.
e)"Can I put a centrifuge in the biohazard cabinet?"
Large objects placed in the biohazard cabinet will impede the airflow in the work area, reducing the
efficiency of the cabinet. Electrical appliances like centrifuges, blenders, etc., will often disrupt the airflow
around them due to their cooling fans. It is better to use a primary barrier on the appliance (such as a
sealed safety cup in the centrifuge) rather than a biohazard cabinet to provide containment.
f) "A total exhaust biohazard cabinet will give better protection than a type a cabinet..."
1. If you're talking about protection from volatile toxic chemicals or radionuclides, you're right.
2. If you're referring to protection from biohazardous aerosols, you may not be.
3. Assuming that the units in question are both nsf listed, then both are subjected to the same
biological challenge tests. Any claims for superior biological containment should be documented
by additional biological challenge test data.
328
g) "There’s nothing wrong with using the biohazard cabinet to store material when not in use."
Yes there is. Storing chemicals and materials in the biohazard cabinet make it more difficult to use when
the need arises. If chemicals leak while stored in the cabinet, the work area of the cabinet could be
damaged. Don't use the biohazard cabinet as a storage area.
h) "All biohazard cabinets should operate continuously, 24 hours-a-day."
1. Some applications of the biohazard cabinet require that the unit operate continuously. When
used to prepare cytotoxic drugs, for example, the unit should operate continuously, to prevent
toxic residue form migrating out of the cabinet ductwork and into the laboratory.
2. if the cabinet is not used in such an application, there is no need to leave it operating
continuously. This will only reduce the life of the cabinet blower and hepa filters.
i) "If I leave my type a cabinet running continuously, it will clean all the air in the room to class 100
conditions."
Not necessarily. Assuming you had an air-tight room, with no ventilation system, an air-tight door seal,
and no activity in it, then a recirculating type a cabinet might clean the room to class 100 levels. This
would also unfortunately shorten the operating life of the motor and HEPA filters (and heat up the room
considerably). Regardless, as soon as the operator opens the room door to enter, particulate-laden air
will contaminate the room, raising it far above class 100 conditions.
17A. 23 Administrative
1. The intent of a laboratory safety program is to provide guidance and training to all laboratory
workers who use hazardous substances or engage in potentially hazardous laboratory
operations. Experience in industry has shown that the laboratory can be a safe workplace,
however, this achievement was accomplished ONLY by the implementation of vigorous safety
planning and training sessions.
2. Educational activities shall be provided for all persons who may be exposed to potential hazards
in connection with laboratory operations including faculty members, students, lab supervisors, lab
workers, maintenance workers, janitorial and storeroom personnel. If other non-lab related
offices are nearby, consideration should be given to providing these workers with the necessary
knowledge to protect them (which might be as simple as telling them which door to use in case of
an emergency). This training process shall be a part of new employee indoctrination or
reassignment.
3. Institutional safety education programs shall be a regular continuous activity and not once-a-year
presentations provided for groups of new students or employees.
4. The following sections are intended as resource documents for administrative benefit.
329
17A. 24 Safety Education And Training Program
1. Our most valuable resource is the people who work for us. Injuries can be prevented. To achieve
this objective, CNBC will make all reasonable efforts to comply with all government regulations
pertaining to safety and health issues. An effective safety and health program will be
implemented throughout our organization.
2. CNBC laboratory provide health and safety training programs for their employees. Attendance at
these training courses is mandatory.
3. The training includes

a) The methods and observations that may be used to detect the presence or release of a
hazardous chemical.
b) The physical and health hazards of chemicals used in the work area.
c) The measures employees can use to protect themselves from these hazards, including specific
procedures such as appropriate work practices, personal protective equipment to be used, and
emergency procedures.
d) The CNBC laboratory safety manual
e) First aid training.
F) Bloodborne pathogens training - all employees gets training on occupational exposure to blood or
other potentially infectious material at least annually.This training must be documented.
17A.25 Safety Surveys
1. Safety surveys are similar to safety audits except they do not evaluate management, attitudes,
nor do they ensure that safety programs are in place.
2. Safety surveys areconducted as walk-throughs of the physical areas of the laboratory and related
areas, with the goal of identifying safety hazards and concerns. The surveys are be conducted
on a monthly basis by the laboratory supervisor. Survey notes problem areas, write reports,
present the report to management, offer recommendations, set completion dates and follow-up to
ensure action has taken place.
.
330
17A.26 APPENDIX A
LABORATORY ENVIRONMENTAL AUDIT FORM
Department: Faculty Member: Date:
Room #:
Fire Protection (Yes/No) Electrical (Yes/No) Biological Safety (Yes/No)
 Easy extinguisher  Absence of  Absence of live

access? overloaded circuits? animals?
 Inspection current?  Electrical cords in  Are the workers

good condition? trained?
How many of each?
 Proper grounding?  Is PPE adequate?
Dry Chem ___ Halon
___  Absence of extension  Are there BioSafety
CO2 ___ APW ___ cords? cabinets?
First Aid (Yes/No) Eye Wash Stations (Yes/No) Safety Showers (Yes/No)
 Is the stock adequate?  Proper location?  Proper location?
 Labeled?  Inspected and tested?  Tested and sealed?
 Easy access?  Plumbed system?  Workable?
 Are the procedures  Labeled?  Labeled?

posted?
Staff Summary (+/-) Hazard Communications Refrigerators (Yes/No)

(Yes/No)
 Safety practices  Lab sign-in?  Absence of food

storage?
 Haz-Com  Safety rules posted?
 Properly installed?
 PPE / spill training  Emergency
procedures?
 Chemical hygiene plan
 Containers labeled?
 Emergency labels on
entrance?
General Use (Yes/No) Housekeeping (Yes/No) General Storage (Yes/No)
331
 Absence of hazardous  Aisles clear?  Absence of leaking
materials? containers?
 Exits clear?
 Absence of  Glass containers all
explosives?  Haz-Waste collection? less than 4 liters?
 Absence of  Absence of  Segregation of

corrosives? eat/drink/smoke? chemicals?
 Absence of previous  Absence of corroded

spills? containers?
 Containers capped?
 Glass shatter-proof?
332
Equipment Summary (count) Ventilation (Yes/No)
Fume Hoods Explos. Frig.  Adequate ventilation?
Perc Hoods Eye Wash  Absence of storage in

hood?
Cano Hoods Exits
 Fume hoods
BioSafety Hoods Safety Shower adequate?
Cylinder Dolly Flam. Cab.  Velocity tested?
Spill Kit Spill PPE  Lab neg. to other

rooms?
 Haz. exhaust labeled?
PPE (Yes/No) Flammables (Yes/No Security (Yes/No)
 Goggles/shields?  Adequate cabinets?  Intrusion alarms?
 Gloves?  Absence of excess  Security procedures?

storage?
 Aprons?  Absence of past
 Spill plan? vandalism?
 Respirators?
 Safety cans?  Key control?
 Eye protection worn?
 Bonded/grounded?  Absence of custodial
 Other necessary serv.?
equip.?  Less than 300
gallons?  Dead bolt?
 Absence of storage by  If 2nd exit, emergency

exits? lights?
Gas Cylinders (Yes/No)
 Cylinders secured?  Two gauges?
 Contents identified?  Less than 3 cyl. in

use?
 Caps on tightly?
 Less than 9 cyl. in
 If NFPA rating >2, 2nd lab?
exit?
 Shutoffs?
Personal Protective Equipment
Type: Material Used On: Condition:
333
Cylinders
Number: Contents: Size:
Fume Hoods
Hood #1 Hood #2
Type of work performed: Type of work performed:
Location of hood in lab: Location of hood in lab:
If next to exit, is there a 2nd exit? (yes/no) If next to exit, is there a 2nd exit? (yes/no)
Emergency shut-off within 50 feet? (yes/no) Emergency shut-off within 50 feet? (yes/no)
Type of hood (check) Type of hood (check)
 Chemical  Chemical
 Perchloric Acid  Perchloric Acid
 Washdown?  Washdown?
 Removable baffles?  Removable baffles?
 Canopy  Canopy
 Biological  Biological
 Radioactive  Radioactive
334
Last inspection date: Last inspection date:
Avg. face velocity (ft./min.) Avg. face velocity (ft./min.)
Location of fan that serves the hood: Location of fan that serves the hood:
Inspector's name: Inspector's name:
Alarms: (check) Alarms: (check)
 Pressure  Pressure
 Face Velocity  Face Velocity
 Other:  Other:
Filters: (check) Filters: (check)
 HEPA  HEPA
 Charcoal  Charcoal
 Scrubber  Scrubber
 Other:  Other:
Ducts: (Yes/No) Ducts: (Yes/No)
Negative pressure? Negative pressure?
Absence of manifold? Absence of manifold?
if no, in shaft? if no, in shaft?
Outlet 10 ft. above roof? Outlet 10 ft. above roof?
(If Perchloric Acid...) (If Perchloric Acid...)
Absence of manifold? Absence of manifold?
Straight path to roof? Straight path to roof?
Comments:
Inspector's Name Inspector's Signature:
335
17B LABORATORY QUALITY ASSURANCE
PROGRAMME
a. Quality Assurance is done with the monitoring of following parameters:
i. Waiting time
ii. Different KPIs related to performance of laboratory.
iii. Turnaround time
iv. An Internal quality assurance program is carried out for all the test performed as
detailed in respective SOP of test.
b. Laboratory is participating in different External Quality Assurance Programs viz.,, IAMM
EQAS for microbiology, Association of Clinical Biochemists of India (ACBI) EQAS for
No Biochemistry, Hematology EQAS (AIIMS) and Coagulation EQAS from CMC Vellore.
Recall and /Redo policy
Recall Report
Recall of reports to be entered in recall /redo register .These would be the reports
entered wrongly by the data entry operator or laboratory technician (Transcription error )
and have been approved by the Faculty incharge.The report would be withdrawn from
HIMS ,record of the same will be mentioned in recall register and new report will be
released with same ID . If the wrong report has been given to the patient then a call will
be made to himand correct report provided to him and same will be documented in the
file. Sometime when patient visit to Doctor in OPD then Doctor on duty also inform
Laboratory regarding wrong reporting and request to provide correct report.
Redo of sample;
Case a . Wrong sample run
b.Discordance of lab report with clinical features .
c.Repeated samples for critically high values.
Process : Test re_do done on the same /repeat samples of the patient. Report verified
by the consultant incharges and entered in HIMS
336
18 Department of Radiology and Imaging Services
Director
Approved by:
Responsibility of updating : Department of Radio-Imaging
August 2020
Last reviewed/updated on :
Version
(CNBC/Radio-Imagine/18/ver1.2)
337
18 Department of Radiology and Imaging Services .................................................................................... 337
18.1 Amendment Sheet ....................................................................................................................... 339
18.2 Introduction .................................................................................................................................. 341
18.3 Process Summary ....................................................................................................................... 341
18.4 Departmental Hierarchy Chart ..................................................................................................... 344
18.5 Departmental Procedures ............................................................................................................ 345
18.6 CT Head Plain ............................................................................................................................. 352
18.7 CT Head Plain & Contrast ........................................................................................................... 353
18.8 CT PNS ........................................................................................................................................ 353
18.9 CT Chest Plain ............................................................................................................................. 354
18.10 HRCT Chest................................................................................................................................. 354
18.11 CT Chest Plain & Contrast ........................................................................................................... 355
18.12 CT Abdomen Plain ....................................................................................................................... 356
18.13 CT Abdomen Plain & Contrast..................................................................................................... 356
18.14 CT Liver Triphasic Study ............................................................................................................. 357
18.15 CT KUB Plain ............................................................................................................................... 358
18.16 CT KUB Plain & Contrast ............................................................................................................. 358
18.17 CT Lower abdomen/Pelvis Plain & Contrast ............................................................................... 359
18.18 C-arm Protocols ........................................................................................................................... 360
18.19 General Recommendations ......................................................................................................... 360
18.20 Departmental Policies .................................................................................................................. 361
18.21 Registration certificates: .............................................................................................................. 361
18.22 Acts: ............................................................................................................................................. 361
18.23 Critical Results Reporting ............................................................................................................ 361
18.24 U.S. Scan Registration for Antenatal scans ................................................................................ 362
18.25 Policy on Quality Control ............................................................................................................. 362
18.26 Policy: Patient Confidentiality ...................................................................................................... 362
18.27 Radiology Brand Standards ......................................................................................................... 362
18.28 Equipment Maintenance .............................................................................................................. 363
18.29 Policy: Department Inventory....................................................................................................... 363
18.30 Quality Plan.................................................................................................................................. 364
18a Radiation Safety Manual .......................................................................................................................... 365
18.31 18a.1Scope Of Radiation Safety ................................................................................................. 366
18.32 18a.2Definitions & Abbreviations ................................................................................................. 366
18.33 18a.3 Radiation Safety Policies ................................................................................................... 367
338
Clause
S.No. Date of no. Amendment Made Reasons of Sign of
Amendme Amendment QM
nt
1. 27/08/10 18.3 Fluoroscopy Based Radiography
- Includes studies with contrast media (Iodinated/Non-
Iodinated/Barium)
Intravenous Urography
Micturating cysto urethrography
Distal cologram
Sinogram / Fistulogram
Barium studies
Ultrasonography-
1. General Ultrasound- Cranium, Chest, Abdomen, Pelvis,
superficial parts, musculoskeletal etc.
2. Color Doppler flow imaging
3. Diagnostic and Therapeutic Interventional
Procedures.
4. ECHO
2. 18.3 Specific:
X-Ray- Add. Replenishment Rate
3. ____ (Point No-1) Check the requisition form for relevant clinical
details.
4. 27/08/10 Add: Bedside & Intra- operative Radiography and Fluoroscopy
Doctor will prescribe the investigation to the patient from Wards

/ Emergency / O.T / ICU.
M/O- Nurses will inform about the investigation and send the
request to the Radiology Dept.
Radiographer and x-ray machine shifted to the ward
X-ray is done & entry made in the register
X-ray films developed in the department, reported & sent to the
respective wards.
5. 18.24 4.3 (5) Monthly PNDT Report (NIL) sent to CDMO office.
6. 4.4.2 (b) “Not” delete replace with “ be”

4.4 (3) Add:Monthly KPI (key performance indicators) Report is
sent to Chief Nursing Officer)
7. 4.8 Consumables (films, Chemicals, contrast & medication)

Instead of medication.
th
8. 14 A computerized tomography scan is an x-ray procedure that
Oct’2011 combines many x-ray images with the aid of a computer to
generate cross-sectional views and, if needed, three-
dimensional images of the internal organs and structures of the
body. A CT scan is used to define normal and abnormal
structures in the body and/or assist in procedures by helping to
accurately guide the placement of instruments or treatments.
th
9 14 Add CT
Oct’2011 Maintenance of Machine
th
10 14 DELETE (It takes 30 minutes for the radiologist to reach the
Oct’2011 hosp[ital before radiologist arrived keep Patient & machine
ready & check patient preparation)
th
11 14 CT Scan Procedure Doctor prescribe the test If contrast needed
Oct’2011 Yes Patient has to come with fasting for a minimum of 4 hours
as per date given by department
339
No Whether sedation required or not No
th
12 14 Below mentioned case will be informed to the treating consultant
Oct’2011 immediate after the procedure in USG/CT
13 Dec 2014 Facility of Echo SUSPENDED DOCTOR
not available
14 Dec 2014 CR system was installed and services was started from nov Addition of
2013 new services
in the
department
15 Dec 2014 Policy for data back up in DVD’s for CT imaging from December
2011
For x-rays and special investigations January 2014
For ultrasound no back up policy
16 Dec 2014 18.2 For Magnetic resonance imaging Deleted
Hospital administration intends to out-source the MRI services
for the patients of Chacha Nehru BalChikitsaklaya, Geeta
Colony, Delhi-110031.
18.3 In this regards,expression of interest is invited from those who
are willing to provide MRI services on outsource basis for
CNBC patients.
Feb 2016 18.3.1 Hospital administration has outsourced MRI services based on Addition of
quality assurance programme. new services
17 in the
department
Inclusion of C-arm
Scope of
radiology in
operation
theatres
HIMS portal and radiology information system
Addition of
18.3.2 new services
in the
Deletion- attainders department
Typographic
18.4 al error
E-lora as introduced by AERB, Govt. of India is now
implemented. So the necessary information is updated on the
site like New Govt.
18.20.3 Policy
 Registration of equipments used for ionizing type of
radiation.
 List of employee radiation workers as well as non radiation
workers
 Details of all workers who are provided with TLD badges
 Details of lead accessories used in the department.
 Provision of associate and dissociate employees in the
department.
Wet processing is to be used as a stand by procedure due to

use of computed radiography.
18a.3.1
2.3 New policy
Addition of recall policy
340
18 Aug 2020 18.3.2 The computerized digital radiography can be converted into X-Ray films
JPEG format and uploaded on HIMS portal for quick review of dispatched to
the radiographs.(Deleted) patients
19 Aug 2020 18.2 For Magnetic resonance imaging New Govt.

18.3 policy
Delhi Govt. policy of Delhi Arogya kosh was introduced in which
patients are directed to designated centres for MRI of the
patients.
20 Aug 2020 18.3

New Digital Radiography Fluoroscopy Machine was installed Addition of
and services was started from July 2019 new Digital
services in
the Dept.
18.2 Introduction
Radiology describes the area of medicine that utilizes X-ray, and ultrasonic waves in order to detect,
diagnose, and guide treatment of numerous diseases and injuries. Currently, the dynamic images that
radiology provides are essential to both physicians and patients, thanks to their realistic depiction of the
anatomy, functions, and abnormalities within the body, radiologists can interpret imaging studies, act as
consultants to other specialists, and perform interventional procedures.
18.3 Process Summary
18.3.1 Services offered
Stations / counter / Process

area
X-rays are a form of radiation, like light or radio waves that can be
General Radiography
focused into a beam. Once it is carefully aimed at the part of the body
being examined, an x-ray machine produces a small burst of radiation
341
that passes through the body, recording an image on photographic film or
a special image recording plate.
Includes studies with contrast media ( Iodinated / Non iodinated / Barium)
Fluoroscopy based  Intravenous Urography

Radiography  Micturating Cystourethrography
 Distal cologram
 Sinogram/ Fistulogram
 Barium studies
Ultrasound or sonography uses high frequency sound waves to see
inside the body. As the sound waves pass through the body, echoes are
produced, and bounce back to the transducer. These echoes can help
doctors determine the location of a structure or abnormality, as well as
information about its make up. Ultrasound is a painless way to examine
internal organs.
Ultrasonography
 General Ultrasound- Cranium, Chest. Abdomen, Pelvis,
Superficial parts, Musculoskeletal etc.
 Color Doppler flow imaging
 Diagnostic and therapeutic guided interventional
procedures. All procedures are documented accurately in
patient record.
 ECHO
 A computerized axial tomography scan is an x-ray
procedure that combines many x-ray images with the aid
of a computer to generate cross-sectional views and, if
needed, three-dimensional images of the internal organs
Computed and structures of the body. A CT scan is used to define
Tomography normal and abnormal structures in the body and/or assist
in procedures by helping to accurately guide the
placement of instruments or treatments. All procedures
are documented accurately in patient record.
Magnetic resonance
imaging Hospital administration intends to out-source the
has outsourced MRI services based on quality assurance
programme.
C- arm
Installed in main operation theatre for various procedures.
18.3.2 Processes
area
Receiving Customers Receiving the customers with radiology request, identifying the
customer and procedure required.
Explaining the Informing the patient about the procedure going to be performed
Procedure and duration of the procedure.
Radiation Protection Lead apron provided to patient to cover non examining part
342
Preparation of the Area of interest made free from metal objects.
patient
Preparation of Required accessories is are made ready.

room/Machine
Machine kept ready with appropriate technical exposure.
Processing of films After exposure film is processed in film processor and once it is
ready, kept for reporting.
HIMS portal and The computerized digital radiography can be converted into JPEG
radiology information format and uploaded on HIMS portal for quick review of the
system radiographs.(Deletion)
Inventory Receiving of indent as per department requirement from stores.
Sufficient department stock maintained.
Linen Inventory Radiographers will maintain stock of clean linen as per requirement
and makes sure soiled linen is send to laundry in time
Concurrent Audit Physical inspection of inventory items of consumables to check

stock status and expiry dates of drugs in use- Done Monthly
Maintenance Radiographers will take care of equipments in use and maintain

of Equipment Instrument history log sheets.

area
Departmental All new staff joining the Hospital is oriented to the department work
Orientation process and uses of machineries.
Patients are explained the need for appointments, appointments

Department
given as per radiologist advice and the clinical emergency of the
Appointments
patient
Radiation Monitoring All radiation workers are provided with TLD cards to be worn during
working hours to monitor their occupational radiation dose.
TLD Sent to Ultratec Lab every quarterly by register post.
18.3.3 End of Day Activities

End of the day activities consists of the activities, which are important to perform on daily basis in
the department.
18.3.4 Common:
 Maintenance of necessary stocks for the respective department
 Maintenance of requisition slips which are useful for the auditing purposes
343
18.3.5 Specific:
a. X-Ray:
i. Daily maintenance of the machine
ii. Checking processing chemical levels and replenishment rate.
b. Ultrasound:
i. Maintenance of the machine.
ii. For performing the US guided procedures sterilized material set is arranged when required
c. Computed Tomography
Maintenance of machine
18.4 Departmental Hierarchy Chart Director
M.S
Radiologist
Radiographers
344
18.5 Departmental Procedures
18.5.1 Out-Patient with Consultation

Patient comes with the
requisition for investigation.
Check the requisition form for

relevant clinical details.
No Does the invstgn Yes

need
preparation?
Yes
Is the Pt. with
necessary
preparation?
No
Can the pt. be
allocated for
invstgn? No
Pt. is told about the requirement

Yes
of appt. & given for the earliest
available time
After investigation entry done in
Register
Pt. will come at that date and
time of appt with preparation
Pt. is directed to the

consultant with report
The radiologist to the

consultant informs critical
reports verbally immediately
345
18.5.2 In patients
Doctor will prescribe the

investigation to the patient
Nurse will inform about the invstgn and the pt.

Doctor will prescribe the
details to the dept.
investigation to the patient
The
Theradiographer will check
radiographer the kindthe
will check of
test and the need for pt. preparation
kind of test and the need for
pt. preparation
Nurse will be No
informed the Is pt. pprtn
time of invstgn needed?
Inform the nurse about the

preparation
The appt. is given No

according to the If Patient is
preparation prepared?
Yes
The nurse is told to send the pt. to the dept with request. OR
radiographer attend the patient in ward itself
Invstgn is done and entry is made.
Patient is transferred back to the

ward.
346
a. Bedside and Intraoperative Radiography and Fluoroscopy
Doctor will prescribe the investigation to the patient from

Wards/ Emergency/ O.T/ ICU
M/O, Nurses will inform about the investigation and send

the request to the Radiology Dept.
Entry made in the register.
Radiographer and X- Ray machine shifted to the ward and

X-Ray done.
X- Ray films developed in the dept, reported and sent to

the respective wards.
347
b. In-patients / Emergency patients (For all Radiology Procedures) After Duty Hours
Doctor will prescribe the invstgn to the

pt. from wards and from Emergency
Room
MO/Nurse will inform about the invstgn &

sent the request to Radiology
Is the pt.
preparation
needed?
Yes
No
Check with the nurse whether the pt. is
prepared or not
pt. is prepared
Before radiologist arrive, keep the patient & machine ready

and check patient preparation.
348
c. Radiology procedures
Patient comes to the dept with requisition
No Yes
Is the Pt.
Inpatient?
Check whether the preparation As the requirements of the pt., preparation

followed by the Pt. is adequate are taken care from before by nurse.
Yes Check the Pt. Identification with the

Is preparation
prescription, and other details
adequate?
(previous reports if required)
No
Send the Pt. for investigation
Is the time Yes

sufficient for
preparation? Guide the Pt. and wait till the Pt. is
prepared. Then take the Pt. for invstgn
No only once when the preparation
completes
Guide the Pt. and fix the appt. for the next
earliest possible date/time
349
d. U.S. Scan procedures
i. Ultra sonogram (Abdomen)
Doctor prescribes the test
Pt. has to come with fasting for a minimum of

4 hours as per dates given by dept.
Before going for the test the Pt. is required to

have full bladder for which the Pt. need to
consume enough amount of water
Before taking the Pt. for the invstgn check for

the satisfactory Pt. preparation conditions
No Yes
Is the Pt. having
full bladder?
Pt. has to consume more

amt. of water and wait till Pt. is sent for investigation
the bladder is full Radiologist do the scan and give their
findings.
350
e. Computed Tomography Procedures
Doctor prescribes the test
No Yes
Is contrast
needed
Whether sedation required or not

Pt. has to come with fasting for a
minimum of 4 hours as per date
given by the department.
1. The ideal temperature of the scanner room & console is between 18-22 Celsius
a. Do not operate the scanner if the temperature of the room is not maintained.
2. Switching on/off Sequence
a. Switch on OR ensure the UPS Panel is ON
b. Switch on OR ensure the Teal transformer is ON
c. Press the console CPU start button
d. Wait until it asks for username/password
e. Type username and press enter key
f. Wait until the systems completes booting up and you can see the Home page
g. Now gently turn the gantry switch ON Key towards you to boot the gantry.
3. Tube warm up
a. Click on Home, select tube conditioning
b. Start Tube conditioning
c. Tube warm should be done every day morning & if no scan is done for three hours prior to a
patient scan
4. Air calibration
a. Do Air calibration weekly.
b. Ensure table is not inside gantry unit while calibrating. The Table should be moved out from
the detector area prior to start of air calibration
c. It takes 15-20 minutes for completion of air cal, so plan this preferably when there is no
patients queue.
d. Go to Home page, click Air calibration and accept all prompts
e. Check the first scan for artifacts & then proceed for complete calibration.
5. Parameters Description
a. kV Kilovoltage : The voltage applied between Cathode and anode within the CT tube
b. mAsMilli amperage X second (Time)
c. mAs: The current applied in the Cathode in one second time of exposure.
351
d. mA: The total current applied on the cathode
e. Thickness The thickness of the planned/ displayed image Interval The space between two slices in a
series is Collimation
6. FOV Field Of View
a. Length: Length of patient body covered in a scan, either in head to toe /toe to head direction.
b. Scan time: Total time taken for completing a planned series
c. Rotation Time (S): Time taken for the X-ray tube/Gantry to make one rotation (360degree)around
patient Filter Post threshold delay
d. The delay time for start of a scan, after the contrast has reached inside an artery (with a prefixed
threshold value) eg: abdomen aorta
7. Post injection delay
Delay time measured from the start of injection to start a scan. , after you press the scan start button.
8. Non-Timed scan -press the start button, scan will start immediately
9. Timed scan - press the start button to start a scan, but scan will start after post – injection delay time
you entered in the box.
10. Bolus tracking: The technique to see the arrival of injected contrast inside any desired blood vessel,
eg Arch of aorta.
11. Automatic
a. Minimum delay if you choose to tick this icon, scanning will start with the least possible delay.
Threshold this is the HU (Hounsfield value) of a blood vessel.
b. (Threshold value inside Aorta prior to start of injection is approx 40 HU Threshold we set for bolus
tracking will be approximately 90-120 )
c. Tracker scan this is a series of axial scanning, the system intermittently acquires at the locator
position to check for the arrival of contrast, ie, bolus.
d. Locator scan a single axial scan planned to get a location for bolus tracking. Position the number
which denote the location of the scan table/patient
12. HU Hounsfield Value
18.6 CT Head Plain
18.6.1 Preparation
a. Remove metallic items from head and neck such as ear pins, hairclips, chains etc.
b. Ensure patient is not pregnant.
c. Instruct the patient not to move during the scanning process.
18.6.2 Positioning
a. Patient lies supine with Head first to gantry position.
b. Both arms extended downwards or folded over the chest.
18.6.3 Procedure Overview

a. Acquire in axial mode for all routine cases
b. Acquire in helical mode for patient who can’t lie still for long (eg children, head injury cases
etc)
c. Wherever 3D images are required, use helical mode acquisitions only.
18.6.4 Scanning Process

a. Use the Brain Axial protocol
b. Acquire a scanogram image
c. Click on the plain scan and plan slices over brain/head from base of skull to Vertex
d. Click “go” button and start plain scan acquisition
18.6.5 Filming
a. Use First film preferably 5 x4 /5x5 format for axial imaging
b. Print a second film for axial bone window images in head injury cases
352
c. Use a third film for contrast enhanced cases in the similar format.
d. Use thin slices to make coronal and sagital recons and print 3 or 4 slices of the interested
area (if required).
18.7 CT Head Plain & Contrast
18.7.1 Preparation:
a. Ensure patient’s attendant is not pregnant
b. Keep adult patients fasting for a minimum of 4 hours period. Reduce the fasting hours in
children appropriately with age.
c. Check drug allergy history, explain the scan procedures and get consent form signed.
d. Remove metallic items from head and neck such as ear pins, hairclips, chains etc
e. Instruct the patient not to move or if sedation is required may be given during the scanning
process.
18.7.2 Positioning
a. Patient lies supine with Head first to gantry position
b. Both arms extended downwards or folded over the chest

a. Acquire in axial mode for all routine case
b. Acquire in helical mode for patient who can’t lie still for long (eg children, head injury cases
etc)
c. Wherever 3D images are required, use helical mode
d. Inject of non-ionic contrast W/V for patients
e. 45-60 second delay from start of injection is helpful to see adequate enhancement of lesions.

a. Use the Brain Axial /helical P+C protocol
c. Click on the plain scan and plan slices over brain/head
d. Click on the contrast scan and plan slices over brain/head
e. Click go button and start plain scan acquisition
f. After plain image displayed, click next series button
g. Click go button& move table to the start location
h. Inject contrast and then click on scan start button
18.7.5 Filming
a. Use first film preferably 4 x 5 format for axial plain imaging
b. A second film for contrast enhanced cases
c. With a third film & using thin slices, make coronal and sagital recons images and print.
18.8 CT PNS
18.8.1 Preparation:
a. Remove metallic items from head and neck such as ear pins, glasses, hairclips, hearing aids,
dentures, chains etc
b. Ensure patient is not pregnant
18.8.2 Positioning
a. Patient lies supine with Head First to gantry position
b. Both arms extended downwards or folded over the chest
353
18.8.3 Procedure
a. Acquire in supine helical mode for all patients
b. Thin image acquisitions are necessary for good coronal recons

a. Use the PNS protocol
b. Acquire a lateral skull scanogram image
c. Click on the plain scan and plan slices over PNS
d. Click ‘Go’ button, press enable table movement and press start scan for scan acquisition
e. Image acquisition will start now and preliminary image will display on the monitor.
f. Review the preliminary images, adjust the window, display FOV etc if required and then click
“YES”
g. Actual images will be reconstructed and automatically archived on the Patient Directory.
18.8.5 Filming
a. Use one film preferably 4 x 5 format for coronal imaging
b. Print a second film for axial PNS images in relevant cases using 4 x 5 format.
c. Use a third film for contrast enhanced cases ( rarely done such as fungus infection cases,
tumouretc)
18.9 CT Chest Plain
18.9.1 Preparation:
a. Ask the patient to get changed into a hospital gown.
b. Remove metallic items from neck & chest such as chains, lockets, metals in inner garments
c. Ensure patient is not pregnant
d. Instruct the patient not to move during the scanning process.
e. Instruct the patient to hold breath in inhalation while scanning
18.9.2 Positioning
a. Patient lies supine with Feet first to gantry position
b. Both arms extended upwards & folded above head
18.9.3 Procedure
a. Acquire in helical mode for all routine case
b. Use Thorax Plain protocol
c. Acquire a scanogram image
d. Click on the plain scan and plan slices over thorax
e. Click go button and start plain scan acquisition
f. Image acquisition will start now and preliminary image will display on the monitor.
g. Review the preliminary images, adjust the window, display FOV etc if required and then click
“YES”
h. Actual images will be reconstructed and automatically archived on the Patient Directory.
18.9.4 Filming
a. Use one film preferably 4 x 5/4 x6 or 5 x 6 format for axial imaging
b. Use a second film for axial Lung window
c. Use a third film for Coronal and few sagital cuts
d. Ensure to use thin slices to make coronal and sagital recons
18.10 HRCT Chest
18.10.1 Preparation:
a. Get the patient changed into a hospital gown.
b. Remove metallic items from neck & chest such as chains, lockets, metals in inner garments
354
e. Instruct the patient in advance how to hold breathing in inhalation while scanning
18.10.2 Positioning
a. Patient lies supine with Feet First to gantry position
18.10.3 Procedure
• Acquire in AXIAL or HELICAL mode for all routine case

a. Use the HRCT protocol
b. Click on Surview Planning & Select “Go” & Press Manual start scanogram of image of the
chest
c. Click on the plain scan and plan slices over PNS
d. Click ‘Go’ button, press enable table movement and press start scan for scan acquisition
e. Image acquisition will start now and preliminary image will display on the monitor.
f. Review the preliminary images, adjust the window, display FOV etc if required and then click
“YES”
g. Actual images will be reconstructed and automatically archived on the Patient Directory.
18.10.5 Filming
a. Use first film preferably 4 x 5/4 x6 or 5 x 6 format for axial lung imaging
b. Use a second film for axial mediastinal window
c. Use a third film for Coronal and few sagital cuts in lung window (if required).
18.11 CT Chest Plain & Contrast
a. Keep adult patients fasting for a minimum of 4 hours. Reduce the fasting hours in children
appropriately with age.
b. Check drug allergy history, Explain the procedure and get consent form signed
c. Remove metallic items from chest such as chains, lockets
e. Instruct the patient to hold breath in inhalation while scanning
18.11.2 Positioning

b. Acquire plain scan first and then proceed for contrast scan

a. Use thorax P+C protocol
c. Click on the plain scan planning and plan slices over thorax
d. Click on the contrast scan planning and plan slices over thorax
e. Click on the syringe icon and ensure post injection delay is adequate.
f. Click on the syringe icon and enter post injection delay as 20-25 seconds
g. Click “go” button and start plain scan acquisition
h. After plain image displayed, click next series button
i. Click go button& move table to the start location
j. Prepare injector and enable the injector
k. Start injector & start scan button simultaneously
355
l. If manual hand injection method is used, do not put any delay time in syringe icon, inject
contrast came out of the scan room and immediately press the scan start button.
18.11.5 Filming
a. No need to print plain scan unless clinically indicated
b. Use first film preferably 4 x 5/4 x6 or 5 x 6 format for axial contrast imaging
c. Use a second film for contrast axial Lung window
d. Use a third film for Coronal and few sagital cuts
e. Ensure to use thin slices to make coronal and sagital recons (if required).
18.12 CT Abdomen Plain
a. Remove metallic items from chest & abdomen such as chains, lockets, pelvic ornaments
b. Change patient into hospital gowns
d. Instruct the patient to hold breath in inhalation while scanning
18.12.2 Positioning

b. Start scans above diaphragm to well below symphysis pubis
18.12.4 Filming
a. Use two film preferably 4 x 5/4 x6 or 5 x 6 format for axial imaging
b. Use a third film for Coronal and few sagital cuts, ensure to include sagital cuts through female
pelvis
c. Ensure to use thin slices to make coronal and sagital recons (if required).
18.13 CT Abdomen Plain & Contrast
18.13.1 Preparation
a. Keep adult patient fasting for a minimum of 4 hours. Reduce the fasting hours in children
b. Start one litres of oral contrast, at least one hour prior to start of study. Oral contrast
consumed in intervals, last 1ooml on table to drink.
c. Check drug allergy history, explain the procedure and get consent form signed
d. Change patient into hospital gowns
e. Remove metallic items from chest such as chains, lockets
f. Instruct the patient not to move during the scanning process.
g. Instruct the patient to hold breath in inhalation while scanning
18.13.2 Positioning

c. Use injector for contrast injection
d. Adult patient approx .70ml contrast injection at 2- 3ml/sec followed by 20ml saline at 2-3ml
per second is recommended
e. Use 40-45 second delay from start of injection
356
f. You can enter this delay in scanner & use timed scan option

a. Use Abdomen P+C protocol
c. Click on the plain scan planning and plan slices over abdomen
d. Click on the contrast scan planning and plan slices over abdomen
e. Click on the syringe icon and enter post injection delay as 38-45 seconds
f. Click “go” button and start plain scan acquisition
g. After plain image displayed, click next series button
h. Click go button& move table to the start location
i. Prepare injector and enable the injector
b. Start injector & scan start button simultaneously
c. If manual hand injection method is used, do not put any delay time in syringe icon, inject
contrast came out of the scan room and immediately press the scan start button
18.13.5 Filming
b. Use first two film preferably 4 x 5/4 x6 or 5 x 6 format for axial contrast imaging
c. Use a third film for Coronal and few sagital cuts (if required).
18.14 CT Liver Triphasic Study
appropriately with age
e. Remove metallic items from chest and abdomen such as chains, lockets, Metals in inner
garments
g. Instruct the patient to hold breath in mild inhalation while scanning
18.14.2 Positioning

a. Insert IV canuula preferably 18g or 20g( Green or Pink) on right antecubital vein
b. Keep Pressure injector ready with 60-80ml contrast and 30-40ml saline
c. Injection flow rate set at 4-ml/second
d. Use the Triphasic liver angio protocol
e. Connect the injector line to patient after Loading the injector with required contrast/saline and
keep it armed

a. Acquire a scanogram image
b. Click on the plain scan and plan slices over the upper abdomen
c. Click on the locator
d. click on the tracker
e. Click on the arterial, portal and delayed series
f. Click go button and start plain scan acquisition
g. Scroll the plain scan images and identify slice which shows clearly the celiac artery and note
down this slice position
h. Click on the locator and enter this slice position on the position field and press Enter in
Keyboard.
357
i. Click on the tracker series
b. Click on the arterial, portal and delayed series, plan the scan field to cover entire upper
abdomen in all series
c. Click go button and acquire locator scan
d. Use ‘draw manual ROI’ pencil from the top panel and draw small circle on the mid of Abdominal
aorta
e. Click OK
f. Now click injector start button and scanner start button simultaneously
g. Angio automatically starts when the contrast reaches the hepatic artery
18.14.5 Filming
b. Use first two films preferably 4 x 5/4 x6 or 5 x 6 format for axial contrast imaging
c. Use a third film for Coronal and few sagital cuts (if required).
18.15 CT KUB Plain
a. Remove metallic items from chest & abdomen such as chains, lockets, pelvic ornaments
b. Change patient into hospital gowns
d. Instruct the patient to hold breath in inhalation while scanning
18.15.2 Positioning

b. Start scans below diaphragm to well below symphesis pubis
c. Ensure to acquire very thin slices to highlight tiny stones in KUB.
18.15.4 Filming
a. Use two film preferably 4 x 5/4 x6 or 5 x 6 format for axial imaging
b. Use a third film for Coronal and few sagital cuts.
c. Ensure to use thin slices to make coronal and sagital recons
d. Make curvilinear MPR images through KUB
18.16 CT KUB Plain & Contrast
b. Oral contrast should not be given for KUB cases!
c. Check drug allergy history, explain the procedure and get consent form signed
e. Remove metallic items from chest & abdomen such as chains, lockets, inner garments, pelvic
ornaments etc
g. Instruct the patient to hold breath while scanning
18.16.2 Positioning
358
d. Adult patient Approx.70ml contrast injection at 3ml/sec followed by 20ml saline at k3ml per
second is recommended
e. Use 40-45 second delay from start of injection & acquire delayed scans at 3-5 minutes,
repeat the scan again at 10-15 minutes to see ureter excretion
f. Acquire a prone image, if ureter excretion is poor.
g. You can enter multiple delay in scanner & use timed scan option
h. Bolus tracking technique can also be used in KUB imaging.

a. Use KUB P+C protocol
c. Click on the plain scan planning and plan slices over KUB
d. Click on the contrast scan planning and plan slices over KUB
f. Click on delayed scan protocol and click on the syringe icon and enter delay 180-300
seconds
g. Click “go” button and start plain scan acquisition
h. After plain image displayed, click next series button
i. Click go button& move table to the start location
b. Prepare injector and enable the injector
c. Start injector & scan start button simultaneously
d. If manual hand injection method is used, do not put any delay time in syringe icon, inject contrast
came out of the scan room and immediately press the scan start button
18.16.5 Filming
a. Plain scan filming is very much essential to show KUB stones.
b. Use first two films preferably 4 x 5/4 x6 or 5 x 6 formats for axial contrast imaging
c. Use a third film for Coronal and few saggital cuts (if required).
d. Ensure to use thin slices to make coronal and saggital reconstructions
18.17 CT Lower abdomen/Pelvis Plain & Contrast
a. Keep patients fasting for a minimum of 4hours.
c. Start one litres of oral contrast, at least one and half hours prior to start of study. Give rectal
contrast enema when rectal/large gut pathology is suspected.
e. Remove metallic items from chest & abdomen such as chains, lockets, inner garments, pelvic
ornaments etc
b. Positioning • Patient lies supine with Feet first to gantry position
a. Both arms extended upwards & folded above head

d. Adult patient Approx .70ml contrast injection at 3ml/sec followed by 20-30ml saline at 3ml per
second is recommended
e. Use 40-45 second delay from start of injection

a. Use Pelvis P+C protocol
359
c. Click on the plain scan planning and plan slices over Lower abdomen/Pelvis
d. Click on the contrast scan planning and plan slices over Low abdomen/Pelvis
f. Click “go” button and start plain scan acquisition
g. After plain image displayed, click next series button
h. Click go button& move table to the start location
i. Prepare injector and enable the injector
b. Start injector & scan start button simultaneously
c. If manual hand injection method is used, do not put any delay time in syringe icon, inject
contrast came out of the scan room and immediately press the scan start button
18.17.4 Filming
a. Use first two films preferably 4 x 5/4 x6 or 5 x 6 format for axial contrast imaging
b. Use a third film for Coronal and few SAGITAL cuts (if required).
18.18 C-arm Protocols

a. Fluoroscopy is the method that provides real-time X ray imaging that is especially useful for guiding a
variety of diagnostic and interventional procedures. The ability of fluoroscopy to display motion is
provided by a continuous series of images produced at a maximum rate of 25-30 complete images
per second.
b. X ray beam is usually moved over different areas of the body during a procedure.
c. The absorbed dose to a specific part of the skin and other tissues is of concern in fluoroscopy for two
reasons: one is the need for minimizing the dose to sensitive organs, such as the gonads and breast,
by careful positioning of the X ray beam and using shielding when appropriate. The second is the
possible incidence of the radiation beam to an area of the skin for a long time that can result in
radiation injuries in cases of very high exposure.
d. In fluoroscopy, as in all types of X ray imaging, the minimum exposure required to form an image
depends on the specific image information requirements. An important characteristic of a fluoroscopic
system is its sensitivity, i.e. the amount of exposure required to produce images. The use of intensifier
tubes and more modern digital flat panel receptors make it possible to optimize the balance of patient
exposure with image quality so as not to expose the patient to unnecessary radiation.
18.19 General Recommendations

1. All persons, other than the patient and those whose presence is essential, must leave the room when
a radiographic examination is carried out.
2. Personnel must always keep as far away from the primary radiation beam as practical. Direct
radiation exposure to personnel must not occur. Deliberate irradiation of an individual for training
purposes must never be allowed.
3. All personnel must use the protective devices available.
4. X-ray tube housing must not be held by hand during operation.
5. All operators of X-ray equipment, together with personnel who routinely participate in radiological
procedures must wear personnel dosimeters.
6. The personnel dosimeter must be worn under the protective clothing.
7. Energized X-ray equipment must not be left unattended.
8. Where a radiation dose in excess of 5% of the recommended dose limits for radiation workers
specified and is being received by any one person, an investigation about the causes and appropriate
remedial steps must be taken to improve techniques and protective measures.
9. C-ARM equipment must only be operated by individuals who have been trained in the safe use of the
equipment by the RSO.
360
18.20 Departmental Policies 18.22 Acts:
1. AERB Safety code No:AERB/SC/MED-
2(REV-1)2001
18.20.1 Scope: Radiology 2. Atomic Energy Act 1962
3. Radiation protection Rules 1971
18.20.2 Distribution list: Radiology 4. Radiation Surveillance Procedures for
Medical Applications of Radiation,1989
18.20.3 Policy:
5. The Bio-Medical Waste ( Management
1. The Radiology Department will operate
and Handling) Rules,1998
within all applicable legislation, regulations
6. Medical X-ray Installations in India
and Registration requirements.
should comply with the following
2. All laws, regulations, directives, guidelines
Regulatory requirements
and registration requirements of Atomic
7. Safety Layout Approval from Atomic
Energy Regulatory Board (AERB) &
Energy Regulatory Board
District Health & Family Welfare Office,
8. Carry out Quality Assurance
Delhi Govt be met and followed.
Performance Test of the x-ray unit
3. All Radiographers must maintain Life
yearly
Member registration with the Indian
9. Employ qualified Staff
Association of Radiological Technologists
10. Provide Personnel monitoring badges
(www.iart.org.in) as per. A photocopy of
for all staff members associated with the
the IART registration certificate of the
operation of x-ray machines
Radiographers shall be kept in the
11. Comply with AERB Safety code
Radiology department Staff Personal file.
No:AERB/SC/MED-2(REV-1)2001
4. All staffs will be provided with Thermo
luminescent Dosimeter to measure 18.23 Critical Results Reporting
(Radiation received during working hours)
Occupational exposure 18.23.1 Scope: Hospital wide
5. All required records will be maintained by
the Radiology Department. 18.23.2 Distribution list: Radiology
6. E-lora as introduced by AERB, Govt. of
India is now implemented. So the 18.23.3 Policy:
necessary information is updated on the 1. The below Mentioned cases will be
site like informed to the treating consultant
 Registration of equipments used for immediately after the procedure in
ionizing type of radiation. USG/CT
 List of employee radiation workers as a. Burst Abdomen
well as non radiation workers b. Deep Vein Thrombosis
 Details of all workers who are c. Perforation
provided with TLD badges d. Hemorrhage
 Details of lead accessories used in the e. Infarct
department.
f. Fracture
 Provision of associate and dissociate
employees in the department. g. Pneumothorax
h. Obstruction
i. Vascular Injury
18.21 Registration certificates:
1. AERB layout Approval
2. Form B – from District Health & Family
Welfare Office
361
18.24 U.S. Scan Registration for Antenatal scans 18.26 Policy: Patient Confidentiality
18.24.1 Scope: Hospital wide 18.26.1 Scope: Hospital wide
18.24.2 Distribution list: Radiology 18.26.2 Distribution list: Radiology
18.24.3 Policy: 18.26.3 Policy:

1. In the course of Performing work
responsibilities all information with
1. Ultrasound Machine Purchased will be regard to patient, their family, their
registered with Health Department.
physician and / or the hospital will be
2. Form B will be issued by the health
department after registration kept confidential.
3. A Registration number will be allotted to 2. As a condition of employment,
the radiology department in form B. personnel are cautioned not to discuss
4. Statutory requirements are as follows: any such information with others.
5. Form B should be displayed in the 3. Casual comments with fellow co-
ultrasound scan room. workers in the hallways, lobby or
6. Scanned Patient details should be
cafeteria may overhead and violate
preserved for 2 years from the date of
Scan. the trust others have placed in our
7. Monthly PNDT Report (nil) sent to CDMO personnel.
office. 4. Personnel are asked to conduct
themselves with professional dignity at
all times.
18.25 Policy on Quality Control 5. Radiologist is the only person
authorized to inform reports to the
18.25.1 Scope: Hospital wide
doctors.
18.25.2 Distribution list: Radiology
18.27 Radiology Brand Standards
18.25.3 Policy:
1. The main objective of quality control is to
enhance the quality of x-ray/results by 18.27.2 Distribution list: Radiology
checking the precision, accuracy and
consistency of tests done. 18.27.3 Policy:
2. Quality Assurance is done with the
following monitoring 18.27.4 Investigations
3. Tracking Turnaround time and waiting 1. All patients’ attendants will be explained the
times process of the diagnostic investigation in
4. Expected and actual waiting time for X- detail before starting the process.
2. All Patient/ Customers will also be explained
ray, Spl investigations, CT and USG is
when and how their reports can be
calculated. is 20 mints. collected.
5. Reject rates for films: It should be Less 3. While undergoing the investigation, all
than 3% of the Monthly consumption. necessary precautions related to patient
6. Monthly KPI (Key Performance Indicators) safety is explained & followed.
Report is sent to Quality department. 4. Special care is taken while undergoing
Investigations of infants/neonatal. The
parent / next to the kin of such patients are
kept informed of the process before
investigations are started.
5. Attention of the patient attendant will be
drawn to the hygiene and safety aspects
before undergoing the Investigation.
6. Consent will be taken whenever required.
362
7. All necessary steps will be taken to reduce
/minimize /eliminate discomfort /pain while
conducting the Investigation. 18.28.3.2 Infection control:
8. In the course of performing work 1. Ultrasound probes should be cleaned.
responsibilities all information with regard to 2. Machines should be cleaned with Antiseptic
patient, their family, their physician and / or Solution after handling Road Traffic
the hospital is kept confidential. As a Accident & Infectious patients.
condition of employment, personnel are 3. Mobile Machines shifted to Operating room
cautioned not to discuss any such and Intensive care units, wheels & area in
information with others. contact with patients should be cleaned
with disinfectant solution before and after
use of the machine.
18.27.5 Reports
18.28.3.3 Breakdown management:
1. In case of any unavoidable delay, patients
1. During breakdowns shutdown and restart the
are kept informed for the reason for the
unit, check all Input & cables for loose
delay and by what time the
connections. In case this fails, complaint
investigations/delivery of reports are likely should be logged into Instrument History Card
to be completed. and Work order should be raised and given to
2. Any patient query regarding the reports will
the Biomedical In charge mentioning the
be dealt with immediately and clearly
Machine Name, time of breakdown.
explained, and further consultation
2. It is the duty of the reporting person to place
arranged. In case of complaints see Machine Out Of Order do not Operate Board
complaint handling standards/protocols. near the equipment.
3. All critical reports are verbally informed to 3. In case of Major Breakdown the MS should be
the concerned consultant immediately by
informed.
the Radiologist.
4. After rectification service report is received
4. No test results are given to Patient /
and filed & the same is entered in Instrument
customer verbally or over telephone. History Card.
5. Incident Report is raised for all Breakdowns
more than 24 hours.
18.28 Equipment Maintenance
18.28.2 Distribution list: Radiology 18.29 Policy: Department Inventory

18.28.3 Policy: 18.29.1 Scope: Hospital wide
18.28.3.1 General
18.29.2 Distribution list: Radiology
1. All staff will clean the Machine in their
Posted unit. Staff will conduct daily check on Policy: A Standard inventory of radiology
its working condition daily & do regular warm department medications for patient administration
up. Shutdown of machine should be done shall be kept in the radiology.
after working hours.
2. Never keep any fluids over or near b. Department consumables will be kept in
equipments. cupboards
3. Monitor Housekeeping staffs during cleaning c. Radiology department orders their
mainly with wet mops. consumables (films, chemicals, contrast
4. Monthly cleaning record should be and medication) on a Indent book
maintained for all equipments. d. All consumables subject to expiry shall be
5. In case of continuous power fluctuation shut replaced and returned to the store through
down all the Machines, till proper power refund indent.
supply is observed.
6. In daily Briefing Working condition &
Breakdowns of machine should be handed
over without fail.
363
18.30 Quality Plan
a. Quality Indicator:
i. Indicator: Turn around time for reports
ii. Benchmark
Date X-ray Pt. Name NO Procedure Done Received Patient taken Duration
No. request time for procedure
In Minutes
b. Other quality initiatives:

i. Quality grading of films
ii. Reject rates for radiology films
c. Forms Documents and Stationary

i) Patient related forms
S No: Form
1 Request Form with consent for procedures
ii) Registers
S No: Form
1 Daily entry registers for all procedures
2 Radiographer log book
iii) Recall policy:-

Reports are recalled or amendment is made where applicable.
c.Clinico radiological meeting is held as per requirement with radiologist and surgeons and other
clinicians.This is for understanding and correlating the imaging results with findings,so used a tool for
improvement of quality these results..
d.Periodic external peer review of imaging results of CTScan is done every 3monthly.
e.Appropriatness of the investigation advised and performed by radiologist is reviewed.
F All imaging equipment are checked for QA annually by external agency which include leakage
rate,congruence of optical and radiation fieldand output consistency.
364
18a Radiation Safety Manual
Responsibility of updating: Department of Radio-Imaging
August 2020
Last reviewed/ updated on:
Version (CNBC/Radio-Imagine/
Safety/18a/ver1.1)
365
18.31 18a.1Scope Of Radiation Safety
1 The Hospital Radiation Safety program applies to all locations where radiation-producing machines
are used or stored, regardless of ownership or the location.
2 It applies to all persons working at or frequenting these locations, regardless of their relationship with
the Hospital
3 It applies to all radiation-producing machines at these locations, regardless of ownership of the
machines.
18.32 18a.2Definitions & Abbreviations

a. Definitions
i. Absorbed Dose: The amount of energy imparted to matter by ionizing radiation per unit mass of
irradiated material. The unit of absorbed dose is the Gray (Gy)
ii. ALARP: Acronym for As Low As Reasonably Possible.
iii. Calibration:The check or correction of the accuracy of a measuring instrument to assure proper
operational characteristics
iv. Critical Organ:The organ or tissue, the irradiation of which will result in the greatest hazard to the
health of the individual
v. Declared Pregnant Worker: A woman who has voluntarily informed her employer, in writing, of her
pregnancy and the estimated date of conception
vi. Dose Rate: The radiation dose delivered per unit of time
vii. Dosimeter: A portable instrument for measuring and registering the total accumulated exposure to
ionizing radiation
viii. Geiger-Mueller (G-M) Counter: Radiation detection and measuring instrument.
ix. Gray:The international (SI) unit of absorbed dose in which the energy is equal to one Joule per
kilogram
x. Half Value Layer:The thickness of any specified material necessary to reduce the intensity of an x-ray
or gamma ray beam to one-half its original value
xi. Inverse Square Law:The intensity of radiation at any distance from a point source varies inversely as
the square of that distance
xii. Ionizing Radiation:Any radiation capable of displacing electrons from atoms or molecules, thus
producing ions
xiii. Occupational Radiation Dose: The dose received by an individual in the course of employment.
xiv. Radio sensitivity: The relative susceptibility of cells, tissues, organs, organisms, or other substances
to the injurious action of radiation
xv. Sievert: The international (SI) of dose equivalent.
xvi. Thermo luminescent Dosimeter (TLD): Crystalline materials that emit light if they are heated after
they have been exposed to radiation
b. Abbreviations:
i. AERB : Atomic Energy Regulatory Board
ii. BARC:Bhaba Atomic Research Center
iii. ALARP: As Low As Reasonably Possible
iv. RSO: Radiation Safety Officer
v. GM: Geiger-Muller Counter
vi. Gy: Gray
vii. Pb: Lead
viii. mSv:millisievert
ix. TLD: Thermo luminescent Dosimeter
x. NOC: No Objection Certificate
xi. SSD: Source-Skin Distance
xii. THF:Tuned high frequency
366
18.33 18a.3 Radiation Safety Policies
18a.3.1 Statutory Requirements

(SOURCE: AERB /BARC guidelines for Radiology Department).
Radiology v. Image intensifiers to be used for

fluoroscopy examination.
18a.3.2 Distribution list: Radiology vi. Periodic inspection of X-ray equipment
and shielding features is conducted
18a.3.3 Policy: regularly.
vii. Personnel monitoring facility be provided
to all radiation workers.
viii. Presence of uninvolved staff, patients and
i. The Atomic Energy Regulatory Board persons in any X-ray room must be
(A.E.R.B) is entrusted with the avoided.
responsibility of developing and ix. Regular maintenance and calibration of
the unit must be carried out.
implementing appropriate regulatory
x. Reproductive organs must be particularly
measures to ensure radiation safety. shielded.
Statutory requirements with regard to xi. Services of qualified radiologists and X-
radiation safety are as follows: rays technologists to be used.
xii. Servicing and calibration of X-rays
ii. Commissioning and Decommissioning of equipment should be undertaken by
X-ray Equipment has to be registered with qualified, trained and authorized service
AERB. engineer.
iii. Direct assistance to the patient while xiii. There should be transfer of radiographs
being X-rayed has to be avoided. If and reports to avoid repeated X-rays
assistance is required, appropriate examinations.
precautions have to be taken by the xiv. X-rays equipment meeting design
person who will assist by making use of certification and type approval requirement
appropriate protective material and by AERB only shall be used.
devises which are available. xv. X-ray examination of pregnant women
iv. Fetal protection measures to be used.
xvi. and children should be avoided as far as possible.
367
18a.3.2 Personal protective equipment
18a.3.2.1 Scope: Radiology d. The operator shall collimate x-ray beam

limitation to ensure that the x-ray field does not
18a.3.2.2 Distribution list: Radiology extend beyond the Region of interest.
e. The Radiographic field shall be restricted to
18a.3.2.3 Policy: the areas of clinical interest as far as practical;
f. A method to observe the patient during the x-
i. No person shall operate or permit the ray exposure (Lead glass) shall be provided
operation of certified or uncertified medical for all units.
radiographic and fluoroscopic equipment g. During radiographic exposure, the operator
systems unless the following conditions are shall stand behind the protective barrier.
met: h. The department Supervisor shall provide
a. Only individuals required for the medical safety rules to each individual operating x-ray
procedure, for training or for equipment equipment including any restrictions as to the
maintenance shall be in the radiographic or operating technique required for the safe
fluoroscopic room during an exposure. operations of the particular x-ray apparatus,
i. Individuals who are present in a radiographer and require that the operator sign a form
or fluoroscopic room during any exposure shall acknowledging that the safety manual was
wear protective aprons of at least 0.25 mm read.
lead equivalent during every exposure. i. No person shall permit or arrange for the
ii. The fluoroscopist shall wear protective gloves intentional irradiation of a human being except
of at least 0.25 lead equivalents. for the purpose of medical diagnosis or
b. When a patient must be provided with auxiliary treatment;
support during a radiation exposure and j. No person shall deliberately expose an
i. Mechanical holding devices are insufficient; individual to the useful beam for the sole
the following procedures shall be followed: purpose of training or demonstration.
k. No person shall operate an ionizing –radiation-
ii. The person holding the patient shall be producing machine unless that person
protected with a lead apron of at least 0.25 understands and uses the principles of
mm lead equivalent; radiation safety to keep radiation exposure as
iii. The person holding the patient shall be low as reasonably possible (ALARP).
protected with lead gloves of at least 0.25 mm o 18a.3.2.4 List of Personal Protective
lead equivalent if the hands must be placed in Equipment:
the useful beam.
iv. Radiographers not to hold the patient during a i. Lead Aprons (0.50 mm Lead) Thyroid
radiation exposure, except in a life-threatening Shields (0.50 mm Lead
situation. ii. Lead Goggles
v. No person shall be employed, routinely iii. Abdominal Shield (0.50 mm Lead)
assigned, or required to hold a patient during iv. Lead Glasses
radiographic and fluoroscopic procedures; v. Lead Screen 6 X 3 Feet (Mobile)( 2mm
vi. If a patient must be held during the x-ray Lead)
exposure, non-radiation workers such as vi. 2mm Lead Lined Doors in all X-ray
nurses or members of the patient’s family may Producing unit.
be asked to perform this duty. vii. A method to observe the patient during the
c. Gonad shielding of not less than 0.5 mm lead x-ray exposure (Lead glass) shall be
equivalent shall be used on a patient during provided for all units.
1. Radiographic and fluoroscopic procedure, viii. Lead Gloves
except for cases in which this would interfere
with Diagnostic procedure.
368
18a.3.3 Safety Guidelines
18a.3.3.1Scope: Radiology v. Take a special interest in the new or

inexperienced persons and help them with
18a.3.3.2 Distribution list: Radiology the small details of the job.
vi. Be sure to notify all persons of any
18a.3.3.3 Policy: dangerous situations that might affect your
work area.
i. All safety guidelines shall be observed. vii. Remember the patient; never leave
ii. Report every injury, no matter how slight, him/her unattended.
to your in charge. viii. Know all the hospital emergency codes
iii. No intoxicating liquor shall be consumed and be sure of your responsibilities.
while on duty. Anyone who is found under ix. When dealing with the extremely large
the influence of alcohol or drugs will be patient, be sure to seek help and lift the
terminated. patient correctly.
iv. Keep fit for your job, eat properly and get x. Know your fire extinguishers, their
sufficient rest to meet the demands of your locations and the use.
job. xi. Use good housekeeping techniques at all
times.
xii. Remember the department security
18a.3.4 General Radiation Protection
18a.3.4.1Scope: Radiology
18a.3.4.2 Distribution list: Radiology
18a.3.4.3Policy:
i. A qualified radiographer must only do all radiographic techniques and procedures. All radiographers
must take necessary steps in reducing radiation dose to the patient.
ii. Check the correct patient for correct examination.
iii. Plan your technique to reduce the radiation dose
iv. Close the X-ray room door properly and tightly.
v. Provide the necessary radiation protection.
vi. Collimate the radiation beam to necessary area only.
vii. Give proper and correct instructions.
viii. Select the appropriate exposure factor.
ix. Place the correct ID Permanent Number for correct patient
x. Avoid unnecessary repeats.
xi. Limit number of people in the X-ray room while X-ray is being done.
xii. Mobile X-ray request only if it is necessary and inappropriate use must be avoided.
xiii. All staffs must wear radiation-monitoring badge while in the radiology department.
xiv. Good combination of X-ray film and intensifying screen to be used for the reduction of radiation
exposure (Blue sensitive).
xv. Clear all staffs from room during Mobile X-ray /Provide Lead apron to the next Bed patient if he
he/she is not able to move.
xvi. Every body should be 6 feet away from x-ray tube during Mobile x-ray
369
18a.3.5 Departmental Safety
18a.3.5.1Scope: Radiology vii. All electrical machines, with heat

producing elements, must be turned off or
18a.3.5.2Distribution list: Radiology unplugged when it is in not use.
viii. Smoking is prohibited, per hospital
18a.3.5.3Policy: smoking policy.
ix. Do not permit rubbish to accumulate.
i. Supervisor of radiology services is x. RSO (Radiation Safety Officer) will check
responsible for maintaining safety the scattered radiation in the Radiology
standards, developing safety rules and Department and maintain the check
supervising and training personnel in report.
departmental standards. xi. Notify the facility department immediately
ii. Supervisor of radiology services is of illumination and Air conditioning effect
responsible for notifying the Management Problems.
in case of any safety hazard. xii. Furniture and equipment must be allowed
iii. All radiology employees shall report adequate passage and access to exits at
defective equipment, unsafe conditions, all times.
acts or safety hazards to Supervisor of xiii. Employee who discovers the spill should
radiology services. inform minor spills, such as water&
iv. Keep electrical cords clear of passage chemical spill to House keeping team.
ways. Do not use electrical extension This shall be done immediately.
cords without prior informing the facility xiv. Report faulty equipment to the vendor as
department. per policy.
v. All equipments and supplies must be xv. Obey warning signs.
properly stored. xvi. Wear suitable clothing, only authorized
vi. Scissors, knives, pins, razors blades and
other sharp instruments must be stored
and used safely.
xvii. personnel shall be allowed in X-ray room.
18a.3.6 Role of Radiographers in safety program
18a.3.6.1Scope: Radiology necessary to perform safely and

effectively in their particular position.
18a.3.6.2 Distribution list: Radiology iii. Individual departments will establish and
publish safe work rules which reduce
18a.3.6.3 Policy: accident probability. Development of these
rules should involve:
i. It is the responsibility of the iv. A review of all work methods and
RADIOGRAPHER to have thorough practices
knowledge and apply on the job v. A review of all past accident experiences
instructions for all personnel regarding vi. Recommendations by supervisory
safe practices. personnel
ii. Department Supervisor is responsible for vii. Recommendations by personnel
the degree to which his/her personnel viii. Investigate personnel injuries within the
have gained the knowledge and skills department
ix. Assist in monitoring
x. Safety Recommendations.
370
18a.3.7 Patient’s Safety
i. When using portable X-ray units, only

18a.3.7.1Scope: Radiology radiographer and the patient shall be in
the room at the time of exposure. The
door shall be closed and the radiographer
18a.3.7.3 Policy: shall stand at least six feet from the
portable unit.
i. All patients shall receive the utmost care j. All X-ray switches shall be in allocation
and attention where they cannot be accidentally
a. Appropriate Personal protective equipment energized.
shall be kept available at all times, personnel k. TLD shall be worn by all Staffs during
shall be trained in their use. working hours in department. Badges will
b. When the lift is used for any patient, one be processed and recorded Quarterly.
staff must be present on the lift. l. A routine check shall be made X-ray
c. All wheelchair will have wheel locked when equipment before using. Recalibrate when
the wheel chair is on the lift and while the tubes are changed or machines modified.
patient is entering or existing the wheelchair. m. If a patient must be held during x-ray, the
d. When a trolley is used for the transportation assistant holding the patient will were a
of the patient, the side rails will always be lead-lined apron during the entire
up. Trolley wheel must be locked while procedure.
trolley is on lift. n. All people assisting or observing at
e. Transportation method for out patient will be fluoroscopy shall wear lead lined aprons.
based on status of the patient when There will be no exceptions to this rule,
assessed by the hospital staff prior to x- including referring physicians, patients
ray/scanning. An out patient determined to and/or translators.
be ambulatory will be allowed to walk to the o. The radiographer shall always stand in
unit. the lead line control cubicle when making
f. The Bed roll of U.S. Scan Table shall be an exposure.
changed frequently to prevent any kind of p. The X-ray tube shall never be pointed
cross Infection/contamination. directly towards the control cubicle, In
g. X-ray Table bed roll will be provided for unavoidable circumstances to collimate
Infectious patients. accurately and wear lead apron.
h. Any of the hospital employees who q. The doors to the X-ray room must always be
knowingly disguard the patients’ safety by kept closed.
disobeying the aforementioned policies will r. Return equipments to its proper location
be subject to disciplinary action by when not in use.
management. s. Do not obstruct fire equipment. Know
location of fire-righting equipment and how
to use it. Know evacuation routes and what
to do in case of fire.
t. Patients such as a children and pregnant
women shall be shielded.
u. The radiographer will ensure that all the
Infant/children being radio graphed have
proper shielding and proper collimation of
371
the X-RAY beam to expose only the required
anatomy.
Switch on “RED LIGHT” indicator while taking X
rays.
18a.3.8 Guidelines for Safe Operation of X-Ray producing Equipment

:
18a.3.8.1 Scope: Radiology 6 with clinical requirements and should

always be aligned accurately with the
18a.3.8.2 Distribution list: Radiology patient and film.
7 Mobile equipment should be used only for
18a.3.8.3. Policy: examinations where it is impractical to
transfer patients to permanent
1 Appropriate personal protective radiographic installations.
equipment (Radiation Protective 8 The operator should stand behind the
devices) is to be worn where there barrier provided for his/her protection
is a risk of Radiation exposure. during radiographic exposures at
2 Personnel monitoring devices should permanent radiographic installations and
always be worn when working with should stand as far as possible (at least 6
radiographic/fluoroscopic equipment. The feet) from the patient when operating the
devices worn should be those issued for mobile equipment.
the current time period and should be 9 Each mobile radiographic equipment
worn under the lead apron. Those operator, prior to making an exposure,
workers wearing TLD badges should should ask anyone within 6 feet of the x-
ensure that the Card has been properly ray tube and/or patient being radio
inserted into the Cassette holder. graphed to move further away until the
3 Only persons whose presence is exposure is complete. Those persons
necessary should be in the radiographic or who must remain within 6 feet of the
fluoroscopic room during exposure. All patient and/or x-ray tube must be
such persons who are subject to direct protected by whole body aprons or
scatter radiation shall be protected by barriers of at least 0.25 mm lead
aprons or whole body protective barriers equivalence. The operator shall give an
of not less than 0.25 mm lead equivalent. audible warning before the exposure is
Note: A lead apron (Pb) of 0.25 mm lead made.
equivalence will reduce scattered x-rays by 10 When Making X-ray exposures, it is
95%. advisable to place the image intensifier
closest to the region of interest. This
4 Mechanical supporting or restraining results in better image quality and reduces
devices shall be used when a patient or risk from potential hazards.
film must be held in position for 11 The hand of the fluoroscopist should not
radiography or fluoroscopy. If a patient be placed in the useful beam unless the
must be held by an individual, that beam is attenuated by the patient and a
individual shall be protected with protective glove of at least 0.5 mm lead
appropriate shielding devices of at least equivalent.
0.25 mm lead equivalence for whole body 12 The minimum source-skin distance (SSD)
protection and at least 0.5 mm lead for all mobile radiographic x-ray units must
equivalence for any part of the holder’s be 30 centimeters.
body that is exposed to the primary x-ray 13 The radiation protection program is guided
beam. by the concept of keeping radiation
5 The x-ray beam should always be exposure As Low as Reasonably Possible
collimated to the smallest area consistent (ALARP).
14 Remember that radiation cannot be seen
or felt, but can be detected with radiation
survey meters.
15 Radiation exposure of all individuals
routinely working with sources of radiation
372
is monitored with a TLD (Thermo
luminescent dosimeter) badge. The
devices are checked quarterly.
16 Radiation exposure can be minimized by
utilizing three basic principles
17 Time: Shorter exposure time means a
lower dose.
18 Distance: Doubling the distance from a
radiation source means one-fourth the
dose rate.
Tripling the distance gives one-
ninth the dose rate.
373
Inverse square law.
19 Shielding: The use of appropriate shielding greatly reduces the dose rate.
Prepared by: Radiology

Department
18a.3.9 U.S. Scan Safety Guidelines
18a.3.9.1 Scope: Radiology
18a.3.9.3 Policy:
1 Patient safety:
Always include proper identification with all patient data and verify the accuracy of the patients
name or ID numbers when entering such data. Make sure correct patient ID is provided on all
recorded data and hard copy prints.
2 Diagnostic Information:
Equipment or incorrect settings ca result in measurement errors or failure to detect details within
the image.
3 Mechanical Hazards:
Damaged probes or improper use and manipulation can result in injury or increased risk of
infection.
4. Electrical Hazard:
A damaged probe can also increase the risk of electrical shock if conductive solutions come in
contact with internal live parts. Inspect probes often for cracks or openings.

Department
18a.3.10 Lead Apron inspection/Radiation protective device
18a.3.10.1 Scope: Radiology
18a.3.10.2 Policy:
1 Lead aprons must be used to protect staffs and patients from unnecessary radiation exposure
from diagnostic radiology procedures.
2 Health care organization must perform inspections on medical equipment, including lead aprons,
lead protective devices etc.
3 Aprons must be stored properly in hangers.
4 Do not fold or pile up.
5 Check for cracks.
374
Department
18a.3.11 Handling of chemicals
18a.3.11.3 Policy:
1 Most chemicals are harmful to some degree. Avoid direct contact with any chemical.
2 Wash thoroughly with hand wash solution and water whenever a chemical contacts your skin.
3 Never taste or smell a chemical.
4 All container and chemicals must be labeled clearly. Do not use any substance in an unlabeled
container.
5 Always pour concentrated solutions slowly into water or into less concentrated solution while
stirring. Always wear safety spectacles and Plastic apron & Mask while diluting solutions.
6 Keep flammable solvents away from heat and sunlight. Do not heat flammable solvents directly
over a naked flame or hot plate.
7 Discard safely
8 Wear mask during preparing fresh and filling/ discarding processing solutions.
18a.3.12 Chemical Waste Disposal
Department
18a.3.12.3 Policy: Wet processing is to be used as a stand by procedure due to use of computed
radiography.
1 This Fixer & Developer is recommended for processing Medical X-ray films in automatic Film
processor equipment.
2 Storage
3 The chemicals must be stored and used at 4 to 29°C.
4 Discard if there is evidence of contamination, dirt, over-dilution, excessive evaporation, or
crystallization safely.
5 Mixing Instructions
6 Instructions for mixing replenish and/or working solutions are provided by leaflets for individual
size packages.
7 Disposal: -Developer: Used Developer should be neutralized (pH 7-9) and flushed with large
quantities of water to the sewer system.
8 UNUSED developer contains hydroquinone which is a toxic substance, so unused developer
cannot go down the drain.
9 Keep developer and used fixer separated.
10 If used fixer and developer accidentally get mixed together, the mixture must be disposed of as
dangerous waste.
11 Disposal: Fixer - Used fixer from X-ray processing is defined as a Hazardous waste because it
contains high concentrations of silver.
375
12 Collect used fixer in a container marked “Hazardous Used fixer”. Keep fixer separately- storage
capacity 200 Liters.
13 The supplier will be asked to take it back at cost. Keep disposal receipts.
14 After sale close all the lids of the sold fixer container seal it with plaster to avoid spillage during
transportation
15 The films are disposed with used fixer to the hypo buyer as solid waste.
Department
18a.3.13 Adverse Drug Reaction (ADR) Policy
1 In case when there is a use of contrast media Patient’s attendant will be explained the procedure
and the after effects of the Iodinated contrast media.
2 Look for any contra indications.
3 Consent will be taken.
4 In case of Neonates temperature of the Fluoroscopy room is maintained and proper steps should
be taken to prevent cross infection.
5 Intermittent fluoroscopy should be done to provide minimal possible Radiation Dose.
6 Emergency medication is used in case of drug reaction. They are categorized as under
a. Mild
b. Moderate
c. Severe
7 In case of severe reaction Patient is transported rapidly to casualty department.
8 Incident reporting is done.
376
19 Manual of Laundry
Created on: October 2010
Responsibility of Updating: Department of Laundry
Last reviewed / Updated on: August 2020
Version no. (CNBC/ Laundry/19/Ver.1.1)
377
19 Manual of Laundry ..................................................................................................................................... 377
19.1 Amendment Record Sheet ................................................................................................................ 379
19.2 Hierarchy of the Laundry ................................................................................................................... 380
19.3 Job Responsibility: ............................................................................................................................. 381
19.4 Introduction:- ...................................................................................................................................... 381
19.5 Categories of Used Linen .................................................................................................................. 381
19.6 Specific Items .................................................................................................................................... 381
19.7. Mattress overlays ..................................................................................................................................... 381
19.8 Handling and Storage Of Used Linen In Ward/ Department ............................................................. 381
19.9 Transporting Used Linen From Ward / Department To Pick-Up Point .............................................. 382
19.10 Transporting Used Linen From The Pick-Up Point To The Laundry ................................................. 382
19.11 Return of Clean Linen To The User ................................................................................................... 383
19.12 Infection Control Issues In The Laundry ............................................................................................ 383
19.13 Spillage of Contaminated Linen ......................................................................................................... 383
19.14 Thermal disinfection times and temperatures and environmental issues in the laundry ................... 384
19.15 Disinfection of used (soiled and fouled) linen .................................................................................... 384
19.16 Disinfection of suspected (or known) infected linen .......................................................................... 384
19.17 Disinfection of heat-labile linen (Blanket) .......................................................................................... 384
19.18 General measures to prevent infection .............................................................................................. 384
378

No. Amendments
1 1 27.8.2020 Add category for linen Onset of corona

from SARI ward / linen infection needs different
of covid positive patient handling protocols
1 19.8.4 27.8.2020 Disinfection of linen Onset of corona

from SARI ward or that infection needs different
of covid positive patient handling protocols
should be disinfected in
the ward itself by
placing in hypochlorite
solution and packed
separately in a properly
labelled bag
379
19.2 Hierarchy of the Laundry
M.O. I/C
Laundry
Laundry
Incharge
Workers
380
19.3 Job Responsibility:
19.3.1 M.O. Incharge:

1. To design and update the manual at predefined intervals.
2. To ensure the implementation of the departmental policies and procedure by the workers.
3. To provide timely training to the workers on the departmental and infection control policies.
19.3.2 Laundry In charge:

1. To monitor and ensure the smooth functioning of the laundry.
2. To ensure the timely preventive maintenance and calibration of the equipments and maintain their
records.
3. To ensure the availability of adequate washing material, personal protective equipment and their
proper usage.
4. To maintain the records for the medical check-up of the laundry workers.
19.3.3 Laundry Workers:
19.3.3.1 To receive and segregate and process the linen category wise
19.4 Introduction:- The purpose of this policy is prevention of infection or injury in patients and
health care staff involved in the use, handling or laundering of hospital linen.
19.5 Categories of Used Linen

1. Used linen
2. Used linen, which may be slightly contaminated with excreta, blood, and body fluids and not
classed as infected.
3. Known or potentially infected/infested linen
All linen which is :
- Grossly contaminated with excreta, blood or body fluids,
- contaminated linen from a patient who is known, or clinically suspected, to be infectious. For
example salmonella, hepatitis A, B or C, open pulmonary tuberculosis, HIV.
19.6 Specific Items
19.7.Mattress overlays
These must be protected by waterproof covers, which are cleaned with soap and water between
patients. Alcohol wipes MUST NOT be used to clean these items as alcohol damages the cover which
may allow fluid to pass through to the mattress foam, the life of the mattress and its ability to protect
patients form cross infection is then reduced. If the cover is damaged or punctured, and the article itself
is contaminated it must be condemned and disposed of as clinical waste. Replacement covers can be
purchased and may be used providing the mattress itself is not soiled stained or has a smell.
19.8 Handling and Storage Of Used Linen In Ward/ Department
381
19.8.1 Used linen must be handled with care to prevent environmental contamination with excretion or
secretions, skin scales or bacteria. Linen must be bagged at the bedside, never shaken or
allowed to touch the floor.
19.8.2 No extraneous items must be placed in the laundry bags, especially sharp objects. This may
contribute to a health & safety risk for the laundry workers.
19.8.3 All linen bags must be placed in the correct color bag, securely tied, labeled as appropriate and
stored in a room or area designated for the purpose, which is safe and separate from patient
areas.
19.8.4 Bags must be less than 2/3 full.
19.8.5 All items that are sent to the laundry must be appropriately marked including mattress overlays,
clothing.
19.8.6 Gloves may also be required if linen is wet. Hands must be washed after handling soiled or
infected linen
19.8.7 Linen should be held away from the body to prevent contamination of clothing.
19.9 Transporting Used Linen From Ward / Department To

Pick-Up Point
19.9.1 Laundry bags must be securely tied.
19.9.2 The pick-up point must be dry and secure and separate from
the clean linen area
19.9.3 The frequency of collection will depend on the volume of

laundry.
19.9.4 Linen handlers must have heavy-duty rubber gloves

available. Guidance on hand washing technique and frequency must be given.
19.10 Transporting Used Linen From The Pick-Up Point To The Laundry
19.10.1 Frequency of collection will be dependent on the volume of laundry and the predefined schedule.
19.10.2 Laundry is responsible for cleaning and disinfection of the Trolley in order to prevent
contamination of clean linen:
a) After any spillage
b) After transportation of dirty laundry, if it is to be used for clean laundry next

at least weekly
19.10.3 There must be no contact between clean and soiled linen at any time. So, clean and dirty/ soiled
linen are transported separately from separate corridors, clean linen are transported in white
trolleys while dirty linen are transported in a red trolley, if the linen is soiled it should be first tied in
a red bag.
382
19.11 Return of Clean Linen To The User
19.11.1 Contamination of clean linen must be prevented by:

a) Storage in a clean, dry area or cage
b) Transport in a white trolley which is cleaned and disinfected prior to loading with clean linen.
19.11.2 Linen that is (or thought to be) contaminated must be returned to the laundry for re-processing.
19.12 Infection Control Issues In The Laundry
19.12.1 No person shall be permitted to work in or about the processing or handling of any article to be
supplied to the hospital while suffering from an infection or skin disease. All contractors’ staff
must report such conditions to the contractor.
19.12.2 Personal protective clothing will be available and worn when handling linen. All such clothing
must be removed and changed each time the person leaves the department.
a) Heavy duty rubber gloves
b) Apron
19.12.3 Disposable items must not be re-used. Reusable gloves must be cleaned and dried at least daily.
19.12.4 A hand hygiene facility complete with soap and paper towels, must be available close to the
working areas.
19.12.5 Staff must be aware of the possibility of extraneous items and sharps containers must be
available.
19.12.6 Staff must be aware of actions to take in the event of a sharps injury.
19.12.7 Systems and machinery will be designed and operated so as to reduce the risk of re-infection of
linen during the course of the laundering process and, to prevent articles being re-infected after
laundering and prior to re issue to the hospital.
19.13 Spillage of Contaminated Linen

Wearing gloves, replace the linen in an appropriate bag. Wash the contaminated surface with
detergent and water and dry. Wash hands thoroughly after removing
gloves.
383
19.14 Thermal disinfection times and temperatures and environmental issues in the laundry
19.15 Disinfection of used (soiled and fouled) linen
19.15.1. A sluice cycle is incorporated into washing machines for the removal of organic matter from
fouled linen.
19.15.2. Put 200gm of bleaching powder (25Ltr water) in one sluice cycle to disinfect soiled linen.
19.15.3. Wash loads will have a mixing time of 8 minutes added to the temperature holding times.
19.16 Disinfection of suspected (or known) infected linen
19.16.1. The temperatures described previously will adequately disinfect linen.
19.16.2. This linen must not be processed in a batch continuous washing machine, but should be
processed in a washer extractor.
19.17 Disinfection of heat-labile linen (Blanket)
19.17.1. If soiled, than first dip the blanket in Bleaching powder (0.5%) for 20 minutes, then sluicing will
be done to wash off any organic material stuck to it.
19.17.2. Linen in this category must be laundered in a

machine at 40°C and dried at 60°C using tumble
dryers.
19.17.3. Bleaching powder (0.5%) may be used in the

penultimate rinse.
19.18 General measures to prevent infection
19.18.1. All surfaces will be kept free from dust, debris

and pests. There will be a system for regular
cleaning of the environment including high level
surfaces.
19.18.2. All washing machines will be kept clean and free

from algae.
19.18.3. All washing machines should be fitted with accurate heat sensors that are correctly positioned.
These must be tested at predefined interval and calibrated. Records must be kept of this and of
regular monitoring of wash temperatures.
19.18.4. Disinfection of linen from SARI ward or that of covid positive patient should be disinfected in
the ward itself by placing in hypochlorite solution and packed separately in a properly labeled bag
384
385
20 Department of Physiotherapy
Date created: February 2011
Responsibility of Department of Physiotherapy

updating:

updated on:
Version (CNBC/ Physiotherapy/20/Ver.1.3)
386
20 Department of Physiotherapy ........................................................................................................... 386
20.1 Amendment Record Sheet .................................................................................................... 388
20.2 Introduction ............................................................................................................................ 389
20.3 Scope .................................................................................................................................... 389
20.4 Other Activities: ..................................................................................................................... 390
20.5 Administrative Process .......................................................................................................... 390
20.6 Departmental procedures ...................................................................................................... 391
20.7 Statutory Requirements ........................................................................................................ 393
20.8 Initial assessment of patients ................................................................................................ 393
20.9 Discharge plan ...................................................................................................................... 394
20.10 Departmental safety .............................................................................................................. 394
20.11 Patient safety......................................................................................................................... 396
20.12 Patient Confidentiality ........................................................................................................... 396
20.13 Cleaning and Disinfection ..................................................................................................... 397
20.14 Equipment Maintenance ....................................................................................................... 397
387
S.no. Clause no. Date of Amendment Reasons Sign of QM
Amendment Made Of
Amendment
Aug, 27 ‘2010
th
1. 20.32 Incorporated As it was not mentioned
OPD timings earlier
Aug, 27 ‘2010
th
2. 20.13.5 Few registers As they were not
and forms are mentioned earlier
incorporated
3. 20.14 November 2014 Policy of Previously it was not
cleaning and documented
disinfection
4. 20.13.5 Dec 2014 Addition of To make it more clear
registers
5. 20.6 Dec 2014 Inpatient and As per the department
Outpatient Work requirement
Process
modified
6. 20.14.4 Dec 2014 Monthly statics To make it more clear
modified
7. 20.14.5 Jan 2016 Addition of KPI Previously not

mentioned
388
20.2 Introduction
20.2.1 Physiotherapy – “Treatment by physical means” or “Tending to cure of disease”
Physiotherapy is a branch of Health care science, which mainly concentrates on the physical aspects
of an individual’s health, by treating their physical ailments. It works towards this by maintenance and
rehabilitation of the individual’s physical activity by bringing back the lost activity to near normal
perfection. Physiotherapy uses physical agents for the treatment of patients.
20.3 Scope
20.3.1 We provide services to the patients attending consultants in the following clinical area:
1. Orthopedics
2. Neurology
3. Medicine
4. I.C.U / I.P.D
5. Special Clinics
6. Neuro and Development Clinic
20.3.2 The physiotherapy team offers a complete assessment, treatment and education to all out
patients and in patients. Thorough assessment, discussion and explanation precede any
physiotherapy intervention.
20.3.3 Modalities used in physiotherapy:
1. Chest Physiotherapy
2. Mobility Exercise
3. Strengthening Exercises
4. Neuromotor development Therapy
5. Positioning and Posture Care
6. Electrical Modalities
7. Ambulatory Exercises
Equipments
Moist Therapy
Shoulder Wheel
Wall Ladder
Shoulder pulleys
Parallel bar &
Mirror
Quadriceps Table
Gym Ball
CPM
Exercise therapy
389
20.4 Other Activities:
20.4.1 Rehabilitation: It is the job of a physiotherapist to rehabilitated “Restore to right, privileges,

reputation”. In others words to bring the patient to the point where he can again take his place as
an independent member of society. It aims at enabling him to reach and maintain his/her optimal
physical, sensory, intellectual, psychological & social functional levels.
20.4.2 Outpatient Service Timings:
9:00am – 4:00 pm (Monday to Friday)
9:00am – 2:00 pm (Saturday)
20.5 Administrative Process
Stations / counter / area Process – department
Departmental Orientation All new staffs joining the hospital is oriented for the department work
process and uses of equipments
Inventory Receiving of indent as per department requirement from stores and

pharmacy. Sufficient department stock maintained.
Linen Inventory Physiotherapists will maintain the stock of clean linen as per
requirement and makes sure soiled linen is sent to laundry in time
Stock check Physical inspection of inventory items of consumables to check stock

status
Physiotherapists will take care of equipments in use and maintain the

Maintenance of Equipments
history book.
390
20.6.1 Inpatient Work Process:
Referral from
consultants
Entry in the inpatient

register and
assessment /evaluation
by the therapist
Treatment and
procedure given and
explained to the care
giver
Progress notes in
referral sheet
periodically
Discharge
Home exercise program
Follow up according to
the status of the
patient in OPD
391
20.6.2 Outpatient work process
Consultant refers to
physiotherapy Dept
Patient with reference enters the

physiotherapy department with PT
card.
Order/ MRD entry done
Patient assessment and

evaluation done
Referral and discussion with

Plan of treatment and
other rehabilitation team
treatment start
memebrs
Home Training program
Follow up and review as per

patient’s diagnosis and set
goals
Discharge
392
20.7 Statutory Requirements
20.7.1 Scope: Physiotherapy
20.7.2 Distribution list: Physiotherapy
20.7.3 Policy:
1. All Physiotherapists should have completed bachelors Degree
20.8 Initial assessment of patients

20.8.3 Policy:
1. An initial assessment of every patient will be entered by a physiotherapist in the MRD.

template to determine a treatment plan depending upon patient’s current clinical
condition.
a. Initial assessment will include information gathered by the physiotherapist as follows:

i. Past medical, surgical history, present historyand family history forms of
treatment
ii. Doctor provided primary and secondary diagnosis, with onset
iii. Patient’s current clinical condition
iv. Pain assessment
v. Muscle power
vi. Range of motion
vii. Functional limitations
viii. Problems of dysfunction
ix. Activities of daily living (ADL)
x. Splints used or anticipated
xi. Treatment plan
b. All assessment and evaluation must be performed by the physiotherapist. Patient’s
progress is entered in MRD and will exhibit overall response to the initial treatment
plan.
393
20.9 Discharge plan
Policy Type: Departmental
Policy Number: CNBC/Dep/physio/03
Dept: Physiotherapy

20.9.3 Policy:
1. Patient will be discharged from the department according to the assessment of the patient’s
level of functioning and treatment goal. Through assessments and evaluations of patient
progress, discharge plans will be formulated. An assessment of the patient’s home
programme will be made upon initial assessment to allow for formulation of early plans for
discharge.
a. The Discharge plan includes:
i. Total length of time in active physiotherapy care.
ii. Comparison of all objective data (range of motion, strength, special testing) to
initial findings
iii. Comparison of patient complaints.
iv. Treatment provided to the patient during the course of treatment.
v. Physiotherapy care.
vi. Patient’s current clinical condition and status as discharged from active
physiotherapy care
vii. Plans for discharge will be formulated in a collaborative manner with the patient.
viii. Communication with the consultant about the patient’s condition
ix. Arrangement of all necessary medical aids for the patient prior to discharge
x. The patient will be discharged when the above mentioned criteria have been met.
xi. If the inpatients have to continue physiotherapy after discharge will be mentioned
in the discharge summary by the consultant.
20.10 Departmental safety
Policy Number: CNBC/Dep/Physio/04
394
Dept: Physiotherapy

20.10.3 Policy:
1. Executive physiotherapist is responsible for maintaining safety standards, developing

safety rules, supervising and training staff in departmental standards.
2. Executive physiotherapist is responsible for informing facility in case of any safety
hazard.
3. All physiotherapy employees shall report defective equipment, unsafe conditions and
acts, or safety hazards to the head of the department.
4. Safety measures include:
a. Keeping electrical cords clear of passageways. Do not use electrical extension cords
without the approval Facilities Department.
b. Proper storage of all equipment and supplies. Do not store heavy items on top shelves.
Scissors, knives, pins, razor blades and other sharp instruments must be safely stored
and used.
c. Turning off all electric machines with heat producing elements when not in use.
d. Notification to facilities department immediately of improper illumination and ventilation.
e. Arrangement of furniture and equipment must be arranged to allow passage and access
to exits at all times.
f. Giving information regarding minor spills, such as water to cleaning team by the
employee who discovers the spill immediately.
g. Reporting faulty equipment to the Facilities Department or vendor as per policy.
h. Obey warning signs.
i. Usage of appropriate personal protective equipment.
j. Safety precautions such as closing file drawers and cabinet doors when not in use. Open
only one drawer at a time. Even distribution of material to prevent the file cabinet from
being unbalanced and tipping over
k. Frequently inspect cords, plugs, switches, sockets and outlets for damage. Report any
defects such as frayed cords, broken plugs, etc. immediately.
5. Not leaving equipment standing in traffic lanes. Return equipment to its proper location
when not in use.
6. Do not obstruct fire equipment. Know location of fire fighting equipment and how to use it.
Know evacuation routes and what to do in case of fire.
395
20.11 Patient safety
Dept: Physiotherapy

20.11.3 Policy:
1. Patient’s safety is at all times our highest priority. No action should be undertaken which
would knowingly be harmful or potentially harmful to patient
2. All patients shall receive the utmost care and attention from the physiotherapy staffs. All
patients shall be assured of their privacy and dignity while on their treatment.
3. Explanation of the procedure and hand out is to be given before the treatment
4. No In patients will be shifted to the physiotherapy department for treatment with out the
staff nurse.
5. Patients will be lifted correctly. Get help when needed. Use mechanical aids when
necessary.
6. Be sure that disc and pads are wrap
7. ped with towels to prevent accidental burns to the patient.
8. Obtain the necessary assistance to safely aid the patient in ambulating and exercise
therapy.
20.12 Patient Confidentiality

Dept: Physiotherapy

20.12.3 Policy:
1. In the course of performing work responsibilities all information with regard to patient, their
family, their physician and / or the hospital will be kept confidential.
2. As a condition of employment, physiotherapist are cautioned not to discuss any such
information with others,
3. Causal comment with fellow co-workers in the hallways, lobby or cafeteria may be overheard
and violate the trust others have placed in physiotherapist
396
Prepared by: Head of
20.13 Cleaning and Disinfection department
Policy Type: Departmental Date Approved: Nov 2014 Approved by: Director
Dept: Physiotherapy Review on: Nov 2014

20.13.3 Policy:
1. All items and wooden equipment in contact with patient are cleaned with alcohol swab
regularly.
2. All items not in contact with patients are cleaned by soap and water.
3. All linen are changed every day and soiled linen are replaced immediately.
4. Dusting is done by moist duster (Soap and water) and then by dry duster twice a day.
5. Mopping and sweeping done twice a day with soap water solution..
20.13.4 Equipments
1. In Hydro collator: - Water is replaced and machine is cleaned every day.

2. Paraffin Wax bath:- Wax is filtered with gauze piece weekly/ As per observation.
Wax is replaced quarterly/ as per observation.
3. Infected patient:- Wax bath is contraindicated.
Dept: Physiotherapy

20.14.3 Policy:
1. The policy covers the following aspects of equipment maintenance.

a. Periodic servicing: Service to be conducted by Qualified company Service personals
b. Proper technical care to be taken during the maintenance.
2. Periodic Servicing:
a. Periodic servicing must be done as instructed by the respective instrument’s manual or
by the company person. Mention in the equipment history card the date of equipment
commissioned and break down during warranty period.
b. Equipment not working must be tagged “OUT OF ORDER”
3. Logging complaint during Breakdown
a. First switch off the equipment.
397
b. Inform the store and higher authorities.
c. Raise the work order.
d. Log complaint to company service department.
20.14.4 Monthly Static’s
For the Month of Patient attended

X Neurology
Outpatient Attendance Orthopedics
Medicine
Surgery
High Risk Clinic
Child Developmental clinic
ENT
Total No of Patient
In-Patient dept. PICU

NICU
st
1 F wd
3rdF wd
th
4 F wd
th
5 F wd
Total No of Patient
Total (OPD+IPD)
20.14.5 FORMS DOCUMENT AND STATIONARY
1. Patient related forms

S No: Form
1 Referral form
2 Physiotherapy card
2. Registers
S No
Registers
1 Attendance Register for trainees
2 Outpatient Register
3 In patient Register
4 Inventory/ Stock Register
5 Maintenance Register
398
6 Laundry Register
7 Complaint Register
8 Mopping/ Dusting record register
9 Non- Consumable items record register
10 Linen Record register
3. Booklets brochures etc

S No Booklets brochures etc
1 Physiotherapy Brochure
a. Evaluation forms
b. MMT(Manual Muscle Testing)
Form
4. Key Performance Indicator

Patient satisfaction Survey
399
21 Department of Occupational Therapy
Responsibility of Department of Occupational Therapy

updating:

updated on:
Version (CNBC/Rehab/
Occupational/21/Ver.1.3)
400
21 Department of Occupational Therapy………………………………………..400
21.1 Amendment Record Sheet 402
21.2 Introduction 403
21.3 Scope 403
21.4 Intervention / Techniques: 403
21.5 Process summary 403
21.6 Departmental procedures 405
21.7 Processes - Administrative 408
21.8 Statutory Requirements 408
21.9 Discharge from Occupational Therapy services 409
21.10 Departmental safety 410
21.11 Patient safety 411
21.12 Patient Confidentiality 411
21.13 Equipment Maintenance 411
21.14 Cleaning and Disinfection 412
21.15 Reports 413
21.16 Wax Bath 414
21.17 Hot pack: 415
401
S. no. Clause no Date of Amendment Reasons Sign of QM
Amendment Made Of
Amendment
1. 21.3 Aug,27’2010 Incorporated few As these clinical areas
clinical areas in the were not mentioned
scope. earlier.
2. ____ Aug,27’2010 Incorporated few As these interventions
more interventions and techniques were not
/ techniques mentioned earlier.
3. 21.6 Aug,27’2010 Incorporated a As MRD entry is done
step in the flow prior to the assessment.
chart
4 21.6.2 Aug,27’2010 Incorporated As it was not documented
inpatient work earlier
process
5 21.6.3 Aug,27’2010 Added speech As it was not added
Therapist in the earlier
team
6 21.16 Aug,27’2010 Changes made in As previously OPD / IPD
the format patients were not
calculated separately.
7 21.16.2 Aug,27’2010 Change made in Appraisal of KPI
the KPI
8 21.16.3 Aug,27’2010 Added few As few new registers and
registers and forms forms has been
implemented.
9 21.16 Aug,27’2010 Incorporated ADL As it was not mentioned
form earlier.
10. 21.15 November 2014 Addition of Earlier it was not
Cleaning and documented
disinfection policy
11 21.6.3 Dec 2014 Addition of To make it more clear

registers
12 21.6 Dec 2014 Inpatient and As per the department
Outpatient Work requirement
Process modified
13 21.15.1 Dec 2014 Monthly Static’s To make it more clear
modified
14 21.15.2 Jan 2016 KPI Drop out rate To identify the

of patient changed department performance
to patient
satisfaction survey
402
4) Prevention and management of tightness,
21.2 Introduction
contractures and deformities.
21.2.1 Occupational Therapy aims to maximize a
5) Upper limb training activities and training of
child's participation in home, school, play various gross and fine hand functions.
6) Purposeful / therapeutic activities based on
and leisure activities i.e. activities of daily
living. a) Neuro-developmental approach

a) Biomechanical approach
21.2.2 Children affected by illness, disease, b) Rehabilitative approach.
7) Prescription, checkout and training of orthotic
traumatic injury or other medical conditions
use
can experience a variety of impairments 8) Therapeutic Exercises (Graded and adapted)
8.1. Active exercises
which affect the child's ability to perform 8.2. Active assisted exercise
8.3. Resistive exercises
everyday activities. Occupational Therapists 8.4. Mobility training exercises
8.5. Breathing exercises
identify these impairments and provide
8.6. Strengthening exercises
rehabilitation and intervention services to 8.7. Co-ordination exercises
8.8. Mat exercises.
develop skills in these identified areas. 9) ADL Training for independence (Simulated
activities and adaptations included).
10) Sensory Integrative therapy.
21.3 Scope
11) Play therapy.
21.3.1 Our services are offered to babies, 12) Group therapy.
13) Adaptive equipment training and modifications.
children and their families. We
14) Use of therapeutic equipments- shoulder wheel,
provide a service to patients Wall-ladder, shoulder pulley, parallel bar,
therapy ball.
attending Consultants in the 15) Joint protection techniques.
16) Fatigue management and energy conservation
following clinical areas:
techniques
17) School skills training.
1. Neurology 18) Social skills training.
2. Orthopedics 19) Parent and family education.
3. Medicine 20) Home training programs.
4. Pediatric Surgery
5. NICU & PICU
6. Special Clinics 21.5 Process summary
a) High Risk Clinic 21.5.1 Occupational therapy (OT) is the therapeutic
b) Development Clinics
use of purposeful activities designed to
21.4 Intervention / Techniques:
improve a patient's function during daily self
care, home, work, school and leisure

1) Developmental facilitation.
2) Sensory, perceptual and motor retraining. activities. Occupational therapists evaluate
3) Seating, positioning and handlingtechniques.
403
and treat patients with a wide variety of
diagnoses including but not limited to
medical, neurological, orthopedic, burns,
hand and upper extremity injuries, surgical,
multiple trauma and cardiopulmonary. All
children treated by Occupational Therapy
here must be under the care of a Consultant
in C.N.B.C. A written referral from the
Consultant is required.
21.5.2 Outpatient Services: Hours 9:00 am – 4:00
pm, Monday – Friday; Hours 9:00 am-
2:00pm. on Saturday.
404
Occupational therapy department

Occupational therapy department
with OT card
Order/ MRD Entry done
Patient assessment and evaluation

done
Referrals and discussion with other
Rehabilitation team members
Plan of treatment and treatment

starts
Home training program
Follow-Up &Review as per

diagnosis and set goals
Discharge
405
Referral from
consultants

register and
by the therapist
Treatment and
procedure given and
giver
Progress notes in
referral sheet
periodically
Discharge
the status of the
patient in OPD
406
21.6.3 Other Activities:
o Multidisciplinary approach
Consultants Physiotherapist Occupational

Therapist
Nurses Psychologist
Rehabilitation
Speech therapist Parents / Care Takers Dietician
407
21.7 Processes - Administrative
Stations / counter / area Process – department
Departmental Orientation All new staffs joining the hospital is oriented for the department work
process and uses of equipments
Inventory Receiving of indent as per department requirement from stores and

pharmacy. Sufficient department stock maintained.
Linen Inventory Occupational therapists will maintain the stock of clean linen as per
requirement and makes sure soiled linen is sent to laundry in time
Stock check Physical inspection of inventory items of consumables to check stock

status
Occupational therapists will take care of equipments in use and

Maintenance of Equipments
maintain the history book.
21.8.1 Scope: Occupational Therapy

21.8.2 Distribution list: Occupational Therapy
21.8.3 Policy: All Occupational therapists should have completed Bachelors Degree
21.9.1 Scope: Occupational therapy

21.9.2 Distribution list: Occupational therapy
21.9.3 Policy:
1. An initial assessment of every patient will be done by Occupational therapist to determine

a treatment plan based on the diagnosis and present clinical condition of the patient.
a. Initial assessment will include information gathered by the Occupational therapist as

follows:
i. Past medical, surgical history, present historyand forms of treatment
iv. Pain assessment
v. Muscle power
vi. Range of motion
408
vii. Functional limitations
viii. Problems of dysfunction
ix. Activities of daily living (ADL)
x. Splints used or anticipated
xi. Treatment plan
b. Patient’s progress will be reviewed and entered and will exhibit overall response to
the initial treatment plan.
21.10 Discharge from Occupational Therapy services

21.10.3 Policy:
1. Patient will be discharged from the department according to the assessment of the patient’s
level of functioning and treatment goal. Through assessments and evaluations of patient
progress, discharge plans will be formulated. An assessment of the patient’s home
programme will be made upon initial assessment to allow for formulation of early plans for
discharge.
A. The Discharge plan includes:
i. Total length of time in active Occupational therapy care.
ii. Comparison of all data (range of motion, strength, special testing) to initial
findings
iii. Comparison of patient complaints.
iv. Treatment provided to the patient during the course of treatment.
v. Occupational therapy care.
vi. Patient’s current clinical condition and status as discharged from active
Occupational therapy care
vii. Communication with the consultant about the patient’s condition
viii. Plans for discharge will be formulated in a collaborative manner with the patient
and the rehab. team members.
ix. Arrangement of all necessary medical aids for the patient prior to discharge
x. The patient will be discharged when the above mentioned criteria have been met.
xi. If the inpatient have to continue Occupational therapy after discharge will be
mentioned in the discharge summary by the consultant
409

21.11.3 Policy:
1. Occupational therapist is responsible for maintaining safety standards, developing safety

rules, supervising and training staff in departmental standards.
2. Occupational therapist is responsible for informing facility in case of any safety hazard.
3. Occupational therapist shall report defective equipment, unsafe conditions and acts, or
safety hazards to the head of the department.
and used.
e. Arrangement of furniture and equipment must be arranged to allow passage and access
to exits at all times.
j. Safety precautions such as closing file drawers and cabinet doors when not in use. Open
being unbalanced and tipping over.
k. Frequently inspect cords, plugs, switches, sockets and outlets for damage. Report any
when not in use.
6. Do not obstruct fire equipment. Know location of firefighting equipment and how to use it.
410

21.12.3 Policy:
1. Patient’s safety is at all times our highest priority. No action should be undertaken
which would knowingly be harmful or potentially harmful to patient
2. All patients shall receive the utmost care and attention from the Occupational therapy
staffs. All patients shall be assured of their privacy and dignity while on their
treatment.
3. Explanation of the procedure is to be given before the treatment
4. Patients will be lifted correctly. Get help when needed. Use mechanical aids when
necessary.
5. Be sure that disc and pads are wrapped with towels to prevent accidental burns to
the patient.
6. Obtain the necessary assistance to safely aid the patient in ambulating and exercise
therapy.
7. Do not leave patients unattended on therapy tables or in therapeutic wax bath.

21.13.3 Policy:
2. As a condition of employment, Occupational therapists are cautioned not to discuss any such
information with others,
and violate the trust others have placed in Occupational therapists.

21.14.3 Policy:
1. The policy covers the following aspects of equipment maintenance.

411
a. Periodic servicing: Service to be conducted by Qualified company Service personals
b. Proper technical care to be taken during the maintenance.
2. Periodic Servicing:
a. Periodic servicing must be done as instructed by the respective instrument’s manual or
by the company person. Mention in the equipment history card the date of equipment
commissioned and break down during warranty period.
b. Equipment not working must be tagged “OUT OF ORDER”
c. Any work carried out by the instrument / equipment’s technician or engineer should be
recorded in Instrument History book as follows:
i. Time spent for servicing.
ii. Description of service being carried out
iii. Status of equipment after servicing
iv. Name of the technician / engineer attended
3. Logging complaint during Breakdown
a. First switch off the equipment.
b. Raise the work order.
c. Log complaint to company service department.
d. Display out of order board near the machine.
e. Once the engineer has diagnosed the problem inform authorities.
21.15 Cleaning and Disinfection
21.15.1 Scope: Occupational Therapy

21.15.2 Distribution list: Occupational Therapy
21.15.3 Policy:
regularly.
3. All linen are changed every day and soiled linen are replaced immediately as per BMW
policy.
5. Mopping and sweeping done twice a day with soap water solution.
6. Equipments
1. In Hydro collator: - Water is replaced and machine is cleaned every day.
2. Paraffin Wax bath: - Wax is filtered with gauze piece weekly/ as per observation.
: - Wax is replaced quarterly/ as per observation.
412
3. Infected patient: - Wax bath is contraindicated.
21.16 Reports
21.16.1 Monthly Static’s
For the Month of Patient attended

X Neurology
Outpatient Attendance Orthopedics
Medicine
Surgery
High Risk Clinic
Child Developmental clinic
ENT
Total No of Patient
In-Patient dept. PICU

NICU
st
1 F wd
3rdF wd
th
4 F wd
th
5 F wd
Total No of Patient
Total (OPD+IPD)
21.16.2 QUALITY PLAN
Quality Indicator: Patient’s satisfaction survey form as KPI
21.16.3 FORMS DOCUMENT AND STATIONARY
1) Patient related forms

S No: Form
1 Referral form
2 Occupational therapy card
413
2) Registers
S No
Registers
1 Outpatient Register
2 Inpatient Register
4 Inventory / Stock Register
5 Maintenance Register
6 Laundry Register
7 Complaint Register
8 Mopping/ Dusting record register
9 Non- Consumable items record register
10 Linen Record register
3) Booklets brochures etc

S No Booklets brochures etc
1 Occupational Therapy Assessment Form
2 Muscle testing Chart
3 ADL Chart
4) Standard Operating Procedures
21.17 Wax Bath
21.17.1 TECHNIQUE OF APPLICATIONS:
21.17.2 EQUIPMENT PREPARATION:
1) Plug the unit to the mains and rotate the switch to on position.
2) Glowing green light indicates the flow of current.
3) Set the thermostat to 75-80⁰C.
4) Red light indicates working of Heater
414
rd
5) Reset at 52-55⁰C when 2/3 of the wax is molten.
21.17.3 PATIENT PREPARATION:
1) Inspect the area and remove all jewellery.
2) Clean and dry the area thoroughly.
3) Explain the procedure to the patient.
4) Position the patient comfortable and safe.
5) Check the temperature with the thermometer.
21.17.4 PROCEDURE:
1) Apply wax on the area of treatment with brush.
2) Repeat until a thick paraffin glove is formed.
3) Wrap with towel for 15-20 minutes.
4) Peel of the wax inside out back into the tank.
21.17.5 INDICATIONS: Joint stiffness, arthritis, joint pain rheumatoid conditions, sprain, contractures and
shortenings.
21.17.6 CONTRAINDICATIONS: PVD, open wound, allergic rash, infective ulcers and pressure sores,
oedema (acute).
21.18 Hot pack:
21.18.1 TECHNIQUE OF APPLICATION:
21.18.2 EQUIPMENT PREPARATION:
1) Plug the unit to the mains and switch it on.
2) Glowing light indicates the flow of current.
3) Set the thermostat to 75-80⁰C.
21.18.3 PATIENT PREPARATION:
1) Remove the clothing and jewellery from the area to be treated.
415
2) Explain the treatment procedure to the patient.
3) Position the patient comfortable and safe.
4) Check the temperature with the thermometer.
21.18.4 PROCEDURE:
1) With the help of tongs, pickup the hot pack.
2) Wrap the hot pack in Mackintosh pad and towel (towel layers may be changed if the patient
perceives less or more warmth).
3) Apply Hot pack and secure it well.
4) After 15-20 minutes, remove the hot pack.
21.18.5 INDICATIONS: Joint stiffness, arthritis, joint pain, muscle spasm, sprain, stiffness after cast
removal, contractures and shortening.
21.18.6 CONTRAINDICATIONS: Acute injury, Hemorrhagic tissue, Thrombophelebitis, impaired
sensation, Malignancy, Infective ulcer, Allergic rash, open wounds, neonates and infants.
416
22 MANUAL OF OPERATIONS
DIETETICS
(CNBC/Diet/23/1.0)
Date created: Ist May 2008

Responsibility of Dept. of Dietetics

Updating:
Last updated on August 2020
Approved by; Director
417
Table of content
Table of content ..................................................................................................................................... 418

22.2 Introduction ............................................................................................................................ 420
22.3 Scope ..................................................................................................................................... 420
22.4 Process Summary ................................................................................................................. 420
22.5 End of day activities ............................................................................................................... 421
22.6 Diet Type: : ............................................................................................................................ 421
22.7 Departmental hierarchy ......................................................................................................... 424
22.8 Job Descriptions .................................................................................................................... 424
22.9 Departmental Procedures ...................................................................................................... 426
22.10 Diet prescription and Counseling .......................................................................................... 430
22.11 Diet service ............................................................................................................................ 430
22.12 Nutritional assessment & reassessment ............................................................................... 431
22.13 SOP’s Nutritional assessment & reassessment .................................................................... 433
22.14 Quality Plan ........................................................................................................................... 433
22.15 Documents, templates .......................................................................................................... 435
22.16 Annexure ............................................................................................................................... 436
418
S.no. Clause Date of Amendment Reasons Sign of QM
no Amendmen Made Of
t Amendment
1 22.6 28-02-2011 Incorporated Types of Diet
2 29 18-02-2011 Incorporated Standard To standardize the

operating procedures for process.
Nutritional assessment and
reassessment
3 30.4 18-02-2011 Incorporated evaluation of To ensure that
kitchen raw material. quality raw material
is being used.
4 22.6.6 7-01-2012 Addition of Types of Feed
5 29.4 Jan2013 Nutritional assessment of To ensure that the

IPD patients patients fall under
target disease
should be
nutritionally
assessed on
priority basis.
6 28.5 Jan2013 Timings of diet distribution To ensure that pts
meal distribution
must be finished
timely
7 32.4 New formats introduced: To ensure better
CNBC-185 observation for
CNBC-186 quality
CNBC-187 improvement.
9 30 Jan16 Personnel hygiene and To improve the
vegetable washing protocol quality of food.
(general and special
method)
10 22.7 August 2020 Addition of MO Ic Kitchen It was missed in
previous hierarchy
419
44.2 Introduction
44.2.1 Department of Dietetics is a paramedical department, which forms an integral part of every in-
patient’s therapeutic care during their hospital stay. The kitchen service has been outsourced by
the Hospital.
44.2.2 The main purpose of the Dietary Department is to provide nutritious food to patients such that it
improves the nutritional status of a hospitalized patient, keeping in mind restriction of certain
nutrients as part of the therapy, by planning meals with the use of nutritional knowledge.
44.3 Scope
22.3.1 The department of dietetics caters to the needs of the patients in the various areas of the
hospital. It aims at providing therapeutic diets to all patients admitted in the hospital appropriate to
their disease conditions and to counsel patients who are referred to the Dietitian.

Process Description
In patient visit All referral in patients are visited daily to ensure

that they get therapeutic diets according to the
cyclic menu.
Rest of the in-patients are also inquired of and
on about the diet they are getting it.
Outpatient diet counseling Patients is advised for 24 hours intake keeping

in mind certain factors such as nutritional
adequacy, food availability, seasonal foods,
like and dislikes. In some cases patients’ 24-
hour diet recall is taken and modified suitably
to achieve the required restrictions without
much alteration in their daily routine. Special
Diets for diseases (e.g. ciliac) is also advised in
the OPD.
Translation of diet orders to patient diet sheet Patient diet sheets are filled out according to
age and clinical condition.
Tasting of food sample The food prepared is tasted and checked

based on their taste, appearance, and texture.
Modifications are done if required.
Storage of food sample The food sample from the food prepared in the
kitchen is sealed in a container and stored in
a refrigerator for 24 hours,
420
44.5 End of day activities
1. Daily diet sheets from all the wards reach to the kitchen at 6:00 a.m.
2. The diet sheet is prepared according to the age and clinical condition of the child by the staff
nurses ordered given by doctors / dietician. The three copies of diet sheet is prepared for the
word, dietician and the kitchen workers.
3. The dietician daily cross checks if the correct diets of the patients matches with the one entered
in the diet sheet.
4. If not then the concerned nurse is informed about it and the details are rechecked and corrected.
5. There are five standard diets i.e. Diet A (0-6 months); Diet B (6 months – 2 yrs.); Diet C (2 yrs. –
5 Yrs.); Diet D (5 Yrs. And above) : Diet E (High Protein & High Calorie Diet) which are prepared
according to the cyclic menu and provided to the in-patients according to the clinical condition
and age of the child.
6. The kitchen workers are trained to cook and to prepare normal and therapeutic diets / foods.
7. Daily referral in-patients nutritional assessment (by 24 hours diet recall method) is done to know
their compliance & health status.
44.6 Diet Type: The type of the diet depends upon Doctor’s advice. The types of diet are
described below:
44.6.1 TYPE A
MILK BASED DIET
0-6 Months
Food Stuff Amount Energy(Kcal) Protein (gm)
Milk 750(ml) 442.5 23.2
Sugar 25(gm) 100 -

_________________________
Total 542.5Kcal 23.2 gm

_________________________
421
44.6.2 TYPE B
WEANING DIET
6 MONTHS TO 2 YEARS
Food stuff Amount Energy (kcal) Protein(g)
Milk (toned) 625 ml 369 20

Pulses 30 gm 100 7
Atta/Rice 60 gm 210 6
Bread 30 (1 slice) 70 2
Vegetables 75 gm 20 1
Potato 50 gm 175 1
Fruit 100 gm 40 -
Sugar 20 gm 80 -
Fat 10 gm 90 -
______________________________
Total 1154Kcal 37 gm
__________________________
44.6.3
TYPE C
PRE SCHOOL CHILD

(2-5 YRS. OLD 1500 Kcal)
Food Stuff Amount Energy (Kcal) Protein(g)
1
Pulses 40 gm 133 9.3
Egg/Paneer one/40 70 7
Bread 60 gm(2 slice) 140 4
Potato 50 gm 175 1
Fruit 100 gm 40 -
Sugar 25 gm 100 -
Fat 20 gm 180 -
______________________________
Total 1593 Kcal 53.3 gm
______________________________
44.6.4 TYPE D: FOR CHILDREN > 5 YRS. OLD
422
Food Stuff Amount Energy (Kcal) Protein(g)

Pulses 60 gm 200 14
Egg/Paneer one/40 70 7
Bread 60 (2 slice) 140 4
Potato 100 gm 350 2
Fruit 100 gm 40 -
Sugar 30 gm 120 -
Fat 30 gm 270 -
______________________________
Total 1975 Kcal 64 gm
______________________________
44.6.5 TYPE E: HIGH CALORIES HIGH PROTEIN DIET

(2000Kcal, 75 gm protein)
Food Group Amount Energy(Kcal) Protein (gms)

Milk 750 ml 442 24
Egg / Paneer 2/60gms 140 7
2
Pulse 60 g 20 0 14
Cereals 160g 560 16
Bread 2 Slices 140 4
Potato 50 g 175 1
GLV 200g 40
Vegetables 200 g 80 4
Fruits 100 g 40
Fats 25 g 225
Sugar 20 g 80
2122 Kcal 77 gmsl
44.6.6 TYPES OF FEEDS AS PER WHO
F-75
Milk 30ml 17.7 0.9
Sugar 1/2tsp 10
Coconut oil 1tsp 45Kcal
(mct)
Water 75ml
72.7 Kcal 0.9gms
F-100
423
Milk 100 ml 59 3.1
Sugar 1tsp 20
Coconut oil 1/2 tsp 22.5Kcal
(mct)
101 3.1gms
Kcal
Composed Feed (100ml)

Milk 80 ml 47.2 2.4
Sugar ½ tsp 10
Coconut oil ½ tsp 22.5 Kcal
(mct)
Corn Starch ½ tsp 8.7
Water 20ml
110.9 Kcal 2.4gms
Note: Egg can be added in the Composed Feed as per the nutritional requirement of the patient.
44.7 Departmental hierarchy
44.7.1 Hierarchy Chart
M.S
MO IC Kitchen
Kitchen Incharge (ANS
Asstt. Dietician
Kitchen Workers
44.8 Job Descriptions

Dietician
424
Key areas of responsibility:
 Therapeutic care of inpatient dietary needs.
 Inpatient and outpatient diet counselling.
Main Job Tasks
 Plan cyclic menus for inpatients in
 Provides dietary advice during preventive health check clinics/camps
 Counsels outpatients referred by the consultants
 Visits referral inpatients on a daily basis and ensures dietary needs are met
 Modifies diet to patient’s age and clinical restrictions
 Takes steps to ensure that hygiene & sanitation standards are maintained in the Kitchen
 Maintain daily diet records.
425
44.9 Departmental Procedures
44.9.1 In patient . Diet protocol on admission
Patient gets
admitted in ward
Is patient referred to Yes Dietician checks doctor

Dietician notes for any specific diet
instructions required
No Dietician meets patient

and explain their diet
Patient diet is recorded by the staff Instruct the kitchen

nurse workers about the
special/specific diets / food
Food is
delivered to the
ward
426
44.9.2 Diet service overview
Check and collect diet sheet received from the

wards (kitchen)
Start dietician rounds
Check for diet changes indicated by the

consultant at the nurse station
Meet patients
New referral patient Existing referral patient
Initial assessment done

Reassessment done
Record findings in the

referral sheet
No Are diet Yes

changes Record changes in the diet
sheet
required?
Food served to patient as Inform the staff nurses about

indicated in the diet sheet changes
Inform the kitchen workers to

do changes in the kitchen
diet sheet and trained them
if special feeds / diets
required
Food served to the patient
427
44.9.3 Food tasting
Food prepared
Tasting done by Asstt.dietician

or Kitchen incharge for the
following
 Texture
 Taste
 Appearance
No
Kitchen workers is
Food found informed of changes
suitable? required
Yes Appropriate change

done
Food loaded in the trolley to

serve
Steward take out the trolley from

the hospital kitchen .(wearing
cap,apron and gloves)
Distribute the food as per diet

sheet/special diet sheet, from
st
Emerg.wd1 , 5th, 4th, 3rd,
PICU, NICU.respectively.
428
44.9.4 Diet Counseling
Doctors refers patients
Dietician receives patient for

counseling
Initial assessment of patients

 Diet recall
 Anthropometric measurements
 Lab results if available
 Doctors progress notes /
referral note
Modify existing dietary intake

according to requirements
Patient counseling on
modifications
Record dietary advice in referral

sheet
Handover diet chart to the patient.

Indicate date of review
Patient leaves
429
44.10 Diet prescription and Counseling
44.10.2 Distribution list: Dietetics
44.10.3 Policy:
1. Initial assessment
a. Every referral patient admitted in the hospital, is met by the Dietitian, the Dietitian does the
nutritional assessment of those referral cases during the ward rounds.
b. Dietician interacts with the treating doctor, patient and patients relatives to help them
understand the diet requirements and to plan the nutritional therapy.
2. Prescription
a. The Dietitian prescribes the special feeds / diets for the in patients when required, and the
staff Nurses records the same in the diet sheet.
b. Ryle’s tube feeds are provided depending on the frequency and quantity mentioned by the
concerned doctor.
c. All the patients on normal diets receive a diet according to the cyclic menu. They can choose
between vegetarian / eggetarian diets.
d. Special diets like renal diets, diabetic diet, gluten free diet are marked for the patients by the
dietitian.
e. The dietitian does lunch tasting and the responsibility is taken over by the kitchen Incharge in
her absence.
3. Counseling
a. All patients referred by a doctor for diet advice are counseled and given a diet chart.
44.11 Diet service
44.11.3 Policy:
Types of Diet Service:
There are three types of inpatient diet service:
a. Liquid Diet Service
b. Soft diet service
c. Solid Diet service
44.11.4 Liquid Diet Service:

a. Is provided to the patients who are unable to take solids following a surgery, or according to
the patient’s clinical condition.
430
b. A liquid diet chart is maintained in the Kitchen which consists of the patient’s name, room
number, type of liquid at that particular time and any special needs (diabetic, renal, RT feed
etc).
c. Liquid Diet Service Timings:
8:00 am, 12:00pm, 4:00 pm, 8:00pm
44.11.5 Solid Diet Service

d. Is provided for the patients who can consume solids. These are again based on patients’
clinical and physiological conditions.
e. Solid Diet Service Timings:

Breakfast 6.50am –8.30am
Mid morning 10:30 am – 11:00
am
Lunch 12:15 noon – 1:30
pm
Evening Snack 3:5 0 pm – 5:00 pm
Dinner 6;50pm – 8:2 0 pm
44.11.6 Trolley Setting

Food trolley is clean before and after loading the food by kitchen workers.
The kitchen worker wears cap ,apron and gloves during loading the food in food trolley.
The loaded food is keep warm by maintaining the temperature of food trolley.
44.12 Nutritional assessment & reassessment
44.12.3 Policy:
1. Nutritional assessment will be done for patient come under the target diseases.(list of target
disease is given below)
2. Nutritional assessment will not be done for patients who are NPO.
3. Reassessment will be done for people on special diets only, as and when there is a diet change (
for eg; liquid diet to soft diet, RT feed to soft diet etc )
4. Assessment will not be done for patients who remain on normal diets throughout their hospital
stay.
5. Reassessment will be documented in the patients’ Nutrition Assessment Screening Program.
6. Nutritional assessment is not done of the PICU & NICU patients, as it is done by the concerned
doctors.
431
44.12.4 LIST OF TARGET DISEASE
1 PEM Gd3 and Gd 4

2. FTT
3. Renal diseases
4. Liver diseases.
5. GIT Disorders
6. Diabetes (IDDM)
7. Celiac disease
8 .6mon-1yr.
9 .Malignancy
10.Thallassemia major
11 .Nutritional anemias
12 Rickets
13. Stoma
14 Ileostomy
15. Oestomy feed
16. Feccal fistula
17. SAIO
18. PUV
44.12.5 List of selected target diseases/ conditions for nutritional re-assessment of IPD patients.
S,NO DIAGNOSIS / CONDITIONS FREQUENCY

1 PEM GRADE 4 (SAM) DAILY
2 IDDM DAILY
3 CELIAC DISEASE ALTERNATE DAY
4 CHRONIC RENAL DISEASE ALTERNATE DAY
5 HEPATIC ENCEPHALOPATHY ALTERNATE
6 ANY DIETARY MODIFICATION SUGESTED BY TREAING ALTERNATE
PHYSICIAN
7 ANY PATIENT FALL UNDER TARGET DISEASE STAY MORE
THAN 6 DAYS.
432
44.13 SOP’s Nutritional assessment & reassessment
44.13.1 Assessment of grade of malnutrition based on anthropometry.
44.13.2 Assessment of clinical conditions for special diet therapy.
44.13.3 Assessment of diet through 24 hr dietary recall method.
44.13.4 Plan dietary intervention based on clinical condition
44.13.5 To conduct dietary counseling of the patient.
44.13.6 To perform reassessment to examine compliance of diet in the patient in case of special diet as
per the clinical condition.
44.14 QUALITY PLAN
44.14.1 Quality control procedures in CNBC basically involve three steps :
A Procuring, storing, cleaning, cooking, distribution adherence to timing, care of trolley before
during and after distribution.
1. Setting out accurate specifications for each food i.e. exact sizes, weights, numbers etc. required.
2. Checking foods for quality.
3. Tasting the finished product.
Moreover, the points to ensure are:
a. Personal hygiene of the kitchen workers.
b. Cleanliness of the environment and equipment.
c. Good behavior of staff / workers in terms of their being courteous, soft spoken and alert in
their movement.
B. To insure that the diet sheet of the patients should be correctly filled out by the staff nurses a
training program after every three months will be arrange.
C. Personnel hygiene :
1. Motivate ,educate, and encourage, to stop handling food when they infected (jaundice, diarrehea,
vomiting,etc)
2.Food handlers should wear clean and proper clothing. They should cover hair and wear gloves and
apron.
433
3.Hand washing facilities should be available.
4.Food handlers should avoid following practices while handling food:
 Chewing or smoking tobacco.
 Chewing betel nut or gums.
 Touching mouth, tongue, nose ,eyes, or other body parts.
 Spitting , sneezing, coughing etc.
5.Food handlers should ensure:

 Careful food handling.
 Protect food from environmental exposure.
6. Periodic Health check-up and immunization of the kitchen worker is done and also done if required
in between.
44.14.2 General instructions for cooking vegetables
 Wash vegetables before peeling and cutting.

 If possible ,cook vegetable without peeling or peel them thinly
 Cut vegetables in to medium size pieces and do not leave expose to air for long after cutting.
44.14.3 Specialized method for vegetable washing.
 Soak vegetables for 30 min with warm water (50-60)C containing 2% common salt solution.
 Wash in a fresh water.
 Cut vegetables in to medium size pieces and cook in a covered pan to shorten cooking time.
44.14.4 Evaluation of Kitchen raw material:
44.14.5 Based on different categories of food groups like pulses, vegetables, fruits, milk, milk product
(cottage cheese/ curd), cereals, and eggs.
44.14.6 The quality is assessed based on their shelf life.
434
44.15 Documents, templates
a. Documents
S No: Form Area
1 Patient diet sheet Kitchen
2 Patient diet sheet Nursing Station
3 Patient Diet Sheet Dietician Room
b. Templates
S No: Form Area
Patient Education templates(Diet Charts for OPD OPD –Dietician Room
1 patients)
2 Nutritional Assessment MRD
435
44.16 Annexure
44.16.1 NUTRITION ASSESSMENT SCREENING FORM
Name---------------------------------- Age/Sex;----------------------
Height(cms)------------------/wt.------------- C.R. No------------------
Presence of oedema;Yes/No-------------Diagnosis--------------------
Grade of Malnutrition;-----------------------
(I.A.P.Classification)
CLINICAL CONDITIONS
Unexplained weight loss Diabetes
Multi-trauma/stress/sepsis Cystic fibrosis
Inborn errors of metabolism Obesity
Celiac disease Cancer
GSD Diarrhoea
Lactose intolerance Vomiting
Renal disease Dehydration
Liver disease Enteral nutritional support
Cardiac disease
Diet History(24hrs.Dietary Recall) Informant;Mother/Father/Other
Breast Feeding Top Milk Feeding Weaning Full Diet
Total calorie intake in last 24 hrs.--------------------------------
Dietary intervention CLINICAL CONDITIONS

NUTRIENTS PE RENA DIABETE ANEMI GI LIVER CELIAC
M L S A DISORDE DISEAS DISEAS
R E E
CLINICAL CONDITIONS
98Kcal/KgIBW
108Kcal/KgIBW
1240Kcal
1690Kcal
1950Kcal
2000Kcal
Protein(g/d)
22
30
41
2g/kgIBW
0.6g/kgIBW
1.2/kgIBW
Sodium restriction
(Avoidtable
436
salt,pickle,papad,sauce,et
c
Potassium Restriction
(mausambi,bael,coconut
water.musk melon etc.)
Fluid Restriction
(500+urine output)
High B.v.Protein
(Egg,milk &its
product,fish,chicken)
Iron rich sources
Diabetic Restriction
Celiac Restiction
High fiber foods
Low fiber foods
Inclusion all food groups
Small frequent meals
others
IBW-ideal body weight

Sign.of Dietician;
Date;
Time;
437
44.16.2 REPORT TITLE: Analysis of Patient feed back pertaining to diet
DEPT: Dietetics Frequency: Once a Week
Submitted to: M.S

ANALYSIS OF PATIENT FEED BACK PERTAINING TO DIET
Date of Visit Name of Patient Ward Complaint Regarding Remarks
44.16.3 Food Evaluation
Date :
Food Samples Product rating Remarks
438
44.16.4 PERSONAL HYGIENE OBSERVATION FORM
Name of Worker:
Observer:
Prof. Cat Prof. Cat Prof. Cat Prof. Cat

Date: Date: Date: Date:
(dd/mm/yy) (dd/mm/yy) (dd/mm/yy) (dd/mm/yy)
Start/End time: Start/End time: Start/End time: Start/End time:
(hh:mm) (hh:mm) (hh:mm) (hh:mm)
Session Session Session Session
duration: (mm) duration: (mm) duration: (mm) duration: (mm)
Op Indication HH Op Indication HH Op Indication HH
p. Action p. Action p. Action
1 Bef. Hand Food Hand 1 Bef. Hand Food Hand 1 Bef. Hand Food Hand
Aft. Hand Food Washing Aft. Hand Food Washing Aft. Hand Food Washing
Gloves Gloves Gloves
Cap Cap Cap
Apron Apron Apron
Missed Missed Missed
During Prep. Cap During Prep. Cap During Prep. Cap

Trans. to Food Apron Trans. to Food Apron Trans. to Food Apron
Trolley Gloves Trolley Gloves Trolley Gloves
Food Distribution Missed Food Distribution Missed Food Distribution Missed
Op Indication HH Action Op Indication HH Action Op Indication HH Action

p. p. p.
2 Bef. Hand Food Hand 2 Bef. Hand Food Hand 2 Bef. Hand Food Hand
Aft. Hand Food Washing Aft. Hand Food Washing Aft. Hand Food Washing
Gloves Gloves Gloves
Cap Cap Cap
Apron Apron Apron
Missed Missed Missed
During Prep. Cap During Prep. Cap During Prep. Cap

Trans. to Food Apron Trans. to Food Apron Trans. to Food Apron
Trolley Gloves Trolley Gloves Trolley Gloves
Food Distribution Missed Food Distribution Missed Food Distribution Missed
439
23 Medical Records
Responsibility of Department of MRD

updating:

updated on:
Version (CNBC/ MRD /23/ Ver.1.1)
440
23 Medical Records................................................................................................................................... 440
23.1 Amendments sheet ................................................................................................................. 442
23.2 Introduction.............................................................................................................................. 444
23.2.1 Scope ...................................................................................................................................... 444
23.2.2 Process Summary ................................................................................................................... 444
23.3 Abbreviations........................................................................................................................... 445
23.4 Departmental Hierarchy Chart ................................................................................................ 446
23.5 Departmental procedures ........................................................................................................ 447
23.5.1 In-patient files flow chart ......................................................................................................... 447
23.5.2 Receiving discharge records ................................................................................................... 448
23.5.3 Issue of Medical Record.......................................................................................................... 449
23.5.4 Release of Patient Information ................................................................................................ 450
23.5.5 Assembly of Medical Records ................................................................................................. 451
23.6 Departmental policies .............................................................................................................. 452
23.6.1 Medical records storage .......................................................................................................... 452
23.6.2 ICD Classification .................................................................................................................... 452
23.6.3 Retention period of medical records ....................................................................................... 452
23.6.4 Destruction of medical records ............................................................................................... 454
23.6.5 Audits on medical records ....................................................................................................... 455
23.6.6 Deficiency Checking of files .................................................................................................... 455
23.6.7 Statistics .................................................................................................................................. 455
23.6.8 Sending of reports to the government agencies ..................................................................... 456
23.7 Quality plan –Quality indicators............................................................................................... 457
23.8 Forms/ Documents maintained by MRD ................................................................................. 457
23.9 Policy and procedure for maintaining confidentiality , security and integrity of the records / data
23.9.1 No person other than MRD staff will have access to records. ................................................ 457
23.9.2 All MLC files will be stored under lock and key. ...................................................................... 457
23.9.3 Regular pest control measures will be undertaken and documented. .................................... 457
23.9.4 If there is a loss/tampering of records, .................................................................................... 457
441
23.1 Amendments sheet
Sl. Clause Date of Amendment made Reasons of amendment Sign of QM
No. No. amendment
1 23.10.4 Sept 2011 The records are Now, the records are
maintained according to maintained as per CR no.
CR No. instead of Date of discharge
2 23.6 Sept 2011 The hierarchy chart has This is done in accordance
been modified to the staff currently working
in MRD.
3 ____ Sept 2011 Deficiency checking has Due to shortage of staff, the
been removed clause has been modified
4 23.3.5 Sept 2011 This section on ‘Statistics’ To provide the fine details of
has been elaborated the statistics being presently
generated by the MRD
5 23.15.2 Sept 2011 New Section ‘Sending of It is now mandatory to send
reports to the government reports to Government
agencies’ has been added agencies including the online
reporting of deaths and
sending morbidity report etc.
6 23.7.2 March 2012 Policy change pertains to Medical Audit cum record
the retrieving the files committee recommendation.
taken out from MRD.
7 23.17 Sept 2011 Quality Indicators have This is done to ensure timely
been modified generation of statistics by
MRD.
8 23.7.3 December Policy for retrieval of To make policy more clear.
2014 medical records during
non office hours
9 Dec 2014 Scanning of patient The same has been
records has been removed discontinued in the hospital
10 23.6.7 Dec 2014 The KPIs has been As per the new list of KPIs
modified generated by MRD
11 23.9 Feb 2015 Addition of policies and Previously it was not
procedures for maintaining mentioned
confidentiality , security
and integrity of the records
/ data and for
safeguarding of data/
record against loss ,
destruction and tampering
442
12 23.6.7 Feb 2015 Addition of sampling Previously it was not
method based on mentioned
statistical principle
13 23.6.7.5 Dec 2015 The following KPI have ICD-10 coding is now being
been discontinued done in HIMS
1. Percentage of files
with ICD-10
coding done in
wards.
2. Reasons for
LAMA.
14 23.6.7.3 Dec 2015 The process for The data is now obtained
generation of monthly from HIMS
morbidity and mortality
statistics has been
modified
443
23.2 Introduction
Medical record is important “Patient forgets but record remembers” the record is valuable to many
individuals and groups: patients, physicians, health care institutions, research teams, teachers and
students, National health agencies, and International the Health organizations
23.2.1 Scope
This document is provided in order to have a uniform system to ensure the following:
1. Proper maintenance of medical records
2. Maintenance of integrity and confidentiality of medical records
3. Submission of required data to government authorities
4. Generation of census and record audits
23.2.2 Process Summary
S Process Details
No
1 Statistics Compiling daily hospital census and reporting to
authorized personnel.
Updating statistics of all OP and IP census to monthly
statistics
2 Separations Listing Discharge, Deaths, LAMA etc listing obtained from patient
care units
Collecting Closed files from all the patient care units
3 Maintenance of medical records Ensure proper assembling and filing of records
Coding as per ICD-10 norms / Indexing in the system.
Systematic maintenance of records -According to Central
Registration Number.
4 Death certificates Death Register Updating
Listing causes of death
Sending Death reports to the MCD.
5 MLC Maintaining hospital copy of all MLC intimations.
6 Retention of records Retention of records as per hospital policy.
7 Others Issue medical records to authorized personnel for audits/
research purposes.
Issue certificates to external agencies / authorities as and
when required after due authorizations
444
23.3 Abbreviations
OP Out-Patient
IP In-Patient
MR Medical Records
MRA Medical Records Assistant
MRD Medical Records Department
ICD International Classification of Diseases
MOI/C Medical Officer Incharge
ER Emergency room
ALOS Average Length of Stay
MLC Medico Legal Case
LAMA Leave Against Medical Advice
Dept Department
H.A. Health Authority
445
23.4 Departmental Hierarchy Chart
Director
Medical
Superintendent
MO IC MRD
Statistical Officer
Medical Record Medical Record

Officer Assistant
Data Entry Operators
446
23.5.1 In-patient files flow chart
File made on admission
Transferred to in patient unit
Receipt of file after

discharge/LAMA/Death
Assembling
ICD Code checking
Filing
447
23.5.2 Receiving discharge records
Obtain daily discharge

list from Wards
Receive patient file

from WARDS
Tally the received files

with discharge list
Obtain missing patient

files, if any
Affix signature in the

nursing register
448
23.5.3 Issue of Medical Record
Complete medical
record
Orders received Other Requests for complete

from court medical record by
consultants
Verify orders
Forward request for
authorization to Mo I/C
Update court
register
Is
Obtain copies of the No authorization
entire medical obtained?
record
Issue original record. Do not issue the

File the copy of the medical record
medical record for Yes
hospital use
Issue Record after putting tracer

Card
1. Records are available during duty office hours from 9:00am to 4:00pm (Monday-Friday) and 9:00am
to 2:00pm (Saturday)
2. If records are required during non-office hours or holidays, MRO will be responsible to make available
the records after giving information to MOIC MRD. In his absence statistical assistant will be
responsible for the same.
3. All files taken out from MRD have to be returned within 1 week.
4. If a file is not returned to MRD within 1 week, a reminder letter will be sent to the concerned person.
5. If the file is not returned to MRD within 4 days of issuing a reminder letter, strict action as deemed fit
by authorities will be taken.
6. In case a medical record is desired by a health care staff for moré than 1 week for valid reasons, the
records may be issued for a maximum of 3 weeks. If a file is not returned with in time, necessary
action as in point 2 & 3 will be taken.
449
23.5.4 Release of Patient Information
Patient information
(Discharge summary, progress notes, certificates & abstracts)
Request from Request from Request from

patient police Govt agencies
Obtain written request
Request authorized by MO I/c

MRD
Mention date of issue of patient info on request letter.
Obtain signature of person collecting the information on the

request letter
File request letter in the

respective files
Issue photocopies of patient documents.
Release patient information
450
23.5.5 Assembly of Medical Records
A. Assemble patient files in prescribed standard order:

1. Front Sheet
2. Initial Assessment Form
3. Investigation Sheet
4. Treatment Sheet
5. Admission Form
6. Discharge Summary
7. OPD/Emergency Card
8. Pre-operative orders
9. Anaesthesia Notes
10. Operation Notes
11. Sign in form/Anaesthesia Check List
12. Time out Form/Surgical Check List
13. Referal Form
14. Procedure Consent Form
15. Dr.Notes
16. Pre Closure Check List for OT
17. Pain Assessment Form
18. Pre Closure Check List for OT
19. I/O Chart
20. Temperature & Vitals Chart
451
23.6 Departmental policies
Prepared by: Medical Record

23.6.1 Medical records storage Head
Policy:
1. All physical records shall be maintained and stored by the MRD.

2. The numbering system of Medical records file shall start with CRN: 0000000001. The files shall
be arranged and stored in medical records room. The CRN shall reflect on the file.
3. Only authorized users can view/ retrieve medical records.
23.6.2 ICD Classification
1. The 43rd World Health Assembly in 1990 approved the 10th revision of the International
Classification of Diseases (WHA 43.24) and endorsed the recommendation of the international
conference for the 10th revision of the ICD held in Geneva from 26th September to 2nd October
1989.
2. All the inpatient files (diagnosis) are coded according to the international Classification of
diseases using 10th edition.
3. All records are verified at MRD for correct ICD-10 Coding.
Prepared by: Medical Record Head

23.6.3 Retention period of medical records
Policy:
1. All Medico legal patient records will be retained for 10yrs or till disposal of medico-legal cases,
whichever is later.
2. All the Death records shall be maintained for 10 years.
3. Digital In-patient records will be maintained permanently.
4. Manual In-patient records (other than medico-legal) will be retained for 10 years.
5. The other records and registers, detailed below, are retained for the period mentioned against
each:
Death Register - Ten yrs
Statistics Files - Ten yrs
Important Circulars file and miscellaneous circular file - Ten yrs
Dispatch Register of Death reports to the Sub-registrar of deaths office - Ten years
Death report file - Ten years
6. Out-patient records are handed over completely to the patient. However, for special clinics,
OPD record retention period is five years.
7. The retention schedule of some after records is as follow:-
S.No. Particulars of Records Retention period
1. Signature book staff & sisters(Roll call book) 1 Year
2. CSSD Book 1 Year
3. Garbage book 1 Year
4. TMT Tracing record or holter record 1 Year
5. Doctors call book 2 Years
6. Absent book 2 Years
452
7. Complain book 2 Years
8. Blanket book 2 Years
9. Lab book 2 Years
10. Daily consumption book 2 Years
11. Signature book class IV 2 Years
12. Repair book 2 Years
13. Articles book 2 Years
14. OT cloth book 2 Years
15. Assignment book 2 Years
16. Casual leave book 2 Years
17. Syringe +bag receiving book 2 Years
18. Staff address book 2 Years
19. S D officer book 2 Years
20. Culture report book 2 Years
21. OT list file 2 Years
22. M.S. book 2 Years
23. Red alert circular file 2 Years
24. Mutual duty book 2 Years
25. Telephone book 2 Years
26. Daily drug book 2 Years
27. Follow up medication book 2 Years
28. Used SDF 2 Years
29. Dressing book 2 Years
30. SDF book 2 Years
31. Echo Reporting register 2 Years
32. Patient’s appointment book 2 Years
33. Tech book stress book 2 Years
34. Cath list 2 Years
35. ANS reporting book 2 Years
36. Posting register 2 Years
37. ANS duty roster 2 Years
38. Internal dak book 2 Years
39. Observation book 2 Years
40. Late sign book 2 Years
41. Leave record book 2 Years
42. ANS record book 2 Years
43. Inventory book 2 Years
44. Value entry book 2 Years
45. Accessories book 2 Years
46. UGE register 2 Years
47. Colonoscopy register 2 Years
48. ERCP book 2 Years
49. EST Book 2 Years
50. EVC book 2 Years
51. ECG record book 2 Years
52. Poision book 3 Years
53. Treatment register 3 Years
453
54. Indent book consumables items 3 Years
55. Stationary book 3 Years
56. Stock register 3 Years
57. Condemnation book 3 Years
58. Medicine book 3 Years
59. Ultrasound book 3 Years
60. Old register 3 Years
61. Drug book 3 Years
62. Suture recovering book 3 Years
63. GAS book 3 Years
64. Perfusion accessories utilization book 3 Years
65. Special items book 3 Years
66. Sigmoidoscopy book 3 Years
67. General indent book 3 Years
68. Medical book fitness book 5 Years
69. Duty book 5 Years
70. Room vacancy book 5 Years
71. General store indent book 5 Years
72. O2 cylinder book 5 Years
73. Discharge book/Admission book 5 Years
74. Annual demand file 5 Years
75. Blood bank book 5 Years
76. Polypectomy book 5 Years
77. Procedure book/OT record book 8 Years
78. Indent vouchers 3 Years
79. Injection book 3 Years
80. Report book 3 Years
81. Laundry book 1 Year
82. Diet book 1 Year
83. Census book 1 Year
84. Over book 1 Year
85. Peon book 2 Years
86. Death book 5 Years
87. Lab item indent book& all indent book 3 Years
88. L.P.Indent book 3 Years
89. Misc. book
90. MRD book
23.6.4 Destruction of medical records
1. Destruction of medical records will be carried out in accordance with the retention policy of the
hospital
2. The Director / M.S will authorize the destruction of medical records
3. A proper record of all medical records destroyed will be maintained.
454
23.6.5 Audits on medical records
Policy:
1. A 6-monthly audit will be carried out by at MRD by a multidisciplinary team constituted for this
purpose by the M.S. The protocol of the audit will be prepared by the MOI/C, MRD after
consultation with the Medical Audit and record committee.
2. Results of the audit will be shared with the medical and nursing staff with a view to improve
the quality of the records.
23.6.6 Deficiency Checking of files

Policy:
1. A deficiency checklist is attached to files at the time of discharge of the patient from the ward by
the nursing staff.
2. The sister in charge/ senior staff nurse of the ward check for deficiencies related to
documentation by the nursing staff and get it corrected. After correction of deficiencies, the sister
in charge / Senior staff nurse put’s her signature on the deficiency checklist.
3. The consultant signing the file check for deficiencies related to documentation by resident doctors
and gets them corrected. After correction of deficiencies, the consultant puts his signature on the
deficiency checklist.
4. A revised and simplified deficiency checklist is used for this purpose.
5. The files are accepted at MRD only after the process of deficiency correction.
23.6.7 Statistics
The MRD will receive daily/monthly data from various In Patient and Out Patient Departments and
generate/maintain the following statistics.
The following data shall be received by MRD daily from the Sister Incharges of casualty and various
Inpatient departments.
1. Daily ward/emergency census

a) Remaining patients
b) New admissions
c) Transfer in
d) Discharge
e) Death
f) Transfer out
g) Transfer to other hospitals
h) LAMA
i) Abscond
j) Balance
k) Casualty referrals.
455
This data shall be used to generate following statistics
a) Monthly census - ward wise and total.

b) ALOS- Overall and Department wise ALOS will be calculated as per the following formula:
ALOS = Balance Patients of whole month/Discharges+Deaths+LAMA+Abscond+Transfer out
c) Gross death rate - Overall and Department wise, calculated as per the following formula:
Gross Death Rate=Total Deaths X 100/Discharges+Deaths+LAMA+Abscond+Transfer out
d) Percentage Bed Occupancy: Calculated as per the following formula:
Percentage Bed Occupancy = Balance Patients of whole month X 100/Total beds X No.of
days in the month
A copy of the data generated will be submitted to Quality Maintainence Department on monthly
basis.
2. OPD census: Daily OPD census including new patients, old patients and total patients will be
maintained by MRD.
3. Monthly statistics
Morbidity and Mortality report – The mortality and morbidity data of all the inpatients (along with the
ICD codes) will be obtained from HIMS. The ICD-10 codes will be checked and corrected by MRO.
This data will be used to generate the monthly mortality and morbidity report and census of reportable
diseases (i.e. measles)
4. Performance indicators: The following performance indicators will be calculated by MRD at the
end of every month
a) Number of vaccines immunization doses given
b) Number of times ambulance used
c) Number of major surgeries, minor surgeries and dental procedures done
d) Number of lab tests, radiological tests and ECG conducted
e) All Staff employed in the hospital including doctors, nursing staff etc.
5. Key performance indicators: KPI’s shall be prepared by the MRD Staff as per the Management
requirements. Presently, the following KPI’s are calculated.
a) ALOS and ALOS excluding nursery transfer.
b) Gross death rate and death rate beyond 48 hours.
c) Nutritional assessment including Dietary assessment and anthropometric assessment.
d) Percentage completion of History and examination.
e) Percentage of files with discharge /death summary.
f) Percentage of missing records/files.
6. KPI No. a, b, and f will be calculated based on the data of all the files discharged in that month.
For KPI no. c, d and e sampling will be done based on cluster random sampling method. Out of
all the dates of a month, a random sample of 12 dates will be chosen using a computer software.
All the files discharged on those dates will be sampled after excluding short admissions.
23.6.8 Sending of reports to the government agencies
1. Delhi Health Services (DHS): Monthly report of morbidity, communicable disease and
performance should be sent online to DHS at discontinued w.e.f. May 1,
2013.http://10.128.152.3:2022/common/loginpage.aspx
2. National Rural Health Mission: Monthly report (as per format) should be sent via e-mail and hard
copy to the NRHM. The report is emailed at miseastd@gmail.com. The hard copy of the report is
sent to CDMO East (H & FW) office, Surajmal Vihar, Delhi by Post.
456
3. Municipical Corporation of Delhi (MCD): Both online and the original Death forms (Form 2 and
Form 4) should be sent to Municipical Corporation of Delhi with in the specified time of 21 days.
The forms are sent online at http://www.mcdonline.gov.in/healthindex.php and an online
completed Death registration forms are generated bearing the registration number, which are
maintained by MRD. The original Death forms are deposited at MCD Office, Shahadra by MRO
on fortnightly basis.
23.7 Quality plan –Quality indicators

1. The time of sending the online monthly report of morbidity, communicable disease and
performance to DHS.
2. The time of sending the monthly report to NRHM, both online and hard copy
23.8 Forms/ Documents maintained by MRD
A. Forms/books
1. Daily ward Census forms
2. Death registration form generated online
3. Police intimation for Medico Legal Cases
4. MRD Circulars
5. Out side Correspondences
6. Govt. Letters
7. ICD-10 – Books Vol. 1,2
8. Monthly KPIs.
B. Registers
1. Death Register (MRD Reg 1)
2. MLC register(MRD Reg 2)
3. MRD files in/out register (MRD Reg 3)
23.9 Policy and procedure for maintaining confidentiality , security and integrity of the records /
data and for safeguarding of data/ record against loss , destruction and tampering
23.9.1 No person other than MRD staff will have access to records.
23.9.2 All MLC files will be stored under lock and key.
23.9.3 Regular pest control measures will be undertaken and documented.
23.9.4 If there is a loss/tampering of records, the same will be intimated to Director and CNBC. A
committee will be constituted by Director CNBC to investigate the matter and advise remedial
measures.
457
24 Code Pink Policy
Date created: June 2013
Responsibility of Department of Safety Management &

updating: Sentinel Event Committee

updated on:
Versionn (CNBC/SMSEC/ 24/ Ver.1.1)
458
24 Code Pink Policy .............................................................................................................................. 458
24.2 Policy Statement: .................................................................................................................. 461
24.3 Policy Guidelines: .................................................................................................................. 461
24.5 Committee’s Responsibility ................................................................................................... 463
24.6 Subcommittee of code pink Event Committee ...................................................................... 463
459

No. Amendments
1. 24.6.1 Jan 2015 As per the updation of
Change in member of safety management and
safety management and Sentinel Event
Sentinel Event Committee members.
Committee.
2 24.6.1 Jan 2017 As per the updation of
Change in member of safety management and
safety management and Sentinel Event
Sentinel Event Committee members.
Committee.
2 24.4 Feb 2018 Addition of security To make policy more
officer and security clear.
supervisor role.
460
24.2 Policy Statement:
24.2.1 CNBC is committed to provide a safe and secure environment for the infants & children and their
caretakers to prevent infant / child abduction in the hospital.
24.3 Policy Guidelines:
24.3.1 Abduction Prevention Team to develop and implement the Abduction Prevention Plan. The
team's responsibilities should include assess and identify vulnerabilities, recommending/
implementing physical security requirements, work practices, and healthcare worker training
programs; developing emergency response plans.
24.3.2 Abduction Prevention Team will consist of :

1. MO I/c Security / CMO (in the absence of MO I/c Security)
2. Treating unit’s faculty/ senior resident on duty (after 4 P.M.)
3. Security officer
4. Security Supervisor
5. Sister Incharge of the Respective Nursing Care Unit
24.3.3 Facility Security Safeguards:

1. Security Camera Systems are used for monitoring and surveillance in the hospital.
2. The access privilege to the clinical areas is given only to staff with authorized ID badges & is
monitored closely.
3. The security guard at the exit of ward and at all other gates ensure that no child leaves the
premises with an identification band on wrist.
4. Security guards to check identity cards of everyone exiting the gates when Code Pink is declared.
Only authorized staff allowed access to clinical areas.
24.3.4 Work Practices for Safeguarding Infants and Children

1. The hospital staff specially in the NICU,PICU,HDU & ED are trained and educated about the
policy & procedures for preventing infant & child abduction
2. Messages about safety measures & precautions to be taken to prevent infant abduction are
displayed prominently.(Social worker)
3. All patients need to wear identification band (hosp made) with their CR number written on that
band or if white bands available with unique id no.(readymade)
4. Below one year, Identification bands are given to infant with matching ID band is given to the
mother / designated family member throughout hospital stay.
5. Nurse, who will allot the identification bands to mother and baby, will write the id no. of that band
on the file of that patient.
6. At the time of discharge, security guard at the exit of ward, will cut that band, write the name and
band number on a register, cross check it with the number written on discharge or LAMA
summary and at the end of his/her shift, handover that band to nursing staff on duty to
crosscheck it.
7. Footprints of the infant are imprinted on the case file in NICU.
8. Distinctive uniforms are provided to the staff working in the neonatal intensive care units.
9. The infants are kept in direct, line-of-site supervision at all times by a authorized staff member or
the mother/ designated family member throughout hospital stay.
10. The patients are transported only by authorized staff
11. The security guard at the exit of ward and at all other gates ensure that no child leaves the
premises with an identification band on wrist.
12. Other hospitals in the area are alerted of any suspicious person as a preventive proactive
measure.(CMO)
13. The parents are explained and advised to supervise their children at all times in waiting rooms
and outpatient clinics
461
24.4 How to Alert Code Pink?
If any child / infant is found missing, patient’s relatives and sister incharge/staff nurse shall
confirm the incident in the respective ward area
Sister Incharge /staff nurse shall immediately inform the security at:
Intercom no: 8 and 240- giving complete details including patient’s name, age, sex ,location,
appearance and color and type of dress worn, id band number, and last time where and when
seen and by whom.
Security Officer /security supervisor shall alert CODE PINK in the Hospital on Public
Announcement System declaring child’s details as given above.
Announcement must be clearly audible, and shall repeat the same three times in English/ Hindi.
Announcement shall be repeated at the interval of 10 minutes for an hour.
Security officer and Security supervisor have to visit the department/site along with Security
guards and they have to search the child inside the department and blind areas.
Meanwhile security guards shall immediately close all exits of the ward and hospital
temporarily, and all the security guards shall search the child in the premises and shall screen
everyone at the exit
Security shall close all the exits leaving one gate opened,( Casualty gate ) fully manned, and
security shall do a stringent checking of everyone including their luggage and vehicles.
Meanwhile Security officer will look at CCTV,for the footage of incidence and try to trace
it.
Blind areas where there is no CCTV should be looked first-like-
This will continue till the child is found or for an hour.
If the child is found within an hour time, he/ she shall be taken to the respective patient care
unit/ to their relatives.
If child is not found for an hour:
Then CMO/ MS shall be informed by the security officer
Police is informed in written by security officer/ CMO
Code pink event recorded
Patient’s relatives will keep in contact with police for further information
Even if patient is located after an hour and the relatives wish to get the child admitted, it will be
done as readmission, new CR no. will be given.
462
24.5 Committee’s Responsibility
As a preventive measure, co-ordinator code pink shall organize the CODE

PINK mock drills and training periodically.
In case, code pink announced or child abduction event occurs, the co-
ordinator code pink shall immediately organize the committee meeting
and shall investigate the root cause.
Root cause of such events shall be communicated among the

organinzation as a lesson learnt to prevent the reccurence of such event
in future.
Committee shall periodically assess the funtioning of the organization to

prevent such events.
24.6 Subcommittee of code pink was formed under the safety management and Sentinel Event
Committee
24.6.1 Following are the members of Committee

1. Dr.Aikta Gupta - Secretary, SMSEC, Assistant Professor, Anesthesia.
2. Mr. R S Chauhan- Incharge Security Officer
3. Sister Madhu Bhutani ANS, CNBC
4. Dr.Mamta Jajoo-Coordinator, Assistant Professor, Pediatrics
463
25 Manual for operations (Security)
Responsibility of DR Anil Aggarwal, Department of

updating: Security

updated on:
Version (CNBC/ /Security/25/Ver.1.1)
464
25 Manual for operations (Security) ...................................................................................................... 464
25.2 Introduction ............................................................................................................................ 467
25.3 Departmental Procedure ....................................................................................................... 472
25.4 Theft of hospital assets ......................................................................................................... 473
25.5 Opening of department / facility after office hour .................................................................. 473
25.6 Key control management ...................................................................................................... 473
25.7 Natural calamities /disaster ................................................................................................... 474
25.8 Theft & Robbery .................................................................................................................... 474
25.9 Employee’s Guest ................................................................................................................. 474
25.10 Handling of Patient attendants by security ............................................................................ 475
25.11 Handling of Staff By Security ................................................................................................ 475
25.12 Forms/Documents/Registers ................................................................................................. 476
25a. Code Red Manual ............................................................................................................................. 477
25a.2 Introduction ................................................................................................................................. 479
25a.3 Implementation ........................................................................................................................... 479
25a.5 Evacuation .................................................................................................................................. 482
25a.7 Fire Safety Training .................................................................................................................... 484
25a.9 Fire Alarm Activation Procedure ................................................................................................. 484
465
S.No. Clause Date of Amendment Made Reason s of Sign of QM

1. 25.12 23rd Nov 2015 HK attendance Abbreviation removed
register now written
as attendance
register
nd
2. 25.2.5 22 August 2020 Thermal screening of COVID -19
hospital entrants at SCENERIO
main gate.
Ensuring one
attendant with one
patient to prevent
overcrowding.
Ensuring social
distances in
outpatient
departments and
wards.
Emphasis on
wearing masks to
patients and their
attendants.
466
25.2 Introduction
25.2.1 Scope
The Security guards are stationed at different areas such as: Emergency door, OPD Entrance, Ward
Block near lift entrance, Administrative Block, OPD Registration area, all ward entrance, basement and
parking area. Responsible for the total safety & security of the internal as well as the external patients.
25.2.2 Process summary
Function Process
Parking Management Responsible for both basement as well as the

front gate parking. Vehicle in & out register to
be maintained properly.
Key Management Keys of all the main areas are kept at the
security and proper procedure to be followed at
the time of issuing/ receiving.
Visitors Management Visitors policy to be followed as per the hospital

policy.
Staff Management Staff in & out time to be maintained. Staff to be

checked at the time of leaving.
25.2.3 End of Day Activities

1. End of the day activities consists of the activities which are important to perform on daily basis.
2. Ensures all the areas are manned properly and there are no gaps left.
3. All the records to be maintained properly.
4. Proper shift handover to be given.
467
25.2.4 Departmental Hierarchy
Director
M.O I/c Security
Security Officer Support Coverage by Delhi

Police Personnel
Security Supervisor
Guards
468
25.2.5 Job descriptions
1. Security Supervisor
POSITION GUIDELINES
Name: Year
Job title: Security Department Security

Supervisor
Job content (purpose of the job)
Is responsible for the following functions :
Round the clock responsible for overall guards performance.
Overall all the activities like – Parking Management, Key Management, Visitor’s Management,
vigilance, security investigations and overall discipline.
Main Job Tasks:
Responsible to conduct briefings at the start of each shift.
Responsible to allocate the duties of the guards.
Responsible to check the uniforms and the grooming of all the guards.
Responsible to ensure that all the registers being maintained at the guard room are done properly and
get it signed by SO.
Responsible for relieving the guards at different post for lunch, tea etc.
Responsible to take briefing from SO and debrief him on all the activities/ Incidents.
Responsible to log all the activities in the log book.
Responsible to ensure enough illumination in hospital premises.
Responsible to keep the duty area clean and hygiene.
469
2. Security Guards
POSITION GUIDELINES
Name: Year
Job title: Security Department Security
Job content (purpose of the job)
Is responsible for the following functions :
Parking Management
Key Management
Visitor's Management
470
Main Job Tasks:
Main entrance security guard:
Responsible for the parking area in front.
To ensure that the vehicles (two wheelers/four wheelers) are parked in their respective parking spaces.
To be alert at any given time and alarm any suspicious person/activity.
Responsible to keep the front of the hospital cleared at all times/ will not allow any waiting vehicles.
Emergency door security guard:
Assisting the patients in getting down from the vehicle with the help of wheel chair/trolley if required.
To ensure the ambulance parking space is not occupied by any other vehicle at any given point.
To be active in case of code red and help in the evacuation via fire exit staircase.
COVID -19 scenario
Thermal screening of hospital entrants at main gate.
Ensuring one attendant with one patient to prevent overcrowding.
Ensuring social distances in outpatient departments and wards.
Emphasis on wearing masks to patients and their attendants.
General:
To check the attendant's/visitor's pass and guide them to their respective wards.
To assist the patient attendantin case of any queries.
In case any person is found without the pass to politely explain the policy and request them to meet
the security supervisor.
471
25.3 Departmental Procedure
25.3.1 Returnable and Non-Returnable Gate Passes

The hospital property can leave premises only through a returnable or a non returnable gate passes
1. Returnable gate pass

The returnable gate passes to be made in duplicate copies to be distributed as follows:
Original - the taking out the items
Duplicate – in the book
2. The first copy is perforated & is to be detached / sent along with the person removing the item (s).
3. Returnable gate passes (RGP) to be signed by the head of department or designated person.
4. The person to take out the items only through staff gate along with two copies of RGP. All the two
copies to be signed and timed etc. by security guard on duty after checking all relevant details
with the outgoing items.
5. The original copy to be taken by the person removing the item (s). The duplicate copy to be kept
in the book.
6. The security department will maintain a returnable gate pass register, where each gate pass to be
entered / filled in chronological order. The RGP register to have following columns:
7. Sl.No, date, gate pass no, item details with qty, name & company of the person removing the
items, out time, signature, department, date of return, in time, signature of the vendor, sign of
security.
8. As for as possible, all returnable goods to be received back through security only during office
hours by the originating dept.
9. Security after making relevant entries of date of receipt in the returnable gate pass register will
put security seal on the white copy & handover copy to the person who has come with the
returnable goods.
10. The total qty mentioned in the returnable gate pass to be cleared in one consignment i.e. or
before due date if not to inform.
11. The items received through security control will be checked at time- office by the security staff.
After the items received by the rep of the originating department & sign on the white copy, which
will be then taken to security control supervisor who will enter in returnable gate pass register,
and keep the white copy as a record.
25.3.2 Non-returnable gate passes (NRGP)

Items covered include:
a) Equipments received for demonstration purpose.
b) Samples received by individual department.
c) Items received on consignment basis.
d) Any other items going out of hospital premises permanently.
e) The NRGP to be made in duplicate, copies to be distributed as follow:
472
f) Original -the person taking out the items
g) Duplicate –in the book.
h) NRGP to be signed by HOD & designated person / Director.
1. The vendor should take out the item through the staff gate along with the original white + one pink
copy of the NRGP. The two copies of the NRGP to be signed, timed etc. By the security guard on
duty after checking all relevant details with the outgoing items.
2. The original copy will be taken by the supplier / person removing the items & other copy will be
retained in the book.
3. The security department will maintain a non returnable gate pass register, where each gate pass
to be entered / filled in chronological order. The NRGP register to have following columns:
4. Sl.No, date, company name, description, quantity, gate pass no., vendor signature, out time,
department, security signature remarks.
25.4 Theft of hospital assets

1. Concerned department to intimate security/Security Officer immediately about the loss, verbally
as well as in written.
2. Security to establish authenticity of the loss from the concerned department
3. Check with the house keeping staff.
4. Make a mental appreciation and interrogate the staff, who have been servicing / working in the
concerned department / area.
5. Check the staff lockers.
6. Increase frisking at the staff gate.
7. Carry out systematic investigation.
8. Render incident report to Security Officer.
9. Report to be forwarded to Director with remarks/comments by the Security Officer.
25.5 Opening of department / facility after office hour

1. The department requiring the material must make a request to medical officer on shift.
2. Medical officer to authorize withdrawal of departmental key from the security control. The
authorized person to withdraw after filling in all columns of the key control register, available in
the security control.
3. The security controls will accompany the person authorized by Director / HOD.
4. Department/ Facility to be opened by the authorized person in the presence of the a security
supervisor / Nodal officer and proper entries should be made in relevant registers.
5. After operating the Department / Facility, the keys to be properly returned to security control after
proper entries in key control register have been made.
Prepared by:
25.6 Key control management Security Officer
1.Scope: Security
2.Policy:
a)Keys of all departments will be kept secure at the security control.
b)An authorized person has to sign in the key register kept at the security control every day while
collecting /depositing the key.
c) Department locks to be changed only with the prior intimation to Director under the arrangement
of HOD.
473
d) In case of the loss of the operating key by the person, should intimate through HOD to Director
Security Officer & HOD. Immediately the lock is changed & new lock is put into operation with
both keys (operational & duplicate).
Prepared by:
25.7 Natural calamities /disaster
1. Scope: Security
2. Policy:
a) Natural calamities
b) These P&P are being issued for security steps to be taken during natural calamities
c) Evacuate PATIENTS / staff to safe area
d) Save hospital property & man all entry & exit
e) Save patients belongings
f) Where necessary evacuation plans for emergency be adopted as given in fire plan
g) Render incident report`
Prepared by:
25.8 Theft & Robbery Security Officer
1. Scope: Security
2. Distribution List: All departments
3. Policy:
a) Assist the patients/attendants in case of loss / theft.
b) Establish the authenticity of the loss by interacting with the attendant / patients
c) Assist the attendant in searching the lost items with the help of the housekeeping staff.
d) Make a mental appreciation & interrogate the team members involved.
e) Check the staff locker
f) Increase the frisking at the time office/team entrance gate
g) Carry out systematic investigation
h) Incase patient attendant wishes to lodge a complaint with the police, provide assistance in doing
so.
i) Complete the investigation & forward the report to the Director and MO I/c Security.
j) To avoid such incident frequent patrolling on the floors
k) Key left by patient on the cupboard knobs, should be removed & handover to the incharge nurse
Prepared by:
25.9 Employee’s Guest
Security Officer
1. Scope: Security
2. Distribution List: Security
3. Policy:
Employee’s guest should be discouraged from coming into the hospital premises during employees’
working hours
474
Prepared by:
25.10 Handling of Patient attendants by security
Security Officer
1. Scope: Security
2. Distribution List: Security
3. Policy:
Special care will be taken to ensure that all Patients attendant of the hospital are treated with honour and
dignity and restraint shall be shown when patient/attendants are abusive / violet.
A. When patient attendant is abusive

i. Isolate the patient attendant when he is abusive, requesting him to Security supervisor / Security
officer who can alienate his problem.
ii. Find the cause of agitation.
iii. Speak politely and ask” What can I do for you now, sir?”
iv. When the guest cools down, do thank him.
v. Do not allow the crowd to gather around.
B. When patient attendant is violent
i. To immediately call the supervisor/Security Officer.
ii. Psychologically subdue the guest with physical presence.
iii. Maintain aggressive posture from a distance while one supervisor acts as a friend.
iv. Do not allow the crowd to gather around.
v. In critical situations security is well trained to call the supervisor/manager who in turn will use their
discretion to handle the situation.
vi. The security staff will not devaluate from above norms while security / dealing with the guests.
Prepared by:
25.11 Handling of Staff By Security Security Officer
1) Scope: Security
2) Distribution List: Security
3) Policy:
a) The entry into the premises of the hospital is maintained, controlled and regulated by the security
department.
b) Special care should be taken by the security staff to ensure that all the employees are treated
with honour and dignity so that they feel proud in being part of this great organization.
c) Security staff will be firm but polite while on duty.
d) Security staff ensure that no visitor of the employees enter hospital without visitor card /
authorization.
e) Security staff deals with disgruntled staff with persuasive skills.
f) All suspicious activities of the staff will be kept under surveillance by security.
g) At the end of each staffs shift the security (female) will be checking the bags of the female team
members and the Male Security Guards will do the frisking of the male team members.
h) At no point of time, security will handle staff however provoking the situation.
i) Security staff is to remain cool, firm judicious and dignified while dealing with staff.
475
25.12 Forms/Documents/Registers
1. Non – Returnable Gate Pass Register
2. Returnable Gate Pass Register
3. Key Register
4. Attendance Register
5. Night Check Register
6. Visitors Register
7. Security attendance Register
8. Security Log Register (Occurrence)
476
25a. Code Red Manual
Responsibility of Updating: Department of Security
Last reviewed/ updated on: Dec 2018
(CNBC/ /Security/25a/Ver.1.1)
477
25a.1 Amendment Record Sheet
S.no. Clause no Date of Amendment Reasons of Amendment Sign of QM

Amendment Made
th
1. ______ Aug, 27 Incorporated As the telephone numbers
’2010 new Telephone have been changed
numbers and
deleted the old
one
2. 25a.3 23 Nov 2015 Safety Change in name of

management & committee
Sentinel Event
Committee
3. 25a.1 Jan 2019 Maintenance Previously not mentioned.

plan of fire
related
equipments
4. 25a.1 22 August Deleted old As the telephone numbers

2020 phone numbers have been changed
478
25a.2 Introduction
The Code Red Protocol was implemented to protect staff, patients, visitors, property and assets of
Chacha Nehru Bal Chikatsalya (CNBC). The Code Red Protocol serves as a guide for establishing and
maintaining fire safety conditions at the hospital. CNBC is under the jurisdiction of the Geeta Colony Fire
Station.
25a.3 Implementation
1) The Safety Management & Sentinel Event Committee (SMSEC) has been established to guard
the health and safety of all patients, staff, visitors and the environment. The purpose of the
SMSEC is to provide a forum for and to facilitate the interaction between and with the hospital
community regarding the identification and resolution of safety-related issues, including fire
safety. The SMSEC was also formed to discover, analyze, and propose solutions to hazardous
situations and subsequently advise Administration on corrective measures. The SMSEC meets
twice a year or whenever necessary.
2) Hospital fire safety is a vitally important area of concern for CNBC. The potential for loss of life or
injury from a fire-related incident is one of the most serious risks a hospital must face. Therefore,
the hospital must have a comprehensive fire-safety program. It requires an on-going commitment
on the part of the community, the institution, and the administration. Careful planning,
implementation, and maintenance are all essential ingredients of a successful fire safety program.
3) It will be the responsibility of the Security Officer to update the manual, and make amendments if
necessary.
479
25a.4Code Red Protocol
In the event of fire, the sequence of FIRE

events is as follows;
Sensors across Fire alarm point glass

hospital detect fire broken
Alarm Received in Fire Control Room (FCR) 319
FCR personnel identify the fire zone & inform Security

officer on 9911101060 or Security supervisor (240) or 8
FCR Facilitator and Security personnel goes to the location assess the threat.
NO YES
Is the threat
genuine?
Assess the cause of 1. Assess the fire

false alarm and take 2. Commence fire fighting
corrective action 3. Inform Security officer/ M.O.I/c Security/ Director
on extn: 327, 322, 332, 243 to announce Code
Red.
Security Team informs Fire
Brigade , Geeta Colony
Immediately 22513330
Point of Control (POC)
Code Red Announced and Point of consists of
Control (POC) established
Director
M.O I/c Security
Fire Officer assesses the fire and Security officer
decides whether to evacuate the Duty Medical
officer
building / part of the building Nurse In-charge
NO YES
Is evacuation
required?
Fire is extinguished
Code Red concluded and Detail A

report of incident to be submitted to
SMSCE
480
A
Fire Officer orders evacuation.
FCR announces Evacuation. Security Team informs Fire

Brigade, Police, neighboring Hospitals & ambulance services.
Evacuation & accounting of patients is the

responsibility of Nurse In-Charge.
Evacuation of other humans & accounting of kitchen
and Housekeeping staff is the responsibility of
Security officer.
Patients are evacuated and brought to the Triage area

(Front of ward block area). Ambulance is placed next to
emergency ward entry.
After triage the patients are disposed off as follows:
1. Priority 1: Evacuate to the nearest Hospital with

facilities immediately.
2. Priority 2: Discharge to home.
Code red is concluded when:
1. All patients are evacuated, accounted for and

disposed off.
2. All other human beings (Patient attendant /
Visitors / Hospital Staff are evacuated and
accounted for.
3. all important marked equipments / Records to be
accounted
4. Fire brigade and Police personnel have arrived
and taken over the situation.
481
25.13 25a.5 Evacuation
1) It is a procedure carried out where patients and staffs from the hospital as a whole, section are
moved to a safe area in the quickest possible time, in a safe and orderly manner.
2) Factors that influence a decision to carry out an evacuation procedure;
3) Site of fire
4) Spread of fire and smoke
5) Presence of highly inflammable items like oxygen cylinders, centralized piped gas system.
6) The decision for evacuation of the whole hospital will only be taken by the Director at the advice
of the Fire department. The nurse in charge of the respective wards takes the decision, on which
priority patients are to be moved first from the ward.
A. Levels of evacuation
i. Level 1 – Transfer of patients/staff to the site safe from the fire – to the lowest floor.
ii. Level 2 – transfer of patients/staff from the building to a safe assembly point.
B. Patient categories:
i. Category 1 – Bed ridden patients/ patients that need staffs help in moving.
ii. Category 2 - Patients who are able to move with assistance of parents/ attendants.
iii. Category 3 – Able to move on their own
Note: IN THE EVENT OF A EVACUATION, PATIENTS IN CATEGORY 3 ARE USUALLY MOVED FIRST
FOLLOWED BY CATEGORIES 2 AND 1.
C. Assembly point:
1. Section evacuation: the Director would decide the area.
2. Full evacuation – The triage would be at near ward block on the ground floor
D. The Director would decide on the next course of action. The location of the point of control may
vary depending on the site of the fire.
482
25a.6Patient Handling Area
In case evacuation is announced, triage will be set up in front of ward block, and the patients/victims will
be transported as follows;
Pt. Handling
Area
483
25.14 25a.7 Fire Safety Training
Educating and training the hospital community is a vital component of the fire safety program. This
section has been designed to address these issues and should be used as a resource for all employees .
The Security officer of the Hospital trains all new joiners
1. Chemistry of Fire
2. Fire prevention and safety measures.
3. Proper use of fire equipment.
4. Escape routes.
5. Fire alarm systems.
25a.8 Fire Safety Equipment
The Hospital is equipped with fire detection and suppression equipments to protect life and property from
fire. These fire safety equipments include sprinkler systems, smoke alarms and heat detectors.
Fire Fighting equipments:
Fire Extinguishers, Fire hydrants are available in adequate quantity in hospital to extinguish fire if
required.
Maintenance plan of fire related equipments: All the equipments are checked by PWD department. on
quarterly basis and report submitted to hospital authority. Based on report corrective and preventive
actions are taken. Any breakdown will be handled on urgent basis.
25.15 25a.9 Fire Alarm Activation Procedure

All employees should be familiar with fire alarm point glass locations in the hospital. The point glass is to
be broken, and the button located inside is to be firmly pushed. The hospitals alarm should be
immediately activated in the event of a fire, or if a person smells or sees smoke. Even if the fire is small,
the alarm should be activated, because a fire can grow quickly and endanger building occupants. After
activating the alarm, get out of the hospital and assemble in the designated area for staff. Provide the
point of control with the location and extent of the fire if known.Any attempts to extinguish the fire can be
made only after the alarm has been activated, if the fire is small, and if you have been trained on fire
fighting methods.
25a.10Mock Drills
Code Red mock drills are held yearly. The drills are conducted to verify:
1. If staff follow correct protocols to announce Code Red.

2. If staff are using the correct exit routes.
3. Correct assembly of staff and patients at designated areas.
4. Evacuation times.
25a.11Fire Extinguishers
The fire extinguishers are strategically located throughout the hospital. The majority of the fire
extinguishers at CNBC are of the ABC variety.
25a.12Fighting a Fire
1. Four things must be present at the same time in order to produce fire
484
2. Enough oxygen to sustain combustion
3. Enough heat to raise the material to its ignition temperature
4. Some sort of fuel or combustible material, and
5. The chemical, exothermic reaction that is fire
6. Oxygen, heat and fuel are frequently referred to as the “fire triangle.” Add the fourth element, the
chemical reaction, and you actually have the “fire tetrahedron.” The important thing to remember
is when you take any of these four things away, you will not have a fire, or the fire will be
extinguished. Essentially, fire extinguishers put out fires by taking away one or more elements of
the fire triangle/tetrahedron. Fire safety, at it’s most basic, is based upon the principle of keeping
fuel sources and ignition sources separate.
25a.13Rules for Fighting Fires
Fires can be very dangerous and you should always make certain to not endanger yourself or others
when attempting to put out a fire. For this reason, when a fire is discovered:
1. Assist any person, who is in any immediate danger to safety, if it can be accomplished
without risk to you.
2. Activate the building fire alarm system.
3. Only after completing the above two, you may use an extinguisher if you are trained and
the fire is small.
However, before deciding to fight the fire, keep these rules in mind:
A. NEVER FIGHT A FIRE IF:

a) You do not know what is burning and you do not know what type of fire extinguisher to
use.
Even if you have an ABC extinguisher, there may be something in the fire, which could explode or
produce toxic smoke. Chances are you know what is burning, or at least have a pretty good idea, but if
you do not know, let the fire department handle it.
b) The fire is spreading rapidly beyond the spot where it is started. The time to use the fire
extinguisher is in the recipient, or beginning stages of the fire. If the fire is spreading
quickly, it is best to simply evacuate the building, closing windows and doors as you
leave.
c) How to Use a Fire Extinguisher
It is easy to remember how to use a fire extinguisher if you can remember the acronym PASS, which
stands for PULL, AIM, SQUEEZE, and SWEEP.
1) Pull the pin. This will allow you to discharge the fire extinguisher.
2) Aim at the base of the fire. If you aim at the flames (which is usually the temptation), the
extinguisher agent will fly right through and do no good. You have to hit the fuel.
3) Squeeze the top handle or lever. This depresses a button that releases the pressurized
extinguishing agent in the extinguisher.
4) Sweep from side to side until the fire is completely out. Start using the extinguisher from a safe
distance away moving forward sweeping the nozzle from side to side. Once the fire is out, keep
an eye on the area in case it re-ignites.
485
26 Department of Transportation (Ambulance)
Responsibility of Department of Security

updating:

updated on:
Version ( CNBC/Trans/ Ambulance /26/Ver 1.1)

486
Contents
26 Department of Transportation (Ambulance) ........................................................ 486
26.1 Amendment sheet ......................................................................................... 488
26.2 Purpose: ........................................................................................................ 489
26.3 Scope: ........................................................................................................... 489
26.4 Responsibility person: Causality Medical Officer ........................................ 489
26.5 Staffing and Job Description: (Add training of staff in BLS & ACLS) ....... 489
26.6 Ambulance Vehicle: ..................................................................................... 490
26.7 Flow Chart. ................................................................................................... 491
26.8 Operating Procedure: .................................................................................... 492
26.9 Ambulances Services For Transfer Out Of Patients: ................................... 492

487
1. 26.5.4 July 2014 Addition in job description of For clarification.

nurses
2. 26.5.4.3 Feb 2015 Addition of Inventory of Previously was not

ambulance must be done and documented.
documented by nursing staff of
the emergency department prior
to dispatch of ambulance
(patient transport vehicle).
3 26.11 Feb 2017 Policy when CNBC doesnot

own the ambulance and use
CATS Ambulance as per
Government orders-
The procurement of our own
Ambulance is under process.
So till then as per order of
Director ,CNBC ,and
Government orders we are
using CATS ambulance.All
the wards,ICU, emergency
department and whoever
needs any ambulance for any
purpose like shifting a patient
for any investigation or
discharging will call CATS
number.They will maintain a
CATS ambulance movement
register.They will check
oxygen ,suction and other
needed equipment of CATS
ambulance before shifting the
patient and replace the
required things from
emergency.Every place will
maintain emergency box/tray
containing Ambu
bag,endotracheal tubes and
emergency drugs like
adrenaline,Atropine and other
required drugs .They will
document the checked items
in the movement register

488
26.2 Purpose: 3. Be clear about the location of the
incident and nearest safe route .to take
To provide an appropriate form of the journey.
transport for patients who due to certain 4. Observe the Highway Code road traffic
medical reasons are unable to make their rules and regulation.
way to hospital or referral centre.
5. Park the Ambulance in a safe, suitable
26.3 Scope: position for easy departure.
6. Prepare the medical to receive the
To Provide First Aid to the Patient and patient, opening real door, gather the
resuscitation To provide appropriate equipment.
medication enroute to Hospital Shift of 7. Assist the medical attendant and deal
patient from on place to another. with other causalities as required by
the incident.
26.4 Responsibility person: Causality Medical
Officer in charge of Emergency services, 8. Before leaving the incident spot check
CNBC to make sure all the equipment. Has
been returned to the ambulance.
26.5 Staffing and Job Description: (Add 9. Close and secure the rear doors.
training of staff in BLS & ACLS) 10. Ensure a safe, smooth and comfortable
journey.
11. Park the Ambulance in suitable
26.5.1 Emergency Room in-charge: entrance to shift the patient to
Coordinating the Ambulance services for emergency room.
effective transfer of patient to the emergency 12. Give return report about the drive to the
department. MO.
13. Always maintain the Logbook.
26.5.2 Ambulance Service In-Charge. : CMO
aided by senior most driver 26.5.4 Nurses (Nursing Sister/Brother)
1. Vehicle maintenance for road worthy 1. Always attend to emergency call.
conditions on a daily basis. Ensure the Ambulance is fully equipped
2. Preparation of duty roster (on shift all functioning and ready to use for all
basic) for the ambulance drivers. emergencies.
3. Documentations of Daily Report of 2. Check for the availability of emergency
Ambulance Movement drugs and see that they are easily
4. Daily check up of Equipments of various accruable and look for Date of Expiry.
ambulances. Checking of drugs & equipments are
5. Receiving Call and arranging the done and documented daily on shift
Ambulance as per call requirements, basis by nursing staff of emergency
6. Issuing instructions to the Ambulance department.
driver for departure. 3. Inventory of ambulance must be done
7. Submission of Ambulance Report to the and documented by nursing staff of the
Higher Authority on a day to day basis. emergency department prior to dispatch
8. Keeping a track of the ambulance of ambulance (patient transport vehicle).
driver’s movement through the Control 4. Message to Ambulance control, arrival
system. on the scene, and give initial feed back
of the incident.
26.5.3 Ambulance Driver: 5. Quickly assess the priority for patient
1. Make sure your vehicle is roadworthy care, and give instruction to the Driver.
2. Properly dressed with clear identity. 6. Give required First aid at the location,
reassure he patient / relative.

489
7. Shift the patient comfortably into the
Ambulance, and carry out tasks in
consolations with the doctor if
accompanying.
8. Instruct the driver to head for the
Hospital.
9. Always travel with the patient, not in the
cabin with the driver.
10. Keep monitoring patientand take
appropriate decisions.
11. Give brief report on the patient's
condition, terminate given on arrival.
12. Document the patient's detail in
conjunction with the sister in the
Emergency room.
26.6 Ambulance Vehicle:

1. The Hospital has a fleet of Basic Life
support ambulance which is fully
equipped to support patient in need of
advance life support. The Ambulance
fleet consist of :
2. Basic Life support Ambulance: one
3. Facilities are available for quick access
of the ambulances, adequate and
marked space for ambulance parking.
4. Ambulance is manned by trained
personnel
5. Ambulance checklist
6. Ambulance equipments and emergency
medications are checked daily.
7. Stable patient could be transferred in
hospital’s patient transfer vehicle and
unstable patients should be transferred
in advanced Life Support ambulance.

490
26.7 . Flow Chart.
Receive Call
Address and Details Recorded
Inform Emergency
CMO Coordinates with the Ambulance In-Charge
AMBULANCE
BLS
DRIVE N.S.
Reach the Hospital
In Patient Ward / ICU Outpatient
Movement Book Record

491
26.8 . Operating Procedure: 26.9 Ambulances Services For Transfer Out Of
1. Ambulance Service for escorting the Patients: The hospital's Ambulance
patient to CNBC: Service is also available for transferring
2. Call is received in the Help line Number outpatient from the hospital.
which is " ".
3. The concerned person in the control 26.10 The ambulance services in-charge makes
Room records the address, the the necessary arrangement in condition
condition of the patient etc which is with clinical team under whom the patient
documented in the incoming call register admitted. Depending on the patient's
maintained by the Ambulance service medical condition the appropriate
department. Ambulance type and trained staff to
4. On the basic of the Condition of the accompany the patient is chosen to
patient the Emergency Medical officer facilitate the transfer of the patient.
coordinates the team and devises kind
of Ambulance and the team to be
dispatched. In case of serious patient
26.11 Policy when CNBC does not own the
the resident doctor and nursing staff ambulance and use CATS Ambulance as
accompanies the ambulance crew in the per Government orders-
advanced Life Support ambulance.
5. The Ambulance has a proper The procurement of our own Ambulance is
communication system by means of under process. So till then as per order of
CUG mobile and landline phone Director ,CNBC ,and Government orders we
connection (Hospital transport vehicle are using CATS ambulance. All the wards,
Extension no- 112, CUG no- ICU, emergency department and whoever
9643308268 and advanced Life Support
needs any ambulance for any purpose like
ambulance CATS contact no-102).
Control room keeps regular contact with shifting a patient for any investigation or
the Ambulance crew through mobile discharging will call CATS number. They will
phones to keep an update of the maintain a CATS ambulance movement
progress. register. They will check oxygen ,suction and
6. Once reaching the site, a consent is other needed equipment of CATS ambulance
taken form the patient representative for before shifting the patient and replace the
the transport of the patient. The crew
required things from emergency. Every place
assists in transferring the patient to the
ambulance after providing the will maintain emergency box/tray containing
necessary initial medical attention the Ambu bag, endotracheal tubes and
patent is secured in the ambulance and emergency drugs like adrenaline, Atropine
transported to the hospital. Throughout and other required drugs .They will
the process the ambulance crew keeps document the checked items in the
in contact with the Ambulance control movement register
Room and updates about the status of
the patient.
7. The Ambulance Crew coordinates with
the Emergency Department staff for the
smooth transfer of the patient to the ED
bed.

492
27 Private Ward
Date created: November 2010
Responsibility of updating: Department of Pediatric Medicine
Last reviewed / updated on: August, 2020
Version (CNBC/ Private Ward/27/ver1.1)

493
CURRENTLY THIS SERVICE IS NOT AVAILABLE IN CHACHA
NEHRU BAL CHIKITSALAYA.

494
27 Private Ward ................................................................................................................................................ 493
27.1 Amendment Sheet ............................................................................................................................... 496
27.2 Hierarchy of the Private Ward .............................................................................................................. 497
27.3 Manual on private ward........................................................................................................................ 498

495
Sl. No. Clause No. Amendment made Reasons of amendment Sign of QM
1 27.3 Billing policy created To clear public confusion
2 27.3 Billing policy revised To make process more clear in

case of siblings admitted
3 27.5 DoR policy created Absent in the manual

496
27.2 Hierarchy of the Private Ward
HOD (Pediatric Medicine)
Senior Resident
Nursing Sister
Staff Nurse
Nursing Orderly

497
27.3 Manual on private ward 13. In a situation where the family wishes to keep twins in
a single bed, they are to be advised not to do so as
27.3.1 Admission Policy there are chances of cross infection. Even if the family
1. Admissions are done directly from OPD or does so, billing shall be done for each patient
wards (Transfer/Admissions). separately.
2. Before admission patient’s attendants are 14. Attendants will deposit Rs.5ooo/-at the time of
informed an estimated budget and about the admission in account office during 9am to 4 pm-
charges that the hospital is going to make Mondays-Fridays & 9am-1pm on Saturdays. Rest of
during the stay. the time any billing amount to be collected by the
3. Admissions are done between 8 am and 4 pm Nursing sister/Staff nurse on duty and the attendants
on working days (Monday to Saturday) are asked to get account cleared during working
routinely. Any patient to be received other than hours from account office and obtain a receipt.
the above mentioned time permission to be 15. On completing 5 days of hospitalization the attendants
obtained from CMO/HOD Pediatric. are advised to deposit Rs.5000/-./each patient.
4. Charges are made as per the CGHS norms. 16. Billing is made on anything other than doctor’s
These sheets are available with the admission consultation and nursing care.
counter as well as the private ward. 17. Approximate expenditure/day is considered as
Rs.1000/-This may vary according to the type of
27.3.2 Billing Policy: investigation and procedures are carried out.
1. Billing will be done from the very first day of 18. Final calculation &billing will be done on separation
admission in the hospital irrespective of which (Transfer out to outside hospital/discharge/death.)
ever day patient started accommodating private 19. Any surplus money will be given back to the
ward. attendants or they are asked to pay in case of due.
2. In case, any sibling/siblings admitted in CNBC, 20. Food, as per doctor’s order will be provided to the
irrespective of which patient care unit he/she is patient only.
occupying, billing will be done as per the 21. One attendant/family may be allowed for normal
private ward norms from the day of hospital vegetarian diet from hospital kitchen on payment basis
admission for the sibling too. if they wish so. Changes in the charges may be
3. Full charge for the bed will be made by private featured time to time.
ward, if the bed is occupied by any attendants 22. Request for meal shall be placed one meal prior.
while patient is kept in some other ward/ICU for 23. Payment for diet is applicable for those mothers for
treatment purpose. whom the patient’s treating doctor has advised for
4. Rest of the bill charge will be intimated to hospital diet also.
private ward by the ward where ever the patient
was kept for treatment during above mentioned Meal cost description
period. The amount must be shown in detail, Full day meal Rs.175.00 Breakfast, Lunch, Dinner and tea
category wise (itemized bill). snacks (only in the evening)
5. All the drugs & consumables will be provided to Break Fast Rs.50.00 Single
the patient by private ward. Lunch Rs.50.00 Single
6. Billing is done on daily basis including drugs & Dinner Rs.50.00 Single
consumables in order to reduce extra burden Tea & Snacks Rs.25.00 only in the evening
on the day of separation.
7. In case sibling/siblings is/are admitted, each
8. Patient shall be billed separately. Advance 27.3.3 Discharges:
amount on admission also to be deposited 1. Discharges are made by 12 Noon (billing
Separately for each patient. calculation time)
9. Two patients will be sharing one room. 2. Photocopy of the discharge slip & bill is
10. One bed is allotted to the family in private ward attached to the file of the patient.
11. if patient/patients are kept elsewhere in
the hospital, but billing is done as per the 27.3.4 In case of DoR (Discharge on Request) or
number of patient/patients; not as per the LAMA.
bed allotted.
Hospital Policy on DoR shall be followed. (Policy on
12. However more beds are allotted to the ily
sibling/siblings are in the ward, according to the patient leaving on request- 2.11)
number of patients.

498
28 HOSPITAL WIDE POLICIES
Compiled by Quality Management Division
Last reviewed / updated on: August 2020
Version (CNBC/ HWP/28/ ver1.4)
499
28 HOSPITAL WIDE POLICIES ......................................................................... 499
28.1 Amendment sheet ............................................................................................................. 502
28.2 Citizen Charter ................................................................................................................. 505
28.3 Incident reporting ............................................................................................................. 509
28.4 Initial Assessment and Reassessment of Patients ............................................................ 511
28.5 Informed Consent ............................................................................................................. 513
28.6 CPR .................................................................................................................................. 516
28.7 Protocol on Management of patients during non-availability of beds ............................. 518
28.8 Policy on smoking within the premises of the Hospital................................................... 519
28.9 Medication Policy ............................................................................................................ 520
28.10 Prescription of Medication ............................................................................................... 521
28.11 Uniform Care Policy ........................................................................................................ 523
28.12 Policy: Blood transfusion ................................................................................................. 524
28.13 Policy on Patients Are Monitored After Medication Administration .............................. 528
28.14 Policy on patients and family members are educated about safe medication and food drugs
interactions ..................................................................................................................................... 529
28.15 Safe Dispensing of Medicine or Medication Administration (Mom) .............................. 530
28.16 Policy on verbal orders for Medication: .......................................................................... 532
28.17 High Risk Medication ...................................................................................................... 533
28.18 Wrong Site Surgery .......................................................................................................... 535
28.19 Patient’s Rights and Responsibilities ............................................................................... 538
28.20 End of Life Care ............................................................................................................... 540
28.21 Near Miss, Medication Error and Adverse Drug Reaction .............................................. 541
28.22 Chemotherapy .................................................................................................................. 542
28.23 Vulnerable Patient ............................................................................................................ 544
28.24 Disaster Plan Index .......................................................................................................... 545
28.25 Narcotic drugs Policy. ...................................................................................................... 561
28.26 Restraint Policy ................................................................................................................ 563
28.27 Mortuary........................................................................................................................... 565
28.28 LASA Drugs .................................................................................................................... 566
28.29 Sentinel Event Policy ....................................................................................................... 574
28.30 CNBC Healthcare Human Resource Philosophy ............................................................. 576
MEDICAL RECORDS OFFICER JOB RESPONSIBILITIES:.................................................... 596
28.31 Employee Health Check-up Policy .................................................................................. 609
500
28.32 Management of Near Expiry and Expired Drugs ............................................................. 610
28.33 Grievance ......................................................................................................................... 611
28.34 Referral Policy ................................................................................................................. 614
28.35 Crash Cart ........................................................................................................................ 616
28.36 Employee ‘s Rights at CNBC .......................................................................................... 619
28.37 Sedation Policy ................................................................................................................ 620
28.38 Hazardous material policy ............................................................................................... 621
28.39 Material Safety Data Sheet (Msds) Policy ....................................................................... 623
28.40 Effective Communication Policy ..................................................................................... 624
28.41 Clinical Handover Policy ................................................................................................. 628
28.42 Document Control Policy: ............................................................................................... 629
28.43 Approved Abbreviations For Use In Medical Records Policy ........................................ 633
28.44 Safe Parenting Policy ....................................................................................................... 643
501
S.No. Clause No. Date of Amendment Made Reasons of Sign of

Amendment Amendments QM
1 28.17 Jan 2014 Situation where close monitoring is required As per the requirement
of NABH.
2 28.3.8 1st July 2014 Time Frame for incident reporting and RCA is To make the policy
defined: more clear and defined
3 28.21.10 1st July 2014 In case of ADRs reported with drug of same Previously it was not
batch number it is to be store incharge and drug defined
recall should be initiated.
4 28.21.11 1st July 2014 Any drug reaction must be reported to QMD as To make the policy
early as possible/within 24 hours of reaction more clear and defined
5 28.34 June 2014 Referral policy is incorporated Previously was not
documented
6 28.35 June 2014 Crash Cart policy is added Previously was not
documented
7 28.20 November Addition of motivation of patient’s guardian for To make the policy
2014 organ donation in the policy for care of end of life. more clear and defined.
8 28.26.10 February Restraint Policy---Assessment, Care, and To make the policy
2015 Monitoring Definitions: Monitor the patient more clear and defined
( 2hourly or earlier as per patient’s condition and
same to be documented in nurses notes
9 28.5.4.3 (I) February Editing in Informed consent policy--The informed Previously was not
2015 consent must be taken from patient’s relative/ documented
guardian in his/her understandable language and
to be signed in same language consent form
(Hindi/English)
10 28.4.4 (16) February Initial assessment shall include height and weight Previously was not
2015 11 in OPD and in emergency department, this shall documented
March 2015 include at least recording of vitals parameters in
triage room Heart rate for <2yrs age child.
Addition in Reassessment criteria for doctors.
11 28.5.4.8 February Addition of blood products like Albumin and IV To make policy more
2015 Immunoglobulin in Informed consent policy. clear and defined
12 28.5.4.3 (E) February Addition of Procedure for which the consent was To make policy more
2015 taken is also to be mentioned in informed consent clear and defined
13 28.5.4.4 February The detailed initial assessment by doctor shall be To make policy more
2015 performed and documented within 30 minutes of clear and defined
admission.
14 28.10.4 February Medication orders shall be revised daily, To make policy more
2015 Abbreviation shall be avoided, clear and defined
Orders like CT all, CST etc must be avoided.
The entry in medical record should be legible,
dated named, timed, signed and the author of
entry should be identified.
15 28.10.4 March 2015 On daily basis if no change in treatment order

then doctor should write in treatment sheet as
“No Change in Treatment” , Abbreviation shall be
avoided,
If any change is made in treatment orders (like
revision of IV fluids/Oxygen therapy/addition or
omission of any medication) then on that
particular day/shift detailed revise treatment
502
should be written by the doctors.
16 28.25 February Replenishment--- Disposal of narcotic drugs To update the policy

2016
17 28.37 February Addition of Sedation policy Previously not
2016 mentioned.
18 28.2 February Citizen Charter updated. To make policy more
2016 clear and defined
19 28.10 February Prescription Policy---Addition- To make policy more
2016 The prescription shall have the name of the clear and defined
patient; unique hospital number; name of the
drug, dose, route and frequency of administration
of the medicine; name, signature and registration
number of the prescribing doctor.
All hand written prescriptions shall be written in
capital letters at least antibiotics.
20 28.17 February Policy on verbal orders for Medication-Time Previously it was not
2016 frame of authorization is mentioned ie, within mentioned.
24hours
21 28.15.18 February Timing of administration of medications is defined To make policy more
2016 in the policy of Safe Dispensing of Medicine clear and defined
22 28.21.11 February Policy for Near Miss, Medication Error and Previously it was not
2016 Adverse Drug Reaction- addition of Medications mentioned
are changed by doctor. When Adverse Drug
Reaction is seen in patient
23 28.21.12 February Near Miss, Medication Error and Adverse Drug Previously it was not
and 2016 Reaction (Timeframe for reporting and analyses mentioned
28.21.13 is defined)
24 28.38 Dec 2016 Hazardous Material Policy Previously it was not
mentioned
25 28.39 Dec 2016 Material Safety Data Sheet Previously it was not
mentioned
26 28.40 Dec 2016 Effective Communication Policy Previously it was not
mentioned
27 28.40 Feb 2017 Addition of situations where effective To make policy more
communication is needed clear.
28 28.6 Nov 2017 Updating of CPR policy To make more clear.
29 28.4.1 Feb 2018 Addition of Defined physiological parameters to To make policy more
identify clinical condition deterioration of pediatric clear and defined
patent including Pediatric Warning Signs
30 28.50 Feb 2018 Addition of Policy on clinical handover among As per the requirement
doctor and nurses of NABH standard
(AAC 12 d).
31 28.16 Revised Verbal Order Policy To make policy more
Feb 2018 clear and defined
28.17 Feb 2018 Addition of List of High-risk medication Previous list was
32 revised
33 28.40 March 2018 Addition of specific tests for employees working Previously it was not
in special areas. mentioned.
503
34 28.52 March 2018 Addition of Use of approved abbreviations Previously it was not
including updated list of abbreviations. mentioned
35 28.51 March 2018 Document control policy Previously it was not
mentioned
28.28 JUNE 2018 Opd Services; Registration timing ,special clinic To update the policy
36
28.2.10 JUNE 2018 Public Guidance and Grievance Redressal To update the policy
37 facilities
28.2.11 JUNE 2018 Medical officers /Branch in charges To update the policy
38
39 28.2.8 June 2018 Special clinics To update the policy
40 28.44 Dec 18 Addition of un acceptable behavior in effective No make policy more
communication clear.
41 28.16 Dec -18 Verbal order policy detailed. List of drugs for To update the policy
verbal order added.
42 28.5.4.1 Dec 19 Addition of HIV testing in list of situations where Previously it was not
informed consent is required. mentioned
43 28.9.1 Dec 19 Addition of Physicians is authorized to use only Previously it was not
those drugs listed in the hospital Formulary in mentioned
medication policy.
44 28.33.1 Dec 19 Revised policy of management of near expiry To update the policy
drugs.
45 28.30.2 Dec 19 Addition of job responsibility of Operation theater Previously it was not
and intensive care nursing officer. mentioned
46 28.25 Dec 19 Addition of usage and discard of narcotic drugs in Previously it was not
narcotic policy. mentioned
47 28.30.40..6 Jan 2020 Dress code of employees Previously it was not
mentioned
48 28.32.3 August 2020 List of sentinel events added Previously not
mentioned.
49 28.28 August 2020 End of life care To update the policy
50 28.30 August 2020 Employee Health Checkup policy No make policy more
clear.
51 28.25 August 2020 Availability of narcotics in the different To update the policy
departments
52 28.2 August 2020 Updated Citizen charter As per the need of
change in OPD rooms
consultation.
53 28.34 August 2020 Grievance redress policy Change in Grievance
redress policy
54 28.7.1.6 & August 2020 Non Availability of bed policy updated for patient Previously not
7 temporary holding. mentioned.
55 28.25 August 2020 Disaster plan updated No make policy more

clear
56 28.28 August 2020 Updating of list of LASA As per updating
57 28.15.22 August 2020 Inclusion of New

Addition of precautions to avoid misconnection of
objective element MOM
tubing, Safe Dispensing of Medicine or th
7(h) { NABH 5 edition}
Medication Administration (Mom)
504
Policy No:- (CNBC/HWP/ CC/ 02)
Released on:I st May 2008
Reviewed By Dr. Mamta Jajoo and Dr. Aikta and Nursing Officer Ganga (QMD)
28.2 Citizen Charter
28.2.1 Vision: To be recognized as leader in quality, patient-centered, cost effective healthcare working towards
Healthy child Wealthy future.
28.2.2 Mission: To provide Pediatric Super- specialty services using state of art Technology Committed to improve
health and satisfaction level of our patients by ensuring continuous improvement by:
1. Training of all categories of staff
2. Latest treatment technologies
3. To provide Teaching and Research facility in pediatric sub specialties.
4. To develop as a leading pediatric referral centre.
28.2.3 Services available at CNBC:

1. OPD Services and Special Clinics
2. Out 221 authorized bedded 210 were functional indoor and medical Emergency Services
3. ICU and Neonatal Intensive care
4. Routine Surgeries in Pediatric Surgery, ENT, Orthopedics, Eye & limited
5. Emergency Surgical Services, till 4 p.m.
6. Support Services
7. CT &Ultrasound, 9.00am to 4 p.m.
8. X- Ray, round the clock
9. Laboratory services, round the clock
10. EEG and BERA services functional
11. G.I. Video-endoscopy
12. Bronchoscopy
13. Hemodialysis
14. Cystoscopy
15. Laparoscopy
16. Speech Therapy
17. Child Development Centre and Physiotherapy/ Occupational Therapy
18. Hospital Website is available at address www.cnbc.delhigovt.nic.in
19. DNB (Paediatric) Course
20. DNB (Paediatric Surgery) Course
21. Video Surveillance (CCTV) System in Place
22. Nominated as one on the Sentinel Surveillance Hospital for treatment of Dengue
23. Library with Internet Facility
28.2.4 Services Not Available at CNBC:

1. Poly Trauma
2. Cardiac Surgery
3. Neuro Surgery
4. Burns & Plastics Reconstructive Surgery
28.2.5 24 hr services
1. Medical Emergency
2. Ambulance (BLS equipped)
3. Ambulance (ACLS equipped) stationed by CATS which can be used for our Hospital purposes also.
28.2.6 General Information:
505
28.2.6.1 How to contact:
Telephone No. Email Website
011-21210216 /21210215 cnbc2003@yahoo.co.in www.cnbc.delhigovt.nic.in
28.2.6.2 Location :Geeta Colony, Delhi – 110031
28.2.6.3 Bus Route No. : 317, 310 and RTV from Laxmi Nagar, Nearest Metro Station - Shastri Park
Police Station : Geeta Colony, Delhi – 110031 , Ph. No. 011-22506665
Building is under Camera Surveillance
28.2.7 Services available in CNBC :

1. OPD Services :Registration timing :
Monday to Friday: 8.00 a.m. to 11.30 am
Saturday : 8.30 a.m. to 11. a.m
OPD Timing: Monday to Saturday: 9.00 a.m. to 1.00 p.m.
2. Sample collection: Monday to Friday: 08:30 a.m. to 11.30 a.m.

Saturday 08.30 a.m. to 10.30 a.m.
SR. NO. OPD SERVICES ROOM NO.

1. Pediatric Medicine 28,20,
21,129
2. Pediatric Surgery 132, 136
3. Immunization 23
4. Skin 150
5. Eye 130, 131
6. ENT 134
7. Orthopedics 39
8. Dentistry 133
9. PAC 135B
10. Lab. sample collection : General 41
Special 145
11. Drug Distribution (Pharmacy) 60
12. Physiotherapy/Occupational Therapy 58
13. Dietician 135 A
15 ICTC 25
16 Speech therapy 140
17 Child development Centre (Aadi) 129
18. EEG / BERA 141
19. G.I. Endoscopy 417
20. Dressing Room 151
22. ECG 141
23. Blood Storage facility 168
25. EEG (with prior appointment) 141
26. Plaster 38
27. Clinical Psychologist 59
3. Special Clinics :
Registration Timing : 01.45 p.m. to 02.30 p.m.
Clinic Timing : 02.00 p.m. to 04.00 p.m.
DAY CLINIC ROOM NO

506
Monday Nephrology 20
Tuesday High Risk Clinic 129
Tuesday Gastroenterology clinic 20
Wednesday Vitiligo 150
Friday Neurology 129
Friday Development Clinic 129
Friday Safe Parenting Clinic 135 B
Friday Chest clinic 20
Friday Hemangioma 150
Friday Endocrinology 21
4. Casualty Services:
Round the clock Pediatric Medical and Surgical Casualty services are available.
Nursing Station Pediatric Casualty 24 hr. Radiology Services Emergency laboratory
Ph. No.21210216 R.No.45 R.No.37 Room No. 41
5. Surgical Facility: (Operation Days)

Day Specialty
Monday Ophthalmology / Pediatric surgery/ Day Care
Tuesday Orthopedics/ Pediatric surgery
Wednesday ENT/ Day Care/ Pediatric surgery
Thursday Pediatric surgery
Friday Orthopedics/Pediatric surgery
Saturday Emergency Case /Pediatric surgery
Dental procedures with prior appointment from Monday-Friday: 02.00 to 04.00 pm
Emergency surgery facility is presently available on working days during working hours
6. Indoor Facilities:
1. In-patient area is completely air conditioned
2. Pediatric ICU and Neonatal ICU with state of art equipments available
3. Pvt. Ward available
7. Radiology Facilities:
Services Dental X- X-Ray USG CT Scan Emergency X-Ray Special Investigation
Ray
Room No. 1st floor Registration – 1 33 57 37 37
Reporting - 33
Dialysis Facilities: (with prior appointment) Room No. 53
28.2.8 User Charges:

User charges details at CNBC are as follows
1. Ultrasound charges for OPD patients is Rs.50/- and free of cost for in - patients.
2. CT Scan
Charges in Rs.
Scan region Plain Contrast
Brain 750 1100
PNS/orbit 750 1100
Neck/Pharynx/Larynx/Thyroid 750 1100
Chest 1000 1600
Abdomen –Upper 1000 1600
Abdomen-Lower 1000 1600
Abdomen –Whole 2000 2500
Chest +complete Abdomen 2500 3000
507
Spine -3 veretebral level(one Region) 1000 2000(only non-ionic
contrast)
Spine (one- Region) 1500 2500

CT guided Biopsy 2000 -
Whole body - 4000
1. The facility of scanning is free of cost shall, however be rendered to all those injured in road accidents or
medico-legal cases. In addition, the Director, CNBC is authorised to offer these facilities free of cost to
15% of the patients who are really poor and in need of this facility.
a. All other services including available drugs and diet are free as on date except private ward.
2. Private ward-as per CGHS rate.
28.2.9 Public Guidance And Grievance Redressal Facilities:

Medical Officer In-charge Dr T.S Daral Extension21210216/128
( Public grievances)
Head of Office Dr. Mamta Jajoo Extension 21210214/355
Director Dr B.L Sherwal 21210201/316
28.2.10 Medical Officers / Branch In-charges

Service Officer In charge Intercom
HOD Ped. Med Dr. Saikia 120
OPD Dr. Saikia 210
Emergency Dr. Ravinderpal singh Dingra 144/120
Pharmacy Dr. Manish Kumar 236
Store Dr. Manoj Kumar 318
Purchase Dr. R.P.S Dhingra 331/214
Sanitation Dr. Neeraj Gupta 243
Security Dr. Anil Agarwal 203
Bio Medical Waste Mgt. Dr. Kirtisudha 124
Pest Control Dr. Neeraj Gupta 243
Nursing I/c A.N.S. 308
Food quality Asst. Dietician 238
Office Establishment O.S. 330
Accounts Mr . Tara Singh (AO) 329
Civil works/ Water JE Civil( PWD) 115
Electrical works/ JE Electrical (PWD) 114
Air-Conditioning
28.2.11 Visiting Time:

1. Morning : 07.00 to 07.30 A.M. (For Tea & Breakfast)
2. After Noon: : 12.30 to 01.30 P.M. (For Lunch)
3. Evening : 05.00 to 07.00 P.M. (Dinner & Visiting Hours)
28.2.12 Expectations from Patients: Smoking, Tobacco chewing and consumption of alcoholic beverages are not
allowed inside the hospital premises.
1. Help keeping hospital and surroundings clean, cooperate with hospital staff.
2. Wait patiently for your turn.
3. Beware of touts.
4. Maintain Silence
508
Policy No:- CNBC/HWP/IR/03
Reviewed By QMD
28.3 Incident reporting
28.3.2 Distribution list: All departments
28.3.3 Purpose: To document, trend & group all occurrences / incidents in the hospital and to ensure timely
implementation of recommendations arising out of the analysis of all such incidents.
28.3.4 Practice
1. All occurrences as described below shall be documented and directed to any of the following
2. Quality Management Division
3. Medical Superintendent
4. All clinical incidents /non-clinical incidents will be reviewed in the QAC meeting.
28.3.5 Definitions
Occurrence: An occurrence is any happening, which is not consistent with the routine operation of the hospital or
the routine care of a particular patient.
28.3.6 Procedure
A. Immediate Procedure
i. Patient Occurrence:
a. The attending Physician will be notified of the occurrence in a timely manner. If he/she cannot be
reached, the medical officer on duty will provide medical care on a priority basis if indicated.
b. Reassurance, information and comfort will be provided to the individual(s) involved in the occurrence who
are experiencing discomfort or distress.
c. If the occurrence is a medication error, the treating physician will be informed immediately , action will be
taken as per
d. the physicians orders and the patient will be continuously monitored till needed.
ii. Non-Patient Occurrences:
If the incident has occurred to an employee or a visitor, the Emergency Room MO on duty will provide care on a
priority basis if indicated.
iii. An Occurrence Report will be completed in the hospital incident report form available in all departments. This will
be done within the shift that the occurrence happened or was first discovered.
B. Follow-Up Procedure
i. The Department In charge or Supervisor will investigate the occurrence while the facts are fresh to determine
causative factors and recommendations for future prevention. Staff counseling will be provided as appropriate.
ii. The investigating team will review the occurrence and investigate further as necessary.
28.3.7 Documentation
a. Incident reporting Form
i. Enter demographic information into appropriate sections and designate if patient, visitor or employee.
509
ii. Describe occurrence clearly (who, what, when and where).
iii. Indicate Notification of Physician with date and time and any comments.
iv. Discovering person should sign the report.
b. For Patient Occurrences
i. Position of side rails and beds when applicable.
ii. Foreign objects or hazardous conditions involved (i.e., water, urine on the floor, etc).
iii. Staff and patient's account of the incident.
iv. Date/time the Physician was notified. Also, indicate if and when patient was seen by the Physician.
v. Patient's vital signs.
vi. Detailed description of nature, location and extent of any injury. Use descriptive words and exact measurements
to enable future determination of pre-existing or subsequent tissue damage.
28.3.8 Time Frame:-

1. Incident reporting must be done within 24 hours of occurrence.
2. Root Cause Analysis (RCA) of incidences should be done within 72 hours of reporting.
510
Policy No:- CNBC/HWP/A&R/04
Reviewed By QMD
4. The detailed initial assessment by doctor shall be
performed and documented within 30 minutes of
28.4 Initial Assessment and Reassessment of admission.
Patients 5. Plan of care and desired outcome/Goal shall be
documented by the doctor on the basis of initial
28.4.1 Policy assessment and counter signed by consultant
within 24 hours.
28.4.2 Purpose: 6. The plan of care shall include preventive, curative
& rehabilitative aspects.
28.4.2.1 To assure care provided to each patient is 7. The nutritional and functional assessments shall
based on an assessment of the patient's be completed within 24 hours of admission of the
relevant physical, psychological, and social patient.
status needs. 8. Continued reassessments shall be documented
throughout in the patient’s medical record.
28.4.2.2 Each patient upon admission shall be
9. Reassessment of the patient shall be performed
assessed by qualified individuals for
at regular intervals in the course of care by
appropriate care or treatment needs / need
medical and nursing staff.
for further assessment. The physical and
10. Reassessments shall be performed to determine
psychological status of each inpatient shall
a patient’s response to care/treatment.
be assessed.
11. Reassessment shall take place when there is a
28.4.3 The scope and intensity of the assessment significant change in a patient’s condition or a
shall be determined by: change in diagnosis.
1. The patient's condition/diagnosis 12. Nursing staff shall reassess patients at least once
2. The care setting in every shift (8 hour shift) or frequent as per
3. The patient's response to any previous patient’s condition.
care and the patient’s consent to 13. Reassessment by Doctors:- Reassessment shall
treatment. be done and documented 24hrly for all stable
4. The patient shall be assessed and the patients or frequent as per patient’s condition and
records shall be documented as 4hrly for all critical patients or frequent as per
appropriate to the patient’s age and patient’s condition. More frequent reassessments
needs. shall be done by both nurses and doctors as per
the clinical condition of the patient.
28.4.4 Frequency of assessment: 14. All patients should be assessed (initial
1. Initial Assessment for casualty/ emergency assessment) and reassessed for the pain and risk
patients shall be done by a duly registered and for fall and risk for developing pressure ulcers and
credentialed doctor within 15 minutes in deep vein thrombosis.
emergency department (after initial assessment 15. The plan of care shall be reviewed regularly in
by nursing staff) and documented in patient consultation with or from written information
emergency card provided by other members of the health care
2. The initial assessment by nurses shall be team and discussed with the patient/family. The
performed within 10 minutes of arrival of patient in plan of care will be revised as appropriate to the
emergency department/ Casualty (Triage) and patient’s condition and shall be explained to the
documented in patient’s emergency card. patient and/or family members in a language that
3. The detailed initial assessment by nurse shall be they can understand and ongoing assessment
performed and documented within 30 minutes of process.
admission/ transfer in of patient in all patient care 16. Initial assessment shall include height, weight and
units. vital signs (TPR) in OPD and in Emergency
department; this shall include at least recording of
vitals parameters (Temperature, Pulse, and
Respiration).
511
17. Detail psychosocial assessment of patients with 5. POISONING (HISTORY OF)
Down syndrome, Mental Retardation, 6. PAIN (SEVERE)
Developmental delay, Attention deficit 7. RESPIRATORY DISTRESS
hyperactivitity disorders, autism and learning 8. RESTLESS, CONTINUOUSLY IRRITABLE, OR
disability shall be done by clinical psychologist. LETHARGIC
9. REFERRAL (URGENT)
28.4.5 Defined physiological parameters to identify 10. MALNUTRITION: VISIBLE SEVERE WASTING
clinical condition deterioration of pediatric 11. OEDEMA OF BOTH FEET OR FACE
patent:- 12. BURNS (MAJOR)
28.4.5.1 PEADIATRIC EARLY WARNING SIGN:- 28.4.6 Responsibility Matrix - Initial Assessment of
1) This is a process to allow any staff or family the patient
member to get immediate evaluation of a A. Initial assessment –Doctor, Nurse,
patient. Dietician.and Clinical Psychologist
2) Warning signs must be reported to the doctor 1. At Admission –
on duty for immediate intervention. a) Medical
PEADIATRIC EARLY WARNING b) Nursing
SIGNS c) Nutritional
These children need prompt assessment and treatment d) Psychosocial
EMERGENCY S IG NS :
1. LETHARGIC/UNCONSCIOUS 28.4.7 Qualified professionals performing
2. CENTRAL CYANOSIS assessment will be registered as applicable
O
3. HYPOTHERMIA(<34 Celsius)/HYPERTHERMIA under the law of the land:
O
(>34 Celsius) a) Professional Basic Qualification
4. SEVERE RESPIRATORY DISTRESS Registration
5. CAPILLARY REFILL LONGER THAN 3 b) Medical M.B.B.S Registered with
SECONDS the Centre / State Medical
6. WEAK AND FAST PULSE Council
7. HEART RATE >160/Minute c) Nursing Diploma / Degree in
8. RESPIRATORY RATE >60/Minute with SCR Nursing Registered with the
9. CONVULSIONS Centre / State
10. SUNKEN EYES d) Nursing Council
11. SLOWING OF SKIN PINCH e) Physiotherapist Bachelor’s
PRIORITY SIGNS Degree in Physiotherapy
1. TINY INFANT (< 2 MONTHS) f) M.Phil. in Clinical Psychology
2. TEMPERATURE VERY HIGH
3. TRAUMA OR OTHER URGENT SURGICAL
CONDITION
4. PALLOR (SEVERE)
512
Policy No:- CNBC/HWP/IC/05
Reviewed By QMD
28.5 Informed Consent
28.5.1 Purpose: To assure that patient and family participate in his / her healthcare decisions
28.5.2 Definitions
28.5.3 Voluntary Informed Consent: - A patient’s consent is informed: When the patient has
been given sufficient information so that he / she understands the nature of his / her
condition, the nature and purpose of the proposed treatment, the risks and consequences
of the procedure or treatment, the feasible alternative procedure or treatment and the
prognosis if the procedure is not performed nor any treatment given
2. General Consent - When the nature and probable risks of the procedure or treatment are of
such a common and ordinary nature so as to be within the patient’s understanding and
knowledge (e.g. injections, etc.)
3. Implied Consent in a Medical Emergency - Consent in emergencies may be implied if the

condition of the patient precludes his/her ability to make a decision regarding treatment or
procedures. A medical emergency is a situation where delay for the purposes of obtaining
consent may reasonably be anticipated as endangering the life of the patient or significantly
increasing the harm to the patient’s health.
4. Surrogate Decision Maker - The priority order of surrogate decision makers is: spouse, adult
children, parents, adult brothers or sisters, adult grandchildren, significant other (close friend).
5. A close friend may sign the consent form only in an emergency.
28.5.4 Policy guidelines
28.5.4.1 General Guidelines

Written “informed consent” using the relevant Consent Form shall be obtained and list of
situations where informed consent is required for:
1. Admission in hospital.
2. All surgical procedures performed in the Operation Theatres.
3. Induction of Anesthesia.
4. Admission in private ward.
5. Admission in both ICUs.
6. High Risk Patients. (In ICUs and Wards)
7. Blood transfusion
8. Transfusion of blood products like Albumin and IV Immunoglobulin Minor OT Procedures
e.g. Incision & drainage of abscess.
9. Chemotherapy.
10. Non-routine diagnostic or therapeutic procedure performed in hospital e.g.
513
11. Intravenous Pyelography.
12. Bone Marrow Aspiration.
13. Lumbar Puncture.
14. Endoscopy
15. Intracranial drainage tube insertion.
16. USG guided procedure e.g. Pigtail catheter insertion.
17. Computerized Tomography Scan.
18. Liver biopsy etc.
19. HIV Testing
28.5.4.2 Non-routine diagnostic or therapeutic procedures performed in the hospital, and not
having a specific consent form. Example: Any procedure under any form of anesthesia,
Blood transfusion etc
28.5.4.3 Specific Guidelines

A. The primary treating Consultant shall discuss in lay terms the procedure, its risks, benefits
and alternatives with the patient attendants or the patient’s surrogate decision maker. The
Consultant shall document the discussion by obtaining the patient’s or his surrogate decision
maker’s written informed consent on the appropriate form.
B. The patient shall sign the consent form. A surrogate decision maker may sign the consent
on behalf of the patient if:
1. The patient is a minor (less than 18 years of age)

2. The patient desires the surrogate to sign on his/her behalf.
3. The patient is mentally incapable of making an informed consent.
4. The patient is mentally incapacitated
5. The patient is unconscious
6. The patient has received sedation within 3 hours
7. The patient is physically incapable of signing the form
A. The order of preference of surrogate shall be as per the definition of “surrogate decision
maker” but may be modified as per the patient wishes or availability of the surrogate.
B. In a life-threatening emergency where the patient is unconscious or unaccompanied,

consent shall be implied; therefore the patient’s signature is not required. In such
Situations, the Consultant shall document in the patient’s medical record both the nature of the
emergency and the inability of the patient or surrogate decision maker to consent.
C. It is the responsibility of the person obtaining the consent to ensure that the consent form
shall be properly filled prior to signing. Procedure for which the consent was taken is also to
be mentioned.
D. All entries shall be in ink.
E. Any available adult who shall be identified on the form by title or relationship to the patient
shall be witness to the patient’s signature or the signature of the surrogate decision maker.
The date and time of signing shall be clearly indicated.
H. The consent form must be signed by the Consultant (Any team member), Anesthesiologist,
patient or his decision maker and the witness prior to entry into the surgical or delivery suite
and before any pre-medication and at least three hours after the administration of sedatives.
G. The informed consent must be taken from patient’s relative/ guardian in his/her understandable
language and to be signed in same language consent form (Hindi/English version)
H. The consent form shall be valid for thirty (30) days from the date of signature by the patient or
his surrogate decision maker.
514
I. If the Consultant (Any team member) or the anesthetist’s signature is not on the consent form,
the procedure shall be postponed or cancelled.
J. The decision regarding the patient’s ability to make an informed consent shall be the
responsibility of the Consultant.
K. A patient or the surrogate decision maker may revoke the consent for the procedure at any
time before it is carried out. In such an event, the Consultant shall discuss the procedure again
and if the patient or the decision maker still wishes to revoke the consent, then the procedure
shall not be carried out. The patient or decision maker shall sign a note to the effect on the
signed consent form. The Consultant shall document this in the progress notes.
28.5.5 Associated documents:
28.5.5.1 General informed consent on admission
28.5.5.2 Informed consent for anesthesia and surgery
28.5.5.3 Authorization for medical and / or surgical treatment and / or procedure
28.5.5.4 Informed Consent for admission and Treatment in NICU and PICU
515
Chacha NehruBalChikitsalaya, Delhi
Policy No:- CNBC/HWP/CPR/06
Prepared By Dr. Sapna Bathla—
Reviewed by Dr Aikta Gupta
b. E.T Tube – 1 each size
c. Syringe – 2ml, 5ml, 10ml
28.6 CPR d. Needles
e. Face mask – 1 of each size
28.6.1 Purpose: To establish criteria for f. Ambu Bag
management of a patient who has g. Drugs
cardiac arrest or respiratory arrest. 16. Set up IV line; use IV cannula of 18 or 16
gauge if none is in place.
28.6.2 Team: 17. Prepare emergency drugs – as required.
1. Senior Resident / Junior Resident of ICU 18. Doctor – on hearing CODE BLUE
2. ICU Paramedical Staff on duty announcement, doctor in the hospital area will
3. Doctor of floor on duty proceed to the site immediately.
4. Staff on duty. 19. First doctor in that area will assess the patient’s
condition and function as team leader until the
28.6.3 Procedure: arrival of the Senior Resident of code Blue
1. Doctor on duty / Staff nurse 1 who finds patient in Team who will then take over as team leader.
collapsed state:- 20. Doctor will do/request intubation if patient is not
2. In ward, call for “Help”. Do not leave patient, inform breathing and decide to defibrillate if necessary
another nurse to initiate CODE BLUE. with help of paramedical staff of ICU.
3. Check vital signs. 21. Drugs to be started as situation demands.
4. If the patient has vomited, put him in left/right lateral
22. Nurse to prepare and administer drugs.
position and apply suction to clear the airway. 23. Continue CPR until patient’s condition stabilizes
5. Maintain the airway – tilt head back, put in an and then shift to ICU.
airway. If patient 24. If the patient has not responded at all after 30
is an RTA case, take care of the neck using jaw minutes of vigorous efforts, the team leader will
thrust technique to open the airway. review the situation and if the situation so warrants,
6. Assess for breathing, pulse – if no breath sounds will take the decision to stop CPR.
are heard or give 2 rescue breaths. 25. Sister Incharge of that floor will Controls the Crowd,
7. Assess for circulation (Pulse) – if two pulse, start Get assistants as required.
CPR. 26. Arrange for stand by team
8. Staff nurse 2 calls (dial-) “CODE BLUE”. a. Radiology tech
9. Nurse will announce CODE BLUE thrice-stating b. Laboratory tech
Patient Name, Floor, Patient unit & bed number on c. Security
intercom no, 135. d. House keeping
10. Nurse informs Code Blue Team. 27. Senior Resident of code Blue
11. Nurse 2 to push Emergency (crash) cart to Team will record the events
patient’s bedside. along with time.
12.
13. Connect to cardiac monitor – note BP, pulse, 28. In the event of death of patient –
and oxygen saturation. If cardiac monitor is not cause of death is to be
available, the paddles of the DC defibrillator will determined by Consultant in
be used for a quick assessment of the ECG change of patient. An ECG
status to rule out the presence of VT/VF. recording will be taken to confirm
14. Nurse 1 will start Ambu bagging and nurse 2 the straight line of asystole and a
initiates cardiac massage. print out of the same will be taken
15. Paramedical Staff will get CPR kit consist of for the records.
following items-
a. Laryngoscope – 2 pairs
516
29. All Code Blue situations will be 28.6.4 Corrective and preventive measures
evaluated by a multidisciplinary will be implemented, if indicated, after
Code Blue committee the above analysis.
30. Consisting of the following after
the event is over:- 28.6.5 Code Blue policy applies to all areas
a. Medical Superintendent except NICU, PICU & Operation
b. Anesthesiologist,HOD theatre and Emergency.
Pediatrics
c. NICU & PICU incharge
d. Sister in charge PICU
e. Pediatric surgeon
28.6.6 Daily Reporting Code Blue Sheet
Name of patient: Age / Sex: Floor / Place:
Unit of patient: CR.No :

Diagnosis
Vitals (Prior to code): GC-------------------, Pulse----------------------, R/R----------------
BD---------------, SPO2---------------, GCS---------------------, Bld Sugar-------------------
Other-------------------, Trauma: Yes/No
Organ system Dysfunction (Tick)
Neurological Cardiac Liver Resp Renal metabolic endocrine Haematologic
Intervention done (encircle)
No of rescuer-------------------
Child responsive / Unresponsive
Position of the patient – Supine, flat, hard surface / Recovery position
Aiway – Head tilt - Child lift / Jaw thrust
Breathing – Chest Rise– Yes / No , Breath sound– Yes / No, exhaled air flow- Yes / No
Rescuer Breaths – No.--------------, Chest rise – Yes/No, Oxygen Yes / No
Circulation: Coughing Yes / No, Movt. Y/N, Pulse:_______ Brachial / carotid /- femoral, Time
taken:_________
Chest compression : 2 thumb / 2 finger / one hand
Vascular Access :
Defibrillation – Given / Not given, Dose---------------, Times---------------
Renew /Completed By: Sign:
Name:
Date/Time:
28.6.7 Post Event Analysis form

No of rescuer –
Duration of activation of code Blue

Time to reach of code Blue team
Airway – No of attempts to open it
rescue Breath – No given
Chest Compression - Duration in starting compression
Thoracic Injury
Defibrillation – Time required to start Defibrillation
Equipment not functioning –
Given—Yes / No , Dose given ---------------, No of times given-------------------
Intubation – attempted /Not attempted
No of times required
Total duration of CPR--------------------------
Outcome of patient - Expired

Stabilized Shifted to PICU
517
Policy No:- CNBC/HWP/Non-Avail/07
Reviewed By QMD
28.7 Protocol on Management of patients during non-availability of beds
28.7.1 Policy:
28.7.1.1 All patients reaching the emergency department will be given first aid and all available
life saving measures to stabilize the patient.
28.7.1.2 Patients are then transferred to the respective in patient departments (wards) after
being seen and advised by the consultant.
28.7.1.3 Patients seen in outpatient departments by the consultant are advised admission based
on the clinical conditions.
28.7.1.4 All the admissions are routed through emergency department.
28.7.1.5 In case of absolute non-availability of beds and concerned specialty, the hospital will
take the initiative to transfer the patients to the nearest hospital by its own ambulance
accompanied by a nurse or a doctor depending on the need after prior intimation to the
referral hospital.
28.7.1.6 In case of non- availability of bed or services.: All patients can be directed to the various
facilities
1. Guru Teg Bahadur Hospital Dilshad Garden, New Delhi, Delhi
2. Lok Nayak Hospital Delhi Gate, New Delhi
28.7.1.7 In case of patient need holding in the hospital, the patient is kept until the completion of
all required formalities such as documentations, transportation etc.
518
Policy No:- CNBC/HWP Smoking/08
Reviewed By M.O. I/c Security
28.8 Policy on smoking within the premises of the Hospital
28.8.1 Purpose
To have a policy on smoking within the premises of the Hospital
28.8.2 Scope
Hospital premises
28.8.3 Policy
Smoking is not allowed on Chacha Nehru Bal Chikitsalaya (CNBC) premises.
519
Policy No:- CNBC/HWP/Medication/09
Prepared By DTC Committee
28.9 Medication Policy
28.9.1 The therapeutic drug treatment of the patient at CNBC is done as per advice of the
treating physician. Physicians are authorized to use only those drugs listed in the hospital
Formulary
28.9.2 All the parental / Oral Drugs prescribed to the patients are provided by the hospital
pharmacy. The availability of drugs in the hospital is as per the guideline and essential
drug list of the Govt. of NCT of Delhi.
28.9.3 The drugs are dispensed by the hospital pharmacy, and when pharmacy is closed the
drugs will be dispensed from Emergency Nursing Counter, and nurse dispenses it to
patient as per the treating doctor advice / Notes. The records of the drugs administer is
maintained by the nurse of concerned ward.
28.9.4 CNBC is a government hospital, Return of medications to the pharmacy is not done,
None of the medications for a particular patient either in OPD or IPD not returned back.
520
Policy No:- CNBC/HWP/Prescription/10
Reviewed By DTC Committee
28.10 Prescription of Medication particular day/shift detailed revise treatment

should be written by the doctors.
28.10.1 Purpose:- This policy sets standard for 11. Orders like CT all, CST etc must be avoided.
Physician orders (Inpatient as well as 12. The entry in medical record should be legible,
Outpatient orders), Verbal/Telephone orders, dated named, timed, signed and the author of
to improve the legibility of prescription orders entry should be identified.
which will be implemented gradually by the 13. The prescription shall have the name of the
hospital. patient; unique hospital number; name of the
drug, dose, route and frequency of
28.10.2 Scope The policy applies to In-patient and administration of the medicine; name,
Out-patient Department. signature and registration number of the
prescribing doctor.
28.10.3 Responsibility: Physicians, RMOs, Nursing 14. All hand written prescriptions shall be written
Officer. in capital letters at least antibiotics.
28.10.4 Physician Orders: 28.10.5 Doses:
1. Only Physicians authorized by CNBC 1. All orders for a drug dose less than one
Hospital can prescribe medications. shall have a zero preceding the decimal
2. Only a registered nurse and a doctor amount. E.g. write 0.25mg instead of .25
authorized by CNBC hospital permitted to mg.
administer medication. 2. Do not use decimal points or trailing zeros.
3. Physicians are authorized to use only e.g. Write 2 mg instead of 2.0 mg.
those drugs listed in the Formulary except 3. Microgram amounts shall be clearly written
in specific instances. as “microgram” to clearly distinguish form
4. All medication orders to be written on milligrams (mg).
CNBC Hospital Prescription Form or the 4. If more than one physician is prescribing
Case Sheets labeled/verified with Patient’s medications for one patient, each individual
name and Registration number. medication order must be written
5. Orders are to be written in a uniform separately and each medication order must
location in the medical records. be signed.
6. History for drug allergies to be 5. To change any of the medication orders,
documented. physician must cease the original order
7. Abbreviations for drug names to be and write a new order.
avoided. 6. The original order must not be obliterated.
8. All medication orders should specify the 7. All the medications prescribed at the time
drug name, dosage or dosage range, the of discharge should be included in the
route of administration, the frequency and discharge summary.
duration of administration. 8. Patient and Family Education
9. On daily basis if no change in treatment order 9. Patient and family are to be educated
then doctor should write in treatment sheet as about safe and effective use of medication.
“No Change in Treatment”, Abbreviation shall 10. Patient and family are to be educated
be avoided, daily renewal of order is also about food-drug interactions.
emphasized. And should follow approved list 11. Process for giving verbal or telephonic
of abbreviations wherever needed. orders:
10. If any change is made in treatment orders (like 12. The Physician will call up the concerned
revision of IV fluids/Oxygen therapy/addition or Resident doctor at the hospital.
omission of any medication) then on that
521
13. The physician identifies self, specifies the should be read as one five), route,
patient’s name and communicates the frequency (e.g. three times daily, not TID)
order. 16. The Receiver should also Request the
14. The Receiver will document the order indication for the medication to assist in
immediately on the physician’s order avoiding errors.
form/case sheet including the date, time, 17. The Receiver should question the
and physician’s name. Receiver’s name, Physician if there is any uncertainty
status and signature. regarding the order.
15. The Receiver should read back the order to 18. The Physician must counter sign the order
the physician including the patient’s name, as soon as possible or within 24 hour after
drug name and spelling of the drug to avoid communicating the order.
an error due to sound alike drugs, Dosage,
pronouncing it in single digits (e.g. 15 mg
522
Policy No:- CNBC/HWP/Uniform Care/11
Reviewed by QMD
28.11 Uniform Care Policy
28.11.1 The policy for providing uniform care right from the admission to discharge, OPD facility,
Lab facility, OT facility, Diagnostics, nursing, dietetic services etc. are uniformly given to
all patients irrespective of category of wards. All protocols are uniformly given in the
same manner to all patients irrespective of the category status.
28.11.2 Uniform care is guided by all laws & regulation.
523
Policy No:- CNBC/HWP/Blood Transfusion/12
Prepared By Blood Transfusion Committee
28.12 Policy: Blood transfusion
28.12.1 Scope:
A. Facilities available :
1. Whole Human blood

2. Fresh Frozen plasma
3. Packed RBC
4. Platelets (on Demand)
5. DCT
6. ICT
B. Not available:
o Cryo and other components
C. Limitations:
1. No bleeding facility. Every donor has to go to Blood Bank Lok Nayak Hospital for bleeding.
2. Platelets can be stored only on demand because the life span of platelet is only 5 days.
28.12.2 Policy:
1. Request
a. To ensure patients' safety, blood / blood components should not be prescribed unless there is
a real indication.
b. Request should be made by a consultant/Sr. Residents.
c. Blood transfusion request form should be filled completely by a doctor.
d. Consent for transfusion should be taken from patient / guardian after explaining the transfusion
requirement or doctor can give consent in case of unaccompanied patients who are incapable of
giving consent.
e. Blood sample should be taken for ABO & Rh grouping and cross matching and labelled at
bedside in both EDTA and serum vials.
f. The entire request for blood / blood component should be sent to the Blood Storage Center.
g. The blood/components will be released only on exchange basis i.e. one donor per request (and
not per adult volume).
h. Blood components will be released without donor only in emergency life threatening situations
and must be clarified in request form as life saving only by the dealing consultants with signature
and stamp.
i. Demand for blood/components without donor is strongly discouraged.
2. Grouping
524
a. All patients should be grouped in case:
i. Any intermediate or major surgery is planned.
ii. Any invasive procedures are planned where a risk of bleeding exists such that blood
transfusion is a possibility.
iii. Transfusion of blood / blood components is planned.
iv. The patient is diagnosed with a medical disease with likelihood of blood /blood components
transfusion requirement.
3. Blood Reservation
a. Blood should be reserved before all elective surgeries. The procedure for the same will be as
under:
i. The requisition for blood along with the consent form duly signed by the guardian and the blood
sample will be sent to the blood storage center immediately on admission / when the need for
transfusion is established.
ii. Availability of the donor (for replacement) must be provided by the requesting doctor.
iii. The blood storage center will ascertain availability of stocks and inform the same to the
consultant / ward nurse.
iv. Cross matching and issue of blood will be done on receiving firm demand from the ward /
operation theater
v. In case of rare blood groups (‘AB’ Rh positive and all Rh negative blood groups), the treating
consultant will discuss with the medical officer in charge of blood storage center before the
patients admission in order that suitable arrangements can be made in advance.
vi. In case of non-availability of required blood group, blood storage facility will try to arrange the
same from regional blood transfusion Centre at LNH.
4. Issuing Blood
a. Blood and blood components will be issued from the department only after compatibility testing
which for red cells normally would minimally take 60 minutes. However for all planned surgeries
and requirements the requests for compatibility should be sent well in advance and during routine
working hrs only.
b. Blood compatibility slip will be issued by the Blood storage Center along with all blood
products. This has to be kept in
patients file and responsibility of the document will be that of the in charge nurse of the floor /
ward / operation theater
c. Blood and blood component bags shall be labeled by the technician before issue of blood. The
labeling should include patient identification information, Date and time of issue, blood bag
number, blood group, name of blood component, date of collection, date of expiry.
d. The issue slip from the patient care unit should be accompanied by a thermocol box with lid for
optimum preservation of blood component during transport from blood storage centre to the
patient care unit.
525
e. After completion of the transfusion, duly filled transfusion feedback has to be dispatched to the
Blood Storage Center within 24hrs of transfusion
f. The date of collection and expiring of all units of blood / blood components will be mentioned
on all units & these will be issued as per inventory maintenance, normally ‘first in-first out' basis in
order to optimize blood usage.
5. Procedure Before Transfusion
a. Blood / Blood components should be checked by the doctor and the following details should be
verified: blood bag with patients' blood group, Name, MRN for correct identification of recipient.
This verification should be recorded in the patients' case record.
b. The same shall be checked and verified by the nursing staff on duty.
c. Check BP / Pulse / Temperature and record in the case file before transfusion.
d. Nursing staff who has received the blood/ blood component is responsible for initiation of the
transfusion.
e. Nursing staff should ensure that all required items (fluids, drugs) are ready along with the blood
bag in a separate tray for each patient.
f. Separate IV stands are to be used for each blood transfusion.
6. Procedure during Transfusion
a. Nursing staff should again check and verify the recipients' details before starting the flow of
blood.
b. Monitoring of vitals can be done by nurses
c. Visual observation is often the best way of assessing the patient during transfusion.
d. Record base line observations at the start of each unit and of each transfusion. Temperature /
Pulse should be measured 15 minutes after the start of each unit and hourly thereafter.
e. Monitor rate of flow to ensure transfusion progress, under no circumstances should any drug
be administered through the same IV line.
f. Management of Blood transfusion reactions:
Step 1 - Stop transfusion
Step 2 - Keep IV line open with 0.9 % NaCl
Step 3 - Notify attending physician and blood bank If transfusion is terminated
Step 4 - Send freshly collected post – transfusion sample of blood (preferably from opposite arm)
and sample of urine to blood bank.
Step 5 - Send the residual blood component unit along with administration set to blood bank.
f. If no reactions occur during transfusion, , fill the feedback form and send it to the blood storage
center.
g. Whole blood / packed cells can be transfused over 3 – 4 hours.
h. FFP / Cryo: Can be issued within 30 minutes, Should be transfused immediately, If not used
cannot be stored again and will not be accepted by the blood storage center
526
i. Blood should only be warmed using a specifically designed commercial device with a visible
thermometer and audible warning. Blood must not be warmed by insertion in hot water,
microwave or on a radiator.
j. Blood giving set must be changed every 2 units or at least every 12 hours.
7. Policy of blood procurement by Blood Storage Center:
a. Screened whole blood/ components are collected from RBTC, LNH twice a week.
b. Whole blood/components are returned to LNH blood bank ten days before expiry.
8. Policy for discard of expired / contaminated / hemolysed blood bags :
All contaminated hemolysed and expired blood units are sent in red bag for disposal.
9. Policy for return of unused blood/ blood component from patient care unit:
The blood/ blood component issued but not used in the patient care unit may be returned to the
blood storage center within 30 minutes of issue of blood/ blood component. If blood is not
returned within 30 minutes from issue, the blood/ blood component may be discarded as per the
procedure defined.
10. Policy of Quality Control:
a. CBC for whole blood and packed cells (RCC), coagulation profile (PT/APTT) for FFP and
bacterial and fungal culture for all components are done for bloodbags from LNH hospital once
in 15 days.
b. All blood transfusion feedback forms will be monitored by blood bank officer and if any reaction
is found, corrective action will be taken by incharge and reported to the transfusion committee.
11. Policy of use of mother bag:
The mother bag is used for giving small volumes of blood/ blood components for only three
occasions within 72 hours of the first use. Remaining blood/ component is discarded after 72
hours in red bag for disposal.
527
Policy No:- CNBC/HWP/Blood Transfusion/13
Prepared By Blood Transfusion Committee
28.13 Policy on Patients Are Monitored After Medication Administration
28.13.1 Patients are monitored after medication administration and are documented.
28.13.2 Adverse drug events are defined and recorded.
28.13.3 Nurse at the time of admission and in between also instruct both the patient and relatives
to call the staff nurse on duty for any purpose.
28.13.4 In Intensive care units direct observation of patients are done by the nurses and doctors
because they are available near the patient always.
28.13.5 Patients with administration of high-risk medicines, concentrated electrolytes,

chemotherapeutic drugs must be closely monitored
28.13.6 Adverse drug events are reported immediately to the primary care consultant / his team
after the event is observed
28.13.7 The incident is informed to pharmacy executive also immediately so that the bottle /
injections with same batch numbers can be withdrawn from all departments.
28.13.8 Adverse drug events reports are sent to the Drug and Therapeutic committee for analysis
and corrective action.
28.13.9 The Adverse Drug Reaction has to be recorded in the case file and nurses records by
doctor / nurse.
28.13.10 Medication is changed based on clinical need/ response of the patient and adverse
drug reaction if any by the doctor on duty.
528
Policy No:- CNBC/HWP/Pat. Edu/14
Prepared By Dr Anup Mohta
28.14 Policy on patients and family members are educated about safe medication and
food drugs interactions
28.14.1 Nursing department of CNBC maintains a policy on patients and family members
regarding safe medication and food drug interactions which are mentioned below:-
28.14.2 Patient family is educated about safe and effective use of medication.
28.14.3 Patient family is educated about food drug interactions, whenever they go with a certain
medicine / drug to the patient.
28.14.4 The nurses do teach them the timings of such drugs ie whether to take in empty stomach,
during food, after food etc and what can happen in case they don’t take the drug on the
prescribed manner.
529
Policy No:- CNBC/HWP/Safe Disp/15
Prepared By QMD
28.15 Safe Dispensing of Medicine or Medication Administration (Mom)
28.15.1 Chacha Nehru Bal Chikitsalaya (CNBC) has laid down policies and procedure for safe dispensing of
medicines as stated below:-
28.15.2 Labeling shall be done on all containers of drugs. Every nurse is expected to follow 6 ‘R’ S for safe
administration of medicines.
28.15.3 6 R’s (Right) should be identified. : Right patient, Right drug, Right dose, Right time, Right route, Right
Documentation.
28.15.4 Identification Band with Name, Age/sex and unique ID no. is provided to all patients and verified before
administering any medication or procedure.
28.15.5 Thus the nurse checks the order of the correct patient by name, bed no., C.R.no. Number. With Patient ID
band and case file and same to be confirmed by patient/ patient relative. (at least two identifiers)
28.15.6 Thus the nurse checks the order of the correct patient by name, bed no., C.R.no. Number.
28.15.7 Medication should be verified from the medication prescription and should be inspected physically for
general appearance and expiry date before administration.
28.15.8 In case of high risk drugs, this should be verified by two different persons (Nurse- Nurse, Nurse- Doctor).
28.15.9 Drug should also be verified for the strength, route, and frequency from the medication order. In case any
discrepancy is observed/ noted, nurse should report deferred the medication, and same should be
corrected immediately
28.15.10 After the check for correct drug, dose route & time, she/ he checks for the expiry date written on
ampoule / vial/ bottle / strips.
28.15.11 Minimum labeling on loaded syringes, burette set/ micro drip set and Intravenous bottles must includes
drug name, strength, frequency of administration & expiry date.
28.15.12 Prepared medication should be labeled prior to preparation of second drug.
28.15.13 She also checks for any discoloration of drug, sediments etc by holding the ampoule/ vial/ bottle against
the light.
28.15.14 After washing hands she sets the tray put on the gloves, go to the patient and with all aseptic technique
she gives the injection/ starts the I/V line or make sure that the patient swallows the medicine in front of
her/ him.
28.15.15 Make the patient comfortable.
28.15.16 Watch for any reaction and if any, discontinue the drug soon and report immediately to the doctor for
necessary action.
530
28.15.17 Record/chart in the medication chart (Medication administration sheet) with name of the drug, dosage
route of administration time, signature/ initials of the name of staff nurse.
28.15.18 Medication orders shall be documented in patient’s medication chart/ administration sheet by doctor on
duty. Medications chart to be written neatly, legibly and in capital letters.
28.15.19 Patient attendant are may be advised for self administration of oral drugs, if deemed fit by nursing staff/
Treating Physician.
28.15.20 Written advice by treating doctor should be given for self administration of oral drugs.
28.15.21 Dosage, route, timing for the medication orders to be verified prior to administration. Counter signature
by doctor on duty or counter nursing staff to be done on treatment chart in case of high risk drugs
administration.
28.15.22 Timing of administration of medications is defined as drugs ordered for 12 hourly are to be
administered at 10am ,10pm and 24 hourly drugs at 10am, 8houlry at 6am, 2pm and 10pm, for 6hourly
drugs 10am,4pm,10pm, 4am, stat orders are to be followed immediately and SOS when required.
28.15.23 Patient’s medication brought from outside the hospital is based on government policy.
28.15.24 The nurse and doctors should take measures to avoid catheter and tubing mis-connections during
medication administration. This is done by using label on extension tubing (Arterial lines, Epidural lines
etc ) with name and date, it is caution marked at the site “no drug to be given through line” in operation
theatre. Staffs are trained to take precautions and care to position functionally dissimilar tubes used in
patient care units away from each other, staff should trace all lines from their origin to the connection port
to verify attachments before making any connections or reconnections, or administering medications,
solutions or other products.
531
Policy No:- CNBC/HWP/Verbal order/16
Prepared By Dr Manish kumar
28.16 Policy on verbal orders for Medication:
28.16.1 What is verbal order?

Verbal orders are medication orders which are given verbally by the doctor to a nursing staff.
Ideally, verbal order should be avoided to decrease the incidence of medication error, but when
received should be “read back” by the receiver. Order must be documented by the prescriber in
the case sheet of the patient within 24 hours of the order. Verbal order should not be given for
high risk drugs and chemotherapeutic drugs; however some drugs may be ordered verbally under
emergency situations where delay in treatment may result in adverse outcome of the patient.
28.16.2 Conditions where verbal orders can be allowed

1. When the doctor is resuscitating a child or performing a sterile procedure
2. Life threatening conditions; like acute seizure, features of impending respiratory

failure (central cyanosis, grunting), congestive cardiac failure, shock, severe
anaphylaxis, arrhythmia, hypoglycemic or hypocalcemic seizure
28.16.3 List of drugs for which verbal orders are allowed

1. Injection Avil (Pheniramine Malleate)- anaphylaxis
2. Injection Dexamethasone – severe stridor, anaphylactic shock
3. Inj. 5% or 10% Dextrose bolus- hypoglycemic seizure
4. Injection calcium gluconate- hypocalcemic seizure
5. Injection Frusemide- congestive cardiac failure
6. Inj. Hydrocortisone – severe bronchospasm
7. Injection Lorazepam- active seizure
8. Injection Lignocaine- local anesthesia while performing a procedure
9. Injection Midazolam – active seizure
10. IV Normal Saline bolus- shock
11. Injection or Syr. or Tab Paracetamol- fever
12. Salbutamol (Asthalin) nebulization – severe bronchospasm
13. Oxygen – severe respiratory distress, SP02<90%
28.16.4 Doctors can give verbal order which nurses can administer.
28.16.5 The person whosoever is taking verbal order should write down the name, route and
dose of drug clearly. in patient’s case sheet.The order is to be read to the doctor to make
sure no error occur.
28.16.6 Nurse should get it authorized from the treating consultant in earliest possible time or
within 24hours. Verbal orders should be avoided as far as possible.
532
Policy No:- CNBC/HWP/High Risk/17
Director
Approved by
28.17 High Risk Medication
28.17.1 Policy
28.17.1.1 High risk medications are drugs that bear heightened risk of causing significant patient
harm when they are used in error. Consequences of an error with these medications
are clearly devastating to patients.
28.17.2 Procedure for verification & administration of high risk medication: As soon as high risk
medication received from the store the container is to be labeled with red before storing
them in the cupboard.
1. In case any high risk drugs are under the category of LASA too, then LASA policy is to be
followed and should be stored apart in different containers, label and colour code.
2. One separate register will be maintained by nursing sisters for high risk medication
verification.
3. At the time of issuing these drugs to the staff, both the parties will check &verify.
4. Both will sign in the register
5. Whenever these medications are issued to staff nurses, each ampoule /vial is labeled
with red.
6. LASA policy will be followed if applicable.
7. High risk drugs shall be entered in medication chart with red ink and it should be signed
by one staff and will be counter signed by second staff /Nursing sister/Doctor ,after
verifying drug, dose, patient& route, before administration to the patients.
28.17.3 Whenever these medications are prescribed the nurse will take special note of these.
1. The dosage prescribed will be checked
2. If the dosage is outside the normal range then the dosage will be confirmed with
the consultant before preparing / setting up the medication.
3. The ampoules or vials as the case may be taken in consonance with the dose.
28.17.4 These will be kept separately and verified for:

1. The pharmacological name & date of expiry
2. concentration and amount of chemical in each ampoule / vial
3. sum of total doses if more than one ampoule/ vial is used
4. Route of medication, i.e. IM/ IV / subcutaneous and whether this corresponds to
the consultant’s orders.
28.17.5 These drugs will then be administered at the rate and by the route advised.
533
28.17.6 Infusion of high risk medication will be clearly labeled and concentration of the drug per
ml will also be mentioned in the label.
28.17.7 The high risk medication will be kept in such a way that it is accessible to authorized
personnel only.
28.17.8 Proper accounting of these drugs will be maintained and any discrepancy will be brought
to the notice of the Director.
28.17.9 Situation where close monitoring is required

1. Patient receiving High Risk Medication.
2. Patient receiving Chemotherapeutic drugs.
3. All patient requiring more than 50% oxygen to maintain saturation & patient with
Respiratory Distress.
4. Patient with raised Intra Cranial Tension.
5. Patient Haemodynamically unstable.
6. All patients requiring close monitoring due to potentially unstable conditions
28.17.10 A list of high risk medication is attached.
List of high risk medicines

High risk medicines are those medicines that have a high risk of causing significant patient
harm or death when used in error (Reference- Institute for safe medication practices).
1. Injection Adrenaline 17. Injection Lorazepam

2. Injection Adenosine 18. Injection Magnesium Sulfate
3. Injection Amiodarone 19. Injection Milrinone
4. Injection Aminophylline 20. Injection Morphine
5. Injection 20% Dextrose or 21. Injection Midazolam
greater 22. Injection Naloxone
6. All Chemotherapeutic agents hydrochloride
(oral and IV) 23. Neuromuscular blocking agents
7. Injection Diazepam (Succinylcholine, Rocuroneum,
8. Injection Digoxin Vecuroneum)
9. Injection Heparin 24. Injection Norepinephrine
10. Injection Hypertonic saline (3% 25. Parenteral nutrition preparations
NaCl) 26. Injection Potassium chloride
11. All immunosuppressive drugs (Kcl)
(Cyclosporine,Tacrolimus, 27. Injection Promethazine
Azathioprine and Methotrexate) 28. Injection Propofol
12. Injection Insulin 29. Injection Radiocontrast agents
13. Inhaled Anesthetic agents 30. Injection Sodium Nitroprusside
(Halothane, Sevoflurane, 31. Injection Vitamin A
Isoflurane)
14. Injection Ketamine
15. Injection Labetalol
16. Injection Lignocaine
534
Policy No:- CNBC/HWP/Wrong Site/18
28.18 Wrong Site Surgery
28.18.1 Purpose: To protect the patient from injury related to wrong patient & surgical
procedure/site/side surgery.
28.18.1.1 Identification of Patients

a. A registered nurse will identify the patient:
i. On arrival in the pre-op area.
ii. On arrival in the procedure room or operating room.
iii. On arrival in Recovery room
b. Identification of a patient is achieved:
i. For non-responsive patients (e.g. infant, comatose patient), by:
 Asking a family member or significant other the patient’s name

 Reviewing the patient’s medical record if a family member or significant other is not
available.
28.18.1.2 Surgical Site Marking

a. Where practical, the surgical incision site(s) or area will be marked when procedures
involve right/left distinction, multiple structures (such as, fingers and toes), and levels (as in
spinal procedures).
b. The area will be marked using an indelible marker for the correct site/side.
c. For hospital inpatients:
i. The surgeon obtaining the informed consent will mark the correct site with the word at the
time the consent is signed.
ii. On the evening before surgery, the nurse will verify that the surgical site is marked. If it has
not been marked, the physician involved with the surgery will be notified.
iii. The nurse completing the Pre- Operative Checklist must verify that the site of surgery has
been marked. If it has not been marked, the senior resident involved with the surgery will be
notified. If the senior resident is not available to mark the site, the nurse will notify the
appropriate operating room
iv. In the Preoperative Holding Area, the nurse checking in the patient will, after identifying the
patient, verify that the operative site/side has been marked and is in agreement with:
i. The statement of patient, family member or significant other.
535
ii. The medical record including imaging studies, if available, informed consent, history
and physical.
d. For patients being admitted for Day Care Surgeries, a senior resident who will be involved
with the surgery should mark the surgical site on the morning of surgery. If the physician is not
available, the nurse caring for the preoperative patient will:
i. Review the surgery schedule for the procedure and site/side of surgery.
ii. Interview the family member or significant other, confirming the patient’s identity
iii. Review the medical record (i.e. consent, Pre Procedure Assessment, history and physical,
and imaging studies, if applicable)
iv. Mark the correct surgical site using indelible ink in a manner that will allow the mark to still
be seen once the patient is prepped and draped.
28.18.1.3 In the Operation Room, the circulating nurse will:

a. Review the surgery schedule.
b. Identify the patient
c. Confirm that the site/side of surgery has been marked.
d. Review the medical record (informed consent, and history and physical) for type and
site/side of surgery.
e. Verify with the patient, parent or guardian (if present) that the procedure and site/side of
surgery to be performed agree with the medical record.
f. Write on communication board in operating/procedure room:
i. Patient name
ii. Procedure(s) planned and the site as appropriate
28.18.1.4 TIME OUT

a. In the Operating/Procedure Room, before the incision is made, all members of the
surgical team (including the Surgeon(s), Anesthetist, the Circulating Nurse, and the Scrub
Nurse or Technician) will orally and simultaneously verify the correct:
i. patient name,
ii. planned procedure,
iii. surgical site and side,
iv. patient position, and
v. Availability/presence of implants, special equipment, or critical supplies to be required

during the procedure.
b. This verbal verification is the “TIME OUT” and occurs immediately prior to incision.
536
c. Personnel Responsibilities
i. All members of the operating team will participate in the TIME OUT.
ii. The scrub nurse or technician is in a unique position to initiate the TIME OUT and should do
so, just prior to handing the knife to the surgeon.
iii. The circulating nurse is responsible to ensure the TIME OUT is accomplished prior to the
start of the operation
iv. The circulating nurse is responsible for documenting the TIME OUT in the medical record.
28.18.2 DISCREPANCIES
In the event of any discrepancy in any of the above controls, a surgeon who will be involved in
the procedure will be called to evaluate the patient and review appropriate clinical data to
ensure that the correct surgical procedure is performed. Questions and concerns will be
resolved before starting any procedure.
537
Policy No:- CNBC/HWP/PRR/19
28.19 Patient’s Rights and d. Expect that any discussion or

Responsibilities consultation involving his / her case will not
be conducted in public and that individuals
28.19.1 Policy: not involved in direct care will not be
It is the policy of the hospital to respect the present without permission of the patient.
individual rights of all persons that come to
this facility for care. e. Have his/ her medical record read only
by individuals directly involved in treatment
28.19.2 Patient rights include: or monitoring of quality, and by other
1. Access to care: individuals only on authorization by the
patient or that of his / her legally authorized
No patient shall be denied admission due representative.
to race, color, religion or country / state
origin. f. Expect that all communications and other
records pertaining to his care be treated as
2. Respect and dignity: confidential.
The patient has the right to considerate, g. Expect that information given to
respectful care at all times and under all concerned family members or significant
circumstances, with recognition of his other legally authorized person, be
personal dignity and worth delivered in privacy and with due
consideration of confidentiality.
3. Privacy and confidentiality
4. Personal safety and security
The patient has the right, within the law, to
personal and informational privacy, as a. The patient has the right to expect
manifested by the right to: reasonable safety in so far as the hospital
practices and environment are concerned.
a. Refuse to talk with or see anyone not To address the needs of patient, visitor and
officially connected with the hospital, staff regarding safety and security, the
including visitors; persons officially hospital security personnel are present
connected with the hospital but who are not round the clock. Other safety and security
directly involved in his care. measures include limited access to the
facility, and the use of employee
b. Wear appropriate clothing and religious identification badges that are to be
or other symbolic items, as long as they do conspicuously displayed.
notjeopardize safety or interfere with
diagnostic procedures or treatment. 5. Identity
c. Be interviewed and examined in a. The patient has the right to know the
surroundings designed to assure identity and professional status of
reasonable privacy. It is the patient’s right individuals providing service to him / her
to have a person of one’s own gender and to know which Consultant is primarily
present during physical examination, responsible for his / her care.
treatment, or procedure performed by a
health professional; and the right not to 6. Information
remain disrobed any longer than is required
for accomplishing the medical purpose for a. The patient has the right to obtain from
which the patient was asked to disrobe. the Consultant responsible for coordinating
his / her care, complete and current
538
information concerning his / her diagnosis a transfer, and unless the transfer is
(to the degree known), treatment and any acceptable to the other facility. The patient
known prognosis. This information should has the right to be informed by the
be communicated in terms the patient can responsible Consultant or his / her
reasonably be expected to understand. designee of any continuing healthcare
requirements following discharge from the
b. The patient has the formal right of hospital.
access to his / her medical records which
will be provided as per existing policy and 11. Hospital rules and regulations
procedure except medico legal cases.
The patient shall be informed of the
c. The patient has the right to information hospital rules and regulations applicable to
on expected cost of the treatment. his / her conduct as a patient.
(Therapeutic / diagnostic)
12. Complaint process
7. Communication: when the patient does
not speak or understand the predominant The patient has the right to file a complaint
language of the community, the hospital regarding services and is entitled to
will make efforts to obtain services of an information regarding the hospital’s
interpreter. mechanism for the initiation, review and
resolution of such complaints. Complaint
8. Consent boxes are made available in emergency
admission counter and ward block lift area.
a. The patient has the right to reasonably
informed participation in decisions involving 13. Patient responsibilities
his / her healthcare. The patient shall not
be subjected to any procedure without his / Patients have the responsibility to:
her voluntary, competent, and informed
consent, or that of his / her legally 1. Provide accurate information about their
authorized representative. health, including past illnesses or health
problems, hospitalizations, allergies and
b. The patient has the right to know who is the current or past use of medication.
responsible for performing the procedures 2. Read all medical forms including
or treatment. consents thoroughly and ask to have the
information explained to them prior to
c. The patient may refuse treatment. When signing if they do not understand.
refusal of treatment by the patient or his / 3. Follow the treatment plan recommended
her legally authorized representative by their health care provider.
prevents the provision of appropriate care 4. Show consideration for the rights of other
in accordance with ethical and professional patients and the hospital by following the
standards, the relationship with the patient hospital rules concerning patient conduct.
may be terminated upon reasonable notice. 5. Do not ask to provide incorrect
information, or certificates.
9. Consultation 6. Observe facility policies and procedures,
including those regarding smoking, noise,
a. The patient, at his own request and and visitors.
expense, has the right to consult a 7. Do not litter the hospital.
physician of his / her choice from the panel 8. Use garbage bins.
of consultants accredited with the hospital. 9. Keep toilets clean after use.
In case a patient wishes to see a 10. Support the hospital in keeping the
consultant not accredited with the hospital, environment clean.
the same may be done after approval from 11. Wait patiently for your turn.
the Head of office on a case to case basis. 12. Maintain silence.
13. Do not bring children below 10 year as
10. Transfer and Continuity of care visitors.
a. A patient may not be transferred to
another facility unless he / she has
received a complete explanation of the
need for a transfer and the alternatives for
539
Policy No:- CNBC/HWP/EOL/20
Revised by:- QMD

Prepared By QMD and ICU department
28.20 End of Life Care
28.20.1 Policy-
28.20.2 Definition-end-of-life care (EOLC) policy for patients who are dying with an advanced life limiting
illness involves limiting inappropriate therapeutic medical interventions and improve the quality of
care of the dying within an ethical framework and through a professional and family/patient
consensus process
28.20.2.1 Patients who have deteriorated to a state such that life is near its end will be cared for as under:
a. Recognizing medical futility and the dying process is the first step in providing end-of-life care (EOLC)
b. Appropriate Pain and palliative care according to the wishes of the family and the patient.
c. The relatives will be informed and documented about the deterioration and the present scenario.
d. The precipitating cause of such an event will be explained to the patient relatives
e. All prescribed treatment is given.
f. Patients and family values, religion and culture should be respected.
g. Patient’s relative can be involved in all aspects of care.
h. Health care provider should respond to the psychological, emotional, spiritual, and cultural concerns of
the patient and family (where possible). A multidisciplinary approach is be used.
i. Symptomatic treatment is provided and to prevent complications to the possible extent. The relatives
should be involved while taking any decisions.
j. Family choices should be respected at every level
k. Hospital should involve multi discipline as-doctors, nurse as well as clinical psychologist
l. Exception will be made to permit relative of the patient to visit the patient in ICU at least once when the
patient deteriorates.
m. The relative may be shown CPR being done for a transient period if he/she wishes.
n. Upon death, the relative of the patient will be informed about the demise and patient will be shown.
o. Medico-legal implications if any will be explained.
p. Death certificate will be prepared.
q. All invasive lines, endotracheal tube etc will be discontinued and removed.
r. The dead body will be cleaned, wrapped in white sheet and placed in body bag.
s. Due respect will be given to the dead body during handling.
t. Doctor on duty motivates the patient’s guardian /relatives for organ donation of the patient, In case
patient’s guardian /relatives like to donate patient’s organ the doctor on duty will be responsible to
inform the concerned department of AIIMS.
540
Policy No:- CNBC/HWP/ADR/21
28.21 Near Miss, Medication Error and Adverse Drug Reaction
28.21.1 A near miss is an unplanned event that 28.21.8 All medication errors and adverse reactions
did not result in injury, illness, or damage for inpatients and outpatients shall be
but had the potential to do so. For reported to the Quality management
example, Injection was about to be given division (during working hours), MO I/C and
to a patient; but staff realized fast that it Head of Office Immediately by the Store In
was not to be given to that particular charge.
patient and not given.
28.21.9 These are analyzed by Drug & Therapeutic
28.21.2 Medication errors are unintentional errors committee. Preventive and corrective
actions shall be taken as recommended.
in the prescribing, dispensing,
administration or monitoring of a 28.21.10 In case of ADRs reported with drug of
medicine while under the control of a same batch number it is to be store
healthcare professional, patient or incharge and drug recall should be initiated.
consumer. They are the most common
single preventable cause of adverse 28.21.11 Medications are changed by doctor.
events in medication practice. When Adverse Drug Reaction is seen in
patient
28.21.3 An adverse drug reaction (abbreviated
ADR) is an expression that describes 28.21.12 Any Near Miss, Medication Error and
harm associated with the use of given Adverse Drug Reaction must be reported to
medications at a normal dosage during QMD as early as early as possible or at
normal use. ADRs may occur following a least within 24 hours.
single dose or prolonged administration
of a drug or result from the combination 28.21.13 Near Miss, Medication Error and Adverse
Drug Reaction are analyzed regularly by
of two or more drugs.
the multi-disciplinary committee as earliest
28.21.4 Medication errors and adverse drug or at least within the 72 hours of reporting
of incident.
reactions should be reported to the
patient’s attending doctor, Nurse and the 28.21.14 Corrective and/or preventive action(s) are
Store In charge immediately. taken based on the analysis where
appropriate based on the Root Cause
28.21.5 Adverse drug Reaction shall be reported Analysis report.
in Adverse Drug Reaction Form (ADR
form) Reporting shall be done as early as 28.21.15 Medication recall are handled effectively,
possible at least within 24 hours of error recall is based on communication from the
occurrence. regulatory authorities, manufacturer or
internal feedback. In case of any
28.21.6 Nursing service must immediately medication recall is needed , a information
implement the physician’s orders. The to all concerned departments is given for
patient’s condition must be closely stoppage of use of medication with batch
monitored as directed. number, manufacturing and expiry details
and further CAPA is also informed.
28.21.7 Documentation of the patient’s condition
and response to treatment must be
recorded during the monitoring period.
541
Policy No:- CNBC/HWP/Chemo/22
28.22 Chemotherapy d. Goggles and masks shall also be made available

for use by employees that perform
28.22.1 Purpose chemotherapy admixtures.
28.22.1.1 Antineoplastic (Chemotherapy) drugs are 28.22.6 Admixing Procedure

known to be carcinogenic, teratogenic or a. Hands shall be washed thoroughly before and
mutagenic. after gloving.
28.22.2 Their toxicity dictates that exposure of the drug b. Care shall be taken to avoid puncturing of gloves.
to medical personnel handling the drug be
minimal. Since many are also injectables, c. Luer-lock syringes and IV sets shall be used for all
aseptic conditions must be maintained during admixtures.
compounding.
d. A plastic-backed absorbent drape shall be placed
28.22.3 Informed Consent for chemotherapy on work counter during the mixing of
1. Informed consent shall be taken before initiating antineoplastic agents. The drape shall be
chemotherapy. Patient /relative shall be given exchanged whenever substantial spillage
sufficient information so that he / she occurs or at the end of each production
understands the nature of his / her condition, sequence.
the nature and purpose of the proposed
treatment, the risks and consequences of the e. Vials shall be vented to reduce pressure or eliminate
therapy and the prognosis if the therapy is not vacuum.
provided to the patient.
2. Single informed consent shall be taken for a f. A sterile gauze swab shall be wrapped around the
complete cycle of chemotherapy if patient neck of an ampoule while opening. Care shall be
remain admitted throughout. If the patient gets taken to make sure that no drug remains in the neck
discharge/leave in between the cycle, a fresh of the ampoule.
consent shall be obtained.
g. The final drug measurement shall be performed
28.22.4 Prescribing:- before removing the needle from the stopper of the
I. May be done by doctors approved by the vial or the syringe from the chemo-dispensing pin.
hospital administration to practice in the hospital
h. All ampoules and vials with excess drug left in them
and must possess the knowledge to monitor
shall be discarded in the yellow plastic bag and
and treat the adverse effect of the drug.
labeled appropriately.
II. All Chemotherapeutic agents/drugs
must be written with the dose, frequency,
i. Personnel shall refrain from applying cosmetics in the
duration and signed by the doctor.
work area. These cosmetics may provide a source
of prolonged exposure if contaminated.
28.22.5 Personal Protective equipment:
a. Disposable non-latex gloves shall be worn for all
j. Eating, drinking, chewing of gum, storage of food or
procedures involving antineoplastic drugs.
smoking in, around or near the preparation area
Double gloving is recommended when cleaning
shall be prohibited. Each of these is sources of
up spills.
ingestion if they are accidentally contaminated by
hazardous products.
b. Disposable gowns shall be worn for all procedures.
k. The nurse manager shall be contacted if a major spill
c. All potentially contaminated garments or gloves
occurs.
SHALL NOT be worn outside the work area.
28.22.7 Disposal
542
a. All disposable items that have potentially come in 28.22.9 Acute Exposure
contact with antineoplastic drugs during a. Overtly contaminated gloves or outer garments shall
compounding shall be discarded in specifically be removed and replaced immediately after an
designated containers. Each container shall exposure.
have a " cytotoxic" label affixed to it.
b. Hands shall be washed after removing gloves.
b. All items used in compounding (excluding partial filled Gloves shall not be used a substitute for hand
ampoules and vials, and needles) shall be placed in washing.
a plastic bag and sealed before removal from the
preparation area. This bag shall then place in a c. In case of skin contact with a cytotoxic drug product,
contaminated waste box outside the hood. This the affected area shall be washed, thoroughly with
contaminated waste box shall have a "Caution-- soap and water as soon as possible. Refer to
Chemotherapy" label affixed to it. professional medical attention as soon as possible.
c. All chemotherapy waste shall be destroyed by proper d. For eye exposure, flush affected eye with copious
incineration. amounts of water. Refer to medical attention
immediately.
28.22.8 Order Processing and storage
a. All Consultant orders shall be sent to the e. Acute exposure episodes shall be documented. The
pharmacy at least one hour in advance of the exposed employee shall be referred for medical
anticipated administration time. examination.
b. These drugs is to be stored separately from
other medication and accessible to only f. Should a spill occur, follow standard procedures for
authorized personnel (Nurses and Doctors) cleanup of the spill.
543
Policy No:- CNBC/HWP/Vul/23
28.23 Vulnerable Patient
28.23.1 Policy:
In order to ensure a safe environment for vulnerable patients the following procedures shall be
followed by the affected departments.
28.23.2 Pediatric Patients

a. Being a pediatric centre all patients are vulnerable to fall. Bed and safety belts
/ side rails shall be on when patient is not under direct care of nurse or
attendant.
b. Accommodation for parents at bedside shall be made whenever practical.
c. Pillows shall be firm and offer support. Light plastic wrappings are not
permitted on sheets and pillows.
d. Children receiving heat treatment of any kind shall be kept under close
supervision.
e. Baby scales shall be placed safely on a table top so that should the infant fall,
baby would not land on the floor.
f. No child shall be left unsupervised while he/she is eating. Food shall be soft
and age specific.
g. Small candies and toys shall not be accessible to a small child, lest he/she
choke or insert them in a body orifice.
h. When a small child has finished eating, his/her feeding equipment shall be
removed and he/she shall be returned to his/her crib immediately.
i. All cleaning supplies will be kept in locked cabinets when not in use.
j. Medication will not be left on the bedside.
k. Any bed ridden patients-with diagnosis like paralysis, immediate post
operative, spinal injury, malnourished or obsessed-are prone to develop
pressure ulcer.
544
Policy No:- CNBC/HWP/DPM/24
Revised on: August 2020 Version No.: 1.3
Prepared By Dr Anil Aggarwal
28.24 Disaster Plan Index
28.24.1 Introduction
28.24.2 Purpose
28.24.3 Introduction about the Hospital/Services Available
28.24.4 Quick Response Team
28.24.5 Type of Disaster
28.24.6 Probable Nearest site
28.24.7 Architectural Details
28.24.8 Network Hospitals
28.24.9 Disaster Member Committee
28.24.10 Action Plan in case of Internal Disaster
28.24.11 Action Plan in case of External Disaster
28.24.12 Situation & Assumptions
28.24.13 Specific Responsibility of Various Deptt.
28.24.14 Standard Operating Procedure (SOP) & Guidelines
545
28.24.16 Purpose:
1. To provide standard operating
guidelines to tackle with the
internal & external disaster of
A). Internal Disaster Plan varied nature.
2. Establishment of a command
a). Evacuation For Internal Disaster nucleus & identify key
responsibilities in the event of a
b). Resources of Patients Transfer
disaster situation so as to
c). Inter Hospital transfer minimize the loss to life & limb of
the patients.
d). Procedure for Transfer 3. Establishment of standard
(simple) treatment guidelines in
e). Hospital Evacuation Plan treatment of emergency.
B). External Disaster Plan 28.24.17 Introduction about hospital:-

Chacha Nehru Bal Chikitsalaya is
a. General Direction For the being developed as 216 bedded
Implementation Super-speciality pediatric hospital to
b. Expansion of facilities provide preventive & quality curative
i. Reception of Patients services to children up to age of 12
ii. Prioritization of Patients years.
iii. Treatment Areas
iv. Records
v. Traffic Control 28.24.18 Note:- In case of Disaster, hospital
vi. When Addition Bed Space is is capable to handle the pediatric
Need patients upto age of 12 years only.
vii. Release of Information to the All adult patients will be given first
News Media aid and transferred to network
viii. Aid & Donation receiving hospitals or the hospitals capable of
Center handling such types of patients.
ix. Bomb Threat Procedure:
x. Receipt of warning 28.24.19 Services available
xi. Search Procedure 1. General Pediatrics
xii. Evacuation 2. Pediatric anesthesia
xiii. Reports 3. Orthopedic surgery
4. Dermatology
c. Hazardous Material Incidents 5. ENT
Protocols 6. Dentistry
d. Acute Management of Chemical 7. Ophthalmology
Burn 8. Pediatric Intensive care
e. General Management of 9. Neonatal Intensive Care
Pesticide Poisoning 10. Pediatric surgery with Endo
f. Annexure-1 (Layout Plan) surgery/ Endo urology
11. Bronchoscopy
12. Physiotherapy
C) Disaster Plan of CNBC Hospital 13. Lab. Services
14. Radiology Services
28.24.15 Introduction: 15. Diet Counseling
Disaster: Any occurrence that causes
damage, ecological disturbance, loss of 28.24.20 CASUALTY SERVICES:
human life, or deterioration of health and 1. Round the clock Pediatric
health services on a scale sufficient to Medical and limited Surgical
warrant an extra-ordinary response from Casualty services are available.
outside the affected community or area.
546
2. At the time of disaster, 16 beds 28.24.23 In Case of Disaster, all M.O I/c’s
of Ist floor are available; they will will be informed
be converted to disaster beds.
28.24.24
28.24.21 Pre- designated quick response
team
1. One Medical Officer
2. Staff nurse
3. Nursing Orderly
28.24.22 Note:- List of Key persons and

members of Quick response team is
available in Casualty Department
along with their phone numbers.
28.24.25 Services and contact number of In-charges Hospital no. 011-22013373/74
Service Intercom
OPD 120
Emergency 216
Pharmacy 216
Store 318
Purchase 331
Sanitation 304
Security 200
Bio Medical Waste Mgt. 339
Nursing I/c 308
Food quality 238
Office Establishment 330
Accounts 329
Civil works/ Water 115
Electrical works/ 114
Air-conditioning
28.24.26
28.24.27 Type of disaster envisaged:

1. Internal disaster (fire/bomb 28.24.28 Probable nearest sites of External
blast/hoax call) disaster:
2. Hospital Evacuation (Partial) 1. Electrical board office (power
house unit)
2. School:
547
a) Sai Memorial School. 1. LNJP Hospital, Delhi
b) St. Lawrence School.
Contact Person – Medical-
28.24.29 Earthquakes Superintendent
Tel: 23232600
28.24.30 Flood EPABX-3233400, 23232400
FAX-23232870
28.24.31 Architectural details of Building: WebSite: http://www.lnjp.delhigovt.nic.in
1. Year of construction: 2003
2. Earth Quake Resistant Building. No of Beds Available:- 1600
3. Layouts are attached as
annexure-1 Trauma beds 150
28.24.32 Network Hospitals: patients are to

be referred at:
2. GTB Hospital, Delhi
1.1.1
Type of Hospital
Teaching Tertiary Care General Hospital
Name of the Hospital
GURU TEG BAHADUR HOSPITAL
Contact Person
Location
Dilshad Garden, Delhi-110095
Hospital Phone No.
EPABX-22586262, Casualty-22588383
No. of beds available
1000
Trauma beds
3. Sushruta Trauma Centre, Delhi
9, Met Café Road – Delhi -110054
Contact Person: Medical Superintendent
Number of Beds Available: 50 Bedded
Phone no.20514488
6. Blood Bank Officer

28.24.33 List of Ambulance Provider:- 7. M.O I/c Transport
1. Networking with CATS is available 8. M.O I/c Security
9. M.O.I/c Sanitation
28.24.34 Disaster Management Committee: 10. Dietitian
1. Director- Chairman 11. Officer In-Charge PWD
2. Head of Office 12. M.O I/c Manifold
3. Head of all Clinical Departments 13. Medical Officer - Emergency
4. Medical Officer-in-Charge – Store
5. Asst. Nursing Superintendent
548
28.24.35 Functions of the Committee Security
1. To establish and coordinate the Disaster Plan 1. Cordon off area affected.
for CNBC. 2. Regulate entry & exit of personnel to ensure
2. To review and update the Disaster Plan on an services vehicles re–allocated exit & entry
annual basis or more frequently. freely.
3. Run semi-annually drills. 3. Unwanted traffic & public gathering shall be
4. After every drill or disaster, a debriefing must controlled by services till local police help
be carried out to review events. available.
5. All relevant phone numbers lists must be 4. Arrange & deploy extra security personnel
regularly up-dated and distributed to all from the outsourced to maintain discipline in
Departments. the hospital premises.
5. Security staff should use the internal
communication phones & they should make
28.24.36 ACTION PLAN IN CASE OF INTERNAL phones to important personnel.
DISASTER 6. To safeguard all the belongings of the
In the event of internal disaster/ fire, the sequence of disaster victims.
events is as follows (Annexure II) 7. Efficient transfer of casualty where indicated
to mortuary & earmarking the areas where
28.24.37 ACTION PLAN IN CASE OF EXTERNAL bodies can be transferred.
DISASTER (annexure III) 8. Morgue register to be kept that lists the
bodies with their identification, date & time of
SITUATIONS AND ASSUMPTIONS: arrival, time of release & removal by a proper
1. Several types of hazards pose a threat to the person.
hospital: 9. All emergency lights to be kept ready.
2. Minor external disasters: incidents involving 10. Lady supervisor & lady guard to be posted for
less than 10 casualties. all ladies.
3. Major external disasters: incidents involving
10 – 50 casualties. Housekeeping & Dietary
4. Disaster threats affecting the hospital or 1. Relocation of manpower to triage area.
community (large fires, flooding, explosions, 2. Providing extra beds/linen in essential &
Air field incidents etc.). previously earmarked areas.
5. CNBC will treat and handle a maximum of 30 3. Arrange for –
paediatrics casualties before diverting patient 4. IV Stands
traffic to other partner hospitals. 5. Extra Patient trolley
6. For COVID-19 pandemic, a special nodal 6. Wheelchairs
officer has been designated and all protocols 7. Be available to help with the movement of
related to pandemic are dealt by him/her. victims from ambulance to triage.
Num Immedi Delayed care Minor
28.24.38 Specific Responsibilities of various ber ate care 30% care 50%
Departments at the time of Disaster: of 20%
pedi
The Nursing Unit atric
1. Identify nursing needs at the particular point s
of time. casu
2. Allocating extra nursing staff in essential altie
area. s
3. Redeploying existing staff & Recalling of staff.
4. Activating the second floor/ Earmarked area 30 6 9 15
in case of a disaster.
5. Assisting in providing basic life support. 8. Be sure all hallways or traffic areas are clear.
6. Liaison with casualty & purchase to arrange 9. Prepare to serve nourishments to patients.
extra bed, drugs, trolleys, oxygen cylinder in 10. Be responsible for setting up menus in
coordination with all supportive departments. disaster situation & maintain adequate
7. Periodic review of arrangements. supplies.
549
Command Centre transferred and the diagnosis or types of
1. Assembly point of all M.O I/c ‘s. injuries.
2. Deputation of special responsibilities after the 3. Hospitals contacted will be asked to provide
situation analysis. emergency ambulance pick-up for these
3. Assign Volunteers to attend to emotionally patients if necessary or CATS to be informed
disturbed relatives /causalities. about same.
4. Assign Volunteers for liaison between
attendants, consultants & hospital. Inter-Hospital Transfers
Policy: If, in the judgment of the emergency physician,
Pharmacy and Store the patient cannot be adequately cared for at this
1. Report to command center & remain in hospital, the patient should be transferred to an
department. appropriate care facility. This applies to the following
2. Have list of drug supplies that can provide conditions:
emergency supplies quickly.
3. Keep minimum supply of emergency drugs on 1. Severe burn patients that require burn center.
hand at all the times. 2. Severe cardiovascular trauma requiring open
4. Pharmacy should remain open & have a heart pump and/or intra-aortic balloon.
nurse to deliver needed items to areas. 3. Patients requiring kidney dialysis.
5. IV Fluids. 4. Intracranial injuries.
6. Dressing Material. 5. The specialty physician desires to transfer the
patient after stabilization and examination.
6. Polytrauma cases requiring multiple blood
28.24.39 Standard Operative Procedures and transfusions.
Guidelines
Procedure for Transfer:
Internal Disaster Plan 1. A copy of the patient's chart or treatment
Evacuation for Internal Disasters record accompanies him with all charting
completed. X-rays and lab reports will be sent
A. Reasons for Evacuation at the discretion of the transferring doctor.
2. That facility shall be contacted prior to the
1. To remove patients and personnel from transfer and agree to accept the patient.
actual or threatened danger such as fire, 3. Physician to physician contact by telephone
explosion, enemy attack, Bomb threat, etc. should take place prior to transfer.
2. To free hospital beds for the care of incoming 4. A Certification of Appropriate Transfer should
casualties. be completed and signed by the transferring
B. Implementation of Internal Disaster Plan physician, the patient, if possible, and the
transfer nurse.
1. The Director/ M.S office (office Hours) or 5. The patient has been adequately prepared for
Emergency (after office hours) will be transfer according to his condition (IV
informed that an "internal disaster" is in effect. established, pressure dressings,
They will immediately notify all departments. immobilization of fractures, patient airway)
2. Patients will be evacuated from stricken areas and is accompanied in the ambulance by
to "safe" areas of the hospital. competent personnel.
3. The decision, as to the extent to which the 6. A nurse to nurse contact should also take
plan is to be implemented, will be determined place. This can be done after patient has left
by the person in charge. for transfer.
4. Roll call will be taken before, during and after
evacuation, if possible. Hospital Evacuation Plan
1. In the event of fire or other internal disaster,
Resources for Patient Transfer all patients and personnel will have to be
1. Network hospitals can be contacted for removed from immediate danger to a safer
transfer of patients, additional supplies, or section of the building, behind fire doors or
additional personnel. removed from the building. For this hospital
2. Contact the Telephone Exchange, if these this area is earmarked as area in front of
other hospitals need to be contacted. They wards.
will need to know the number of patients to be
550
2. Moving will be done first behind fire doors on Superintendent that a major disaster situation
the same floor and then if those areas exists.
become dangerous, patients and personnel 1. The telephone receptionist in the hospital will
will be moved to lower floors or to the outside notify the following people:
of the building. 2. Emergency Room Doctor, who will assign
3. Moving will be done in a systematic fashion triage nurse duties.
by moving all patients and personnel closest 3. Doctor on call...then all other doctors on staff,
to the danger first. as deemed necessary.
I. For further details kindly refer to CODE 4. Other "on call" people (e.g., Emergency
RED Nursing Team, Emergency surgical team, lab,
II. External Disaster Plan x-ray, all Intensive care units e.g. PICU/NICU
III. General Directions for the etc).
Implementation of the External Disaster 5. Nursing Incharge will call department heads
Plan. at home from here.
6. The C.M.O will be in administrative charge
Day Shift until a person higher in line of authority
a) The Director/ Medical Superintendent/ CMO/ arrives.
Telephone Receptionist receiving the 7. The on-call paediatrician will be in medical
communications about the disaster situation, charge.
should implement the first step of the disaster
plan by notifying the M.O I/c Security that a B. Expansion of Facilities
disaster situation exists and requesting to 1. Reception of Patient
notify the following: I. A receiving and sorting station will be
1. Chairperson of Disaster Committee established in the Casualty Department
2. M.O. I/c Security hallway where all patients will be quickly
3. Nursing Incharge tagged with a Disaster Tag and will be known
4. CMO on Duty by the number on the tag until more
5. Department Heads in the hospital information is available.
6. The nurse in immediate charge will notify the II. Tie hospital disaster tag to ambulance tag
doctor (or doctors) on call or she will ask with hospital tag on top. Put admitting time on
another nurse to notify them. tag. Send to appropriate Treatment Areas for
7. Deputed hospital personnel, at the direction lifesaving care with nurse assigned to each
of Director/ M.S or the M.O I/c Security will patient.
then make the following announcement on 2. Prioritization of Patients
the paging system and repeat it 3 times: Casualties will be classified into 4 categories.
"YOU’RE ATTENTION; PLEASE...DISASTER a) Care of Priority 1 – Immediate Care
ALERT or CODE YELLOW." I. This type of casualty includes:
8. At this announcement, all department heads II. Major hemorrhages
will report to the Command Center at Police III. Severe smoke inhalation
control room in the CNBC Hospital for IV. Asphyxiating thoracic and cervico-
instructions. maxillo facial injuries.
9. All patients involved will be triaged through V. Cranial trauma with coma and rapidly
the Receiving Station (the Emergency progressive shock.
Department hallway). VI. Compound fractures
10. The "Command Center" will be at the Police VII. Extensive burns (more than 30%)
control room in the CNBC Hospital. Additional VIII. Crush injuries
nurses should be requested through the IX. Any type of shock
Command Center. Other department heads X. Spinal cord injuries
or their alternates will contact the number of XI. The following actions are
additional personnel they need. recommended:
 First aid (clearing of the wind pipe,
A. Evening and Night Shifts stopping of hemorrhages by means
b) The CMO will implement the first step of the of haemostatic pads and
disaster plan by announcing the DISASTER positioning the casualty in the
Alert and notifying Director/ M.S. / M.O I/c recovery position).
Security and the Asst. Nursing  Resuscitation
551
 Oxygen administration, except in X. Waiting area in front of ward block-
areas of fuel or fuel soaked area identified for complete
clothing. evacuation.
 Placing the injured under shelter XI. Room no. 150 Ist floor- Media Room.
pending transportation. XII. Waiting area on Ist floor – Waiting
space for media.
b) Care of priority 2 Casualties: XIII. Waiting Hall in front of USG Room –
Delayed Care volunteer’s area.
I. This type of casualty includes: XIV. Corona screening OPD- dead body
II. Non-asphyxiating thoracic trauma storage.
III. Closed fractures of the extremities
IV. Limited burns (< 30%)
V. Cranial trauma without coma or shock 4. Personnel Assignments
VI. Injuries to soft parts I. Specific assignments will be issued to
personnel by their department heads.
Department heads should have more
c) Care of Priority 3: Minor Care than one alternate.
Casualties II. All employees reporting on duty will go
I. This type of casualty includes minor to their department. Their department
injuries only. Certain accidents will head or alternate will then assign
occur where passengers have either specific duties. (All nurses, nursing
minor or no injuries. Because these assistants and unit coordinators report
casualties could interfere with other to Command Center.)
priorities and operations it’s important III. The nurse assigned to a patient being
that they be transported from the moved from Triage must stay with this
accident site to the designated holding patient until relieved by another
area where they should be re- competent person or until the patient is
examined. admitted to a unit and signed off to
II. The first qualified, medically trained appropriate person in charge of that
person available will immediately unit.
begin initial triage. This person will 5. Records
continue triage till more qualified I. Records should be minimized,
personnel relieve him. Victims will be depending on circumstances.
moved from triage area to a more II. Numbered disaster tags will be
appropriate holding area before available in the Receiving Area and
definitive treatment is rendered. affixed to EVERY patient until the
proper outpatient chart or hospital
chart is prepared. Tie this tag on top of
3. Key Areas any ambulance disaster tag and
I. Police control room-Command Centre record time.
II. Triage room in casualty- Triage area III. Sufficient information should be
III. Bed next to triage room- resuscitation recorded in order to aid in identification
room and determination of extent of injuries.
IV. Emergency O.T in Casualty area - This should be done in Treatment
Immediate surgery required. Areas rather than Receiving.
V. Observation room in emergency - IV. Medical Records will prepare casualty
Holding area for surgery and transfer list.
patients. V. Report any major change of the
VI. PICU/NICU - Patients needing life- patient's condition to this Command
support care. Center.
VII. X-Ray Department /OPD area - VI. PICU/NICU, Lab, and x-ray should
Walking wounded, waiting for care. include the patient's disaster tag
VIII. Waiting Hall in front of Registration number and the patient's location in
counter – visitors and relatives. the hospital. Be sure these slips are
IX. ICU Care or direct hospital admissions made out.
- Major medical problems. 6. Traffic Control
552
I. If necessary, the M.O I/c security will is authorized to release information to
notify Police on Tel No.100 and the media.
request assistance in handling III. When information cannot be released,
external traffic. the release should be refused with an
II. Incoming patients and emergency explanation. If delays are encountered,
vehicles will arrive at the Casualty the media should be so advised.
Department entrance.
III. Discharged hospital patients will leave Aid and Donation Receiving Center
by the exit door. The loading dock 1. Only the authorized person from Director/
(Area where utility trucks for supplying M.S is authorized to accept donations and aid
liquid oxygen and other materials etc. from outer agencies. Designated person will
for hospital) will be used for incoming be accountable to all aids received.
supplies. 2. Bomb Threat Procedure
IV. The transfer of victims to other A. Receipt of Warnings:
hospitals will take place at the
Casualty Department entrance but via 1. When a phone call is received:
Exit door marked for such situation. 2. Prolong the conversation as long as possible;
The Holding Area for the transfer 3. Be alert for distinguishing background noises,
patients will be the designated such as music, voices, aircraft, and
Observation Room until the Casualty church/Temple bells;
Department is cleared and cleaned. 4. Note distinguishing voice characteristics;
7. When Additional Bed Space is needed 5. Ask where the bomb will explode, and at what
I. Disaster ward is opened. time;
II. Empty beds in the hospital will be 6. Note if the caller indicates knowledge of the
utilized first. hospital by his/her description of the location.
III. If necessary, the medical staff will 7. Notify authorities and key personnel:
discharge the following types of 8. POLICE
patients until adequate space is 9. Chairperson Disaster committee.
available: B. Search Procedure:
IV. Diagnostic problems and observation
cases those are not bedridden. 1. After the basic details are provided by the
V. Patients about to be discharged. person receiving the call, the M.O I/c Security
VI. Release of Information to the News or his designee should make all the
Media necessary decisions, issue orders, and
VII. The objectives of this guideline are: prepare for the arrival of assistance.
VIII. To protect the privacy, health, and 2. Police should be put in complete authority
welfare of patients. upon arrival. Cooperation with the police and
IX. To address the public's need for others involved is most important. Hospital
information. personnel with master keys should be
X. To improve the flow of information and available.
avoid conflicts which may arise 3. The M.O I/c Security must depend upon his
between the news media, hospitals, key personnel and the equipment
and physicians. immediately available.
C. Hospital Spokespersons: 4. Local authorities may not be as familiar with
I. Only the authorized spokesperson is the floor plan as hospital personnel, nor will
authorized to release information to they have sufficient manpower to conduct an
the media based on these guidelines. adequate search within a reasonable period
If He/she is unavailable, He/she may of time.
delegate this to a qualified staff 5. Therefore, the building will be divided into
member who has been designated by sections, and certain employees be made
Director/ M.S, who has knowledge of responsible for the search in each assigned
the situation and is familiar with these area.
guidelines. 6. Watch for and isolate suspicious objects such
II. In the case of a disaster, a as packages and boxes.
communication center will be set up.
The Director/ Medical superintendent
553
7. Public areas such as the lobbies, cafeterias, B. Approach the scene with caution.
public toilets, and stairwells should be
thoroughly searched. C. Attempt to identify the hazardous material.
8. The search should be thorough, eliminating
those areas which are locked and unavailable D. Obtain further information and assistance for
to the public. equipment, etc.
9. If the caller indicates the area in which the
bomb is located, this area should receive E. Avoid contact with hazardous material and person.
immediate attention. Tight security should be
F. TRY to contain the material as much as possible in
maintained on each area searched until the
one place. Try decontaminating the person, as much
entire search is completed.
as possible at the scene. Setting up the
10. Lifts should be kept available for local
decontamination area should be done ASAP.
authorities.
11. If what appears to be a bomb is found, DO With few exceptions WATER is the UNIVERSAL
NOT TOUCH IT. Clear the area and obtain ANTIDOTE. For biological hazardous materials use
professional assistance. Also, try to isolate BLEACH.
the object as much as possible by closing
doors. General Management of Decontamination Following
12. Generally, personnel should remain calm and Radiation Exposure
alert. Personnel should be properly trained so 1. Before undertaking decontamination, detailed
that patients will not become alarmed. monitoring should be done and recorded. If
13. Notify the Administrator or his designee clothing is contaminated, remove it carefully
promptly of significant developments, and do and slowly so that deposited material does
not divulge to the patients that a bomb threat not become airborne. Wear gloves, gown,
has been received. mask, and shoe covers to protect yourself
14. In the event the patients do learn what is from contamination.
taking place, they should be reassured that all 2. Place all contaminated material into large
is well. plastic bags and seal them. Ensure that no
C. Evacuation: unauthorized personnel are allowed into the
patient decontamination area. In practically all
If a bomb is found, the police will notify the proper contamination cases, the material is easily
authorities to come and disarm it. We WILL NOT removed by a gentle soap and water
EVACUATE unless a bomb is found. If evacuation washing.
becomes necessary, this will be a decision of the 3. After the clothing has been removed, it is
Administrator or person in charge and the police. usually the face and hands that remain as
contaminated areas. During the general
D. Reports:
survey of the patient any abrasion or break in
1. Each person involved should report to the the skin integrity should be carefully searched
M.O I/c Security immediately after a thorough for.
search of his area has been completed 4. Any such areas should be covered by a water
indicating the results of the search. proof adhesive dressing to prevent
2. Key personnel should prepare written contamination and subsequent internal
comprehensive reports to the M.O I/c Security incorporation of the contaminated material. In
outlining any difficulties encountered during washing a contaminated area, wash from the
the incident. These reports will be used to periphery towards the center of the most
update or revise the existing bomb threat contaminated area.
procedure. 5. Use paper towels to mop up the
contaminated soapy water. It is imperative to
treat the skin gently. Do not use an abrasive
Hazardous Material Incidents Protocol scrub or strong detergent. Do not shave hairy
At present the CNBC hospital does not have facilities areas. If redness or tenderness of the skin
for handling patients with hazardous material develops the procedure should be stopped.
exposure. 6. It is important to realize that complete
decontamination of the skin is not something
A. Protect yourself. that has to be achieved at all cost within the
shortest possible time.
554
7. If externally contaminated skin cannot be 6. Hospitalization of patients with chemical
cleaned after several tries, then a skin cream burns should be considered for those with
is applied and time is allowed for the skin to debilitating illness, involvement of the eye,
heal before repeated attempts at cleaning the face, hand, foot, and perineum, burns greater
following day. than 15% TBSA and deep burns.
8. General treatment for internal contamination
is an involved process that is specific for General Management of Pesticide Poisoning
specific isotopes. For example, for radioactive 1. Diagnosis - assess signs and symptoms
iodine the patient is given large doses of non-
radioactive iodine to prevent uptake of the I. Assess basic ABC first - Airway,
radioisotope by the thyroid gland. Breathing, Circulation
9. Certain radioisotopes such as Tritium can be II. TREAT ABC first then assess other signs
flushed from the body by volume diuresis. and symptoms
Consider transfer to Decontamination Center. III. Assess exposure situation: Identify
pesticide or pesticides involved
Acute Management of Chemical Burns IV. Attempt to quantify exposure - ask about
1. Acute management of chemical burns, as dose, duration, route of exposure
with all emergencies, must begin with V. Look for other toxic exposures -
assessment of the patient's airway, breathing particularly solvents, vehicle used to
and circulation. dissolve pesticide
2. The next step is to effectively remove the VI. Specific laboratory tests -
offending chemical. The patient should be VII. If organophosphate or carbamate - draw
completely undressed and all identifiable plasma and RBC cholinesterase level
particulate matter removed. Pooling of the before treatment
chemical in skin folds, nail folds and hair VIII. Cholinesterase Level Symptoms
bearing areas should be identified. a) >50% No symptoms
3. Immediate and prolonged irrigation should be b) 20-50% Mild Poisoning
sought. Immediate and prolonged irrigation c) 10-20% Moderate Poisoning
should then begin. Care should be taken to d) <10% Severe Poisoning
protect personnel from the chemical. IX. ABG, SMAC, CBC
Successful irrigation may be monitored by X. Rodenticide anticoagulants - PT, PTT
checking the pH of the wound. XI. Pesticide levels - interesting and may
4. Once emergency therapy has been started, a help diagnosis but levels often not
specific history of the injury should be taken. clinically helpful and tests expensive
This ideally includes the name and XII. serum organoclorine level
concentration of the chemical, duration of XIII. chlordane, DDT, Dieldrin, Lindane, Endrin
exposure and general health of the patient. XIV. urine organophosphate level
Adequate tetanus prophylaxis is always XV. Chlorpyrifos, diazinon, malathion,
necessary. parathion
5. Repeat examinations of the burn wound XVI. urine 2, 4D, 2,4 5T level
should be made after several hours, at XVII. fat Dioxin level or serum
twenty-four hours and at one week.
555
28.24.40 Annexure-1
Layout Plan In case evacuation is announced, triage will be set up in front of ward block, and
the patients/victims will be transported as follows
Ground floor
first floor
556
557
28.24.41 Annexure II
Code Red Protocol

In the event of fire, the sequence of events is as follows
FIRE
Sensors across Fire alarm point glass

hospital detect fire broken
Alarm Received in Fire Control Room (FCR)
FCR personnel identify the fire zone & inform Security

officer on 327 or Security supervisor (240)
FCR Facilitator and Security personnel goes to the location assess the threat.
NO YES
Is the threat
genuine?
Assess the cause of Assess the fire Commence

false alarm and take fire fighting; Inform Security
corrective action officer on extn: 327 to
announce Code Red
Security Team informs Fire
Brigade, Geeta Colony
Immediately
Point of Control (POC)
Code Red Announced and Point of
Control (POC) established MS
M.O I/c Security

Fire Officer assesses the fire and
decides whether to evacuate the Security officer
building / part of the building
NO YES
Is evacuation
required?
Fire is extinguished
Code Red concluded and Detail A

report of incident to be submitted to
HSC
558
A
Fire Officer orders evacuation.
Telephone operator announces Evacuation. Security Team informs Fire Brigade,

Police, neighboring Hospitals & ambulance services.
Evacuation & accounting of patients is the responsibility of Nurse In-Charge.
Evacuation of other humans & accounting of kitchen and Housekeeping staff is the
responsibility of Security officer.
Patients are evacuated and brought to the Triage area (Front of ward block area).
Ambulance is placed next to emergency ward entry.
After triage the patients are disposed off as follows:
Priority 1: Evacuate to the nearest Hospital with facilities immediately.
Priority 2: Discharge to home.
Code red is concluded when:
All patients are evacuated, accounted for and disposed off.
All other human beings (Patient attendant / Visitors / Hospital Staff are evacuated
and accounted for.
All important marked equipments / Records to be accounted
Fire brigade and Police personnel have arrived and taken over the situation.
559
28.24.42 Annexure III
ACCIDENTS
EARTH QUAKE FIRE
CASUALTY
MEDICAL
OFFICER
ACTIVATE EMERGENCY TEAM
MO I/C SECURITY TRIAGE OFFICER

MEDICAL SUPERINTENDENT
A COMMAND OFFICER
C RESOURCE MOBILIZATION
T
INFORM ALERT I STAFFING POOL
V
A ALT. TRIAGE AREA
DIRECTO LNH/TRAUMA CENTRE T NURSING SUPERVISOR
STANDARD OPERATION TREATMENT
R E
PLANS
DISTRICT AUTHORITIES
SPL.SECY
FOOD & SUPPLIES
Health SECURITY MS
VOLUNTEERS REVIEW OF SITUATION STATUS COMMAND

FIRE
SERVICE OFFICER
PLANNING OFFICER CENSUS CONTROL
PWD
COMMUNICATION REPORT TO HIGHER
OFFICER RELEASE INFORMATION TO AUTHORITIES
COMMUNICATION OFFICER MEDIA & PUBLIC
560
Policy No:- CNBC/HWP/Narcotic/25
Revised By Secretary D & TC and QMD
28.25 Narcotic drugs Policy.
28.25.1 Policy;-
The hospital will adhere to the laws concerning control and use of narcotics substances.
st nd
Availability:- Narcotic drugs are available in PICU, NICU, OT 1 floor (emergency OT), OT 2
Floor (Elective OT) and emergency departments only.
a. Prescribing
i. May be done by doctors approved by the hospital administration to practice in the hospital and
must possess the knowledge to monitor and treat the adverse effect of the drug.
ii. All narcotic drugs must be written with the dose, frequency, duration and signed by the doctor.
Narcotics can be prescribed only for the patients of this hospital.
iii. Procurement and storage
iv. Drugs are procured after permission from drug control department (inj. Morphine) or after
license from excise department (inj. Fentanyl).
v. Demands are asked from each user department at beginning of the year. A consolidated
demand forwarded to purchase section. The total demand of the hospital will not increase more
the approved from licensing authority.
vi. All purchase orders must be signed by store in charge & approved by M.S.
vii. Only store in charge will receive & sign for narcotics.
viii. These drugs are to be stored separately from other medications.
c. Requisition for the first time of narcotics
a. The in charge Nurse/Technician of the ward/OT will determine the requirement of quantities of
narcotics and prepare the requisition in the separate narcotics indent book.
b. Issue of narcotics will be done only to nursing/technician in charge.
D Replenishment
I. Narcotic stock will be replenished on Recorder level basis.

II. The pharmacist/ store keeper shall check the stock levels in the nursing/technical units from the
records on the day stocks are issued
III. Request are to be made on the ‘Narcotic Indent Book” and must be signed by the
nursing/technician in charge & countersigned by the M.O.I/c of the concerned department.
IV. The person who receives and the person who supplies must sign on the Requisition as well as the
Narcotic issue register.
V. User department directly send the broken ampoules of narcotic drugs to the in charge Bio- Medical
Waste Management for proper disposal of the same after proper record keeping and verified by
concerned Mo Ic. -
561
VI. Monthly report of the usage of narcotics of each department has to be sent to the drug &
therapeutic committee for the evaluation.
e. Records & supply & receipt
I. Separate Narcotic stock book
II. Records of supply and receipt of the narcotics will be done in a bound book Called the “Narcotic
stock book”.
IV. The Narcotics stock book should have entries of – ‘Date, Name and address of the supplier,
Transport permit number, Narcotic license number, and quantity received and balance stock.
V. No cancellation, obliteration or alteration using eraser, correction fluid is allowed in the ‘Narcotics
Stock Book’. In case of the corrections due to clerical error, the same will be in the form of a neat
crossing and will be authenticated by the store executive, in the form of a marginal/foot note with
date and initials.
VI. Narcotics issue register will be maintained separately and the signature of the person receiving the
stock will be obtained on it.
VII. All the Narcotics should be stored in the double lock cabinet & the key of the locks should be
kept in the hand of two different people.
f. Usage and Discard Policy
The narcotics (Morphine /Fentanyl) to be used will be prepared by Pediatrician or Anesthetist in

required concentration and will put proper label on the syringe. Label will contain Drug name and
concentration. Drug prepared in a syringe will be used for same day only and left over drug will be
discarded by doctor/technician in running water in front of supervisor.
562
Policy No:- CNBC/HWP/Restraint /26
Director
Approved by
28.26 Restraint Policy
28.26.1 Definitions: Restraint is any involuntary method (chemical or physical) of restricting an individual's
freedom of movement, physical activity, in order to ensure the physical safety of a child.
28.26.2 Purpose
1. To prevent interference /obstruction with medical treatments.
2. To protect medical devices (such as intravenous lines, in - dwelling urinary catheters, and feeding
tubes).
3. To prevent falls and injury of any kind.
4. To control disruptive behavior (such as agitation, wandering, and combativeness).
5. To preclude the possibility of harming self, staff and other patients.
28.26.3 Responsibility: Nursing staff, Physicians, Support Staff.
28.26.4 Chemical restraint: The use of a sedating psychotropic drug to manage or control behavior.
Psychoactive medication used in this manner is an inappropriate use of medication.
28.26.5 Physical restraint: The direct application of physical force to a patient, without the patient's permission,
to restrict his or her freedom of movement. The physical force may be human, mechanical devices, or a
combination thereof.
28.26.6 Policy: Patient dignity should be maintained during restraint.
28.26.7 Physician Orders

1. Restraints shall be applied with only a physician's order that defines the reason for restraint, less
restrictive alternatives, attempted/considered, type of restraint to be used, and duration for which
the restraint may be applied.
2. This time limit shall not exceed one calendar day, after which new orders are required if restraints
must be continued.
3. Verbal restraint orders must be co-signed by the physician within 24 hours of the initiation of
restraint.
28.26.8 Device Application:

1. Restraint shall be applied only by staffs that have appropriate training and knowledge of using
restraints.
2. Documentation in the medical record shall reflect the reason for restraints and frequent
monitoring.
3. The patient and/or family, whenever possible, shall be educated regarding:
563
4. Reason for restraint
5. How the patient/family can avoid restraint
28.26.9 Reassessment of Use: The treating Doctor, in collaboration with the health care team, shall evaluate
the patient at the end of the prescribed duration of restraint to determine the need for continued use of
the device(s). If restraint remains necessary, the order must be renewed. In the absence of order
renewal, restraints shall be removed by the responsible Nursing staff.
28.26.10 Assessment, Care, and Monitoring Definitions: Monitor the patient (2hourly or earlier as per patient’s
condition and same to be documented in nurses notes.) Each aspect of patient assessment and care is
considered complete and may be initialed when the following criteria have been met.
28.26.11 Position: Proper alignment of the restrained limb(s) is maintained.
28.26.12 Circulation: The affected limb(s) has been checked and device application has been determined not
to impair circulation to the extremity:
28.26.13 Pulse is present above and below restraint.
28.26.14 Restraint Status: A plus sign (+) is recorded when restraints are on; a minus sign (-) when they are
off. Caregiver initials are recorded at the bottom of the column to indicate the caregiver completing the
assessment of care. The full signature, name, date and time are recorded.
28.26.15 Documentation: A narrative note is recommended at the time restraints are discontinued and should
reflect any changes in patient condition related to the decision to discontinue the use of restraints.
564
Policy No:- CNBC/HWP/Mortuary/27
28.27 Mortuary
CNBC does not have its own mortuary. All the dead bodies are handed over to the relatives after due
certification. In case of MLCs and longer duration is required for handing over the dead bodies the dead
bodies are transferred to LNH Mortuary.
565
Policy No:- CNBC/HWP/Look Alike Sound alike drugs (LASA)
Revised on: September 2020
Prepared By Dr Manish and QMD
28.28 LASA Drugs
28.28.1 All LASA drugs will be kept in different containers different places.
eg. Inj dobamine and Inj dobutamine must be kept in separate container and places (Different shelves)
28.28.2 LASA drugs will be labeled, one with blue and the other one with green color.
28.28.3 Any time either colored drugs is picked up by the staff for administration to the patient this is to be
brought to mind that there is one more drug is there in the patient care unit either LOOK ALIKE or
SOUND ALIKE &must be cautious. In case, LASA drugs come under the category of high risk
medication, blue/green color also will be used along with red color which is already stuck for high risk
medication identification.
28.28.4 Drugs used in CNBC which may be under category of “Look Alike Sound Alike” include:
28.28.5 COLOR CODING FOR HIGH RISK AND LASA DRUGS
28.28.6 COLOR CODING FOR HIGH RISK AND LASA DRUGS.

HIGH RISK DRUGS RED COLOR STICKER
Red sticker on package to be fixed before storing
Every ampoules/Vials to be labeled with red sticker before issuing to patient care units.
Every syringe to be labeled with red sticker as soon as it is loaded.
Any infusion with high risk drug to be labeled with red sticker.
List of high risk medicines
High risk medicines are those medicines that have a high risk of causing significant patient harm or death
when used in error (Reference- Institute for safe medication practices).
1. Injection Adrenaline 12. Injection Insulin

2. Injection Adenosine 13. Inhaled Anesthetic agents (Halothane,
3. Injection Amiodarone Sevoflurane, Isoflurane)
4. Injection Aminophylline 14. Injection Ketamine
5. Injection 20% Dextrose or greater 15. Injection Labetalol
6. All Chemotherapeutic agents (oral and 16. Injection Lignocaine
IV) 17. Injection Lorazepam
7. Injection Diazepam 18. Injection Magnesium Sulfate
8. Injection Digoxin 19. Injection Milrinone
9. Injection Heparin 20. Injection Morphine
10. Injection Hypertonic saline (3% NaCl) 21. Injection Midazolam
11. All immunosuppressive drugs 22. Injection Naloxone hydrochloride
(Cyclosporine,Tacrolimus, Azathioprine
and Methotrexate)
566
23. Neuromuscular blocking agents 29. Injection Radiocontrast agents
(Succinylcholine, Rocuroneum, 30. Injection Sodium Nitroprusside
Vecuroneum) 31. Injection Vitamin A
24. Injection Norepinephrine
25. Parenteral nutrition preparations
26. Injection Potassium chloride (Kcl)
27. Injection Promethazine
28. Injection Propofol
LASA in HIGH RISK RED & GREEN/BLUE COLOR STICKER
As per hospital policy, High Risk drugs are labeled with red label.
LASA policy also to be followed where LASA drugs are in High Risk drugs
One drug will be labeled with green and the other one may be labeled with blue
COLOR CODING FOR HIGH RISK AND LASA DRUGS.LASA GREEN AND BLUE COLOR STICKER ALIKE
28.28.7 LOOK ALIKE DRUGS

LOOK ALIKE SOUND ALIKE DRUGS IN OPD DISPENSARY,
Any drug from the under mentioned List shall be labeled with Green colored sticker.
Any drug from the under mentioned List shall Any drug from the under mentioned List shall be labeled
be labeled with Green colored sticker. with Blue colored sticker.
LOOK ALIKE DRUGS
LOOK ALIKE SOUND ALIKE DRUGS IN OPD DISPENSARY, updated on 14/09/2020

Syp Amoxycillin Syp Cefixime
Syp Albendazole Drop Dicytomine
Syp leveteracetam Syp Dipenhydramine
Syp Domperidone Syp Ondasetron
Tab Metronidazole Tab Hydroxy Chloroquine Sulfate
Eye Drop Tobramycin Eye Drop Ciprofloxacin
Syp Cholorquine Syp Azithromycin
Tab Pantoprozole Tab Cefixime
Tab Acyclovir Tab Fluconazole, Carbamazepine 200 mg
Linezolid 600mg Tab Lansoprazole
567
Tab Amoxy-clav 375mg Tab Amoxy-clav 625mg
Levothyroxin 25mg Tab Levothyroxin 50mg
SOUND ALIKE DRUGS
TAB Clobazam Tab clonazepam 0.5mg
Tab Cyclophosphamide Cap Cyclosporine
Tab Azithromycin Tab Azathioprine
Tab Hydroxyzine Tab Hydroxy Chloroquine Sulfate
Tab Levocetrizine Tab Leveteracetam
Ointment Clotrimazole Ointment clobetasol
LOOK ALIKE SOUND ALIKE DRUGS (DIALYSIS UNIT)
LOOK ALIKE DRUGS
INJ CALCIUM GLUCONATE INJ SODIUM BICARBONATE , INJ POTASSIUM

CLORIDE
INJ ADRENALINE INJ ATROPINE
INJ MEDAZOLAM INJ HEPARIN
HEMODIALYSIS SOLUTION WITH POTASSIUM HEMODIALYSIS SOLUTION WITHOUT

CHLORIDE POTASSIUM CHLORIDE
SOUND ALIKE DRUGS
INJ EPINEPHRIN INJ ERYTHROPOITIN
INJ PHENIRAMINE MELEATE INJ PHENYTOIN
TH
LOOK ALIKE DRUGS 4 FLOOR
568
INJ CALCIUM GLUCONATE INJ SODIUM BICARBONATE ,
INJ POTASSIUM CHLORIDE
INJ DOPAMINE INJ DOBUTAMINE
INJ CEFOTAXIME INJ CEFTRIAXONE
INJ PIPERACILLIN-TAZOBACTUM INJ MEROPENEM
INJ CLOXACILLIN INJ HYDROCORTISONE
SYRUP ZINC SYRUP CHLOROQUINE
SYRUP DIGENE SYRUP CALCIUM CARBONATE
SOUND ALIKE DRUGS
ADENOSINE AMPHOTERICINE B
CEFOTAXIM CEFTRIAXONE
DIAZEPAM DIGOXIN
DOPAMINE DOBUTAMINE
MEROPENAM MIDAZOLAM
PHENYTOIN PHENIRAMINE
VITAMIN K VITAMIN A
VANCOMYCIN VINBLASTIN
DAUNORUBICIN DOXORUBICIN
VINCRISTINE VINBLASTIN
RD
LOOK ALIKE SOUND ALIKE DRUGS IN (I P D) 3 FLOOR ON 17-09-2020
INJ CALCIUM GLUCONATE INJ POTASSIUM CHLORIDE , INJ SODIUM

BICARBONATE
INJ PHENIRAMINE MALATE INJ PARACETAMOL
INJ SODIUM BICARBONATE INJ DOBUTAMINE
INJ CEFOTAXIME INJ CEFTRIAZONE
569
INJ PEPERACILLIN-TAZOBACTUM INJ MEROPENAM
INJ CLOXCILLIN INJ HYDROCORTISONE
INJ AMIKAICIN INJ DEXAMETASONE
INJ ADERNALINE INJ ATROPINE
INJ DIAZAPAM INJ DIGOXIN
INJ PHENIRAMINE INJ MAGNESIUM
INJ PHENYTON INJ PHENIRAMINE
SYP ZINC SYR CHLOROQUINE
SYP DIGENE SYP CALCIUM CARBONATE
SYP CEFIXIME SYP AMOXY-CLAV
SYP DOMPERIDOME SYP LEVOCETRIZINE
SYP METROGYL SYP 25% DEXTROSE
RD
SOUND ALIKE DRUGS 3 FLOOR
ADENOSINE AMPHOTERICINE-B
CEFOTAXIME CEFTRIAXONE
DOPAMINE DOBUTAMINE
MEROPENAM MIDAZOLAM
PHENYTOIN PHENIRAMINE
LOOK ALIKE DRUGS, PICU 17-09-2020
INJ CALCIUM GLUCONATE INJ KCL, INJ SODIUM BICARBONATE
INJ CEFTRIAZONE INJ PANTOPRAZOLE
INJ PHENIRAMINE INJ PARACETAMOL
570
INJ AMOXYCLAV INJ VANCOMYCIN
INJ AMIKACIN INJ DEXAMETASONE
INJ LEVETERACETAM INJ SODIUM VALPROATE
INJ DIAZEPAM INJ DIGOXIN
INJ PHENIRAMINE INJ MAGNESIUM SULPHATE
INJ PHENYTOIN INJ PHENIRAMINE
INJ FILGRASTIM/G-CSF INJ ENOXAPARIN
INJ PIPERACILLIN-TAZOBACTUM INJ LIGNOCAINE
INJ VITAMIN K INJ ADRENALINE
INJ 3% NaCl INJ 25%DEXTROSE
SOUND ALIKE PICU
INJ MEROPENUM INJ MIDAZOLAM
INJ ADENOSINE INJ AMPHOTERICINE B
INJ VITMAIN K INJ VITAMIN A
INJ FILGRASTIN INJ ENOXAPARIN
INJ LORAZEPAM INJ DIAZEPAM
SYP LOOK ALIKE DRUGS PICU
SYP ZINC SYP CHLOROQUINE
SYP DIGENE SYP CALCIUM CARBONATE
SYP CEFIXIME SYP AMOXY-CLAV
SYP DOMPERIDONE SYP LEVOCETRIZINE
571
LOOK ALIKE DRUGS IN NICU
INJ CALCIUM GLUCONATE INJ SODIUM BICARBONATE / INJ POTTASIUM

CHLORIDE
INJ PIPERACILLIN-TAZOBACTUM INJ MEROPENAM
INJ GENTAMYCIN INJ DEXAMETHASONE / AMIKACIN
INJ LEVETERACETAM INJ SODIUM VALPROATE
SOUND ALIKE DRUGS
INJ CEFOTAXIM INJ CEFTRIAXONE
INJ MEROPENUM INJ MIDAZOLAM
INJ VITAMIN-K INJ VITAMIN-A
INJ CAFFEINE CITRATE INJ MORPHINE
TH
LOOK ALIKE DRUGS 5 FLOOR
INJ MIDAZOLAM INJ HEPARIN
INJ ADRENALINE INJ VITIMIN K
INJ ACYCLOVIR INJ CEFTRIAXONE
SYP AMOXY-CLAV SYP AMOXYCILIN , SYP CEFIXIME
INJ CALCIUM CARBONATE INJ SODIUM BIACARBONATE , INJ POTASSIUM

CHLORIDE
INJ ONDENSETRON INJ TRAMADOL
572
INJ LASIX/FUROSEMIDE INJ MAGNESIUM SULPHATE
INJ LUMINOL/PHENOBARBITONE INJ ADRENALINE
INJ CLOXACILLIN INJ CEFTAZIDIME, INJ AMOXYCLAVE
INJ COLISTIN INJ PANTOPRAZOLE
INJ METROGYL INJ LIGNOCAIN
TH
SOUND ALIKE DRUGS 5 FLOOR
INJ CEFOTAXIM INJ CEFTIRAXONE
INJ DOXORUBICIN INJ DACTINEMYCIN
INJ CEFTAZIDIME INJ CEFOTAXIM
573
Policy No:- CNBC/HWP/Sentinel Event Policy/28.30
st
Released on: 1 May 2008
Prepared By QMD
28.29 Sentinel Event Policy 12 Medication error leading to the death of patent
reasonably believed to be due to incorrect
Sentinel Events administration of drugs
28.29.1 An unexpected incident, related to system 13. Infant discharged to wrong family or infant
or process deficiencies, which leads to abduction.
death or major and enduring loss of
function* for a recipient of health care 28.29.4 Goals of the Sentinel Event Policy
services. A. The policy has four goals:
1. To have a positive impact in improving patient
28.29.2 Major and enduring loss of function refers care, treatment, and services and preventing
to sensory, motor, physiological, or sentinel events.
psychological impairment not present at the
time services were sought or began. The 2. To focus the attention of an organization that
impairment lasts for a minimum period of has experienced a sentinel event on
two weeks and is not related to an understanding the causes that underlie the
underlying condition. event, and on changing the organization’s
systems and processes to reduce the
28.29.3 Sentinel events that is subject to review probability of such an event in the future.
includes but is not limited to any
occurrence that meets any of the following 3. To increase the general knowledge about
criteria: sentinel events, their causes, and strategies for
1. Wrong Surgery on wrong part prevention.
2. Anesthesia related death 4. To maintain the confidence of the public and
accredited organizations in the accreditation
3. Mismatched blood transfusion process.
4. Baby charring in NICU 28.29.5 Action Plan
The product of the root cause analysis is an
5. Gangrene of the limb of the baby
action plan that identifies the strategies
8. Fall from bed that the organization intends to
implement in order to reduce the risk of
9. Green stick injury similar events occurring in the future. The
plan should address responsibility for
10. Suicide of a staff/ relative of patient implementation, oversight, pilot testing as
appropriate, time lines, and strategies for
11. Retained instruments or other material after measuring the effectiveness of the
surgery requiring re-operation or further surgical actions.
procedure
574
28.29.6 Process:
Accident/ incidents are

reported in a designated
format
Report will be sent to the QMD
QMD evaluate the reports and

filter the potential Sentinal
events
Sentinel events are further

forwarded to Secretary- Safety
and sentinel event Committee.
Secretary- SSEC will intensively

analyze the event
SSEC meeting will be

conducted on Emergency basis
and the issue is addressed.
RCA of the event will be done
Corrective action will be taken

to prevent the recurrence of
the event.
575
Policy No:- CNBC/HWP/ HUMAN RESOURCE DEVELOPMENT
Revised on: Jan 2019
28.30 CNBC Healthcare Human Resource Philosophy
CNBC is public hospital under Govt., of NCT of Delhi. All HRD rules, regulations and guidelines followed at
CNBC are governed by HR rules laid down by the Government. People form an integral part of the service
delivery itself. It is evident that CNBC Healthcare will be delivered by people with right skills, value, attitude
and inspiration.
28.30.1 We at CNBC Healthcare are committed to:-
28.30.2 The growth, development and welfare of our people, upon whom we rely to make this happen.
28.30.3 Get the right people into the right job.
28.30.4 Make currently employed people more effective.
28.30.5 Ensure that there is effective leadership both at the top and throughout the organization.
28.30.6 Ensure that the management development processes work in practice.
28.30.7 Build organizational motivation.
28.30.8 We empower employees in their work responsibility, value hard work, collaborative working and
candidness at work. We believe in having fun, not at the cost of work.
28.30.9 KEY PRINCIPLES OF HUMAN RESOURCES

1. Organizational structures will be lean, with a minimum number of levels and with clear individual
reporting and accountability.
2. At every level of the organization, we will select people of the highest quality and with the highest
potential to advance our business.
3. To inculcate a culture of personal growth and organizational excellence based on the principle of
performance based result.
4. We will aim for world-class managerial and technical excellence using continuous learning and
development to support the business and encourage growth from within.
5. We will provide careers, not merely jobs, to our people, through developing them in ways where
organizational needs are matched with personal strengths and potential.
28.30.10 VALUES
1. Create an environment of excitement, informality and trust….reward improvements…and
celebrate results.
2. Demonstrate …always with infectious enthusiasm for patient…the ‘4Es’ of CNBC Culture: the
personal Energy to welcome and deal with the speed of change…the ability to create an
atmosphere that energizes others…. the edge to make difficult decisions…and the ability to
consistently execute.
576
28.30.11 IMAGE
1. It makes you proud of where you work.
2. It makes your family feel happy about your job.
3. It gives credibility to your abilities and competencies.
28.30.12 UNACCEPTABLE BEHAVIOR

1. Entitlement mentality (world owes me something because I have passed some exams)
2. Ego (Untouchable spirit)
3. Lack of respect (Not understanding that many bright people exist in all disciplines)
4. Inflexibility (Inability to deal with the rapidly changing environment)
5. Paralysis by analysis (Too much precision and not enough decision)
6. Stonewalling (Looking at large problems and declaring them impossible, instead of taking them
apart in bite sized chunks)
7. Mysterious black-box mentality (Avoiding discipline, accountable approach by making something
appear more complicated than that it is)
28.30.13 DONT’S…
1. Do not give out customer information.
2. Comment on action of competitors.
3. Comment on issues that are in litigation.
4. Discuss financial projections.
5. Discuss plans, programs, products or operations that have not been announced publicly.
28.30.14 HR PLANNING
A. Manpower and Recruitment
I. As per the services planned, Manpower Planning is done with the collaboration of administrative
reforms (AR) Department Govt. of NCT, Delhi for various posts under different categories.
II. Regular appointments are done through various recruitment boards of Delhi government and
central government like, UPSC, DSSB etc. Pending regular appointments by various statuary
bodies, contractual appointments are being done. Posts in office establishment, accounts section
and planning are filled by the cadre controlling authority and postings are done through
interdepartmental transfer as per govt. policy.
III. Electrical and civil maintenance work is governed by Public Works Department (PWD) and
availability of staff is made by PWD and is governed by rules and regulations of PWD.
IV. The availability/recruitment of the staff is done as per recruitment policy of the government taking
into consideration required qualification and experience of the applying staff for a particular post.
V. Total sanctioned posts for the CNBC are detailed as follows:
STAFF POSITION OF CNBC
1.1.2 1.1.3
S No Designation Sanctioned Posts
A Medical Staff 1.1.4
1.
Director
1.1.5 1.1.6 1
1 Head of Office 1
577
2 Professor(Ped.) 3
3 Professor(Ped.Surg.) 1
4 Assoc. Prof.(Ped.) 5
5 Assoc. Prof.(Ped.Surg.) 2
6 Asstt. Professor 31
7 Asst. Prof. (Cl.Psy.) 2
8 CMO/SMO 1
9 Medical Officer 3
10 Dental Surgeon 2
11 Senior Residents 61(71)
12 Jr Residents 64(42*)
Total A 182
B Nursing Staff 1.1.7
13 Nursing Officers 213
14 Senior Nursing Officers 20
15 ANS 3
1.1.8 1.1.9
Total B 236
C Para Medical Staff .10
16 Sr Radiographer 2
17 Jr Radiographer 5
18 Tech. Astt.(Lab.) 1
19 Lab Tech. 14
20 Lab Asst. 14
21 Lab. Attendant 7
22 Tech. Supervisor (OT) 2
23 Tech. Asstt. (OT) 1
24 OT Tech 6
578
25 OT Asstt. 15
26 OT Attendant 8
27 Dresser 4
28 Asstt.ICCU 3
29 Dark Room Asstt. 1
30 Technician (Blood Bank) 1
31 Lab.Asstt.(Dialysis) 1
32 Technician (BERA) 1
33 Technician (EEG) 1
34 Endoscopic Tech. 1
35 Physiotherapist 1
36 Occupational Therapist 2
37 Speech Therapist 2
38 Social Worker 1
39 Development Worker 1
40 ECG Tech 4
41 Audiometry asst 1
42 Refractionist 1
43
Dental Hygienist 1
44
CSSD Tech 1
45
CSSD Attendant 2
46
Pharmacist 10
Total C 115
D Administrative Staff
47
OS 1
48
Head clerk 2
49
UDC 5
50
LDC 5
51
Cashier 1
52
RO 1
579
53
SO 1
54
Asstt.Programmer 1
55
SI 1
56
JAO 1
57
Stenographer 2
58
Peon 4
Total D 25
E
Ancilliary Staff
59
Asst. Dietician 2
60
Asstt. Librarian 1
61
Library Clerk 2
62
Ambulance Driver 5
63
Ambulance Attendant 4
Total E 14
.11 .12
Grand Total 618
ORGANIZATIONAL CHART, CNBC
Govt.of N.C.T. of Delhi
580
Governing council, CNBC
Finance Executive Director,

Committee, CNBC Society Committee, CNBC Society CNBC Society
HODs of Clinical
HOO/MS Committee Secretaries Departments
Purchase & Outsourcing ANS MRD & Care taking

Accounts
store Dept Services
Administration All Nursing

Branch Officers
Pediatric
Medicine Ophthalmolog
Orthopedics y
Pediatric QMD
Anesthesia
Surgery Radiology Dermatolo
gy
Biochemistry HIC
Dental Microbiology
ENT
Pathology
28.30.15 Outsourced Services

1. All the support services that are outsourced as per decision of the competent authority includes:
2. Housekeeping
3. Nursing orderly
4. OPD registration
5. Laundry
6. Security
581
7. Horticulture
8. Pest Control
9. Biomedical Waste Disposal
10. Staff cafeteria
11. Reception and telephone operator
12. Kitchen
Outsourced Support Services selection is done through tender process.
All the service related documents are maintained by office establishment branch.
28.30.16 EMPLOYEES CODE OF CONDUCT
1. The vision of the CNBC is to deliver world class health care with a service focus by creating an
institution committed to the highest standards of excellence, patient care, scientific knowledge and
medical education. Employee has to keep in mind that reputation and integrity of the CNBC are the
most valuable assets that are vital for the Hospital to attain it’s vision. Each employee is responsible
for conducting his duties/responsibilities in a manner that demonstrates a commitment to our values.
2. The purpose of this Employees Code of Conduct is to provide guidance to help employees
recognize and deal with ethical issues and foster among employees a culture of dedication, honesty
and accountability. No code of conduct can replace the thoughtful behaviour of an ethical
employee. Accordingly, dishonesty or unethical conduct or conduct that is illegal will constitute a
violation of this code, regardless of whether the code specifically addresses such conduct.
3. The organization expects its employees to maintain high standard of integrity, absolute devotion to
duty, promptitude and fairness in the conduct of his assigned responsibilities. All the staff shall
contribute to the emphatic growth of the institute and shall work towards mission and vision of the
Hospital.
4. All the staff of the institute shall maintain discipline and follow hospital policies.
5. All the staff shall display punctually, dedication and honesty in all the activities of the institute at all
times.
6. Co workers must be treated fairly and courteously in respect of their race, religion, caste, creed,
colour, gender, age or nationality.
7. All the staff shall always be polite and sympathetic to the patients attendants and practice high
ethical traditions. All visitors, patients and their attendants are to be attended promptly with all due
courtesy irrespective of their race, religion, caste, creed, colour, gender, age or nationality.
8. Any staff at the institute may be called for duty at any time of the day or night in shifts as per the
needs of the Institution. Duty hours in a single shifts shall normally not exceed beyond 8 hours,
subjective to exigencies of work and convenience of fellow colleagues.
9. Staff, normally required to function on ‘round-the-clock’ shifts basis, shall not leave unless the next
person on duty has reported and has duly taken over the charge of his/her shift. Duty hours for such
shifts shall be fixed as per the convenience of the majority of the staff.
10. No employee shall engage in any business, relationship or activity, which might detrimentally conflict
with the interest of the organization or to the society to which the organization belongs.
11. The employee shall not disclose to any one directly or indirectly, except when the duties may
require, during or subsequent to the term of employment, any trade secret or confidential information
with regard to organization. Trade secret or confidential information for this purpose shall include,
but not be limited to information with regard to Patients, doctors, employees, investigation process /
procedure, diagnostic methodology/facilities, organization’s policies & procedures and any kind of
financial information (including Budget, Turnover, Payments, Salaries of employees including
consultants, contractor, labours etc.)
12. All employees of the organization including consultants on contract, casual/daily rated or part time
shall abide by the provisions of various statutes and Acts as applicable and the rules/regulations
issued by the Central Government/State Government/ Terms and conditions of the contract or any
statutory agencies etc. without limiting the generality and scope of the forgoing, the various codes of
conduct as applicable on this organization shall be deemed to be part and parcel of this code and
582
the employees shall abide and adhere to these codes, which is being Public documents are not
being reproduced herein for sake of brevity. All employees shall carefully peruse such of these
codes as may be applicable to them depending upon the work allocation/responsibility and ensure
compliance thereto.
13. All employees to immediately inform the hospital authorities if they suspect any activity, which is
even prima-facie in contravention with any laws of the land and or any of the statutes/codes
applicable on the organization.
14. Every employee holding a supervisory position shall take all possible steps to ensure the integrity
and devotion to the duty of all the employees for the time being under his control and supervision.
15. No employee shall, in the performance of his duties or in exercise of powers conferred to him, act
otherwise than his best judgment except when he is acting under the direction of his official
supervisor and shall, where he is acting under such direction must obtain the direction in the writing,
whenever applicable and where it is not applicable to obtain the directions in writing, he shall obtain
in writing confirmation of the direction as soon as possible.
16. Employee should not act in a manner prejudicial to the interest of the organization.
17. Employees should not indulge himself in subordination or disobedience of reasonable orders of the
superior, absenting himself from the appointed place of his duties without the permission or
sufficient reason.
18. Employees should not absent himself without leave or over stay the sanctioned leave without
sufficient grounds or satisfactory explanation.
19. Employees should not misuse the medical facilities given to him by the organization.
20. Employee should not receive directly or indirectly any kind of payment, remuneration, gift, donation
or comparable benefits which are intended to or perceived to obtain business or uncompetitive favor
for conduct of its business. .
21. For all those categories of employees for whom uniform/badge are compulsory, must wear the
uniform and badge while on duty.
22. No employee without the permission of management shall accept any kind of part-time employment
or the position of responsibility such as consultant/advisor with any other organization, nor provide
free lance services to any one.
23. Use of any kind of electronic media (Computer/phone etc.) to send or forward messages that
contain intimidating, harassing or offensive material i.e. threatening, disruptive, absence or profane
language or images that may offend on the basis of race , ancestry, place of origin, ethnic origin,
marital status, sexual orientation, family status or physically challenged is strictly prohibited.
24. All appointments of the organization is based on the facts furnished by an employee in the
attestation form and if any information furnished in the attestation form is found to be false and then,
he is liable to be terminated without any notice.
25. All employee shall ensure that the senior management, particularly decision makers have access to
all the relevant documents/information about the hospital on a timely basis.
26. Any change in personal particulars with reference to marriage, change of address shall be
communicated on a timely basis to the Human Resource Department. All communications sent in
the normal course at the address given by the employee, shall be deemed to have been received by
the employee.
27. The telephone ring tones to any of the phones (Landline and Mobile) shall not be those of
embarrassing music. Rather, instrumental tones which do not go against corporate image of the
organization are acceptable.
28. In case of cessation of employment, the respective employee shall not solicit any business from the
existing clientele of the hospital nor engaging in canvassing for any such purpose till the period of 2
years after leaving/dismissal/termination from the services under the organization. The organization
may take up the matter as per law, if any person is found violating this undertaking of the same.
29. No employee should indulge in any act of sexual harassment to any women on her work place. The
employee, who is incharge of work place shall take appropriate action to prevent sexual harassment
to any women at work place. “Sexual harassment” includes such unwelcome sexually determined
behaviors whether directly or indirectly such as:-
30. Physical contact and advance;
31. Demand or request for sexual favour;
32. Sexually coloured remarks;
583
33. Showing pornography; or
34. Any other unwelcome physical, verbal or nonverbal conduct of a sexual nature.
35. Staff of the Institute shall not indulge in use of tobacco or any other prohibited intoxicant in any form
while in the institute premises and shall ensure that his/her visitors too observe this rule.
36. Staff of any level at any stage shall not participate in any strike, agitation or any such form of protest,
which directly or indirectly might disturb patient care services at the institute or disrupt harmony at
institute in any form.
37. While on duty, the staff shall wear neat, clean and ironed uniform, wherever applicable as
prescribed for various categories of employees at the institute. All the staff wear their identity card all
the time in the hospital premises.
38. All of staff members as per their departmental policies are required to maintain proper the records.
All clinical entries in the patient’s medical record shall be accurately dated and authenticated.
NOTE:- The above instances of misconduct are illustrative in nature, and not exhaustive.
28.30.17 PROBATION AND CONFIRMATION

All employees appointed in CNBC will undergo a period of probation as per policy of Govt. of NCT Delhi.
28.30.18 LEAVE RULES

Govt. of NCT Delhi Policy
28.30.19 REWARDS
28.30.20 HOSTEL ACCOMMODATION

28.30.21 Misconduct
Disobedience of any provision of the code of conduct will be treated as misconduct. The employee shall be
liable for the disciplinary action for the misconduct if found guilty of the misconduct during the departmental
inquiry.
28.30.22 Procedure for initiating action against any employee for misconduct
Any kind of misconduct of an employee has to be reported to HR Department by the concerned Unit /
Departmental Head with a note of nature of misconduct with the supporting evidence. The HR Department
on receipt of complaint of misconduct against an employee will initiate the action as per Delhi Govt. Policy
/Terms of contractual appointment.
28.30.23 Medical and / or Hospitalization Assistance: -

Medical and / or hospitalization assistance are available for the employee who’s deduction on
conformation towards DGEHS (regular staff). However, for outsourced: Vendor through ESI.
28.30.24 Outsourced staff

1. Out sourced staff shall have no status of employee of the organization.
584
2. All outsourced staff shall be governed by the terms & conditions of the contract agreement with the
agency / firm providing the services.
28.30.25 Training & Development Plan

1. Induction of Hospital
Ongoing Training Programs
28.30.26 NDUCTION IN THE HOSPITAL
1. Induction is an attempt to introduce and familiarize a new employee with the working and culture of
the organization, his or her job, colleagues and the surrounding environment. This exerts a marked
influence on his or her job tenure and effectiveness in the organization. This process accomplishes
several objectives which include the development of favorable impression about the organization, ,
development of a sense of belongingness , the facilitation of learning and team work on the part of
the employees.
2. Steps of induction program.
3. The detailed orientation program will be outlined / developed by the Human Resource Department in
consultation with the concerned Unit / Departmental Head of the hospital. The program will be
coordinated by the HR Department. The induction training program will have following
components:-
I. Hospital Awareness Training.
II. Technical Training.
III. Soft Skill Training.
IV. Quality Management System Training.
The process of induction will begin on the date of joining, as soon as the joining formalities are completed.
4 An induction manual consisting the following will also be provided:-

I. Introduction of the vision and mission of the hospital.
II. Structure chart of the hospital.
III. The note outlining hospital objective, policies and rules regulations etc.
IV. A note with regard to the various department and facilities provided by the hospital.
1. A new entrant would also be required to study the hospital manual made available to him/her during
the course of induction training.
2. If, there are any queries of the new entrants with regard to induction manual then it will be the
responsibility of the unit and the departmental head to clarify.
3. If the Unit/Departmental head is not in a position to clarify any of the queries to the new entrant then
he would be immediately directed to meet HR Department for the clarifications.
4. All the unit / departmental heads would ensure that new employee:-
5. has been introduced to all the members of his or her department.
6. Clearly understands his or her job reporting channel.
7. Has a clear understanding of the function of the department.
8. Is fully aware of his or her job description and responsibility.
9. Is absolutely clear about his or her level of financial authority and responsibility.
10. Is aware of the process of decision making in the hierarchy of the hospital and in his or her
departmental in particular.
11. Ongoing Training Programs
12. Predefined Training programs are available in hospital.
585
13. It is compulsory to attend all the Internal training program for all the categories of staff
14. The training modules, in addition to academic program will include ingredients of Quality
Management Systems, procedures and soft skills
15. The attendance & performance in these program will be one of very important factor considered at
the time of appraisals.
28.30.27 Performance Appraisal

Performance Appraisal is done as per Govt. Policy for regular staff as per the Performa designed by NCT of
Delhi & for contractual staff appraisal are done by the respective HOD’s.
28.30.28 Disciplinary Action

Rules & Disciplinary Action are governed by existing Govt. Rules for regular staff & for the contractual staff
same are govern by terms & conditions of appointment.
28.30.29 Medical Examination

Candidates selected will be required to go for a medical checkup. The appointment letter will be effective
subject to employee being medically fit.At the time of appointment of staff members regular as well as
contractual staffs are medically examined by as per existing rules of Govt. of NCT of Delhi.
CNBC shall perform annual medical test for all the staff annually.
28.30.30 DUTIES AND RESPONSIBILITIES OF STAFF IN HOSPITAL
27.31.1.1 DIRECTOR
1. Overall supervision of the working of the hospital.

2. Coordination and interaction with the Ministries, MCD, Police and other departments.
3. Planning, Development and budget monitoring of the hospital.
4. Exercise of the financial and Administrative power delegated to him as ‘Head of the Office”.
5. Manpower planning.
6. Interaction and assigning duties to immediate subordinate officers and Head of clinical Departments
so as to ensure smooth functioning of the hospital.
7. Official spokesperson of the hospital.
8. To institute an effective grievance redressal system both for the employees and the patients.
9. The repository of the information pertaining to the hospital.
10. To discharge legal responsibilities, if any, as Head of the institution under various Acts and Court
orders.
11. Any other responsibility given by Department of Health & Family Welfare from time to time.
12. Monitoring of Services
HEAD OF OFFICE/MEDICAL SUPERINTENDANT
1. Liaison officer in the absence of director. He /She will be responsible for all the job assigned to
Director.
COMMITTEE SECRETARIES
586
1. Secretaries of all the committees are responsible for formulation and updating of Terms and
Conditions of individual committee.
2. They will conduct concerned committee meetings at defined interval.
3. Details of individual committees are already mentioned in concerned committee file.
27.31.1.2 MEDICAL STAFF
A. HEADS OF CLINICAL DEPARTMENT
1. They will be responsible for the smooth and efficient functioning of their respective department. They
will be responsible for all the medical staff working in their respective department.
2. They will be responsible for the development and utilization of services of medical and clerical staff
working under them. They will keep the Medical Superintendent informed/take his approval in
important matters in this regard.
3. They will be responsible for maintaining the functional status of all equipments under their
department and will promptly ensure that these equipments function smoothly/repaired, and without
lengthy downtime. They will keep liaison with the company maintaining the machine, officer incharge
of M & R, officer incharge of purchase in this regard.
4. They will be responsible for the proper segregation and collection of hospital waste in their
respective department as per the guidelines issued by CPCB and other authorities from time to time.
A proper record is to be kept by them in this regard.
5. They will be responsible for the sanction of casual leave of staff working under them and will keep a
record of leave. They will make alternative arrangement in case an official proceeds on leave or their
application is forwarded by them.
6. They will assign duties to the various Heads of Units working under them from time to time.
7. They will ensure that all serious patients admitted in their department are well attended and will
keep Medical Superintendent informed about any event which may affect the attention of press,
higher administration authorities or parliament.
8. They will ensure that all records relating to patients especially the MLC cases are in order, complete
and is kept in safe custody.
9. They will be responsible for the general upkeep, sanitation, cleanliness and availability of essential
supplies in their respective departments.
10. They will be the designated authority on behalf of M.S. for issuing condemnation certificate to
declare unserviceable, old & non functionary equipment/furniture etc., where all other sources of
condemnation certification is not possible or available.
11. Organizing teaching/training of P.G. Students/other staff, of the department.
12. Any other duty assigned by M.S.
B. HEAD OF CLINICAL UNITS / OTHER SPECIALISTS
1. They will be responsible for the proper medical care and due attention to all patients admitted in
their units (Indoor, Emergency Wards & ICU).
2. They will be responsible for the smooth and efficient working of their units.
3. They will be responsible for the deployment and utilization of services of medical & clerical staff
working under them. They will keep their Head of Department informed about important issues.
4. The Head of Units must see all patients as soon as possible after admission. Due attention should
be given to all serious patients admitted under them. They will ensure that all serious patients are
well attended and keep their superiors informed about them.
587
5. Heads of units should be easily available for consultation in case of need of patients in their units.
No patient should ordinarily be discharged from the hospital except clear cut instructions from the
head of unit.
6. They will ensure that patients records especially of the MLC cases are up to date, complete and
kept in safe custody. It should be true and faithfully record various events in connection with
treatment, referrals and progress of patients in the hospital.
7. They will be responsible for the general upkeep of their wards/unit, sanitation, maintenance &
functioning of equipments under their charge, adequate availability of essential supplies in their
respective wards. They will keep regular liaison with the officer incharge of maintenance & repair,
sanitation, purchase, stores in this regard.
8. They will be responsible for the proper segregation and collection of hospital waste in their
respective wards as per guidelines issued by CPCB and other authorities issued from time to time.
They will also keep the necessary records.
9. Any other duty assigned by the Head of Department/Medical Superintendent.
10. They will be responsible for teaching and training of residents and P.G. students.
11. Shall have to under go trainings as per policy of the Hospital.
C. ASSISTANT NURSING SUPERINTENDENT
1. Guide planning, implementing and evaluating the total patient care.

2. Maintain the standard of patient care with accepted objectives and policies of the hospital.
3. Provide direct nursing care to the difficult and serious patients.
4. Analyse and evaluate, the kind and amount of nursing service required in each nursing unit.
5. Maintain safe environment and implement hospital infective control policy.
6. Make schedule of duty of Staff Nurses and Group ‘D’ and plan for rotation of nursing staff in her
department to ensure good nursing care.
7. Check attendance register of Staff Nurse, Nursing Sister and receive evening and night reports from
the department.
8. Making recommendation and arrangements for adequate flow of supply of surgical supplies,
equipments, stationary, diets etc.
9. Make an Arrangement for adequate flow of supply of drugs and linen and maintenance of their
accounts.
10. Report about any medico legal cases.
11. Assist in verification of ward stock, their indents maintenance and condemnation etc.
12. Compile and submit statistics / census to the concerned authority.
13. Organise staff meeting with departmental and inter-departmental staff.
14. Act as liaison Officer between Hospital Administration & Nursing staff, Public and other departments.
15. Keep the Administration Office informed of the needs of the Nursing units/ward under her
supervision and of any special problem.
16. Deals with problems, complaints of nurses, nursing students, patients and relatives and of Group ‘D’
staff of Hospital and solve them.
17. Supervise all the nursing functions listed in the duties and responsibilities of staff nurse and nursing
sister posted in nursing units / wards which are under her charge.
18. Write confidential reports of Staff Nurse of hospital.
19. Arrange classes and clinical teaching of nursing staff in the ward.
20. Arrange and conduct staff development programme of hospital.
21. Organize planned teaching of nursing students in the ward.
22. Organize orientation programme for new staff of ward.
23. Provide counseling and guidance of nursing staff and students.
24. Conduct clinical research.
25. Participate in various professional activities. eg. Staff education and staff meeting etc.
26. Any other duties assigned by the seniors from time to time.
27. Review the monthly report and send it to the M. S. Office.
588
1. SENIOR NURSING OFFICER
2. Responsible for overall planning of nursing care of patients and for assignment of patients to nurses
working in the ward.
3. Rendering direct nursing care to the ill patients & directly assisting the surgeons in major operations.
4. Ensuring that total health needs of patients are met.
5. Ensuring nursing standards are maintained throughout the day.
6. Participating in ward rounds with physician, nursing personnel.
7. Coordination of patient care with other department of the hospital.
8. Taking over the patient in each shift and reporting to the senior if anything significant.
9. Custody of poisonous drugs record and their administration.
10. Ensuring safe environment in the ward.
11. Reporting regarding defective equipments and gadgets which are not in working condition.
12. Reporting failure of supply of supply of electricity, water etc. to the Asstt. Nursing Supdt. / PWD
maintenance staff.
13. Taking prompt action in any emergency situation arising in the ward and reporting to the appropriate
authority.
14. Ensuring that ward statistics are regularly maintained and submitted.
15. Interpreting hospital policies and regulation and observing the same.
16. Coordinating and facilitating students teaching programme for new staff.
17. Participating in in-service education programme as well as making sure staff nurses attend classes
in rotation.
18. Providing incidental teaching to patients relatives, staff nurses, student nurse and other Group D
staff.
19. Assisting Asstt.Nursing Supdt.in organizing orientation programme for new staff.
20. Ensure that arrangements are made to assign nurse in emergencies where ever they occur.
21. Ensure welfare of all patients and provisions of special care wherever and whenever it is necessary.
22. Participate in evaluation activities related to the Nursing personnel.
23. Guide her subordinates to maintain a good Inter Personal Relationship with in the Nursing and other
departments.
24. Act as a liaison office between the Asstt. Nursing Supdt.and other Nursing personnel.
25. Organise staff meeting for ANS, Sisters and Staff Nurses from time to time (e.g. How to take care of
the legal aspects, how to take care of a dead body, any change in rules and regulations etc.)
26. Assist in physical verification of stock of hospital and department as required.
27. Deal with the problems and complaints of the Nursing Staff, the public and Grade D staff.
28. Attend the emergency call of hospital and nursing duties in the evening and night.
D. INFECTION CONTROL NURSE

1. The ICN conducts Infection control rounds daily and maintains the registers.
2. The ICN is involved in education of paramedical staff including nurses and housekeeping staff.
3. Maintains registers and data of Sharps/Needle stick injuries and Post –exposure prophylaxis and
other incident reports.
4. Initiates and ensure proper immunization for Hepatitis B Virus Immunoglobulin and HBsAg vaccine,
in consultation with microbiologist (Member HICC) in case of suspected exposure to any hospital
worker. Also initiate for other immunization needs and PEP agains suspected HIV exposure to
HCW.
5. Ensures that all positive culture cases are been tracked and for each positive culture from inpatient
unit a hospital infection information sheet or surgical site infection Sheet is filled and keep record for
each positive culture case. All probable cases of nosocomial infections and anomalous/irrational use
of antibiotics must be discussed in HICC meetings.
6. Track the indicators of infection control and present the data to the HICC meetings on regular basis.
7. Conducts special tasks given to him/her regarding hospital infection control.
E. BIOMEDICAL WASTE MANAGEMENT MONITORING NURSE
589
1. Conducts bio medical waste management activities rounds daily and maintains the registers.
2. Is involved in education of paramedical staff including nurses and housekeeping staff esp regarding
segregation and management of bio-medical waste.
3. Maintains registers and data of waste generation, disposal cumulative for hospital and individual
units.
4. Initiates and ensure visit to the outsourced waste disposal contractors’ disposal sites and methods..
5. Present the data to the HICC meetings on regular basis.
6. Conducts special tasks assigned to him/her by Bio medical waste incharge and/or Infection control
officer.
QUALITY ASSURANCE NURSE (Nursing officers in Quality Management Division)
1. Provide effective leadership manages all activities of the Quality Assurance Department and taking
care of quality assurance measures and programs.
2. Conduct Internal Audits to define conformance to NABH standards, Kayakalp, NQAS and Nursing
Excellence standards.
3. Responsible for establishing and maintaining an assessment program, which includes internal, external
assessment functions.
4. Assist with the development and implementation of SOPs (Standard Operating Procedures) and
Manuals of departments.
5. Supervise employees working in Clinical and non clinical areas of the hospital for Continual Quality
Improvement.
6. Responsible for establishing program, training implementing including orientation training/ induction
with all appropriate personnel.
7. Responsible for reviewing collecting and analyzing data, in order to recognize trends and opportunities
for improvement/corrective action, by using process capability other statically and quality tools.
8. Involve in Documentation control policy of the hospital.
9. Lead and participate Continuous Improvement activities.
10. Provide effective leadership manages all activities of the Quality Assurance Department and taking
care of quality assurance measures and programs.
11. Conduct Internal Audits to define conformance to NABH standards, Kayakalp, NQAS and Nursing
Excellence standards.
12. Responsible for establishing and maintaining an assessment program, which includes internal, external
assessment functions.
13. Assist with the development and implementation of SOPs (Standard Operating Procedures) and
Manuals of departments.
14. Supervise employees working in Clinical and non clinical areas of the hospital for Continual Quality
Improvement.
15. Responsible for establishing program, training implementing including orientation training/ induction
with all appropriate personnel.
16. Responsible for reviewing collecting and analyzing data, in order to recognize trends and opportunities
for improvement/corrective action, by using process capability other statically and quality tools.
17. Involve in Documentation control policy of the hospital.

590
18. Lead and participate Continuous Improvement activities.
1. NURSING OFFICER
2. She will attend to the patients with utmost sincerity and devotion.
3. Safai - Karamchari and Nursing Orderlies will provide full cooperation to Nursing Staff by providing
bed pan and urine pot to the patient.
4. Nursing orderlies will assist personal in making the bed, feeding the patient and arrange for
investigation and diagnostic procedure to the patients.
5. She will carry out administration of Oxygen, cauterization, dressing and toileting of patients.
6. She will maintain record of pulse, B.P. Intake/output, medicines and injections administrated with
date and time & regular care of IV sites.
7. She should be polite and sympathetic to the patient.
8. She will administer the medication to the patient admitted at their bed side as per treatment orders
given by the doctor.
9. She shall have to under go training as per the hospital policy.
10. Discharge his/her duties as per standard procedure / hospital policy.
Job responsibilities of Operation Theater Nurse

1. Provide efficient and effective preoperative nursing care to patient.
2. Perform duties as the scrub/ circulating/ pre and post operative nurse as needed based on knowledge
and expertise for a specific procedure.
3. To assist surgeons throughout the operation.
4. Maintain surgical services in accordance with competency standards.
5. Follow all Surgeon/ physician orders, administer medications.
6. Prepare operating room with surgical equipment, sterile linens and supplies that will be needed during
surgery
7. Assist with patient care in recovery room, procedure room and operating room.
8. Develop and implement nursing care plan for assigned patient.
9. Postoperative room (Recovery)-Do Postoperative monitoring, intervene and discharge patients
according to discharge criteria and orders by anesthesiologist. Assess post operative patient’s pain
level, take interventions as per doctor’s order. do monitoring of patients and
10. Execute proper use, care and handling of surgical equipments to ensure safety of operating staff and
patient.
11. Maintain current and in-depth knowledge of sterile techniques.
12. Assist in ordering, storing and maintaining surgical equipment and supplies.
13. Maintain order, cleanliness and sterility in operating room.
14. Prepare timely and accurate records of patient history and recovery charts.
15. Adhere to safety standards and precautions.
16. Adhere to Surgical Safety Checklist (SSC) to prevent wrong site./ wrong surgery/ wrong patient and
other adverse events.
17. Attend training as per the hospital policy.
591
18. Discharge duties as per standard procedure / hospital policy.
Job responsibilities of Intensive Care unit Nurse

1. Identify patients' age-specific needs and alter nursing care plans as necessary to meet those needs.
2. Identify sudden or subtle changes in patient’s medical condition.
3. Follow all physician orders, administer medications, and conduct treatments and tests for patients in a
timely manner.
4. Assist physicians with procedures such as lumber puncher, biopsy, endotracheal intubation,
endotracheal suction and other aseptic procedures..
5. Monitor patients' fluid intake and output to detect emerging problems such as fluid and electrolyte
imbalances.
6. Deliver regular updates to treating doctor, patients and family members.
7. Develop and implement effective nursing care plan for assigned critically ill patients based on
assessment data and identified needs.
8. Responding to life-saving situations, using nursing standards and protocols for treatment.
9. Document patients' medical histories, treatment plans, interventions, outcomes and assessment
findings
10. Maintain patient’s medical record and other ICU documents.
11. Set up and monitor medical equipment and devices such as cardiac monitors, mechanical ventilators
and alarms, infusion pump sets, oxygen delivery and suction devices etc.
12. Supervise and monitor other health team members.
13. Assess family adaptation levels and coping skills to determine whether intervention is needed.
14. Follow the all hospital policies including End of life care and Effective & Enhancing communication
skills.
15. Adhere to safety standards and precautions.
16. Attend training as per the hospital policy.
17. Discharge duties as per standard procedure / hospital policy.
27.31.1.3 DIETICIAN
1. Management of dietetic department.
2. Management of therapeutic kitchen.
3. Standardization of recipes and supervision of cooking & diet distribution..
4. Teaching dietetic trainees, nursing staff and others.
5. Maintaining duty roster of kitchen staff, leave record, six monthly health records of Class IV
employees and other records required for personnel management.
6. Running nutrition clinic and to attend to Dietetic Clinic.
7. Taking surprise visits to ensure proper distribution of food to patients particularly therapeutic diets.
8. Checking of bills of contractor with regard to diets per month rates and passing them on to Accounts
section through Kitchen Incharge.
9. Maintenance of proper accounts for all diets.
10. Sanitation and cleanliness of kitchen areas.
11. Supervision of fire precautions in the department.
592
12. Any other duty that may be specified by the Medical Superintendent.
F. LABORATORY TECHNICIAN
1. To perform Collection of blood and body fluid samples.
2. Processing of all types of specimens in the laboratory.
3. Preparation of manual/computerized reports.
4. Maintain all kind of laboratory documents including but not limited to report registers, quality control
registers, inventory registers.
5. Shall be responsible for all consumables, kits and equipments related to his/her bench work.
6. Do shift/rotational duties as per needs of the department.
7. Discharge his/her duties as per standard procedure/hospital policy.
8. Shall undergo various training programs at hospital or arranged to other places.
9. Shall participate in departmental teaching programs and workshops.
10. Should be polite and sympathetic to the patients/attendants.
11. Shall report failure of electricity/water etc. to the superiors. / PWD maintenance staff / service
engineer as directed by laboratory consultants.
12. Shall not share any information related to laboratory reports/patient details without consent of the
consultant incharges.
13. Shall perform any other duties assigned by the seniors from time to time.
14. Compile laboratory statistics or other data as and when required by the consultant incharges.
15. Shall actively participate in departmental research activities.
G. LABORATORY ASSISTANT
1. To perform Collection of blood and body fluid samples.
2. Processing of all types of specimens in the laboratory.
3. Preparation of manual/computerized reports.
4. Maintain all kind of laboratory documents including but not limited to report registers, quality control
registers, inventory registers.
6. Do shift/rotational duties as per needs of the department.
7. Shall assist laboratory technicians in their work.
H. PHLEBOTOMIST
1. Draw blood specimens from patients by using finger stick, heel stick and /or venipucture.
2. IV cannulation
3. Collect throat culture specimens.
4. Greets patients and instructs them in proper specimen collection methods.
5. Label specimens for identification purposes and enters specimen data into computer.
6. Prepares specimens for reference laboratory by using centrifuge to spin blood.
593
7. Maintain alphabetical filing system for patient information.
8. Answer telephone calls and routes calls to appropriate member of the medical or laboratory staff.
9. Write test results sent from reference laboratory into patient report, distributes report to clinicians.
10. Inventories and requisitions medical laboratory supplies; stock work area as needed.
11. Keep work area clean and orderly; washes laboratory glassware as needed.
I. Resident Job Responsibility
1. Residency training is an experience designed to offer residents the opportunity to participate in the
clinical evaluation and care of patients in a variety of patient care settings. The service provided by
residents is secondary to the educational objectives of the residency. All aspect of patient care
rendered by resident physicians will receive close supervision.
2. All aspects of patient care are ultimately the responsibility of the attending physician and
consultants. It is the attending physician's responsibility to advise the resident of admissions in a
timely manner and to provide oversight to the students and residents involved In the care of the
patient
3. It is the resident's responsibility to communicate effectively with the attending /supervising physician
regarding the findings of the patient's evaluation, physical examination, interpretation of diagnostic
tests and Intended interventions on a continuous basis.
4. Attending physicians shall review all resident hospital admissions, history and physical
examinations, daily progress notes, and daily orders and shall personally communicate with the
appropriate resident on a dally basis.
J. SENIOR RESIDENTS
1. The Senior Resident will be directly responsible for supervision of patient care in his unit with the
assistance of Junior Residents, specially the emergency cases under the direct control of their Unit
in charges.
2. Perform and record concise physical examinations on patients and verify the findings of the students
and residents under their supervision and will make corrections where necessary and put his/her
notes and plan of care of action.
3. He will be contacted by the Junior Resident on duty in case of emergency. If he thinks necessary, he
should consult the physician/surgeon incharge of the unit or specialist when available.
4. He will go through all the case notes written by Junior Resident
5. Besides taking round in the wards during day time, he will daily take round late in the evening, with
the Junior Resident on call.
6. On admission days, he will attend to case referred for medical opinion from other wards. If
necessary, he may contact the physician/surgeon incharge for necessary advice.
7. In case of death, it is his responsibility to scrutinize that case documentation is complete in every
respect and will write a brief summary of the case, before it is sent to the Medical Records Section.
8. He will maintain a book to indicate the patients in his charge who would need attention after the
night rounds and he will apprise the junior resident of such cases.
9. He will ensure proper communication with families of patients regarding condition of patient etc.
10. Discharge planning, including prescriptions and follow up care, will be developed in consultation
with the attending physician.
11. He will oversee the general upkeep and sanitation of the wards earmarked to him with the help of
nursing staff.
12. Sr. Residents will certify death.
13. Fully participate in the teaching program including teaching conferences, morning report. Grand
Rounds, attending rounds, care conferences and other educational experiences. It is expected that
Senior Residents will be self-directed learners, including continuing education outside the structured
594
residency educational program. They will conduct teaching session for undergraduate, post
graduate and Junior Residents. He will assist the HOD/HOU in research work.
14. He/she will ensure proper documentation of OPD records, indoor patient records etc. as per policy
of the hospital.
15. They shall have to under go training as per the policy of the hospital.
16. Any other duty given by HOD.
K. JUNIOR RESIDENT
1. Junior residents will provide patient care under the supervision of senior residents and attending
physicians. Residents will be given graduated responsibility for patient care based on training
received during the course of the residency as well as the experience and knowledge gained by
each resident, Junior residents (PG / Non PG) will:
2. He will take advice from Sr. Resident for guidance and efficient execution of professional care of his
patients.
3. In OPD, Junior Resident will refer the case to the Senior Resident with a short history and physical
findings of the case written on the OPD card, if required.
4. Junior Resident is primarily responsible for the case allotted to him. Besides, he would have a
general idea of all the cases in the ward. As soon as a case is admitted, patient will be examined by
the Junior Resident who will complete the case sheet in all details. He will then show the case to the
senior resident. He will see that all necessary investigations are done in time and entered in the
case sheet.
5. In case of actually ill patients, it is his responsibility to show the case immediately to the Senior
Resident/GDMO or specialist for advice.
6. He will enter the daily follow up to the case in case – sheet. In case of any seriously ill patients, the
progress of the case will be recorded every time the patient is examined.
7. On admission days junior resident will be physically present on duty in emergency department as
per duty roster and will not leave the department. Unless permitted by the Senior Resident/ GDMO/
specialist on duty in the emergency department. & his /her substitute has arrived for attending to
case admission there.
8. On other days the junior resident on duty should be present in the wards allotted to them.
9. On Sundays and gazetted holidays junior resident will perform the duty according to roster prepared
by the unit.
10. Night emergency duty in ward –
11. Junior Resident from each unit / sub-unit will be on emergency duty in the night for the respective
units in additions to one junior resident staying in emergency department. The junior resident on
night call will apprise himself by direct contact with the Senior Resident who need special attention.
12. Requisite forms for laboratory and X ray investigations should be filled in the previous evening with
full clinical notes for routine cases. In emergency it should be done immediately. The reports of
investigation should be collected in time to be useful.
13. Discharge planning, including prescriptions and follow up care , will be developed in consultation
with the Senior Resident / attending physician.
14. Be actively involved in teaching, training activities.
15. They shall have to undergo training as per the policy of the hospital.
16. If required, Jr. Resident will have to accompany the patient during transfer / investigation within or
out side hospital for patient safety.
17. To carry out any other duties as assigned by the Senior Resident/ consultant.
L. SENIOR RESIDENTS (PATHOLOGY, MICROBIOLOGY & BIOCHEMISTRY)
1. Shall participate in clinical rounds to patient care units as and when required.
595
2. Shall communicate reports with panic values to senior residents/consultants of the concern units.
3. To perform Collection of blood and body fluid samples in difficult/special cases.
4. Shall supervise processing of all types of specimens in the laboratory.
5. Shall process the specimens themselves as and when required.
6. Shall examine and prepare processing notes for all types of clinical specimens and procedures.
7. Shall supervise preparation of manual/computerized reports or prepare them as and when require.
8. Shall supervise and maintain all kind of laboratory documents including but not limited to report
registers, quality control registers, inventory registers.
10. Do shift/rotational duties as per needs of the department including Sundays/other holidays.
MEDICAL RECORDS OFFICER JOB RESPONSIBILITIES:
1. Ensures that medical records and reports are organised and compiled in timely manner.
2. Maintains patient records information confidential.
3. Maintain security and accuracy of the medical records.
4. Shall assign, verify ICD-10 coding of all patients.
5. Ensure that information contained in the record is complete, accurate, and only available to authorized
personnel.
6. Ensure arrival of all patient files and documents and their archival in electronic and physical format.
7. Shall make and/ or verify data entry of patient records into the HIMS to ensure completeness, recording
the data on deficiency checklist and accuracy of medical records in timely manner.
8. Retrieves medical records by following procedure as per hospital/MRD manual.
9. Ensure timely destruction of medical records as per hospital procedure in timely manner.
10. Shall record and maintain various forms and documents e.g. ward census, death registration forms,
police information for MLC cases, MRD circulars, monthly KPIs, Death Register, MLC register etc.
11. Compile data as per requirements of hospital and other outside agencies (DHS, NRHM, MCD etc.) after
appropriate approvals in timely manner based on hospital medical records.
12. Collect data for medical research and for calculating hospital occupancy rates, death rates etc.
13. Prepare statistical reports as per requirements of the hospital.
14. Conducts medical record audits as per laid down criteria by medical records committee.
15. Facilitate regular MRD audits and record audits with other departments of the hospital planned time to
time.
16. Adhere to professional standards, hospital policies and procedures, state, and local requirements, and
NABH standards.
17. Conducts work in MRD as desired by Director, Medical Superintendent or designate from time to time.
M. Security Staff
1. The Security Supervisor will be responsible for overall security arrangement of the concerned
Department covered in the contract.
2. Security Supervisor will ensure that all the instructions of the administration are strictly followed and
there is no lapse of any kind.
3. No outsiders are allowed to enter in the building without proper Gate Pass issued by the Authorized
Officer of the concerned Department.
596
4. No items are allowed to be taken out without proper Gate Passes issued by the competent officers
as laid down in the contract or authorized by the employer for in-out movement of stores. The
specimen signatures and telephone numbers of the above stated officers will be available with the
Security personnel.
5. The officers and staff of the Department will keep the Identity cards with them got checking and
allowing entry by the security personnel.
6. Deployment of Guards/Gunmen/Security Supervisors will be as per the instructions of the authorities
of the Department and the same will be monitored personally by the concerned authorities from time
to time and will be responsible for its optimum utilization.
7. Security personnel deployed in the premises on holidays and Sundays will be assessed as per
actual requirement and the number of personnel will be suitably reduced.
8. The Security Supervisor/Guard will also take round of all the important and sensitive points of the
premises as specified by the Department.
9. Security personnel shall also ensure door keeping duties.
10. The Guards on duty will also take care of vehicles, scooters/motor cycles/bicycles parked in the
parking sites located within the premises of the Department.
11. Entry of the street-dogs and stray cattles into the premises is to be prevented. It should be at once
driven out.
12. The Guards on patrol duty should take care of all the water taps, valves, water hydrants, etc.
installed in the open all over the premises.
13. It should be ensured that flower plants, trees and grassy lawns are not damaged either by the staff
or by the outsiders or by stray cattles.
14. The Security Guards/Supervisors should be trained to extinguish fire with the help of fire
extinguishing cylinders and other fire fighting material available on the spot. They will also help the
fire fighting staff in extinguishing the fire or in any other natural calamities.
15. In emergent situations, security staff/supervisor deployed shall also participate as per their role
defined in the disaster plan, if any, of the Department. Guards/Supervisors should be sensitized for
their role in such situations.
16. The Security Supervisor/Guards are required to display mature behaviour, especially towards
female staff and female visitors.
17. The Security Guard on duty shall not leave the premises until his reliever reports for duty.
18. Any other provisions as advised by the Department may be incorporated in the agreement. The same
shall also be binding on the contractor.
N. Nursing Orderly
1. He will assist nursing personnel in patient care
2. He will take call-book/referral letter to various departments.
3. He will transport the patients from one department to another or for investigations, diagnostic
procedure and referrals, where necessary.
4. He will get the indent/ drugs/linen from stores and also bring sterilized items from CSSD.
5. He will check the oxygen cylinders in use and also replace them as needed or as directed.
6. He would assist the dietary department personnel in orderly distribution of diet in the wards.
7. He will do dusting of the department including cobwebs and will also assist nursing personnel for
disinfection of the rooms. He will take appropriate care of the instruments used in the hospital.
8. He will assist nursing staff in packing the dead body and their transportation to mortuary.
9. He will provide first aid to patients as and when required.
10. He will also perform any other duties assigned by the HOD from time to time in addition to normal
duty roster.
11. At least 10 % of the nursing orderly deployed should be female.
12. The Agency shall ensure economical usage of electricity and water round the clock
13. All nursing orderlies should be courteous in behavior with employees and visitors, and
knowledgeable about the location of various departments to guide visitors
accordingly.
14. They shall not smoke within the hospital premises and prevent use of tobacco in all forms within the
hospital
597
15. The nursing orderly will also help the rescuers in case of any calamity in the hospital.
16. He will be responsible for cleaning articles such as furniture , switch boards, spittoons, fire fighting
equipments, cleaning of tiles above skirting (including wall tiles), furniture in the O.P.D.(before
working time), cleaning of windows (including cleaning from outside), cleaning the facade of the
building , removal of cobwebs etc.
O. Housekeeping Staff
S Job Responsiblities Shifts

N
o
1. Sweeping and wet-mopping washing, scrubbing, swabbing etc in One shift (OPD area)
covered area and cleaning articles lying there in , cleaning of wash
basins , cleaning of windows (including cleaning from outside), Three Shifts (Ward,
cleaning etc. I.C.U., O.T. & emergency
Area)
2. Sweeping open spaces like roads, courtyards, pathways, Garages , Two Shifts
terrace etc
3. Cleaning open spaces like lawns etc kept clean by picking paper-bits One shift
etc & by partial sweepingwherever necessary
4. Cleaning latrines, bathrooms, urinals etc. including dressing rooms ____

and including taps and other sanitary fixtures.
5. Collection, segregation & disposal of garbage as per standard ____

guidelines for disposal of biomedical waste policy of CNBC.
28.30.31 Credentialing & Privileges

1. Office establishment in consultation with C& P committees is responsible for collecting, verifying and
evaluating the credentials (education, registration, training and experience) of medical professionals
permitted to provide patient care without supervision for Doctors, nurses & Paramedical Staff.
Doctor’s credentials are verified online from their medical council website, Nurses and paramedical
credentials are verified with their original documents at the time of their joining.
2. C& P Committees has the right to authorize all medical professionals to admit and treat patients and
provide other clinical services commensurate with their qualifications for doctors, nurses &
paramedical staff.
3. The clinical privileges attached to a particular post/designation are deemed to be accorded to the
incumbent accepting the job offer letter at the time of joining as per clinical privileging guide of
CNBC affixed in apex manual (these privileges are accorded as general privileges). Additional
specific privileges are accorded as per qualifications/training or experience of the health care
worker/employee.
598
27.31.1.4 Procedures
Residents may perform only those procedures and treatments for which the attending physician has
privileges. Residents must by supervised during procedures and treatments by a credentialed attending or
credentialed supervising resident until they have been individually credentialed by the residency program
director as having attained mastery of the particular procedure of treatment.
27.31.1.5 Department of Pediatrics

Clinical Privileging
A. Junior resident/ 1st year postgraduate student (unsupervised)

a. Venepuncture
b. Arterial puncture
c. Intravenous cannulation
d. Nasogastric/ orogastric tube insertion
e. Bladder catheterization
f. Suture laceration
g. Endotracheal intubation
h. Cardiopulmonary resuscitation
i. Intraosseous cannulation
j. Venesection
B. Junior resident/ 1st year postgraduate student (under supervision)

a. Lumbar puncture
b. Incision & drainage of superficial abscess
c. Thoracocentesis
d. Abdominal paracentesis
nd rd
C. 2 year/ 3 year postgraduate student (unsupervised)
a. Arterial line
b. Bone marrow aspiration
nd rd
D. Senior resident or 2 year/ 3 year postgraduate student (under supervision)
a. Chest tube insertion
b. Liver abscess aspiration
c. Peritoneal dialysis catheter insertion
d. Central venous catheterization
e. Umbilical venous/ arterial catheterization
f. Exchange transfusion
g. Liver biopsy
h. Subdural/ ventricular tap
i. Pain management
j. Conscious sedation
k. Suprapubic tap
l. Bone Marrow Biopsy
E. Consultant/ Sr. Resident/ postgraduate student doing thesis in concerned specialty (Under
supervision)
a. Renal biopsy
b. Bronchoscopy
c. Gastrointestinal Endoscopy
d. Dialysis
599
27.31.1.6 Department of Pediatric Surgery
Clinical Privileging Guide
A. Junior residents
1. Independent
a. Dressings
b. Debridement of wounds
c. Urinary bladder catheterization
d. Nasogastric tube insertion
e. Aspiration of abscess
f. Suturing of lacerated wounds
g. Suture removal
2. Under supervision for first two months and then independent
a. Venesection
b. Chest tube Insertion
c. Incision and drainage of abscess
d. Reduction of paraphimosis
B. First year Senior resident in Pediatric surgery

1. Independent 2. Under supervision
a. Incision and drainage of abscess a. Neonatal colostomy
b. Tube Thoracostomy b. Neonatal gastrostomy
c. Pediatric appendicectomy c. Pediatric hernia and

hydrocele
d. Cystolithotomy d. Undescended testis
e. Circumcision e. Hypertrophic pyloric stenosis
f. Excision of superficial f. Iloeostomy/Colostomy

swellings/lymph node biopsy closure
g. Pediatric laparotomy for peritonitis g. Umbilical hernia
h. Venesction h. Torsion testis
i. Central line insertion i. Colostomy and biopsy for

Hirschsprung’s disease
j. Guided Aspiration of liver/splenic j. Urodynamic studies
abscess etc
k. Peritoneal lavage k. Anorectal manometry
l. Pediatric Laparotomy for intestinal l. Ranula

obstruction
m. Meatotomy m. Branchial remnant excision
n. Percutaneous nephrostomy n. Open cholecystectomy
C. Second year Senior resident in Pediatric surgery

a. Neonatal colostomy a. Neonatal laparotomy of intestinal

obstruction
600
b. Neonatal gastrostomy b. Exomphalos
c. Pediatric hernia and hydrocele c. Gastroschisis
d. Undescended testis d. Malrotation volvulus
e. Hypertrophic pyloric stenosis e. Esophagostomy
f. Iloeostomy/Colostomy closure f. Cystoscopy
g. Umbilical hernia g. Nephrostomy
h. Torsion testis h. Vesicosotomy
i. Colostomy and biopsy for i. Ureterolithotomy

Hirschsprung’s disease
j. Urodynamic studies k. Distal hypospadias
urethroplasty/Chordee correction
l. Anorectal manometry m. Anoplasty for low ARM
n. Ranula o. Congenital diaphragmatic

hernia/eventration
p. Branchial remnant excision
.13
q. Open cholecystectomy
.14
D. Third year Senior resident in Pediatric surgery

a. Neonatal laparotomy of intestinal a. Primary Tracheoesophageal fistula

obstruction repair/esophagostomy
b. Exomphalos b. PSARP
c. Gastroschisis c. Modified Duhamel’s procedure
d. Malrotation volvulus d. Swenson’s procedure
e. Esophagostomy e. Soave’s procedure
f. Cystoscopy f. Pyeloplasty
g. Nephrostomy g. Cleft lip/palate repair
h. Vesicosotomy h. Proximal hypospadias repair
i. Ureterolithotomy i. Epispadias repair
j. Distal hypospadias j. Laparoscopy - diagnostic

urethroplasty/Chordee correction
k. Anoplasty for low ARM k. Nephrectomy for benign disease and
Wilms’ tumour
l. Congenital diaphragmatic l. Primary turn in for Exstrophy
hernia/eventration
601
Post doctoral Senior resident may directly be given higher privileges based on experience as assessed by
the head of Department.
28.30.32 Department of Orthopedics

27.31.1.7 Non postgraduate Junior Resident (unsupervised)

Basic preventive, promotive, curative & rehabilitative aspect of orthopaedics at primary level of contact
1. Recognition of bone injuries and sprains and deliver first aid measures for common fractures and
sprains.
2. Manage uncomplicated fractures of clavicle, Colles's, forearm, phalanges etc.
3. Techniques of splinting, plaster immobilization of uncomplicated fractures etc.
4. Incision and drainage of abscesses
5. Perform the management and suturing of superficial wounds
6. Administer local anaesthesia and nerve block e.g. digital block
27.31.1.8 Senior Resident (unsupervised)

Independent work in consultation with consultant
1. Skin traction
2. Skeletal traction of upper Tibia, distal Tibia, lower Femoral
3. Olecranon, Calcaneal and Skull traction
4. Closed reduction of uncomplicated fractures & dislocations.
5. Management of open fractures: Debridement, external fixation.
6. Open reduction and internal fixation of uncomplicated fractures.
7. CTEV manipulation and POP application
8. Tendo Achilles lengthening
9. Bone & Joint Infections: Aspiration of joint; arthrotomy
10. Drainage of abscess
11. Amputations
12. Identify congenital, skeletal anomalies and their referral for appropriate
13. Correction or rehabilitation
14. Recognize common metabolic bone diseases such as rickets as seen in this country and their work
up
27.31.1.9 Final year senior resident (under supervision) / consultant

1. Spine surgery
2. Hip surgeries
3. Postero-medial soft tissue release in CTEV
4. Bony procedures including triple arthrodesis
5. Tendon repair; Tendon transfer procedures
6. Corrective osteotomies of Femur and Tibia
7. Limb lengthening / Illizarov procedure
8. Arthroscopy of joints
9. Tumor surgery
28.30.33 Department of Anesthesia

602
27.31.1.10 Junior resident(unsupervised)
1. Intravenous Cannulation
2. Nasogastric/orogastric tube insertion
3. Venepuncture
27.31.1.11 Junior resident(supervised)

1. Endotracheal intubation
2. Spinal anesthesia
3. Caudal block
4. LMA insertion
5. Cardiopulmonary resuscitation
27.31.1.12 Senior resident

1. IV Cannulaion
2. Endoracheal intubation
3. Spinal anesthesia
4. Pain management
5. Sedation
6. Shifting the patient to Post- OP and ICU
7. Epidural anesthesia
8. CPR
27.31.1.13 Sr. Resident (under supervision)/and Consultant

1. CVP line insertion
2. Arterial cannulation
3. Anesthesia in neonates
4. Regional Blocks
5. Anticipated difficult airway management
6. Fibreoptic intubations
7. Anesthesia in ASA Grade3/4 patients(patients with co morbid conditions)
28.30.34 Department of ENT

27.31.1.14 Junior Resident (Unsupervised)

1. Venepuncture
2. Intravenous Cannulation
3. Nasogastric Tube Insertion
4. Bladder Catheterization
5. Ear Syringing
27.31.1.15 Junior Resident (Supervised)

1. Incision and Drainage of Abscess
2. Cyst Removal
3. Foreign body removal from Ear & Nose
4. Anterior and Posterior nasal packing
5. Indirect Laryngoscopic Examination
27.31.1.16 Senior Resident (Unsupervised)

1. Suction cleaning of Ear
2. Laceration repair under local anaesthesia
3. Endotracheal Intubation
4. Tracheostomy of child >5 years age
5. Examination of child- Hallpike Manouevre
603
6. Caloric test
7. Direct Laryngoscopic Examination
27.31.1.17 Senior Resident (Supervised) or Consultant

All surgeries to be performed under General Anaesthesia
1. Oesophagoscopy
2. Bronchoscopy
3. Tracheostomy of child < 5 years age.
28.30.35 Department of Ophthalmology

27.31.1.18 Jr. Resident / 1st yr. PG. student (unsupervised)

1. Visual acuity determination.
2. Torch light examination.
3. conjunctival swab for c/s.
4. lacrimal massage.
5. Contact lens application/ removal.
6. suturing of lid lacerations.
27.31.1.19 Jr. Resident / 1st. yr. PG student (under supervision)

1. Refractions under cycloplegia & pmt.
2. Determination of contact lens specifications.
3. -syringing/ probing of co-operative/ older children in opd.
4. direct ophthalmoscopy
5. 90 D examination.
6. schiotz tonometry of older/ cooperative children in the opd
7. i& d of preseptal/ lid abscess in the OT.
8. -syringing / probing in G.A.
9. slitlamp examination and staining procedures.
10. schirmer test.
11. Keratometery
12. Scan
13. B-scan
14. artificial eye application.
15. treatment of ocular trauma.
27.31.1.20 2nd/3rd yr. P.G. students ( unsupervised)

1. IOL power determination
2. diagnosis of the peripheral lesions of retina.
3. examination under anaesthesia.
4. exploration& repair of the globe.
5. evisceration / enucleation.
27.31.1.21 2nd/3rd yr. p.g. student (under surervision) or Sr. Resident

1. ECCE with IOL.
2. squint surgery
3. DCR surgery.
4. R.D.surgery.
5. anterior and pars plana vitrectomy.
27.31.1.22 Senior resident under supervision / Consultant

1. Independent squint surgery.
2. Independent R.D. surgery and cryo application.
3. Independent IOL exchange surgeries
604
4. scleral fixation IOLs
5. Independent vitrectomies.
28.30.36 Department of Dermatology

27.31.1.23 Junior Resident (unsupervised)

1. Venepuncture
2. Intravenous cannulation
3. Suture laceration
4. Needle extirpation of Molluscum Contagiosum
5. Taking samples for pus culture
6. Preparing slides for Gram’s or Giemsa stain examination
7. Aspiration of bullae
8. Stitch removal
9. Cardiopulmonary resuscitation
27.31.1.24 Junior Resident (under supervision)

1. Chemical cautery with trichloro aceitic acid
2. Electrocautery for viral warts (verruca vulgaris, not on face)
3. Incision and drainage for abscesses.
4. Skin Biopsy
5. Slit skin smaear
6. Triamcinolone acetonide injections for keloids
27.31.1.25 Senior Resident (unsupervised)

1. Electrocautery for viral warts (verruca plana, lesions on face)
2. Electrocautery for pyogenic granulomas or other skin growths.
3. Patch testing in cases of suspected contact dermatitis.
4. Excision of larger skin growths
5. Nail surgeries like Nail avulsion and treatment of ingrown toe nail
27.31.1.26 Consultant or Senior Resident (under supervision)

1. Sclerotherapy with polidocanol for hemangiomas
2. Nail surgeries like Nail biopsy
3. Vitiligo surgery
28.30.37 Blood Storage Centre
27.31.1.27 Junior Resident (Under Supervision)

1. Blood Grouping
2. Cross Matching
3. Coomb’s Test – Both Direct & Indirect
4. Maintenance of Blood Storage Facility
5. Record Keeping
605
27.31.1.28 Senior Resident (Un-Supervised)
1. Blood Grouping
2. Cross Matching
3. Coomb’s Test – Both Direct & Indirect
4. Maintenance of Blood Storage Facility
5. Record Keeping
6. Maintenance of the Stock
7. Disposal of Bags
8. Disposal of Bio-Medical Waste
27.31.1.29 Medical Officer / Senior Resident (Supervised)

1. Data Generation
2. Data analysis
3. Quality control monitoring
4. Training of Junior Staff (Doctors& Para Medics)
5. Implementation for rational use of Blood & Blood Components
28.30.38 Department Of Pathology

27.31.1.30 Junior Resident (Under Supervision)

1. TLC (Total Leukocyte Count)
2. DLC (Differential Leukocyte Count)
3. Fluid Cytology (Cell Count & Differential)
4. Urine Microscopy
5. Feeding Blood Sample in the Cell Counter
st
Senior Resident 1 Year (Under Supervision)

4. Urine Microscopy
5. Platelet Count
6. Peripheral Smear Count
7. Coagulation Profile
8. Reticulocyte Count
nd rd
27.31.1.31 Senior Resident 2 & 3 Year (Un-Supervised)
4. Urine Microscopy
5. Platelet Count
6. Peripheral Smear Count
7. Coagulation Profile
8. FNA (Fine Needle Aspiration)
9. Record Keeping
10. Reticulocyte Count
rd
27.31.1.32 Consultant / Senior Resident 3 Year (Supervised)
1. FNAC (Fine Needle Aspiration Cytology)
2. BMAC (Bone Marrow Aspiration Cytology)
3. BAL Cytology
606
4. Peripheral Smear with Abnormal Cells
5. Special Stain Cytology
6. Quality Control Slides
7. HPLC Reporting
8. Sickling Test
28.30.39 Department of Biochemistry

27.31.1.33 Junior Residents (under supervision of senior residents)

1. Preparing the biochemistry auto analyzer (OLYMPUS AU 400); running calibrator and quality control
samples in the same.
2. Preparing and running quality control samples in electrolyte analyzers (ECOLYTE and COMBILINE).
3. Running patient samples in auto analyzer and electrolyte analyzer with assistance from technicians.
4. Maintenance of registers.
5. Calibration of pipettes.
6. Daily record of temperature charting of refrigerators and cold storage.
27.31.1.34 Ist Year Senior Residents ( under supervision of senior SRs/ Consultants)
1. Monitoring of the daily quality control data in OLYMPUS AU 400 auto analyzer and Electrolyte
analyzer.
2. Calibrating and running quality control samples in METROLAB 2300 auto analyzer.
3. Calibrating and running quality control samples in automated immunoassays (BECKMANN
COULTER) and running patient samples in the same.
4. Doing manual ELISA.
5. Doing urine aminoacidography by thin layer chromatography ( to be started soon...)
6. Reconstitution and preparation of reagents whenever required.
7. Panic value reporting and recording.
27.31.1.35 IInd and IIIrd year Senior Residents ( under supervision of Consultants)
1. Supervising the daily work of technicians/Junior residents/ first year Senior residents.
2. Analyzing the quantity control data from Levey-Jenning chart in OLYMPUS AU 400 analyzer.
3. Preparing Levey-Jenning chart (manually) for each parameter being done on METROLAB 2300
analyzer, electrolyte analyzer and analyzing the data for the same.
4. Maintenance of internal quality control record.
5. Updating the results and maintaining records for external quality assessment scheme.
6. Responsible for proper maintenance of all equipments.
7. Cross checking the stock position of reagents in store and maintaining proper record of the same.
28.30.40 Department of Clinical Microbiology and Infectious Diseases

27.31.1.36 Junior Residents (Unsupervised)

1. Preparing Slides for KOH, Gram stains, other stains
2. Instructions to the patients regarding methods and care of clinical samples
27.31.1.37 Junior Resident (Supervised)

1. Reporting gram stains from culture
2. Urine microscopy
3. Stool microscopy
4. Panic value reporting
5. Record keeping – entering reports in registers and computers
6. Molecular diagnosis procedures
7. Serology procedures
607
27.31.1.38 Senior Resident (Unsupervised)
1. Preparing Slides for KOH, Gram stains, AFB Slides, other stains
2. Instructions to the patients regarding methods and care of clinical samples
3. Reporting gram stains from culture
4. Urine microscopy
5. Stool microscopy
6. Panic value reporting
7. Record keeping – entering reports in registers and computers
27.31.1.39 Senior Resident (Supervised)

1. Molecular diagnosis procedures and reporting
2. Serology procedures and reporting
3. ELISA Reporting
4. Maintenance of records and Quality Control data
5. Fungal cultures reporting
6. Pyogenic culture reporting
7. Taking part in hospital infection control program
8. Reporting Direct gram and KOH preparations
9. Any other special procedure
10. Any kind of scientific research
27.31.1.40 MSc Students doing summer projects in clinical microbiology - (supervised)

1. Research activities related to their projects
2. Data generation
3. Writing project report
28.30.41 Dress Code

1. It is compulsory for doctors to wear apron in OPD/ Ward.
2. Dress code of nurses and paramedical are as per Govt. of NCT of Delhi/ Hospital policy.
3. For outsourced staff (Nursing Orderly, Housekeeping, and Security guard) dress code are as per
concerned tender document.
4. It is compulsory to wear identity card with defined dress for all employees working in the hospital.
5. Proper PPE to be used wherever required.
608
Policy No:- CNBC/HWP/32
Released on: February 2012
Director
Approved by
Revised by Dr. Aikta
28.31 Employee Health Check-up Policy
28.31.1 Purpose: To ensure the fitness of the employees working in the Hospital.
28.31.2 Scope: All employees involved in direct patient care.
28.31.3 Policy:
28.31.3.1 Health Check-ups are done at two levels:

A. Pre- Employment Health Check-ups
B. Annual Health Check-ups (Regular health checkup )
A. Pre- Employment Health Check-ups:

It is mandatory for all categories of employees joining the Hospital to go through pre-employment
health check-up before joining as per government recruitment rules; records are kept in the
Personal Record Files of the staff.
B. Annual Health Check-ups:

1. It has been done for those employees who have been working for more than 1 year and recorded
in the Annual health check-up Performa and investigations are done if required on the
recommendation of the Doctor.
28.31.3.2 In annual health check up some specific area staff will require specific test like
28.31.3.3 Staff working in

1. Gas Plant- Audiometry
2. Kitchen staff – Stool examination and Nasal smear.
3. Laundry – Dermatologist consultation
4. DG set- Audiometry
5. Driver-Eye Examination
609
Policy No:- CNBC/HWP/ 28.33
Released on: Jan 2014
Revised on: - August 2020
Prepared By Drug and Therapeutic Committee
28.32 Management of Near Expiry and Expired Drugs
28.32.1 To promote the optimum utilization of drugs and to prevent the wastage of drugs due to expiry, near
expiry drugs shall be identified three months prior to the date of expiry. The nursing sister in-charge
shall contact the other patient care units to exchange the drugs with longer shelf life or patient care
units with higher demands of the drug so that it can be utilized with required documentation. If the near
expiry drug could not be utilized in the hospital within the period, written information is given to store for
further information to other govt. hospitals in Delhi NCR for the utilization of the same.
28.32.2 Drugs with expiry date up to one month can be dispensed from OPD pharmacy; however the same can
be used for in patients (wards) under supervision till the date of expiry to prevent wastage of drugs.
28.32.3 28.33.2 In case the drugs expire, the condemnation of the expired drugs shall be done as per the GFR
and Delhi Govt. guidelines.
610
Policy No:- CNBC/HWP/GRC/28.34
Reviewed By HOO, Grievance Officer and QMD.
28.33 Grievance
28.33.1 Definition-
An official statement of a complaint over something believed to be wrong or unfair.
or
A feeling of resentment over something believed to be wrong or unfair.
28.33.2 PURPOSE:
 The purpose of this policy and procedure is to provide a complaint and

Grievance handling framework for the complainants as well as complaint recipients,
 To provide guidelines on how to lodge a complaint or grievance and how that
Complaint or grievance will be dealt with.
 To investigate the complaint by unbiased and experienced people of hospital, solve the matter and do
CAPA for it.
28.33.3 RESPONSIBILITY: HOD/Supervisor, HOO, Director, Grievance committee
28.33.4 DISTRIBUTION: All the employee of the Hospital.
28.33.5 A Complaint and Grievance Redressal (CGRC)Committee
28.33.5.1 A Complaint and Grievance Redressal ) Committee (CGRC) was established in Chacha Nehru Bal
Chikitsalaya to look into the complaints made by public and employees.. The hospital has a Grievance
Redressal Committee (Public and Staff) constituted as follows:
1. Dr T S Daral, Consultant -- Chairman
Contact detail:- 011-21210215, Ext no. 128
2. Dr MamtaJajoo, HOO -- Member,
Contact detail:- 011-21210215,Ext no. 104
3. Dr D Saikia, HOD (Pediatrics) --Member
4. Dr Manoj Kumar Gupta, DMS --Member
5. Dr RPS Dhingra, CMO --Member Secretary
28.33.6 The Complaints/Suggestions boxes are installed at strategic public locations in the hospital (Out
Patient Department registration counter, casuality and ward block area. complaints can also be
submitted directly to the Director,CNBC or Medical Superintendent, CNBC. In case of any emergency
beyond the routine working hours, the complianant can contact the casuality medical officer (CMO) or
senior resident (SR) posted in casualty. The Complaint/Suggestion Boxes are opened weekly
(Thursday) in the presence of designated officer and documented in register. . In case of any public
611
holiday on Thursday, the box is opened on next working day. If required, the recommendation of the
Committee are subsequently sent to the administration / concerned section for action taken under
intimation to GRC.
Dr T S Daral, Consultant, designated Grievance Redressal Officer under Section 23 RPwD Act, 2016.
Shri Amit Kumar, Pharmacist is designated as Nodal Officer (1031 helpline) , Ext no;318
Disciplinary authority – Executive body headed by the Director CNBC

Appellate authority - Governing council CNBC.
28.33.7 Management Of Grievances For Employees

POLICY:
Grievance redressal procedure shall be explained to the employees during the hospital orientation programme
so that they can address their grievances to their supervisors / Section Heads / HOD / Senior Management.
The redressal procedure shall address the grievance and with help and advice of the supervisor / section head /
HOD / Senior Management attempts to redress the grievance and sort out the problems at all levels.If not
satisfied then they can appeal the committee through Grievance redressal officer as shown below.
Appropriate actions shall be taken to redress the grievance by the HOD and Senior Management. Counseling
sessions shall be scheduled, with the individual and all attempts shall be made to ensure that there is a
redressal of the grievance to everyone’s satisfaction.
Complaints to the HOD(Head of department)
.15
Complaints to the Grievance Redressal Officer
.16
Grievance Redressal (CGRC) Committee
Interventions and feedback to complainant
Disbursement.
612
28.33.8 Management of grievances of patients/ attendants.
CNBC receives grievances by different modes
1. Directly lodge the complaint to the HOO

2. through suggestion box
3. PGMS Portal
4. CPGRAM portal .
Dealing of compliant through various modes
1. Directly received complaint ( HOO office) and through suggestion box are marked to committee . If
required complaint sent to Grievance Redressal (CGRC) Committee for detailed investigation and feed
back communicated to complianant accordigly.
2.PGMS Portal ( Public Grievance Monitoring System) : PGMS system is owned and maintained by
PGMS,Chief Ministers officers,Govt of NCT of Delhi.
All complaints/grievances concerned to CNBC are forwarded to CNBC by PGMS and addressed by
concerned individual/HOO
2. CPGRAM portal (Central Public Grievance Redressal and monitoring portal /toll free no.1031) at
https://pgportal.gov.in/Home/LodgeGrievance
It is a standardized web based solution.CPGRAM is functional at the board (CBEC) level. Grievance
lodged by citizen are received by the nodal officer and then forwarded to CNBC for appropriate action.
CNBC deals with the grievance and update the portal with feedback by HOO
613
Policy No:- CNBC/HWP/Referral/28.35
st
Released on: 1 June 2014
Reviewed By QMD
28.34 Referral Policy
28.34.1 INTRODUCTION: - An effective referral system ensures a close relationship between all levels of
the health system and helps to ensure patients receive the best possible care.
28.34.2 PURPOSE: -
28.34.3 Access to hospital services is via the submission of a written referral form.
28.34.4 Referrals received should contain the minimum data required for safe, efficient, administrative,
and clinical management of referred patient.
1. It should make clear that required consultation is urgent or on routine basis and whether
bed side consultation is required or not.
2. All urgent referral must be seen within 1hour, and routine case shall be seen within
24hours.
3. Referral can also be done by telephonic message which may be appropriately
documented in the referral form.
614
28.34.5 Flow Chart of Referral System.
28.34.6 Patient assessed by consultant
Plan of Referral for required consultation
Referral form filled by treating doctor
Urgent (1hour) Routine
Consultation is informed Referral from is sent to

concerned
Telephonically by treating doctor / consultant
Call sent to concerned department
Call noted by concerned person Call noted by concerned

consultant
Call attended
Bed patients are attended at the bed side walking patient are seen in the concerned department
Notes- All patients referring within the hospital should be accompanied by nursing orderly and Junior
residents for unstable patients.
615
Policy No:- CNBC/HWP/Crash Cart/35
st
Prepared By QMD
28.35 Crash Cart
28.35.1 INTRODUCTION
1. A crash cart is the trolley for storing
lifesaving equipment and drugs in all
patient care units. The cart is 28.35.2 PURPOSES:
characterized by being easily movable and To enhance the Code Blue team’s response
readily accessible into all sides of the cart to patients with emergency medical
for quickly viewing and removing situations by providing immediate
equipment and drugs during a crisis access to supplies and medications.
situation.
2. A crash cart is a set of 1. A specific crash cart type facilitates staff
trays/drawers/shelves on wheels used in familiarity with equipment
hospital for transportation and dispensing 2. It is help to ensure a properly stocked
of medication/equipments at site of emergency cart will be readily available
emergency. Crash carts are located in 3. It also ensures a properly functioning
areas of patient care in case of a life- defibrillator will be readily available.
threatening occurrence. Doctors & nurses 4. It helps to save the valuable time at the
must become familiar with the contents of time of emergency.
this cart. It contains necessary equipments CONTENTS A
to handle an emergency situation. Crash Cart contains the tools and drugs
3. A crash cart is enabling healthcare needed to treat a person in or near
providers to manage medical emergencies cardiac arrest. These include:
easily and confidently.
616
28.35.2.1 CRASH CART CHECK LIST (Injections)
S No. INJECTION QUANTITY
1 INJ. ADRENALINE 5 (Amp.)
2 INJ.ATROPINE 5 (Amp.)
3 INJ.CALCIUMGLUCONATE 3 (Amp.)
4 INJ. DERIPHYLLIN 5 (Amp.)
5 INJ. DEXTROSE 25% 2 (Vac)
6 INJ. DIGOXIN 3 (Amp.)
7 INJ. DOPAMINE 3 (Amp.)
8 INJ.FRUSEMIDE 5 (Amp.)
9 INJ. HYDROCORTICONE 3 (Vial)
10 INJ. XYLOCARD 2 (Vial)
11 INJ. MAGNESIUM SULPHATE 5 (Amp.)
12 INJ. MIDAZOLAM 3 (Vial)
13 INJ. PHENARAMINE MALEATE 5 (Amp.)
14 INJ. PHENYTOIN SODIUM 5 (Amp.)
15 INJ.SODIUM BICARBONATE 3 (Amp.)
28.35.2.2 CHECK LIST FOR CRASH CART

1. TOP SHELF: I/ V FLUIDS b. Suction catheters
a. Ringer lactate - 2 vacs c. Adhesive tape
b. 5% Dextrose - 1 vac d. Surgical blade
c. 10% Dextrose - 1 vac e. Xylocaine Jelly
d. N/2 - 1 vac e.
th
e. N/4 - 1 vac 4. 4 DRAWER:
f. N/S - 2 vacs a. I/V Cannula 24, 22, 20G)
b. Surgical gloves different sizes)
c. Spirit swabs
2. INJECTIONS IN CONTAINERS: (1 to d. 3 way adapter
6) e. Clave connector
f. I/V set
g. Pediatric drip set
1. PLATFORM:
a. Hand rub - 01 th
5. 5 DRAWER:
b. Defibrillator - 01 (If available) Syringes & needles (all sizes
c. Oxygen key - 01
th
d. Ambu bag (large) - 01 6 DRAWER:
st
1 DRAWER:
a. Feeding tubes
a. Injection (7 to 15) b. Mucous extractor
b. Distilled water c. Oxygen tubing with mask
d. Ryle’s tube
nd
2. 2 DRAWER:
a. Laryngoscope Blades with cells- 01 6. OXYGEN CYLINDER STANDS:
b. Ambu bag with mask (different sizes) Oxygen cylinder complete
c. Airway
d. Torch
3. Electrodes
rd
3 DRAWER:
a. E.T tubes (all sizes)
617
GENERAL INFORMATION:
1. A nursing staff in each shift is

designated by the nursing sister of the
department is responsible for checking
the crash cart, oxygen cylinder levels,
defibrillator, drugs & consumables and
documenting compliance on crash
cart checklist.
2. The cart is to be checked after every
use and staff will replace any missing
supplies.
3. Crash cart is checked every shift and
inventory recorded.
4. Defibrillator load checks will be
performed in every shift with the
defibrillator plugged in and unplugged.
5. Sterile items will be checked for
package integrity and expiration date.
6. Items with expiration dates expiring
within the month will be replaced.
7. Laryngoscopes will be checked to
ensure it is in working condition
8. Oxygen cylinders & flow meter are
checked in every shift & replaced when
the pressure gauge shows less than 40
Kg/cm2.
9. Drawers of crash carts are to be clearly
labeled to identify contents.
618
Policy No:- CNBC/HWP/ Employee ‘s Rights at CNBC
st
Prepared By QMD
28.36 Employee ‘s Rights at CNBC
28.36.1 Are treated fairly and free from discrimination against on account of race, gender, ethnic or social
origin, colour, marital status, pregnancies, sexual orientation, disability, age, political persuasion,
conscience, culture, language or family..
28.36.2 To ensure equal opportunity in the workplace to pursue their career.
28.36.3 To ensure that their suggestions, inputs and ideas are taken into consideration when making
decisions affecting them.
28.36.4 To report anyone involved in fraud, corruption, nepotism, maladministration and any other act which
constitutes an offence irrespective of his or her position.
28.36.5 To work in environments that are free of sexual harassment.
28.36.6 To be treated with Dignity and Respect by Management, staff and colleagues and the public at all
times.
28.36.7 To be free to voice complaints, grievances and concerns through the normal channels without
victimization in any way.
28.36.8 To utilize effective mechanisms in place to promote effective communication between Management
and staff and vice versa.
28.36.9 To have their concerns addressed in a fair and just manner.
28.36.10 To have their rights as contained in the constitution respected and protected. .
28.36.11 To a safe working environment which is equipped with the necessary physical, material and
personnel requirements.
28.36.12 To receive appropriate orientation and goal-directed in-service education & skill development
relevant to their career pathing.
28.36.13 To a working environment which is free of threats, intimidation and interference as far as possible.
28.36.14 To obtain moral support and guidance from Supervisors or Management within reason.
28.36.15 Can be involved and represented in the workplace
619
Policy No:- CNBC/HWP/Sedation Policy
Prepared By MO IC Anesthesia
28.37 SEDATION POLICY
Please refer policy 13.27 (Chapter 13- Department of Anesthesia Manual, Version- 4.6).
620
Policy No:- CNBC/HWP/HAZMAT
Prepared By QMD
28.38 HAZARDOUS MATERIAL POLICY
the maximum usage requirements for a

28.38.1 .Definition:- Hazardous Material: A reasonable time period.
product, waste or combination of
substances which because of its quantity, 28.38.4.1.2 Hazardous Material Receipt
concentration, physical, chemical, toxic,
radioactive, or infectious characteristics
may reasonably pose a significant, actual, When the hazardous material is received, the
or potential hazard to human health, container, bottle, etc., shall have the label affixed
safety, welfare, or the environment when
improperly treated, stored, transported, to the container by the department ordering the
used, disposed of, or otherwise managed. hazardous material. The label must include the
Hazardous materials include - without expiration date of the material.
limitation - synthetic organic chemicals,
petroleum products, heavy metals, The material shall be stored, if not used
radioactive or infectious materials immediately, in accordance with the
manufacturer's MSDS (Material Safety Data
28.38.2 Purpose: To ensure the safety of the Sheet) or label warnings.
employees working in the Hospital.
28.38.4.2 Handling and Use of Hazardous Material
28.38.3 Scope: This policy is prepared in
accordance with CNBC Plans, Policies
28.38.4.2.1 A. Storage
and Standard Operating Guideline.
28.38.4 Policy: All hazardous material must be stored in

appropriate cabinets. until use and returned for
28.38.4.1 Procurement of Hazardous Materials safekeeping after use. Containers of hazardous
materials should not be left on bench tops when
28.38.4.1.1 A. General requirements not in use.
1. Only authorized faculty and staff may 28.38.4.2.2 B. MSDS Information

order hazardous materials or acutely
hazardous materials. 1. It is important that anyone using
2. Before ordering hazardous materials, hazardous material read the Material
ensure that suitable materials are not Safety Data Sheet (MSDS) associated
available with the hazardous material before its use.
3. Procure hazardous materials in the 2. Anyone handling or using hazardous
smallest quantities available which meet material shall use personal protective
equipment as noted in the MSDS.
621
28.38.4.2.3 C. Disposal of Empty Hazardous
Material Containers
1. Empty containers may be discarded into a

wastebasket as appropriate. A container is
considered empty if the contents have
been removed by the normal procedure
for that hazardous material, pouring,
scooping, etc.
28.38.4.2.4 D. Hazardous Material on hand without

Future Use
Any hazardous material which is deemed

unacceptable for future use or is identified as
excess material without future need, will be
declared hazardous waste by attachment of the
appropriate hazardous waste label and managed
in accordance with the manufacturer’s
recommendation.
28.38.4.3 Training
28.38.4.3.1 A. Responsibility
1. It is the responsibility of the department

supervisor (MO ICs and Sister incharges
and QMD) to schedule and provide
training for all persons who require
hazardous material and safety training as
a part of their normal job functions.
2. Any person who has needed to handle or
use hazardous materials and has not had
the required training shall notify the Mo IC
or QMD for training.
28.38.4.3.2 B. Applicability
Hazardous material handling training is strongly

recommended .it requires training for all persons
involved with hazardous waste in the normal
course of their work
1. Any employee who is involved with

chemicals handling must receive annual
formal training.
28.38.4.3.3 C. Record Keeping
1. Records of training will be maintained for

each person trained. Information in the
record will include the course, date
attended.
2. Records will be maintained by the MO ICs
and QMD for one year.
622
Policy No:- CNBC/HWP/MSDS
Prepared By QMD
28.39 MATERIAL SAFETY DATA SHEET (MSDS) POLICY
28.39.1 Material Safety Data Sheets (MSDS) are developed by chemical manufacturers or importers of each
chemical or product supplied to record available scientific evidence used in making hazard
determination.
28.39.2 They provide the following information for the consumer:
28.39.2.1 Chemical and common name(s) of the material(s)
28.39.2.2 Physical and chemical characteristics of the material
28.39.2.3 Physical and health hazards of the material
28.39.2.4 Signs and symptoms of exposure
28.39.2.5 Medical conditions aggravated by exposure
28.39.2.6 Primary route(s) of entry
28.39.2.7 Permissible exposure limits
28.39.2.8 Precautions for safe handling and use
28.39.2.9 Applicable control measures
28.39.2.10 Emergency and first aid procedures
28.39.2.11 Name, address, and telephone number of party responsible for preparing the
28.39.2.12 MSDS
28.39.2.13 Other related material regarding the hazardous material.
28.39.3 Supervisors of departments shall be responsible for maintaining a current MSDS for each hazardous
chemical in their area(s) of responsibility.
28.39.4 It must be readily accessible to each employee who may come in contact with the hazardous
chemical. Supervisors are also responsible to provide department-specific training on hazardous
chemicals for their employees.
28.39.5 When a new product is purchased, the purchaser must obtain the MSDS from the product
manufacturer or distributor.
623
Policy No:- CNBC/HWP/Effective Communication Policy
Prepared By Grievance Officer
28.40 EFFECTIVE COMMUNICATION POLICY
28.40.1 Introduction-
28.40.1.1 Good communication is an essential component of providing care and in building a relationship
between health care providers and their patients. Communication is defined as ‘the process where
messages are conveyed effectively from person to person’.
28.40.1.2 Effective communication is necessary to keep the patient or patient’s guardian informed about the
condition and progress of the child to seek their support and trust in the healthcare. Additionally, it
should also be used as the health care provider’s primary tool for conveying respect, empathy and
compassion to patients and their families.
28.40.2 Purpose:
28.40.2.1 To establish positive Health Care Worker-patient relationships
28.40.2.2 To be effective in expressing interest/concern for patient/family
28.40.2.3 To provide health care information
28.40.2.4 To communicate with colleagues
28.40.3 Advantages of an effective communication:
28.40.3.1 Patients and caregivers develop trust and a healthy relationship with the caregivers.
28.40.3.2 Communication improves compliance and adherence to treatment thus improving clinical
outcomes.
28.40.3.3 Communication prepares the family for likely poor outcomes in any sick child or child with chronic
illness.
28.40.3.4 Communication decreases malpractice claims and acts of violence by parents/ guardians.
28.40.4 Components of communication:
624
28.40.5 Key aspects of communication: Verbal Non-verbal communication
28.40.5.1 Active Listening – most important communication

Vocabulary Personal appearance
28.40.5.2 Empathy
Shared meanings Posture and gait
28.40.5.3 Respect
Culturally sensitive Facial expression
28.40.5.4 Genuineness Pace, Tone Gestures
28.40.5.5 Using touch Clarity Eye contact

Timing Sounds
28.40.5.6 Using silence
Relevance Personal space and touch
28.40.5.7 Paraphrasing and clarifying
28.40.5.8 Culturally sensitive
28.40.6 Conducting an effective communication:
28.40.6.1 Always introduce yourself. Ask the parents or caregivers to introduce themselves too.
28.40.6.2 Make the person comfortable.
28.40.6.3 Drop any prejudices or foresights before you begin a communication.
28.40.6.4 The senior most person available on duty should conduct the communication.
28.40.6.5 Content- Explain the current situation. Ensure transparency. Explain what the likely plan of action
and care and what is required of them as parents/ caregivers. Also inform about the available
choices for the parents to enable them to make a decision.
28.40.6.6 Closing - Summarize what you have narrated. Before closing, give them time to ask if they have any
questions. Be receptive to the questions. In case of uncertainty, do not mislead or give any wrong
information. Be truthful. Don’t ask- ‘Do you understand? Instead ask ‘Is there anything that is not yet
clear or you need further clarifications?
28.40.7 Pitfalls during communication which should be avoided:
28.40.7.1 Don’t make judgments
28.40.7.2 Don’t make the parents or caregivers guilty.
28.40.7.3 Don’t embarrass the parents or caregivers
28.40.7.4 Don’t raise your voice or tone of voice even if the parent is agitated. Be gentle.
28.40.8 SPECIAL SITUATIONS WHERE :-

Some specials situations are listed below where effective communication or prognostication is
needed.
1. Breaking Bad news.

2. Disclosing Death.
625
3. Handling an aggressive patient/Family.
4. Communication in case of emergency/disasters.
5. Disclosure of an adverse event
28.40.9 Breaking news of death:The initial communication of the death of a loved one is the first step in the
bereavement process. In order to facilitate a normal grieving process, it is essential that relatives
receive excellent communication and support from healthcare professionals.
28.40.9.1 This news should be ideally provided by someone who is the treating senior care provider and not a
stranger. Where possible, death should be anticipated and relatives encouraged to spend time with
the patient before death occurs.
28.40.9.2 While breaking bad news and maintain eye contact, medical professionals are advised to sit and
make patient’s relatives comfortable by providing/offering seat too.
28.40.9.3 Assess the relatives’ existing knowledge before breaking the news.
28.40.9.4 Information should be honest and accurate, tailored to meet the family’s needs and shared in an
empathetic and caring way.
28.40.9.5 Avoid euphemisms. Words such as “dead” and “died” should be used and repeated several times.
The healthcare provider should respond appropriately to relatives’ reactions and gives them time to
ask questions.
28.40.9.6 All questions should be answered.
28.40.9.7 The sanctity of the conversation should be maintained.
28.40.9.8 The use of non-verbal communication is important- avoid crossed arms, maintain low tone of voice.
28.40.9.9 The family should be prepared for dealing with practical matters, such as collecting the death
certificate.
28.40.9.10 If the relatives are not present when the patient dies, they should be contacted by telephone and
encouraged to attend the hospital. However, if they ask if their relative is alive or dead, they must be
told the truth.
28.40.10 Documentation
Prognostication of patients to be explained to patient’s relatives whenever required and to be
documented in defined format. (Form no. CNBC 210).
28.40.11 Unacceptable Behavior:-

Unacceptable behavior (including bullying, harassment and victimization), may involve actions, words
or physical gestures that could reasonably be perceived to be the cause of another person’s distress or
discomfort. Bullying or harassment may be by an individual against an individual or involve groups of people.
Eg. Abusing patients, Hurting the religious or cultural sentiments, communicating with
disrespect.
626
627
Policy No:- 50/ CNBC/HWP/Clinical handover
Released on: August 2020
Prepared by QMD
28.41 CLINICAL HANDOVER POLICY
28.41.1 28.41.1 Definition-

Patient handover is a communication that occurs between two shifts/patient transfer where by the
specific purpose is communicate information about patient under the care of them.
28.41.2 28.41.2 Purpose:

1. To maintain the continuity of care
2. To improve the quality of care
3. To ensure patient safety
4. To increase service satisfaction
5. To prevent delayed treatment
6. To prevent medication error
7. To prevent communication error
8. To prevent duplication
28.41.3 SCOPE
This policy is prepared in accordance with patient care in CNBC, ensuring patient safety .
28.41.4 POLICY: As per this policy complete handover to be given to the recipient department (HCW)
including following parameters;
 Patient Identification
 Diagnosis
 General Condition
 Complete Case file with treatment
 Special handover (if any)
A structured format to be used for patient handover during shift change/ transfer of the patient.
28.41.5 Structured format of clinical handover

SL Patient Age/Sex CR.No Diagnosis General Complete Special Handed Taken
no Name Condition case file handover over over
including (if any) by(Name by(Name
treatment with with
Signature) Signature)
If any significant change observed in the patient condition during handover, should be informed to superior
(Clinician, Sister In charge).
628
Policy No:- CNBC/HWP
Released on: August 2020
Director
Approved by
Prepared by QMD
28.42 Document Control Policy:
28.42.1 Purpose
28.42.2 The purpose of this document is to establish the CNBC document control Policy
28.42.3 Scope
28.42.4 The document control policy applies to hospital Policies, Manuals, Standard Operating Procedures,
Protocols, Various CNBC Forms, Templates and Supporting Documents that are governed by the
CNBC.
28.42.5 Roles and Responsibilities
28.42.5.1 Quality Manager

1. Function as the document owner for the Document Control policies, processes and procedures.
2. Oversee the daily operations of the Document Control Process
3. Update the document control policy and procedural documents to maintain currency with best
practices and requirements
4. Manage controlled documents in accordance with approved procedures for document control
5. Controlled Document Numbering and Approval
28.42.5.2 Quality Management Division

1. Establish and operate the Document Control System
2. Participate in the controlled document review and approval process
3. Establish and manage a system and procedures for managing controlled documents throughout the
document lifecycle
4. Maintain the quality record for the document control system.
28.42.5.3 Employees
 Follow approved procedures for creating, revising, reviewing and accessing controlled documents
Participate in the controlled document review and approval process
629
28.42.6 Related Documents
Document Number Document Title
28.42.7 Supporting Documents

Document Number Document Title
28.42.8 Process
28.42.9 Controlled Document process

The CNBC is documented through structure of controlled documents. The controlled documents used and
the types of documents are:
Hospital Policy documents
o Apex Manual
o Standard Operating Procedure (SOP)
Support documents
o Form
o Protocol
o Template
o Registers
28.42.10 Controlled Document process for Hospital Policy Documents

Controlled documents exist within a defined controlled document lifecycle. The following are the steps in the
controlled document lifecycle.
1. Writing documents
2. Review of draft documents
3. Approval of draft documents resulting in controlled documents
4. Access and use of controlled documents
5. Periodic review of controlled documents
6. Revision of controlled documents, if necessary
630
7. Retirement of controlled documents.
8. Archival of controlled documents.
28.42.11 Controlled Document process for Support Documents

1. they are reviewed and approved with their parent procedure (including periodic review).
2. they are intended for one-time use and/or
3. they are approved by qualified personnel prior to and/or in conjunction with their use .
The following are the primary steps in the support document lifecycle.
4. Writing support documents.
5. Review of draft support documents.
6. Approval of draft support documents resulting in controlled documents.
7. Effective support documents are made accessible and available for use.
8. Execution of a support document.
9. Review and approval of the completed support document.
10. Archival of completed support documents as controlled records.
28.42.12 Creating Controlled Documents

Controlled documents are created in a consistent format and style according to the work instruction Controlled
Document Content, Format and Style Requirements
The document author is required to create all necessary supporting documents.
At the approval review stage, supporting documents must be submitted for review along with the parent
controlled document.
28.42.13 Controlled Document Numbering and Approval

1. When review is complete, the document author makes the necessary edits to the document and
submits the final document to the Quality Management department. A document manager assigns a
unique identifying number and routes the document for final approval signatures according to policy
instruction Controlled Document Numbering .
2. Controlled Document Release, Access and Availability
3. Once all required approval signatures are obtained, the document manager makes any previous
version of the document obsolete and releases the new document for use according policy.
28.42.14 Controlled Document Periodic Review

Controlled documents may be reviewed and revised annually; however, controlled documents are subject
to an automatic periodic review every year from the effective date of the document. The Quality management
department initiates and manages periodic review according to the policy.
28.42.15 Controlled Document Retirement

631
There are two pathways to controlled document retirement. Upon release of a new version of a controlled
document, the previous version is retired. During periodic review or any interim review, a controlled
document may be identified for retirement. In some circumstances, a controlled document may be retired
with no replacement. The Quality Assurance document management department retires documents in
accordance with the policy and Archiving
28.42.16 Controlled Document Archival

Retired controlled documents are retained as part of the quality record. Retired controlled documents will be
retained in accordance with the requirements and methods established in the record management process.
28.42.17 Exceptions
 Documents that are not identified as controlled documents in the quality manual and which are not
required to be managed under the document control system are exempt from the requirements of this
policy. Such documents frequently include but are not limited to documents and records that are
created and pertain to CNBC financial information, in as much as they are not required to be
maintained under the quality system for compliance to federal, state or local law.
28.42.17.1 Quality Records

 The Quality Record/Hospital policy Records (Historic records of the Quality Management Division)
 Document review and approval records
28.42.18 Document History

Date Version Description of Change
632
Policy No:-51/ CNBC/HWP/Use of abbreviation
Prepared By QMD
28.43 APPROVED ABBREVIATIONS FOR USE IN MEDICAL RECORDS POLICY
28.43.1 Policy:-
1. This policy contains the authorized list of abbreviations to be used at Chacha Nehru Bal Chikitsalaya,
Delhi.
2. It applies to all medical records whether hard copy, electronic, in other forms.
3. It replaces any local abbreviation lists held at discipline or department level.
4. All medical records must be legible and easily understood by all persons who access them.
5. Only approved abbreviations and symbols may be used in patient’s medical record.
6. Medical diagnosis must be written in full.
7. If however, a medical diagnosis appears on the Approved Abbreviation list, it must be written in full in
the first instance, followed by the abbreviation in brackets and then the abbreviation may be used
thereafter. For example, urinary tract infection (UTI).
8. No abbreviation will be accepted other than approved standard list of abbreviations.
9. The use of abbreviations is not permitted when documenting:
I. On Consent Forms
II. Discharge summary/ LAMA.
28.43.2 LIST OF APPROVED ABBREVIATIONS IN CNBC

S.NO. ABBREVIATION/SYMBOL FULL FORM
1 # FRACTURE
2 @ AT THE RATE
3 AA ARYTENOID ADUCTION
4 ABG ABG-ARTERIAL BLOOD GAS
5 ABM ACUTE BACTERIAL MENINGITIS
6 ABR AUDITORY BRAINSTEM RESPONSE
7 ACHD ACYNOTIC HEART DISEASE
8 ACL ANTERIOR CRUCIATE LIGAMENT
9 ADEM ACUTE DISSEMINATED ENCEPHALOMYELITIS
10 ADHD ATTENTION DEFICIT HYPERACTIVITY DISORDER
11 ADPKD -AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY
DISEASE
12 AEC ABSOLUTE EOSINOPHIL COUNT
13 AED AUTOMATED EXTERNAL DEFIBRILLATOR
14 AEP AUDITORY EVOKED POTENTIAL
15 AFO ANKLE-FOOT ORTHOSIS
16 AGA APPROPRIATE FOR GESTATION AGE
17 AGE ACCUTE GASTRO ENTRITIS
18 AGN -ACUTE GLOMERULO NEPHRITIS
19 AHI APNEA-HYPOPNEA INDEX
20 AI APNEA INDE
21 AKD CACUTE KIDNEY DISEASE
633
22 AKI -ACUTE KIDNEY INJURY
23 ALP ALKALINE PHOSPHATASE
24 ALTB AIRBORNE LASER TEST BED
25 AML ACUTE MYELOID LEUKEMIA
26 ANA ANTINUCLEAR ANTIBODY
27 ANA ANTINUCLEAR ANTIBODIES)
28 ANT ANT-ANTERIOR
29 ANT. ANTERIOR
30 AOM ACUTE OTITIS MEDIA
31 AOP APNOEA OF PREMATURITY
32 AP ANTEROPOSTERIOR
33 APSARP -ABDOMINO POSTERIOR SAGITTAL
ANORECTOPLASTY
34 APSGN - ACUTE POST-STREPTOCOCCAL
GLOMERULONEPHRITIS
35 AR ALLERGIC RHINITIS
36 ARM ANORECTAL MALFORMATION
37 ARM -ANORECTAL MALFORMATION
38 ARPKD -AUTOSOMAL RECESSIVE POLYCYSTIC KIDNEY
DISEASE
39 ASA ASA-AMERICAN SOCIETY OF ANESTHESIOLOGISTS
40 ASD AUTISM SPECTRUM DISORDER
41 ASIS ASIS-ANTERIOR SUPERIOR ILIAC SPINE
42 ASIS ANTERIOR SUPERIOR ILIAC SPINE
43 ATT ANTITUBERCULAR THERAPY
44 AV ARTERIOVENOUS
45 AVM ARTERIOVENOUS MALFORMATION
46 B/L -BILATERAL
47 BAER BRAINSTEM AUDITORY EVOKED RESPONSE
48 BAHA BONE ANCHORED HEARING AID
49 BBD -BOWEL BLADDER DYSFUNCTION
50 BCG BCG VACCINE
51 BD TWICE DAILY
52 BERA BRAIN STEM EVOKED RESPONSE AUDIOMETRY
53 BIND BILIRUBIN INDUSED NEUROLOGICAL DYSFUNCTION
54 BIS-BI BIS-BI SPECTRAL INDEX
55 BMP BMP-BIO MECHANICAL PREPARATION
56 BNR -BLADDER NECK RECONSTRUCTION
57 BOA BEHAVIOR OBSERVATION AUDIOMETRY
58 BOTOX BOTULINUM TOXIN
59 BPD BRONCHOPULMONARY DYSPLASIA
60 BPD -BRONCHOPULMONARY DYSPLASIA
61 BPPV BENIGN POSITIONAL PAROXYSMAL VERTIGO
62 BTE BEHIND THE EAR
63 BX BIOPSY
64 C1-C7 CERVICAL VERTEBRAE
65 C3 COMPLEMENT COMPONENT
66 C3GN -C3 GLOMERULONEPHRITIS
67 C4 COMPLEMENT COMPONENT
68 CAH CONGENITAL ADRENAL HYPERPLASIA)
69 CAH CONGENITAL ADERNAL HYPERPLASIA
70 CCAM -CONGENITAL CYSTIC ADENOMATOID
634
MALFORMATION
71 CDH -CONGENITAL DIAPHRAGMATIC HERNIA
72 CDH CDH-CONGENITAL DIAPHRAGMATIC HERNIA
73 CDH CONGENITAL DIAPHRAGMATIC HERNIA
74 CECT CONTRAST ENHANCED COMPUTED TOMOGRAPHY
75 CH CONGENITAL HYPOTHYROIDISM
76 CHD AACYANOTIC CONGENITAL HEART DISEASE
77 CHD CONGENITAL HEART DISEASE
78 CHD CONGENITAL HEART DISEASE
79 CHF CONGESTIVE HEART FAILURE
80 CHL CONDUCTIVE HEARING LOSS
81 CK CREATINE KINASE
82 CKD -CHRONIC KIDNEY DISEASE
83 CKD -CHRONIC KIDNEY DISEASE
84 CLD CHRONIS LUNG DISEASE
85 CLD CHRONIC LUNG DISEASE
86 CLE -CONGENITAL LOBAR EMPHYSEMA
87 CMC CARPOMETACARPAL (JOINT)
88 CML CHRONIC MYELOID LEUKEMIA
89 CNS CENTRAL NERVOUS SYSTEM
90 CO2 CO2-CARBON DIOXIDE
91 COM CHRONIC OTITIS MEDIA
92 CP CEREBRAL PALSY
93 CPA CEREBELLOPONTINE ANGLE
94 CPAP CONTINUOUS POSITIVE AIRWAY PRESSURE
95 CPAP CONTINEOUS POSITIVE AIRWAY PRESSURE
96 CPC -CONGENITAL POUCH COLON
97 CPK CREATINE PHOSPHOKINASE
98 CPK CREATINE PHOSPHOKINAS
99 CRP C REACTIVE PROTEIN
100 CSF CEREBROPSINAL FLUID
101 C-SPINE CERVICAL SPINE
102 CT COMPUTED TOMOGRAPHY
105 CTEV CLUBFEET
106 CVA CEREBROVASCULAR ACCIDENT
107 CVP CVP-CENTRAL VENOUS PRESSURE
108 CVT CONGENITAL VERTICAL TALUS
109 CXR CXR-CHEST X-RAY
110 CXR CHEST X-RAY
111 DB DB- DISTOBUCCAL
112 DCMP DILATED CARDIOMYOPATH
113 DCR DACROCYSTORHINOSTOMY
114 DCT DIRECT COOMBS TEST
115 DDH DEVELOPMENTAL DYSPLASIA OF HIP
116 DEXA DUAL-ENERGY X-RAY ABSORPTIOMETRY
117 DI DI –DISTO INCISAL
118 DIC DISSEMINATED INTRAVASCULAR COAGULATION
119 DIP DISTAL INTERPHALANGEAL (JOINT)
120 DK DIABETIC KETOACIDOSIS
635
121 DL DIRECT LARYNGOSCOPY
122 DLC DIFFERENTIAL LEUCOCYTE COUNT
123 DLC DIFFERENTIAL LEUCOCYTE COUNT)
124 DMD DUCHENNE MUSCULAR DYSTROPHY
125 DMD DUCHENNE MUSCULAR DYSTROPHY
126 DNS DNS-DEXTROSE AND NORMAL SALINE
127 DOTS DIRECT OBSERVED THERAPY, SHORT COURSE
128 DPC DPC-DIRECT PULP CAPING
129 DPT DIPHTHERIA TETANUS PERTUSIS
130 DSD DEVELOPMENTAL SEXUAL DISORDER
131 DSD DISORDER OF SEX DEVELOPMENT
132 DTRS DEEP TENDON REFLEXES
133 EAC EXTERNAL AUDITORY CANAL
134 EBV EPSTEIN-BARR VIRUS
135 ECG ELECTROCARDIOGRAM
136 ECOG ELECTROCOCHLEOGRAPHY
137 EEG ELECTROENCEPHALOGRAM
138 EHBA -EXTRAHEPATIC BILIARY ATRESIA
139 ELBW EXTREMELY LOW BIRTH WEIGHT
140 ELBW ELBW-EXTREMELY LOW BIRTH WEIGHT
141 EMG ELECTROMYOGRAPHY
142 EMG ELECTROMYOGRAM
143 EMG ELECTRO MYOGRAPHY
144 ENG ELECTRONYSTAGMOGRAM
145 ENOG ELECTRONUROGRAPHY
146 ENT EAR NOSE AND THROAT
147 EONS EARLY ONSET NEONATAL SEPSIS
148 ESR ERYTHROCYTE SEDIMENTATION RATE
149 ESR ERYTHROCYTE SEDIMENTATION RATE
150 ESRD -END STAGE RENAL DISEASE
151 ESS ENDOSCOPIC SINUS SURGERY
152 ETCO2 ETCO2-END TIDAL CARBON DIOXIDE
153 ETD EUSTACHIAN TUBE DYSFUNCTION
154 ETT ENDOTRACHEAL TUBE
155 FABER FLEXION ABDUCTION EXTERNAL ROTATION
156 FB FOREIGN BODY
157 FB FOREIGN BODY
158 FC FC-FORMA CRESOL
159 FEES FUNCTIONAL ENDSCOPIC EVALUATION OF
SWALLOWING
160 FESS FUNCTIONAL ENDOSCOPIC SINUS SURGERY
161 FNAC FINE NEEDLE ASPIRATION CYTOLOGY
162 FRNS - FREQUENTLY RELAPSING NEPHRITIC SYNDROME
163 FSGS -FOCAL SEGMENTAL GLOMERULOSCLEROSIS
164 FX FRACTURE
165 GA GENERAL ANAESTHESIA
166 GDD GLOBAL DEVELOPMENTAL DELAY
167 GER -GASTRO ESOPHAGEAL REFLUX
168 GERD -GASTROESOPHAGEAL REFLUX DISEASE
169 GERD GASTROESOPHAGEAL REFLUX DISEASE
170 GERD GASTROESOPHAGEALREFLUX DISEASE
171 GERD GASTROESOPHYGEAL REFLUX
636
172 GIC GIC-GLASS INOMER CEMENT
173 GSD GLYCOGEN STORAGE DISEASE
174 GTCS GENERALIZED TONIC CLONIC SEIZURE
175 HA HEARING AID
176 HARM -HIGH ANORECTAL MALFORMATION
177 HB HEMOGLOBIN
178 HB HAEMOGLOBIN
179 HBV HEPATITIS B VACCINE
180 HD HIRCHSPRUNG’S DISEASE
181 HD -HEMODIALYSIS
182 HDN HAEMMARAGIC DISEASE OF NEWBORN
183 HDU HIGH DEPENDENCE UNIT
184 HDUN -HYDROURETERONEPHROSIS
185 HHHNCF HEATED HUMIDIFIED HIGH FLOW NASAL CANULA
186 HIE HYPOXIC-ISCHEMIC ENCEPHALOPATHY
187 HIE HYPOXIC ISCHEMIC ENCEPHALOPATHY
188 HMD HYALINE MEMBRANE DISEASE
189 HPV HUMAN PAPILLOMA VIRUS
190 HRLY HOURLY
191 HS NIGHT TIME
192 HSP -HENOCH-SCHONLEINPURPURA
193 HUS -HEMODYLISIS UREMIC SYNDROME
194 I&D INCISION AND DRAINAGE
195 I&D -INCISION AND DRAINAGE
196 I&D I&D- INCISION AND DRAINAGE
197 I.M INTRA MUSCULAR
198 I/O INPUT/OUTPUT
199 I/O INTAKE OUTPUT
200 IAC INTERNAL AUDITORY CANAL
201 ICH INTRACRANIAL HAEMMARAGE
202 ICP INTRACRANIAL PRESSUE
203 ID INTELLECTUAL DEFICIENCY DISORDER
204 IEM INBORN ERROR OF METABOLISM
205 IEM INBORN EWRROR OF METABOLISM
206 IFRNS -INFREQUENT RELAPSING NEPHRITIC SYNDROME
207 IHPS -IDIOPATHIC HYPERTROPHIC PYLORIC STENOSIS
208 IM INTRAMUSCULAR
209 INJ INJECTION
210 INS -IDIOPATHIC NEPHROTIC SYNDROME
211 IOPAR IOPAR-INTRA ORAL PERIAPICALLY RADIOGRAPH
212 IP INTERPHALANGEAL
213 IPC IPC-INDIRECT PULP CAPING
214 IPPV IPPV-INTERMITTENT POSITIVE PRESSURE
VENTILATION
215 IPV NTRAVENOUS PYELOGRAM
216 IR INTERNAL ROTATION
217 IRM IRM-INTERIM RESTORATIVE MATERIAL
218 ITP IDIOPATHIC THROMBOCYTOPENIC PURPURA
219 IUGR INTRAUTERINE GROWTH RETARDATION
220 IV INTRAVENOUS
221 IV INTRA VENOUS
222 IVC -INFERIOR VENA CAVA
637
223 IVC IVC-INFERIOR VENA CAVA
224 IVF INTRA VENUS FLUID
225 IVH INTRAVENTRICULAR HAEMMARAGE
226 IVRA IVRA-INTRAVENOUS REGIONAL ANAESTHESIA
227 IVRA IV-INTRA VASCULAR
228 JIA -JUVENILE IDIOPATHIC ARTHIRITIS
229 JNA JUVEMILE NASOPHARYNGEAL ANGIOFIBROMA
230 JRA JUVENILE RHEUMATOID ARTHRITIS
231 KAFO KNEE ANKLE FOOT ORTHOSIS
232 KFT KFT(KIDNEY FUNCTION TEST)
233 KMC KANGAROO MTHER CARE
234 KUB - KIDNEY URETER BLDDER
235 L1-5 LUMBAR VERTEBRAE
ST
236 L1-L2 L1-L2- 1 LUMBER VERTEBRA
237 LA LA-LOCAL ANAESTHESIA/LOCAL ANAESTHETICS
238 LAARP LAPAROSCOPY ASSISTED ANORECTOPLASTY
239 LARM LOW ANORECTAL MALFORMATION
240 LAT LATERAL
241 LBW LOW BIRTH WEIGHT
242 LBW LOW BIRTH WEIGHT
243 LCL LATERAL COLLATERAL LIGAMENT
244 LCP LEGG CALVE PERTHES DISEASE
245 LCR LCR-LIGHT CURE RESTORATION
246 LDH LACTATE DEHYDROGENASE
247 LFT LIVER FUNCTION TEST)
248 LGA LARGE FOR GESTATIONAL AGE
249 LGA LARGE FOR GESTATIONAL AGE
250 LIF LEFT ILIAC FOSSA
251 LIH LEFT INGUINAL HERNIA
252 LMA LMA-LARYNGEAL MASK AIRWAY
253 LONS LATEONSET NEONATAL SEPSIS
254 LPR LARYNGOPHARYNGEAL REFLUS
255 LRTI LOWER RESPIRATORY TRACT INFECTIONS
256 LS LUMBOSACRAL (SPINE)
257 L-SPINE LUMBAR SPINE
258 LT -LEFT
259 LTB LARYNGOTRACHEOBRONCHITIS
260 M/F MALE/FEMALE
261 MAC MAC-MONITORED ANAESTHESIA CARE
262 MAC MAC-MINIMUM ALVEOLAR CONCENTRATION
263 MAS MECONIUM ASPIRATION SYNDROME
264 MAS MECONIUM ASPIRATION SYNDROME
265 MC METACARPAL
266 MCD -MINIMAL CHONSE DISEASE
267 MCL MEDIAL COLLATERAL LIGAMENT
268 MCP METACARPOPHALANGEAL (JOINT)
269 MCU -MICTURATINGCYSTOURETHROGRAM
270 MICRO-PAN - MICROSCOPIC POLYANGIITIS
271 MMC - MENINGOMYELOCELE
272 MO MO-MESIOOCCLUSAL
273 MOD MOD-MESIOOCCLUSALDISTAL
638
274 MP MP MALARIAL PARASITE
275 MPGN -MEMBRANOPROLIFERATINGGLOMERULO
NEPHRITIS
276 MRA MR ANGIOGRAPHY
277 MRI MAGNETIC RESONANCE IMAGING
278 MRI MAGNETIC RESONANCE IMAGING
279 MRS MAGNETIC RESONANCE SPECTROSCOPY
280 MTP METATARSOPHALANGEAL (JOINT)
281 MX TEST MANTOUX TEST
282 N2O N2O-NITROUS OXIDE
283 NBM NBM-NIL BY MOUTH
284 NCC NEUROCYSTICERCOSIS
285 NCV NERVE CONDUCTION VELOCITY
286 NCV NERVE CONDUCTION VELOCITY
287 NEC NECROTISING ENTEROCOLITIS
288 NEC NECROTISING ENTEROCOLITIS
289 NET NERVE EXCITABILITY TEST
290 NG NASOGASTRIC TUBE
291 NG NASOGASTRIC TUBE
292 NHL NON-HODGKIN'S LYMPHOMA
293 NIHL NOISE INDUCED HEARING LOSS
294 NIT NEONATAL ALLOIMMUNE THRMBOCYTOPENIA
295 NNH NEONATAL HYPERBILIRUBINIMIA
296 NNS NON NUTRITIVE SUCKING
297 NOF NECK OF FEMUR
298 NP NASOPHARYNX
299 NPC NASOPHARYNGEAL CARCINOMA
300 NPO NPO-NIL PER ORALLY
301 NPO NOTHING PER ORAL
302 NPO NIL PER ORAL
303 NS NS-NORMAL SALINE
304 NSAID NASOPHARYNGEAL ANTI-INFLAMMATORY DRUG
305 NSAID NONSTEROIDAL ANTI-INFLAMMATORY DRUG
306 NTD NEURAL TUBE DEFECT
307 NV NEUROVASCULAR
308 O2 O2-OXYGEN
309 OA OSTEOARTHRITIS
310 OA -OESOPHAGEAL ATRESIA
311 OAE OTOACOUSTIC EMISSIONS
312 OE OTITIS EXTERNA
313 OI OXYGENATION INDEX
314 OM OTITIS MEDIA
315 OME OTITIS MEDIA WITH EFFUSION
316 OPG OPG-ORTHO PANTO GRAPHY
317 OPV ORAL POLIO VACCINE
318 ORIF OPEN REDUCTION INTERNAL FIXATION
319 ORL OTORHINOLARYNGOLOGY
320 ORTHO ORTHOPEDICS
321 OSA OBSTUCTIVE SLEEP APNEA
322 OT OT-OPERATION THEATRE
323 P/A -PER ABDOMEN
324 P/R -PER RECTAL
639
325 PAC PAC-PREANAESTHESTIC CLINIC
326 PAC PAC-PRE-ANAESTHETIC CHECKUP
327 PACU PACU- POST ANAESTHESIA CARE UNIT
328 PAN - POLYARTERITISNODOSA
329 PCL POSTERIOR CRUCIATE LIGAMENT
330 PD -PERITONEAL DIALYSIS
331 PDA PATIENT DUCTOUSARTERIOSUS
332 PDA PATIENT DUCTOUS ARTERIOSUS
333 PEEP PEEP-POSITIVE END EXPIRATORY PRESSURE
334 PER OP PER OPERATIVE
335 PFFD PROXIMAL FOCAL FEMORAL DEFICIENCY
336 PIGN - POST-INFECTIOUS GLOMERULONEPHRITIS
337 PIP PROXIMAL INTERPHALANGEAL JOINT
338 PONV PONV- POST OPERATIVE NAUSEA VOMITING
339 POP PLASTER OF PARIS
340 POST POST–POSTERIOR
341 POST OP POST OPERATIVE
342 POST. POSTERIOR
343 POSTOP POSTOPERATIVELY
344 PPHN PERSISTANT PULMONARY HYPERTENSION
345 PRE OP PRE OPERATIVE
346 PREOP PREOPERATIVELY
347 PS PERIPHERAL SMEAR
348 PSARP - POSTERIOR SAGITTAL ANORECTOPLASTY
349 PSARVUP -POSTERIOR SAGITTAL ANORECTAL VAGINO
URETHROPLASTY
350 PSVT PAROXYSMAL SUPRAV
351 PTA PURE TONE AUDIOMETRY
352 PTB PATELLAR TENDON BEARING
353 PTH PARATHYROID HORMONE
354 PTH PARATHYROID HARMONE
355 PUJ - PELVI-URETERIC JUNCTION
356 PUJO -PELVI URETERIC JUNCTION OBSTRUCTION
357 PUV -POSTERIOR UERTHRAL VALVES
358 PUV -POSTERIOR URETHERAL VALVE
359 QID FOUR TIMES DAILY
360 RBS RANDOM BLOOD SUGAR
361 RCT RCT-ROOT CANAL TREATMENT
362 RD RESPIRATORY DISTRESS
363 RDS RESPIRATORY DISTRESS SYNDROME
364 RF RADIOFREQUENCY
365 RFA RADIOFREQUENCY ABLATION
366 RIF RIGHT ILIAC FOSSA
367 RIH RIGHT INGUINAL HERNIA
368 RL RL-RINGER LACTATE
369 ROM RANGE OF MOTION
370 ROP RETINOPATHY OF PREMATURITY
371 RPGN RAPIDLY PROLIFERATING GLOMERULONEPHRITIS
372 RR RR-RESPIRATORY RATE
373 RS RS-ROOT STUMPS
374 RT RIGHT
375 RVG RVG-RADIO VISIO GRAPHY
640
376 RVT RENAL VEIN THRMBOSIS
377 S CA SERUM CALCIUM
378 S PH SERUM PHOSPHORUS
379 SAB SAB-SUB ARACHNOID BLOCK
380 SAM SEVERE ACCUTE MALNUTRITION
381 SBC SIMPLE BONE CYST
382 SCC SQUAMOUS CELL CARCINOMA
383 SDNS STEROID DEPENDENT NEPHRITIC SYNDROME
384 SE SERUM ELECTROLYTE
385 SGA SMALL FOR GESTAIONALAGE
386 SGA SMALL FOR GESTAIONAL AGE
387 SIMV SIMV-SYNCHRONIZED INTERMITTENT MANDATORY
VENTILATION
388 SIMV SYNCHRONISED INTERMITTENT MECHANICAL
VENTILATION
389 SIPS SUDDEN INFANT DEATH SYNDROME
390 SLE SYSTEMIC LUPUS ERYTHEMATOUS
391 SLR STRAIGHT LEG RAISING
392 SMAS SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM
393 SNHL SENSORINEURAL HEARING LOSS
394 SOS IF NECESSARY
395 SPC - SUPRAPUBICCYSTOSTOMY
396 SPO2 SPO2-OXYGEN SATURATION OF HEMOGLOBIN IN
ARTERIAL BLOOD FROM PULSE OXIMETERY
397 SRNS STEROID RESISTANT NEPHROTIC SYNDROME
398 SSPT SINGLE SURFACE PHOTOTHERAPY
399 SVC SUPERIOR VENA CAVA
400 SYRUP SYP
401 T1-T12 THORACIC VERTEBRAE
402 TAB TABLET
403 TAP TAP-TRANSVERSE ABDOMINAL PLANE
404 TAPVC TOTAL ANOMALOUS PULMONARY VENOUS
CONNECTION
405 TB TUBERCULOSIS
406 TB TUBERCULOSIS
407 TBM TUBERCULOUS MENINGITIS
408 TCA TRICHLORACETIC ACID
409 TCB TRANSCUTANEOUS BILIRUBIN
410 TDS THREE TIMES DAILY
411 TEF TEF-TRACHEO- OESOPHAGEAL FISTULA
412 TEF TRACHEOEOSOPHYGEAL FISTULA
413 TEF TRACHEOESOPHAGEAL FISTULA
414 TEP TRACHEOESOPHAGEAL PUNCTURE
415 TF TF-TMPERORY FILLING
416 TFT THYROID FUNCTION TEST
417 TIVA TIVA-TOTAL INTRAVENOUS ANAESTHESIA
418 TLC TOTAL LEUCOCYTE COUNT
419 TLC TOTAL LEUCOCYTES COUNT)
420 TM TYMPANIC MEMBRANE
421 TMJ TEMPOROMANDIBULAR JOINT
422 TMJ TEMPOROMANDIBULAR JOINT
423 TNE THERMO NEUTRAL ENVIRNONMENT
641
424 TPR TEMPERATURE/PULSE/RESPIRATORY RATE
425 TSH THYROID STIMULATING HORMONE
426 TTNB TRANSIENT TACHYPNOEA OF NEWBORN
427 TV TV- TIDAL VOLUME
428 TVC TRUE VOCAL CORD
429 UDC -UNINHIBITED DETRUSOR CONTRACTIONS
430 UDS -URODYNAMIC STUDY
431 UDT - UNDESCENDED TESTES
432 UGS - UROGENITAL SINUS
433 URI URI-UPPER RESPIRATORY INFECTION
434 URI UPPER RESPIRATORY INFECTION
435 URI UPPER RESPIRATORY TRACT
436 USG ULTRASOUND
437 USG ULTRA SONOGRAPHY
438 UTI URINARY TRACT INFECTION
439 UTI URINARY TRACT INFECTION
440 UVC UMBLICUS VENOUS CATHETER
441 VC VOCAL CORD
442 VENT VENTILATOR
443 VEP VISUAL EVOKED POTENTIAL
444 VIT-D VITAMIN D
445 VKDBD VITAMIN K-DEPENDENT BLEEDING DISORDER
446 VLBW VERY LOW BIRTH WEIGHT
447 VLBW VERY LOW BIRTH WEIGHT
448 VRA VISUAL RESPONSE AUDIOMETRY
449 VSD VSD-VENTRICULAR SEPTAL DEFECT
450 VSD VENTRICULAR SEPTAL DEFEC
451 VT VENTRICULAR TACHYCARDIA
452 VUJO VESICO URETERIC JUNCTION OBSTRUCTION
453 VUR VESICO URETERIC REFLUX
454 VUR VESICOURETERICREFLLUX
642
Policy No:-51/ CNBC/HWP/Use of abbreviation
Prepared By QMD
28.44 Safe Parenting Policy
28.44.1 Policy:-
Accidental injuries are the most common cause of death in children.
1. Parents are educated regarding safe parenting with the following:-

2. Parents should be educated for safe parenting in wards.
3. Public announcement in hospital is used for educating parents regarding safe parenting and safety of children.
4. Handouts/ Pamphlets/Posters are used for parents education.
SAFE PARENTING सुरक्षित परवररश
 Nutrition (पोषण)
 Immunization (टीकाकरण)
 Hygiene (स्वच्छता)
 Safety (सुरिा)
 Health Checkup (स्वास््य जाांच)
Important Facts related to safe parenting:-
 Nutrition:-
Exclusive breastfeeding till 6 months 6 महीने तक क्षवशेष स्तनपान
Cook & serve food in clean method
स्वच्छ तरीके से भोजन पकाना और सेवन करें
Select well balanced diet according to age (eg: green leafy veg , उम्र के अनुसार सांतुक्षित आहार का चयन करें (जैसे: हरी पत्तेदार
Milk, fruits. Etc) सक्षजजयाां, दूध, फि आदद)
 Immunization:-
Immunize your baby according to immunization schedule. टीकाकरण अनुसूची के अनुसार अपने बच्चे को टीकाकरण करें
 Hygiene:-
Take daily bath दैक्षनक स्नान िे
Wash hands whenever required हाथ धोएां जब आवश्यक हो
Cut short & clean nails अपने नाखूनों को छोटा और साफ रखना
wear clean clothes साफ कपडे पहनें
 Prevention from fall & accident:-

Closely supervise the child to prevent any type to fall / दकसी भी प्रकार के क्षिरने / दुर्घटना को रोकने के क्षिए बच्चे की सावधानीपूवघक
accident (eg: from stairs , windows, balcony, electric क्षनिरानी करें (उदाहरण: सीद़ियों, क्षखडदकयाां, बािकनी, इिेक्षरिक सर्कघ ट से)
circuit)
 Health check up:-
Assess physical & mental development of your child अपने बच्चे के शारीररक और मानक्षसक क्षवकास का आकिन करें
Check height , weight & teeth, annual eye check up. ऊांचाई, वजन और दाांत की जाांच कराए
तथा वार्षघक आांखों की जाांच कराएi ।
643
Name of the Department: Pharmacy Sub: Pharmacy Manual CONTROLLED COPY
Title: Manual of Operations Subtitle: Contents
Effective Date: November 2013 Review Date: August 2020 Revision: None
Responsibility :MO IC Pharmacy Total no. of pages: 16
29 Manual for Operations Pharmacy

Date created: November 2013
Responsibility of Drug & Therapeutic committee

updating:

on:
Version (CNBC/ Pharmacy/30/ ver1.0)

644
Manual for Operations Pharmacy ................................................................................................. 644
29.1 AMENDMENT SHEET .............................................................................................................. 646
29.2 INTRODUCTION- ..................................................................................................................... 647
29.3 PHARMACY SERVICES POLICY ............................................................................................ 647
29.4 DTC COMMITTEE- ................................................................................................................... 648
29.5 GUIDANCE FOR PREMISES ................................................................................................... 649
29.6 STORAGE AND STOCK/ HOSPITAL STORE ......................................................................... 651
29.7 GUIDANCE FOR STAFF AND SUPERVISION ........................................................................ 652
29.8 THE PHARMACY TEAM ........................................................................................................... 654
29.9 GUIDANCE FOR SERVICES ................................................................................................... 654
29.10 PROCESS-............................................................................................................................ 655
29.11 LICENSURE AND PROFESSIONAL STANDARDS ............................................................. 656
29.12 ACTIVITY AND RESPONSIBILITY: ...................................................................................... 656
29.13 DISPENSING OF PRESCRIPTION- ONLY MEDICINES ..................................................... 656
29.14 DATA MANAGEMENT WITHIN THE PHARMACY .............................................................. 658
29.15 PROTOCOL TO OBTAIN MEDICATION WHEN PHARMACY IS CLOSED ........................ 659
29.16 POLICIES FOR IMPLANTABLE PROSTHESIS AND MEDICAL SUPPLIES ...................... 659

645
29.1 AMENDMENT SHEET
S.No. Clause Date of Amendment Made Reasons of Sign of QM

1. 29.12 24.08.2020 The re-order level for these Buffer stock for
medicines shall be fixed at a minimum 3 months
level so as to ensure its will be maintained to
availability during lead time avoid stock out.
(purchase procedure time), to
meet demand at least for three
months.
2 29.15 24.8.20 Protocol to obtain medication SOP followed but not

when pharmacy is closed documented before
3 29.16 24.8.20 Polices for implantable SOP followed but not

prosthesis and medical documented before
consumables

646
29.2 INTRODUCTION-
Medication related all issues are documented here in Pharmacy manual and hospital wide polices.
1. Pharmacy manual ensures promotion of best practices in the provision of pharmacy services in
the interest of the health, safety and welfare of the public.
2. Medical Officer In charge (MOIC), Pharmacy, under the guidance of medical

superintendent/Director of the hospital will issue guidance to assist pharmacists in meeting
regulatory requirements.
3. Our hospital pharmacy consists of two parts- (1) Hospital store- serves the purpose of making
demands and storing medicines for hospital use. User departments send indents to store for
various medicines. (2) OPD pharmacy- dispenses medicines to patients coming to OPD and
emergency. For all practical purposes term “pharmacy” will be used for OPD dispensing area of
the pharmacy.
4. Pharmacist in charge of hospital store is overall responsible for availability of medicines in the
hospital and minimize the stock out situation by sending regular demands in consultation with
user departments.
29.3 PHARMACY SERVICES POLICY
29.3.1 POLICY:
The department of pharmacy stocks adequate amount of all medicines as listed in hospital’s drug
formulary and dispenses medicines to patients coming to OPD and Emergency.
29.3.2 PURPOSE:
It shall be ensured that stock out situation is not reached for the medicines. Pharmacist should ensure to
have a buffer stock for a minimum duration of 30 days to avoid stock out situation.
29.3.3 SCOPE:
This policy is directed towards pharmacy.

647
29.3.4 RESPONSIBILITY:
Pharmacy In charge, Drug & Therapeutics Committee (DTC), chief and assisting pharmacists and
Prescribing/Treating Doctors
29.4 DTC COMMITTEE-
It is a Multi disciplinary committee. Members are from administration (Director, Head of office),Clinicians,
HIC nurse from Quality department, Pharmacist, ANS(rep from Nurses),and Medical office in charge.
29.4.1 Objectives of committee-
To ensure safe and organized medication process in hospital.
29.4.2 Responsibilities-
1. The DTC shall oversee the implementation of medication policy and also issue additional
protocols for safe medicine usage and effective pharmacy services.
2. Developing and revising Hospital formulary-Aspects of patient safety, changing disease pattern
,resistance pattern, cost and need of clinicians is considered during review.
3. Evaluating medication usage
4. Evaluating safety incidents/ADR following medications.
29.4.3 Frequency-
The DTC shall meet once in three month and minutes of meeting with timeline shall be
documented.
29.4.4 Quorum of Meeting

1. 75% of the members should be there to do a meeting.
2. Formulary-Drug formulary
Drug Formulary with Essential drug list is maintained and updated once a year. An aspect of
patient safety, changing disease pattern, resistance pattern, cost and need of clinicians is
considered during review of this list. This list is made available to clinicians on their emails.
Physical list of OPD drug list is also made in OPDs. Clinicians adhere to formulary. Organization

648
adhere to Government process of acquisition of medications (Vendor selection, reorder levels,

indenting process ,generation of purchase order and receipt of goods).Implants -orthopedics and
Eye implants are also included in formulary list.
29.4.5 DISTRIBUTION:
This policy is to be distributed in hospital store, OPD pharmacy and purchase department.
29.5 GUIDANCE FOR PREMISES
29.5.1 OPD PHARMACY PREMISES
29.1.1.1 SCOPE
1. OPD Pharmacy premises should be well maintained, readily identifiable and easily accessible
for the public. A pharmacy premises should enable and facilitate a safe and effective working
environment.
29.1.1.2 METHODS
1. OPD pharmacy runs from 8am to 8 pm. The drugs are dispensed by the hospital pharmacy,
and when pharmacy is closed the drugs will be dispensed from Emergency Nursing Counter,
and nurse dispenses it to patient as per the treating doctor advice / Notes. The records of the
drugs administer is maintained by the nurse of concerned ward.
2. All aspects of the pharmacy should be well maintained and facilitate a safe working
environment, with the professional services area identifiable to the patient.
3. The pharmacy should be maintained in a clean and orderly condition.
4. Temperature should be controlled and monitored with due regard to the requirements to store
medicinal products within certain specified temperature parameters.
5. Any signage used in the pharmacy should be clear and not misleading and should take into
account patient profiles and communication difficulties if appropriate.
6. The pharmacy title should be displayed on the premises. Opening time, closing time, lunch
hour should be clearly displayed.
7. A safe and accessible entrance to the pharmacy premises should be provided. Publicly
accessible areas should be clear of stock and any other obstructions.
649
8. The pharmacy should operate with a direct, dedicated telephone line. Medicines in OPD
pharmacy should be stored in alphabetical order. Dispensing counters should not be
cluttered. All pharmacy medicines to be dispensed should be located well within reach of
dispensing pharmacist. Medicines must not be removed from blister or foil packs at the time
of dispensing. Split packs should be clearly marked, and mixing of stock of the same product
from different batches avoided.
9. Particular care should be exercised in the storage of different medicines presented in similar
packaging, and of different strengths of medicines presented in similar packaging. To
minimize the incidence of a dispensing error occurring, such similarly packaged medicines
should not be stored adjacent to each other on the dispensary shelf. The problem of
inadvertent dispensing of the wrong medicine due to similar packaging can be overcome by
educating staff, and by making sure all dispensary staffs are aware of products which are
likely to be prone to such dispensing errors. Such medicines should be categorized under
LASA (look alike or sound alike category). All LASA drugs will be kept in different containers
with different color labels, one as blue and other as Green.
10. Only authorized persons for a specific purpose should be allowed to come inside the OPD
pharmacy. There should be arrangements for the proper storage and disposal of waste
materials. Appropriate, designated, covered bins should be used and these should be
emptied and cleaned regularly. No waste material should be permitted to collect in the
dispensing area
11. Disposal of pharmaceutical waste should occur in a manner compliant with environmental
and other legislation. Waste medicines, whether out of date stock held or patient returns,
should be stored appropriately under the control of the pharmacist until removed for
destruction.
12. An approved, appropriate type of fire extinguisher should be present.
st rd
13. Online request for the drugs is sent to hospital store on 1 and 3 week of every month.
Drugs are made available to pharmacy only after getting approved from MOIC pharmacy.
Nursing orderly from pharmacy collects required drugs from store.
29.5.2 Audit on OPD Pharmacy Premises:

S. No Question Yes No N/A Required Action
1. Are the premises readily identifiable as a healthcare facility?

650
2. Is signage appropriate?
3. Are the premises accessible to all patient groups?
4. Do the premises comply with relevant building and fire
safety regulations?
5. Does the layout of the pharmacy allow for pharmacist
supervision of all supplies of medicinal products?
6. Are the premises maintained in an orderly, clean and
hygienic manner?
7. Are the premises safeguarded by appropriate alarm
systems in respect of fire and theft?
8. Is a suitable waiting area provided for patients, with
adequate seating?
29.6 STORAGE AND STOCK/ HOSPITAL STORE
29.6.1 SCOPE
There should be a comprehensive, auditable system for the control and maintenance of an
appropriate level of legitimate stock which is held within prescribed storage conditions and
facilities.
29.6.2 CRITERIA
1. Stock must be stored in appropriate and auditable environmental conditions.
2. Appropriate conditions of light, humidity, ventilation, temperature and security should be
ensured.
3. All medicinal products must be stored in accordance with the manufacturer’s directions
29.6.3 METHODS
1. Pharmacy stock should be stored under suitable conditions, appropriate to the nature and stability
of the product concerned.
2. Particular attention should be paid to protection from contamination, sunlight, UV rays, moisture
and extreme temperatures.
3. During storage, medicines should be retained in the manufacturer’s original packaging. Any
product received in packaging that is damaged or discolored should be quarantined and returned
to the supplier via stores.
4. All stock of medicines in the pharmacy should have batch numbers and expiry dates.
651
5. A documented procedure for regular and systematic checking of expiry dates should be in place.
All stock which has reached expiry date should be removed for disposal or destruction. The
pharmacy in-charge should ensure that any disposal of medicinal products is carried out in a
manner consistent with legal requirements.
6. If the packaging of a medicine has suffered any damage, Over-the-counter (OTC) medicines
whose packaging is damaged or otherwise rendered unusable should be returned to the supplier
or disposed of in a suitable manner.
29.6.4 Hospital drug formulary list

Pharmacy should have a copy of hospital drug formulary list. If any drug from the list is not
available in pharmacy and prescriptions are received from OPD, an indent for the drug should be sent to
the store. It’s a collective responsibility of all the pharmacists to make all essential drugs available in the
pharmacy, if the drugs are available in hospital store.
29.6.5 Purchasing procedure

Hospital store is responsible for purchasing all drugs and surgical products required for the
treatment of the patients coming to the hospital. Purchases are done through-
a) Centralized procurement agency (CPA)
I. CPA is responsible for making bulk purchase for the hospital
II. Store sends periodic indent to CPA depending on the use of the consumables
b) Self purchase – hospital has a rate contract list for drugs and surgical products which are not in
the CPA list. On demand from the user side, store confirms non availability of the items and
forwards the demand to the purchase section. Orders for supply are placed after a PPC meeting
to the authorized vendors.
c) Local purchase (LP)- local purchase is made from the hospital authorized vendors only when not
listed in drug formulary or in case of emergent need of drugs purchase from usual source is not
possible from other known sources because of time constraints. This should be reserved only for
essential items, and not for routine use.
29.7 GUIDANCE FOR STAFF AND SUPERVISION
A. PHARMACISTS

652
29.7.1 SCOPE
The activity of a pharmacy is the professional responsibility of the pharmacist in charge. Differing
levels of accountability will apply in respect of differing roles fulfilled, but all practitioners are
required to possess, maintain, update and display competence and accountability in respect of
the management of the health of a patient and the delivery of an acceptable standard of
pharmaceutical care.
29.7.2 CRITERIA
1. Any pharmacist exercising their professional role must be registered, safe and competent to
practice
2. A pharmacist must be fully aware of the particular professional role they fulfill and the boundaries
and accountability of that particular role.
29.7.3 GUIDANCE
1. Any professional activity of a pharmacy should occur under the direct supervision of a registered
pharmacist who accepts responsibility for the dispensing of medicines, and the provision of all
pharmacy services, for the time period within which that pharmacist is present.
2. A registered pharmacist who is “in whole time charge of the carrying on of the business of a
pharmacy”, and is named as Supervising Pharmacist
B. Supervising pharmacist:
1. Is accountable for all professional activities carried out in the pharmacy.
2. Is responsible for personally managing, controlling and supervising the pharmacy.
3. Is responsible for prohibiting any individual from unduly influencing, directing, controlling or
supervising the professional activity of the pharmacy.
4. Is responsible for the generation and application of policies and procedures for all personnel
operating in a pharmacy in accordance with current law and best practice.
5. Is charged with the maintenance of an appropriate duty log, clearly indicating the identity of the
pharmacist in attendance at any given time within the notified operating hours of the pharmacy.
6. Should ensure that all personnel operating within a pharmacy are aware of the limits and scope
applicable to the management of the professional services provided.
7. Any registered pharmacist operating in a pharmacy (who is not the supervising pharmacist) must
act in accordance with all legislative requirements, guidance of the regulator and appropriate
internal policy procedures, and is personally accountable for all professional practices overseen
and carried out by him or herself.

653
29.7.4 Audit on Pharmacists:

S.No Question Yes No N/A Required
Action
1. Are all pharmacists employed in the pharmacy are registered?
2. Are all pharmacists employed aware of their professional role?
3. Are all professional activities of a pharmacy carried out under
the supervision of a pharmacist at all times?
4. Does the supervising pharmacist produce and review policies
and procedures for the operation of the pharmacy?
5. Does the supervising pharmacist attend for a reasonable
period of time at the pharmacy?
6. Is a duty log maintained and signed by the pharmacist(s) in
charge?
29.8 THE PHARMACY TEAM
29.8.1 SCOPE
 The professional activities in a pharmacy at any time are the responsibility of the pharmacist in
charge.
29.8.2 CRITERIA
1. All staff must be appropriately informed and trained in respect of their area of operation.
2. All staff must be aware that the patient is the primary focus of service provision, and must respect
the confidentiality and integrity of their interaction with patients.
29.9 GUIDANCE FOR SERVICES
A. PROCESS DETAILS:
29.9.1 5.1.1. PHARMACY SERVICESs
The department of pharmacy provides wide range of services. The following is an overview of these
comprehensive services. —
1. Pharmacy shall dispense medicine to OPD patients only on valid prescription.

654
2. Pharmacy shall provide counseling to the patients at the time of dispensing

3. Pharmacy shall Stock only Formulary listed Drugs, however Non formulary drugs may be ordered
for individual patient, when sound pharmacological or therapeutic consideration so dictate
4. Pharmacy shall dispense in Unit packs & no cuttings shall be dispensed nor shall be taken back
5. Pharmacy shall ask / inform the concerned physician in case of Substitution
29.10 PROCESS-
29.10.1 OUT PATIENT SERVICES
1. Pharmacist (OPD) receives the prescription

2. Pharmacist will verify for the authenticity/validity of prescription.
3. Pharmacist will take out the stock physically from the storage area.
4. Pharmacist will counsel the patient for medicines prescribed.
5. Pharmacist will check the batch/expiry of the medicines to be dispensed.
29.10.2 IN PATIENT SERVICES
1. Pharmacist (store) will receive the indent order.

2. Pharmacist will take out the stock physically from the storage area.
3. Pharmacist will check the batch/expiry of the medicines to be dispensed.
29.10.3 EXPIRATION
1. Pharmacist will remove all the Near expiry / Expiry out from the stock which is likely to expire with
in next three month
2. In case of non availability, medicines from near expiry stock will be dispensed with prior
instruction to user.
29.10.4 STOCK INSPECTION
1. MOIC pharmacy and Medical superintendent may come for stock inspection and verification at
anytime in pharmacy.
2. All discrepancy in stocks should be notified and documented.
3. All discrepancies will be documented and brought to notice of chief pharmacist.
4. Pharmacist should explain the reason for any stock discrepancy.

655
29.11 LICENSURE AND PROFESSIONAL STANDARDS
 Pharmacy will comply with the statutory requirement for pharmacy operations.
29.12 ACTIVITY AND RESPONSIBILITY:
S. No. Procedural steps Responsibility

1. Pharmacist shall determine the average annual consumption and Pharmacy In charge
consumption rate of all drugs and maintain sufficient stock of the
same on the basis of consumption rate.
2. The re-order level for these medicines shall be fixed at a level so as Pharmacy In charge
to ensure its availability during lead time (purchase procedure time)
and equal amount as buffer stock, to meet demand at least for three
months.
3. Storage shall be done as per the manufacturer’s recommendation Pharmacy store
and as per policy document ‘storage of medicines’
4. Dispensing of medicines shall be done as per policy document Pharmacist
‘dispensing of medicines’. Caution shall be taken to prevent
dispensing error.
29.13 DISPENSING OF PRESCRIPTION- ONLY MEDICINES
29.13.1 SCOPE
1. Dispensing involves the complete process which occurs from receipt of the prescription or
request at the pharmacy, to the prescribed item or medicine being collected by the patient or their
representative.
2. The patient is the primary focus of the dispensing process, and prescribed medicines must be
assessed as appropriate for that individual, and delivered in a manner which reflects diligence
and care in the receipt, review, assembling, checking, recording and dispatch.

656
29.13.2 CRITERIA
1. The pharmacist must ensure that dispensing is carried out accurately and medicines should be
dispensed for prescribed duration. If sufficient stocks are not present, the same should be
communicated to the attendants
2. Patient confidentiality must be respected and safeguarded in the dispensing process.
3. Each prescription must be critically reviewed prior to dispensing to ensure that the medicinal
product(s) supplied are safe and in the best interest of the patient.
4. The pharmacist must contact the prescriber regarding medicines and patient issues when the
need arises, and must always exercise his/her professional role and expertise in the appropriate
use of medicines.
5. Patients must be given complete and comprehensive details regarding their medicines at the time
of dispensing, so that they fully understand what the medicine is and what it is for.
6. Adequate information must be given to the patient regarding the safe storage of their medicine.
7. The medicine dispensed must be of suitable quality and fit for use over the course of treatment
8. All high risk medicines will be cross verified by two pharmacists and will be signed by both before
dispensing in pharmacy.
29.13.3 METHODS
1. All dispensing of medicines should be carried out by the pharmacist.
2. The patient details (name, age, sex and hospital ID number) must be verified by the pharmacist
dispensing the medicines.
3. The authenticity of any prescription presented for dispensing should be established prior to
supplying any medicinal product. The pharmacist must be satisfied that the prescription is written
by a practitioner authorized to do so.
4. There must be no ambiguity in respect of product, method of use or dosage regime. If no specific
directions for use are stated by the prescriber, the pharmacist should first ascertain whether these
have been verbally transmitted to and understood by the patient. If this is not the case, then the
prescriber should be contacted and the pharmacist should agree the directions in consultation
with the prescriber. If the prescriber cannot be contacted, then the pharmacist should proceed by
exercising their professional knowledge and judgment as to the appropriate dosage directions to
safely dispense the medicine.
5. The pharmacist should ensure the patient details are correct, and make a clinical assessment as
to the appropriateness of the prescribed medicine therapy for the individual for whom the
prescription is issued. This should include screening for any potential drug therapy problems,

657
including therapeutic duplication, drug-drug interactions (including with OTC medicines), food-
drug interactions, incorrect drug dosage or duration of treatment, known drug allergies and
clinical misuse/abuse.
6. Where a prescriber specifies a particular product on the prescription, the pharmacist is required to
dispense the product specified. The pharmacist cannot supply a different equivalent product
without consulting the prescriber concerned. In circumstances where the prescriber cannot be
contacted, and the patient is in need of the medication, the pharmacist may exercise his
professional judgment and dispense an alternative equivalent group of medicine if satisfied that it
is safe and clinically appropriate to do so. The pharmacist should notify the prescriber
subsequently of this action and record details of this notification.
7. If there is any change with a repeat prescription, this should be confirmed with the patient prior to
dispensing the prescription. If there is no change in a repeat prescription, the continuation of the
therapy at the same dose and regime should be confirmed with the patient.
8. When the clinical review of medicine therapy reveals an issue needing further clarification, the
pharmacist should exercise professional judgment in order to evaluate and decide on a course of
action. When deemed necessary, the pharmacist should act in consultation with the practitioner
who issued the prescription. In a case where the prescriber cannot be contacted, the pharmacist
must exercise professional judgment in the best interests of the patient
9. All medicines should be checked for expiry dates. A product must not be supplied after its expiry
date. No product that is short-dated can be supplied where it is likely that the course of treatment
with that product will continue beyond the expiry date specified on the product.
10. All medicines should be dispensed for the prescribed duration. A maximum of 2 weeks supply is
given to the patients in a single visit. Under special circumstances, on prescriber’s request a
maximum of 4 weeks supply can be dispensed during a single hospital visit.
29.14 DATA MANAGEMENT WITHIN THE PHARMACY
29.14.1 SCOPE
1. A pharmacy must recognize the importance of data management and provide for the associated
responsibilities.
2. Suitable procedures must be provided that make due provision for the safe management of
personal patient information, and allow for records to be maintained that are compliant and satisfy
all legal and ethical responsibilities.

658
29.14.2 CRITERIA
1. A data management system must be in place to account for the appropriate management,
utilization and irretrievability of any data and information obtained in the course of the operation of
a pharmacy. Such information must be collected, recorded and used in a manner that protects
confidentiality and privacy.
2. Information should be held in a clear, concise and consistent manner which will not create any
ambiguity in interpretation.
29.14.3 METHODS
1. Record keeping for the dispensing of prescriptions and other supplies of medicines should be
maintained either electronically or in a bound prescription book. If maintained electronically, it is
necessary to print out the record on a daily basis and have it signed and dated by the pharmacist.
These should be filed and retained for at least two years in the pharmacy. It should be noted that
adequate secure backups must be made of records which are maintained electronically, and this
back-up process regularly verified.
2. The pharmacy should have suitable filing facilities available to file all records, registers and
dispensed completed prescriptions, and allow for their timely and efficient retrieval by all
interested parties authorized have access to such records.
3. Records are legally required to be retained on the premises for two years from the relevant date.
29.15 PROTOCOL TO OBTAIN MEDICATION WHEN PHARMACY IS CLOSED
Our hospital has a central store(Pharmacy )which supplies medication to both OPD and IPD(all
departments).OPD pharmacy /Dispensary run from 8amto 8pm.
Sister in charges of each department keeps adequate stock of all drugs related to drug formulary, so in
the night when central pharmacy(Store) is closed then also in ward areas adequate stock is there and
time to time this stock is updated .Pharmacist in very emergency also can come and open the pharmacy.
29.16 POLICIES FOR IMPLANTABLE PROSTHESIS AND MEDICAL SUPPLIES
1. Usage of implantable prosthesis like in orthopedics and Eye department is guided by scientific
criteria and national guidelines for each item.
2. The detailed Procurement, storage, vendor selection and evaluation, indenting process is there
in material management manual. It is according to government policies and regulations.
659
3. After procurement of these items they are indented to user department by central store.
4. The item is used after the concerned clinicians and committee approve the supply .Before
dispensing condition of item is checked by the person who dispense it and person who opens
the packets before usage. It could be checking opened package, discoloration, physical
damage and expired etc.
5. In OT before its usage patients and families are counseled about its precautions, if any at the
time of taking consent and in OPDs.
6. All the supplies and implants are used and stored in safe and secure manner
7. Sound inventory practices are followed at user and store level.
8. Batch, serial number and stickers (whatever available) are recorded in patient record master
log book of OT, and discharge summary.
9. Recall of implants may be done-a) On receiving communication from regulatory authorities b)
Internal feedback c) Communication from manufacturer.

660
30 MANUAL FOR OPERATIONS
DEPARTMENT OF GAS MANIFOLD
(CNBC/ANEST/GAS MANIFOLD/17.b)
Date created: 1st May 2008 (Ver 1.0)

Approved by: Dr. B L Sherwal (Director)
Responsibility of Dr Aikta Gupta M.O.I/c(Gas Plant)

Updating: Department of Anesthesia
Last reviewed/ August 21st 2020

updated on: Version (3.0)
Replacing Ver 2.1
661
30 MANUAL FOR OPERATIONS ...........................................................................................661
30.1 Amendment Record Sheet .................................................................................................663
30.2 Policies For Gas Manifold Room .......................................................................................664
30.3 Hierarchy chart of Medical Gas pipeline Division ..............................................................665
30.4 Design Of Medical Gas Distribution System ......................................................................666
30.5 Through Manifold Room.....................................................................................................667
30.6 Instruction for Gas Plant technicians in case of failure in central oxygen supply ..............667
30.7 Flow Chart for Gas Plant technicians in case of failure in central oxygen supply. ............668
30.8 Instruction for users/patient care units in case of failurein central oxygen supply: ............669
30.9 Nitrous Oxide:- ...................................................................................................................671
30.10 Instruction for O.T. personnel in case of failure in Central manifold N2O supply:- .......671
30.11 Medical compressed Air is supplied in few departments of the hospitals …………….672
30.12 Instruction for Gas Plant technicians in case of failure in central medical Air supply:-.672
30.13 Instruction for /Patient care units in case of failure in central medical Air supply:-......672
30.14 Vacuum:- .......................................................................................................................672
30.15 AGSS (SCAVANGING SYSTEM) :- .............................................................................673
30.16 Outlets For (O2, N2o, Air, Vacuum) :- ............................................................................673
30.17 Staffing:- ........................................................................................................................674
30.18 Procedure in Gas Manifold Department .......................................................................674
30.19 Fire Safety In Medical Gas Plant:- ................................................................................675
30.20 Maintenance Process:- .................................................................................................675
30.21 Record’s Generation:- ...................................................................................................677
30.22 Emergency Contact numbers of Hospital Authorities ...................................................678
30.23 Emergency contact numbers of vendors/Service Provider (Medical Gas Plant):- ........679
662
S.no Clause Date of Amendment Reasons Sign of QM
. no. Amendment Made Of
Amendment
1. 30.4 20.01.16 Director & Technical Supervisor Previously not

added in the Hierarchy Chart mentioned.
2. 30.8 20.01.16 Clause no. 30.8 mentioned Previously clause
number not mentioned
and vendor details updated number not mentioned
and vendor details
updated
and Emergency contact details number not mentioned
updated and emergency contact
details updated
8. 5.8(3) 16.11.17 Deleted one sentence “N2O Previously the said
Cylinder (all)”,Clause no. 5.8(3) sentence was
mentioned due to
typographical error.
9 5.9 16.11.17 S.No. 2) Name of Dr. Mamta Information updated as
Jajoo, HOO added inplace of on date.
Dr. Promila Gupta, Ex-MS
S.No.5) Name of Vineet Kr.
Arora, TS inplace of Mr. Umesh
Chandra, TS
Contact number updated
10 5.4(3) 16.11.17 S.No. 3:- Designation changed Information updated as
as TS(OT) instead of TA(OT) on date.
11 5.9.1 16.11.17 Contact number corrected as Information updated as
earlier mentioned wrong on date.
12 5.9.1 12.01.19 Name of Director, CNBC Dr. B.L. Sherwal taken
updated over the charge of
Director, CNBC.
13 30.15.3 21-8-20 Pipeline colour coding updated Pipeline colour coding
added
14 30.19.4 21-8-20 Safety precautions followed in Information updated
GPL even though followed
15 30.22 21-8-20 Phone numbers updated Phone numbers
updated
663
30.2 Policies For Gas Manifold Room
30.2.1 Scope of Services:-

1. Supply four medical gases through central pipe line (i.e. O 2, N2O, compressed Air and
Vacuum).
2. Provide scavenging facility of CO2 & anesthetic waste gases from O.T. to outdoors through
Anesthetic Gases Scavenging System (AGSS system).
3. Provide maintenance of medical gas pipe line and related apparatus used in different patient
care units.
664
30.3 Hierarchy chart of Medical Gas pipeline Division
30.3.1 HIERARCHY CHART OF GAS PLANT
30.3.2
DIRECTOR
MEDICAL SUPERINTENDENT
H.O.D.(ANAESTHESIA)
M.O.I/C (Gas Pipeline [GPL])
Technical Supervisor
O.T.TECHNICIAN (CSSD&GPL)
_______________________________________________________________
O.T.ASSTT. O.T.ASSTT. O.T.ASSTT. O.T.ASSTT. O.T.ASSTT.
(CSSD/GPL) (CSSD/GPL) (CSSD/GPL) (CSSD/GPL) (CSSD/GPL)
665
30.4 Design Of Medical Gas Distribution System
30.4.1 Work areas of medical gas pipeline division

1) Liquid oxygen tank.
2) We have separate rooms for gas control panel’s (manifold room) & plant room for compressor of
medical air & vacuum as per standards.
3) Piping of the central supply done by the concerned company as per standards & guidelines.
30.4.2 OXYGEN
There are two provisions for central supply of oxygen gas in various departments of this hospital as
follows:
1. Through Liquid Medical oxygen Tank (LOT)
2. Through Manifold Room
30.4.3 Liquid Oxygen Tank

 In this system the oxygen is stored in liquid form in a tank and supplied after converted in
gaseous form in various patient care units of this hospital. Liquid oxygen tank was
installed on 6/7/2009.
 The pressure of liquid oxygen tank is monitored & recorded in each shift by on duty
technician. The capacity of the tank is 5.91 cubic meter.
 It is filled at an interval of 2-3 days or when the pressure of tank reaches below 1000 mm
Wc.
 Liquid oxygen supplied by the company conforms to Indian pharmacopoeia 2007 and test
certificate is provided at the time of refilling of tank every time.
 Oxygen is supplied at pressure of 45-60psi to respective patient care unit through central
pipe line.
666
30.5 Through Manifold Room
30.5.1 In this system the oxygen is supplied through bulk 10X10 bulk D Type cylinders which are controlled by
Automatic control panel.
30.5.2 This system is a standby system for use in emergency condition like in case of breakdown/failure of liquid
oxygen tank.
30.5.3 The system is checked and run on every alternate Monday (next working day if Monday is a holiday) to
ensure functionality of the system.
30.5.4 Liquid oxygen supply is stopped and then oxygen is supplied from manifold by 10 nos. of bulk cylinders for
checking the functional status of standby system.
30.5.5 Beside this there is one emergency backup system containing three oxygen bulk cylinders.
30.6 Instruction for Gas Plant technicians in case of failure/ Breakdown in central oxygen supply
1) If there is any failure/breakdown in the oxygen supply from Liquid medical oxygen tank then the on
duty technician have to immediately turn on the oxygen supply from standby manifold system
(manifold elective 10x10) for uninterrupted oxygen supply at normal pressure. Then he has to
analyze the cause for this failure and take corrective action immediately and inform to his seniors
& also to higher authorities of this hospital.
2) If there is also some fault/failure in Manifold control panel, Then the on duty technician have to
immediately turn the emergency manifold supply containing 03 cylinders of bulk type. He should
immediately turn on the 02 cylinders of emergency backup and one cylinder in the line should be
kept as reserve for the time required to replace the empty cylinders in the emergency backup
manifold. After this corrective action he has to inform to his senior & also to higher authorities of
this hospital.
3) Inform to the service provider for immediate repair of the defective oxygen control panel and
record the complaint in faulty equipment register of gas plant .
667
30.7 Flow Chart for Gas Plant technicians in case of failure/ Breakdown in central oxygen supply.
668
30.8 Instruction for users/patient care units in case of failure/ Breakdown in central oxygen supply:
1) In case of failure of central oxygen supply, the healthcare professionals (i.e. Doctors, Nurses,
Technicians & Other ancillary staff) posted in patient care units have to take immediate & prompt
action to prevent any mishap. They have to immediately provide the oxygen therapy to patients
with the help of oxygen cylinders (B & D Type) provided in their respective units. D- Type cylinders
must be connected with the ventilators and turn on immediately for oxygen supply at required level
& B-Type cylinder must be turned on and oxygen must be supplied to the needy patients with the
help of other accessories (like Ventury mask, AMBU Bag, Oxygen hood etc.) as required to the
patients.
2) As instructed above a prompt action with presence of mind is required in this situation to save the
precious life of patients.
3) Inform telephonically on intercom 145 (Gas Plant Technician) to take urgent necessary action for
restore the smooth oxygen supply.
4) Inform to the Technical In charge (Ext. 119) & M.O.I/c (Gas Plant) on intercom 129 regarding the
incident.
Instruction for Wards/Patient care Units, In Case of Disruption/Breakdown of Central Oxygen Supply
Monitor O2 pipeline pressure YES

Whether in normal range
NO
Immediately call to Gas plant Tech. Ward Area: Record atleast twice
on ext. 145, 143 OR (10:00AM and 3:00PM) daily
CUG 8595919363 & ICU/OT areas: Record atleast four

times (10:00AM, 3:00PM,
Keep ready oxygen cylinders & other
10:00PM, 5:00AM) daily
accessories.
669
YES
Whether O2 pressure restored in
normal range ( i.e. 45-60 PSI) O.K. , Record in
register.
NO
If pressure not restored and falls below 40psi
- Immediately Use oxygen-D type cylinders for critical patients on ventilators.
- Start oxygen therapy with O2 cylinders and other accessories like AMBU Bag, Ventimask
etc.
- Indent additional cylinders from gas Plant.
- Provide oxygen therapy to patient from oxygen cylinders till central supply restored.
Ok, Record the

event in the
register. Inform to
M.O.I/c(GPL)
670
30.9 Nitrous Oxide:-
30.9.1.1 Nitrous oxide structural elements:

 Nitrous oxide is supplied in the O.T.’s centrally through Bulk type cylinders.
 Two separate banks of 2x2 bulk cylinders for nitrous oxide are available - one bank is utilized at
a time and another bank is kept as reserve bank
 A control panel installed between both banks ensures that both banks do not supply gases
st
simultaneously & the control of gases automatically shift the flow of gas from 1 bank to
st
reserve bank when the I bank pressure falls below the set level.
 Beside this there is also one emergency backup containing one nitrous oxide bulk cylinder,
which may be used in case of failure. N2O is supplied at pressure of 45-60 psi to respective
patient care unit through central pipe line
30.9.1.2 Instruction for Gas Plant technicians in case of failure/ Breakdown in elective (2x2) manifold N 2O
supply:-
1. If there is some fault/failure in N2O control panel, Then the on duty technician have to immediately
start the emergency N2O supply containing 01 cylinders of bulk type. He should immediately turn
on the N2O cylinder of emergency backup and he has to inform to the operation theaters elective
as well as emergency OT to check & ready their A type cylinders fitted in Anesthesia machine &
also to his seniors about this fault.
2. Inform to service provider for repair the defective N2O control panel and record the complaint in
faulty complaint register of gas plant.
30.10 Instruction for O.T. personnel in case of failure/ Breakdown in Central manifold N 2O supply:-
1) Immediately turn on the A type cylinder fitted in Anesthesia machine.
2) Inform telephonically on intercom 145 (Gas Plant Technician) to take urgent necessary action for
restore the smooth central supply.
671
30.10.1 Medical Air :-
30.11 Medical compressed Air is supplied in few departments of the hospitals (PICU, NICU, Elective OT,
Emergency OT, Casualty deptt. & Disaster ward)
- There are two air compressors that generate air and air is dried through drier and then this air filtered
through filters of 0.1 micron filters to prevent any contamination and then only it is supplied to central
pipe line at a desired pressure between 45-60 psi.
- By-pass valve between compressors, Dual air Driers and dual air filters & dual line regulators are
present for uninterrupted supply in case of any breakdown in one part or during maintenance.
30.12 Instruction for Gas Plant technicians in case of failure/ Breakdown in central medical Air supply:-
1) First of all immediately analyze the reason for breakdown and take corrective action for smooth supply
and if not corrected then,
2) Inform to all user/patient care units to manage with other resources like inbuilt compressors in
ventilators.
3) Inform to service provider for repair of the defective system and record the complaint in the faulty
equipment register of the gas plant.
30.13 Instruction for users/Patient care units in case of failure/ Breakdown in central medical Air supply:-
1) In case of failure/breakdown of central air supply, users have to immediately turn on the compressors
of ventilators.
2) Inform to Gas plant technician on ext. 145 to take corrective action to restore the central Air supply.
30.14 Vacuum:-
30.14.1.1 Structural elements of vacuum system

- Our vaccum sources in the plant room consist of two vaccum pumps duplexed with provision for
operation alternatively/simultaneously as per demand. Each pump have by-pass valve to isolate the
other pump for maintenance. Exhaust from vaccum pumps situated outdoors.
30.14.1.2 Instruction for Gas Plant technicians in case of failure/ Breakdown in central Vaccum supply:-
1) First of all immediately analyze the reason for breakdown and take corrective action for smooth supply
and if not corrected then,
2) Inform to all patient care units to make ready their electrically operated suction apparatus and Foot
suction and use them wherever required.
3) Inform to service provider for repair of the defective system and record the complaint in the faulty
equipment register of the gas plant.
30.14.1.3 Instruction for users/Patient care units in case of failure/ Breakdown in central Vacuum supply:-
1) In case of failure/breakdown of central Vacuum supply, The user have to immediately keep ready the
electrically operated vacuum machines and use them wherever required.
672
2) In Case of power failure, user has to keep ready foot suction machine and may use Foot suction
apparatus wherever required.
3) Inform to Gas plant technician on ext. 145 to take corrective action to restore the central Vacuum
supply.
30.15 AGSS (SCAVANGING SYSTEM) :-
30.15.1 Structrual elements of Anesthetic gases scavenging system (AGSS)
30.15.2 AGSS system is installed in the plant room to dispose off medical waste gases through a vacuum system
from O.T.’s. This system can be operated through O.T. by the anesthetist./Technicians who are
administrating anaesthesia to patient on closed circuit ventilation. This will prevent the O.T. environment
pollution. It has two pumps & they operate alternatively.
30.15.3 Instruction for Gas Plant technicians in case of failure/ Breakdown in AGSS supply:-
1) First of all immediately analyze the reason for breakdown and take corrective action for smooth supply and
if not corrected then,
2) He has to inform to the operation theaters elective as well as emergency OT to disconnect the pipeline of
AGSS from anesthesia machine.
30.16 Outlets For (O2, N2o, Air, Vacuum) :-
30.16.1 Structural elements of gas pipeline outlets

In various wards, ICU & O.T. area specific outlets are provided for specific gas to prevent mixing or
confusion. These outlets also have locking facility with probes to prevent leakage. There is particular
color coding on all the outlets for a specific gas.
30.16.2 Alarm monitoring:-

- We have advanced alarm monitoring system in our medical gas plant. In our manifold room we have
one master alarm for all four gases ( O2, N2O, Vaccum, Air). In wards, ICU& O.T.’s. We have area
alarm for supplied gases. In this type of alarm there is digital & audiovisual system. They give audible
sound to indicate variation of pressure falls or down beyond the normal limits.
- Normal Limits are as follows:-
Oxygen, N2O & Air --- 45-60 PSI.
Vacuum --- 15-25 in Hg
29.1.1 Pipe line system
All the gases are supplied through pipeline system which are colour coded (ISO standards)
Oxygen-white
N2O-Blue
Air-Black
AGSS-Purple
Suction/Vaccum-Yellow
Pipelines are annually painted by the maintenance company.
673
30.17 Staffing:-
1) Round the clock trained O.T.Asstt. are posted for operation and monitoring of the Medical gas Plant.
2) In each shift one trained O.T.Asstt. is posted and he is responsible for smooth supply of medical gases in
various department of the hospital.
3) Supervision of posted staff done by Technical Supervisor i.e. TS (OT).
4) One Anesthesia faculty designated as M.O.I/c (GPL) for overall management.
30.18 Procedure in Gas Manifold Department
30.18.1 STORAGE & SUPPLY:-

1) All the cylinders received in gas plant checked by on duty staff for proper seal, label, weight, hydrostatic
test and pressure.
2) After receiving cylinders are stored in predefined area with chains to prevent falling.
3) Stored & sealed D-Type cylinders are periodically checked by measuring weight on weighing scale on
weekly basis.
30.18.2 OXYGEN:-
1) We have one Liquid medical Oxygen tank for storage & supply of oxygen
2) We have Oxygen bulk cylinders to supply O2 through central pipe line system.
3) We also supply oxygen-B type cylinders to various wards, ICU, O.T. area to shift the pt. With oxygen on
trolley.
30.18.3 NITROUS OXIDE (N2O) :-

1) We supply N2O from bulk cylinders through central pipe line to O.T.area.
2) We also supply N2O- A type cylinders to O.T.’s for emergency purpose. These types of cylinders can be
easily fitted in anaesthesia machine.
30.18.4 MEDICAL AIR:-

1) We have two compressors to generate compressed air that can be supplied through central pipe line after
process of drying & filtration.
2) Air generated through compressor’s first stored in tank and then supplied through central pipeline.
30.18.5 VACCUM:-
2) We also have two compressor’s to generate vacuum (-ve pressure) that can be supplied through central
pipe line after storage in tank.
674
30.18.6 AGSS SYSTEM:-
1) We have two pump to vacuum Co2 & anesthetic waste gases from O.T.
30.19 Fire Safety In Medical Gas Plant:-
1) As gas plant is a fire prone area so the fire safety training is given to all the staff posted in gas
plant and preventive measures are taken to prevent the spread of fire.
2) Gas plant is declared strictly no smoking zone.
3) Adequate number of Fire extinguishers are located in the gas plant and they are regularly checked
by Chief security officer.
4) Fire sensor and alarm are installed in medical gas plant for quick activation of code red so that
corrective can be taken immediately to prevent any mishap.
5) Regular training is provided to staff posted in gas plant regarding how to use fire extinguishers and
other safety measures.
30.20 Maintenance Process:-
30.20.1 PREVENTIVE MAINTENANCE SERVICES (PMS) :-

a. Preventive maintenance service is provided by the concerned company on half yearly as gas
plant system is under warranty. In the event of any fault we call the company people and they sort
out the problem.
b. Purification of medical air is done on annual basis.
c. All jobs done by the concerned company are recorded in our faulty equipment record register. &
informed to HOD (Anesthesia)/MO/ I-C(GPL).
d. Tool kit is also kept in medical gas plant to rectify the minor problems arises during day to day
functioning.
30.20.2 Calibration Of Devices:-

- All the equipments are calibrated annually
- All the persons using the equipments are professionally trained and they also undergone in a basic
training/demonstration of the equipments by the expert of company at the time of installation. All the
pressure gauges are calibrated annually.
30.20.3 Preventive Measures To Be Taken By Users (Icu, Wards & Other Patient Care Units):-
1. Regular monitoring & recording of pipeline pressure of oxygen, vaccum, Air & N2O from the audio
visual alarm monitoring device installed in the patient care units.
2. Keeping adequate number of B & D type of filled oxygen cylinders as backup with accessories (i.e.
regulators, tubing & key) in access.
675
3. Check the pressure of stored cylinders regularly & keep a record.
4. Availability of adequate number of all the resuscitation devices like AMBU bag, ventimask etc. at
predefined place in each patient care units.
5. Air compressor of the ventilators should be checked & started once in 15 days.
29.1.2 Safety Issues followed in Gas plant
1.Standardized colour coding of all cylinders-Oxygen Black with white shoulders,N2O-Blue,CO2-Grey
2.Checking of all cylinders
3.All cylinders are kept chained.
4.Standardized colour coding of pipeline through out hospital.
5.Compressed air purity checked once a year at ICU and OT.
6.Pressure gauges are all calibrated
7.Proper instruction for No Smoking Zone at manifold with checked Fire extinguisher placed there.
8.Annual health check up especially hearing test of employee working there.
9.Ear muffs provided to employee to prevent occupational hazard.
10.Alarm units installed at all user areas
11.Pin index system
12.Alternate sources are regularly checked.
13.Quaterly training of our employee-related to hospital wide policies,Gas plant policy and Codes.
676
30.21 .Record’s Generation:-
30.21.1 Record of refilling of oxygen tank.
30.21.2 Stock register of cylinders in & out.
30.21.3 Record of fault in any equipment and servicing report in
30.21.4 Register all the preventive maintenance services (PMS) done by the concerned company
30.21.5 Record of changeover of line/bank in cylinder status register.
30.21.6 KPI (Key performance indicators)-Pressure monitoring of N20,O2, vacuum, air at GPL & patient
care units
29.2 Vendor Details:-
1) Liquid medical oxygen is being supplied by M/s Linde India Ltd.
2) Oxygen cylinder A & B Type, N20 cylinders ( all ) type are supplied by M/s Seth Traders.
3) Oxygen cylinder D Type, are supplied by M/s Goyal MG Gases Pvt. Ltd.
677
30.22 Emergency Contact numbers of Hospital Authorities
S.No. Name of person Designation Contact Number
1. Dr. B.L. Sherwal Director 9868168400
2. Dr. Mamta Jajoo H.O.O. 882524924
3 Dr. Geeta kamal HOD(Anes) 8595919329
4. Dr. Aikta Gupta M.O.I/c (GPL) 9643308230
5. Mr. Vineet Kr. Arora Technical Supervisor 8595919303
7. CUG on Rotation Gas Plant & On Rotation 9643308264

CSSD
678
30.23 Emergency contact numbers of vendors/Service Provider (Medical Gas Plant):-
S. Vendor Details Services Provided Name of person Contact Number
No.
1. MPS Company Maintenance & Repair Mr. Pradeep Saini 9811274452
Mr. H.S.Saini 9350231258
Company Number 01125925960
2. Linde India Ltd. Supply of liquid Oxygen Toll Free number 180029456789
(LMO) Mr. Rakesh 88606291761
Company 91-3330411515
30. Seth Traders Supply of Oxygen (A&B Mr. Anil Seth 98111296654
type), N2O cylinders
Company 0120-40429591
0120-41169229
4. Goyal MG Gases Pvt. Ltd. Supply of D-Type Oxygen Mr. Anuj Chauhan 8588861604
Cylinder
Company 0120-28404629 to
67
30.23.1
679
31 MATERIAL MANAGEMENT
(PURCHASE, STORE AND MAINTENANCE)
Responsibility of updating: Department of Material Management (Purchase, Store

and maintenance)
Last reviewed / updated on: August 2020
Version (CNBC/Material Mgt./31/Ver.1.0a)
680
31.1 Amendment Sheet ............................................................................................................................. 683
31.2 Procurement Objectives and Purchase Policies................................................................................ 684
31.3 Product Reservation .......................................................................................................................... 684
31.4 Items Reserved For Procurement From Ssi Units. ............................................................................ 685
31.5 Price Preference ................................................................................................................................ 685
31.6 Small Scale Units When They Quote In Consortium Under .............................................................. 685
31.7 Purchase Preference For Public Sector Undertakings ...................................................................... 686
31.8 General Principal of Entering Into Contracts ..................................................................................... 687
31.9 Competency of Parties: ..................................................................................................................... 687
31.10 Consent of Both Parties;: ................................................................................................................... 688
31.11 Free Consent Of Both Parties:........................................................................................................... 688
31.12 Consideration : ................................................................................................................................... 689
31.13 Lawfulness of Object; ........................................................................................................................ 689
31.14 The consideration or object of an agreement is lawful, unless it is forbidden by law. ....................... 689
31.15 Communication of an Offer Or Proposal:. ......................................................................................... 689
31.16 Communication of Acceptance: ......................................................................................................... 690
31.17 Acceptance To Be Identical With Proposal: ...................................................................................... 690
31.18 If the terms of the tender or the tender, as revised and modified,. .................................................... 690
31.19 Withdrawal of An Offer Or Proposal: ................................................................................................. 690
31.20 Withdrawal of Acceptance: ................................................................................................................ 690
31.21 Changes In Terms of A Concluded Contract: .................................................................................... 690
31.22 Discharge of Contracts: ..................................................................................................................... 691
31.23 Stamping Of Contracts: ..................................................................................................................... 691
31.24 Authority For Execution Of The Contracts By Dgs&D: ...................................................................... 691
31.25 Contracts on Behalf of The Central Government or State Governments : ........................................ 691
31.26 Contracts on Behalf of Parties Other Than The Central Government And The State Government:. 692
31.27 Governing Law In Purchases Made By Dgs&D: ................................................................................ 692
31.28 Store Planning and Management ...................................................................................................... 694
31.29 Technical Particulars for tenders: ...................................................................................................... 696
31.30 Methods of Purchase ......................................................................................................................... 697
31.31 Earnest Money and Performance Security ........................................................................................ 705
31.32 Elements of Price and Their Variations ............................................................................................. 709
31.33 Evaluation of Tenders and Formulation of Purchase Proposal ......................................................... 711
31.34 Rate Contracts ................................................................................................................................... 719
31.35 Post Contract Management ............................................................................................................... 732
31.36 Inspection of Stores Preamble:.......................................................................................................... 735
31.37 Payment of Cost of Stores Supplied Against Contracts .................................................................... 740
31.38 Purchase of Stores Manufactured In Foreign Countries ................................................................... 746
31.39 Delegation Of Purchase Powers Preamble ....................................................................................... 769
681
31.40 Registration of Firms Preamble: ........................................................................................................ 774
31.41 Settlement of Disputes ....................................................................................................................... 777
31.42 Reorder Level Policy.......................................................................................................................... 779
31.43 Maintenance Plan and Department ................................................................................................... 780
682
S.no. Date of Clause no Amendment made Reason for Amendment Signat
Amendment ure of
QM
1 Feb 2011 ____ Re-order level policy has been To ensure the proper
incorporated inventory management
2 Jan 2012 ____ Equipment Management Policy has To ensure the proper
been incorporated equipment management
3 December 31.43.6 Warranty of equipment: As per present terms &

2014 a) Upto 2 lacs- 3 years. conditions.
b) More than 2 lacs upto 5 lacs-
5 years. EPC, GNCTD has been
Now equipment costing more abolished and Now, Hospital
than 5 lacks also procured by the purchase section is
hospital through open e-tender, procuring Equipment costing
previously done by EPC. As per more than 5 lacks as per
hospital policy these equipments GNCTD policy.
are covered under 7 years CMC
including all spares,
consumables, accessories,
wires, etc.
4 Feb’2016 31.42.2 Amendment done regarding demand Previously demands for

sent to CPA on nirantar portal procurement sent to CPA
through central store manually.
5. -do- 31.32.1(A) Category of Indigenous goods Previously not elaborated
elaborated as Indigenous goods or
goods of foreign origin located within
in India
6. Feb’2016 31.32.1(A) Note added regarding All goods must Incorporated as per revised
be supplied by DVAT registered guidelines of GNCTD.
dealer as per GNCTD guidelines.
7 June 2019 31.43.12 Previously not elaborated
Medical Equipment recall policy
8 June 2019 31.43 Previously not elaborated

Maintenance plan
683
31.2 Procurement Objectives and Purchase 31.3 Product Reservation
Policies
31.3.1 Purchase of Khadi Items –Procurement
31.2.1 Procurement Objectives from Kvic.
The main objectives of public buying are: i) All items of handspun and hand woven textiles
items, termed as ‘Khadi’ are reserved
31.2.1.1 To procure the stores and services of
requisite quality and in required quantity for exclusive purchase from KVIC. List of all such
necessary for performance of duties by the khadi items is given in Annexure– 3.I
government departments.
ii) Purchase of Khadi Items should be made from
31.2.1.2 To procure stores as per the required KVIC and the payment made as per price finalised
delivery schedule so as to minimize the
inventory and cost thereof. by Cost Accounts Branch of Ministry of Finance.
31.2.1.3 To procure the stores on a competitive iii) All the items to be purchased from KVIC are
basis at the most economical manner required to conform to relevant Indian Standard
ensuring value for money. Specifications as applicable for these items.
31.2.1.4 To ensure transparency, and equitable iv) The supply orders on KVIC is to be placed based
approach in the procurement process. upon their capacity. For determination of the
capacity, , reliance may be placed on the report of
31.2.2 Purchase Policy
Cost Accounts Branch of Min of Finance or a
31.2.2.1 The purchase policy of Government certificate from KVIC duly signed by their
procurement follows the principles internal/statutory Auditor. Normally, the quantity in a
contained in General Financial Rules (GFR year should not exceed their annual capacity plus
17). The salient features of which are : 10%
a) To Purchase the stores and services required for
public service, in such a way as to encourage 31.3.2 Purchase Of Handloom Textiles Items
development and availability of indigenous products Including Barrack Blankets: Procurement
and services to the optimum extent. From Kvic/Acash /Wdo
i) All items of Handloom Textiles required by Central
b) To provide the price and/or purchase preference
Government Departments are reserved for exclusive
upto specified limit as may be prescribed by the
purchase form KVIC, notified Handloom Units
Government from time to time, to the notified
Through the Association of Corporations and Apex
sectors/agencies. Following types of preferences are
Societies of Handloom (ACASH) and Women’s
provided to KVIC, ACASH (Associations of
Development Organisation WDO Dehradun.
Corporations and Apex Societies of Handloom),
WDO Dehradun, SSI Units and Public Sector ii) The Handloom Textile items are to be purchased
Undertakings: from KVIC, ACASH and WDO Dehradun dividing the
qty. equally among them subject to the capacity of
i) Product reservation
individual agency. However, for requirements below
ii) Purchase Preference
iii) Price Preference Rs.5.00 lakhs, order can be placed on any one
c) To make available products and services of latest agency.
affordable technology and quality
iii) The payment of Handloom Items to the above
agencies will be made as per prices finalised by
Cost Accounts Branch of Ministry of Finance.
iv) DGS&D also enters into a rate contract with KVIC

and ACASH for supply of certain handloom/textile
684
items. Hence, where there is an existing rate Secretary. These items will be identified by definite
contract, the same should be utilized, before issuing specifications.
tender enquiry to these agencies.
31.5 Price Preference
v) The inspection of stores supplied by ACASH shall
be carried out as per existing procedure, for other 31.5.1 Where offers are received from large
supplies. For civil demands, no capacity verification scale unit as well as SSI units, but some
will be required before placing order on ACASH. of the lowest offers are from large scale
units, the offers of SSI units are to be
However in respect of Defence demands, with
given a price preference of up to 15%
inspection by Defence Authorities, capacity over the lowest acceptable offer from
verification of the units will be carried out, and orders large scale private sector unit, provided
placed only on receipt of satisfactory and capacity that the stores are technically acceptable
verification report. and satisfy the basic consideration of
delivery schedule and capacity.
vi) Testing arrangement will generally be provided
by the ACASH notified units. 31.5.2 However, the price preference
admissible to SSI units will be accorded
Where the same is not available, testing charges for on tender to tender basis, on merits of
each case in consultation with Finance.
testing the stores in outside laboratories by the
Further, this price preference may be
inspectors will be borne by ACASH or its notified accorded in a manner to provide SSI
units. Units an incentive to grow up and
discourage inflation and profiteering
vii) The list of items reserved for purchase from the
handloom sector in accordance with the procedure
outlined above and the IS specifications to which 31.5.3 In cases where the cottage and SSI units
these items should conform, is given in have established themselves as a
Annexure – 4. supplier of certain items on competitive
terms and enjoys an advantage over
31.4 Items Reserved For Procurement From Ssi large scale unit, no price preference need
Units. to be given.
i) This category comprises items in respect of which
31.5.4 The price preference would not be
the demand, can be fully met by KVIC/ACASH/Small
granted in the following cases:
Scale Sector Units or any combination of these
i) Where competition exists amongst the Small Scale
sectors and such items of stores are reserved for
units alone or where the items are exclusively
exclusive purchase from them. With regard to these
reserved for purchases from SSI Units; and
items, other things being equal, where KVIC are in a
position to meet the requirements, purchase would ii) Where the tenders are received from both the SSI
be made from KVIC. Units and large scale units and the lowest offers are
from SSI units and their capacity is more than
ii) Presently, 358 items are reserved for exclusive
adequate to meet demand in hand.
purchase from small scale sector – as per list given
in Annexure V. However, such items, which are
31.6 Small Scale Units When They Quote In
included in this list, but are not exclusively reserved Consortium Under
for production by SSI units, are also treated as
unreserved items. This list is reviewed at periodical 31.6.1 The Nsic/Ssidc/State Leather Developm
intervals by Standing Review Committee set up Ent Corporation / State Government
under the chairmanship of Secretary (Commerce), Handicraft Development Corporation :
and Development Commissioner SSI as Member i) Where the NSIC / State Development Corporation
themselves quote on behalf of some SSI Units, their
685
offer will be considered as an offer from SSI Unit 2. The above policy of allowing price preference to
registered with the DGS&D/NSIC. The NSIC/ State PSUs was extended up to 31.3.2004. (Proposals
Development Corporation will shoulder the normal have been submitted to Government by Bureau of
responsibilities applicable under terms and Public Enterprises, to extend this preference by
conditions of the DGS&D contracts and fulfil all the another two years.). All the Central Govt. PSUs or
contractual obligations on behalf of the units for joint ventures with PSUs, with minimum value added
which they quote. content of over 20% are entitled for consideration of
purchase preference, subject to purchase being in
ii) These facilities will not apply to the procurement excess of Rs. 5.00 Crores.
of the under mentioned items :
3. In case where there is a conflict between the
(a) Paint items for the Railways incentive to be given to small scale sector and the
incentive to be given to the public sector
(b) Drug
undertaking, the interest of the small scale sector will
(c) Medical and Electro-medical equipments prevail over that of the PSUs. In other words where
the acceptable offer of the small scale unit is lower
(d) Requirements of Defence where inspection is to to or equal to the offer of the public sector
be carried out by the Defence Inspection enterprises or even within a range of price
Organisation. preference of up to 5% over the public sector
undertaking contract would be placed on SSI unit in
(e) Items where technical competence, capacity and preference to a public sector unit, provided the price
manufacturing facilities are required to be verified preferences are admissible according to the existing
before placement of order. policy and it does not exceed 15% over the lowest
offer of a large scale private unit.
31.7 Purchase Preference For Public Sector
Undertakings 4. A Public Sector Undertaking would not be entitled
i) Purchase preference to Public Sector to any price preference when it quotes as an agent
Undertakings, is admissible, when they compete of an Indian or foreign manufacturer/supplier.
with large scale private units in accordance with
Govt. policy notified from time to time . Present However, where a Public Sector Undertaking is
Policy of the Govt. in this respect is as per Appendix selling goods or services of another Public Sector
‘A’. Undertaking it would be allowed the benefit of price
preference.
31.7.1 ANNEXURE ‘A’
5. In cases where the products of Public Sector
1. In ad-hoc purchases, the purchase preference in
Units have been offered by a Private Sector as the
favour of PSUs will be applicable as per following
sole selling/authorized agent, the private sector will
guidelines:
not be eligible for price preference.
a)Where the quoted prices of Public Sector
6. The above policy of purchases preference is not
Undertakings is not within the 10% of lowest
applicable to State Government Public Sector
acceptable price, such offers may be rejected
Undertakings.
without any further consideration.
7. Excepting for purchase preference to be
(b) Where the quoted price is within 10% of the
considered as above, in all other matters such as
lowest acceptable price, other things being equal,
capacity, specification, deliveries, payments etc. the
purchase preference may be granted at the lowest
Public Sector Undertakings would be treated at par
acceptable price.
with the Private Sector Undertakings and will be
686
bound by all commercial obligations, as per terms of b)Proposal or offer: When one person signifies to
the contract and tender enquiry. another his willingness to do or to abstain from doing
anything , with a view to obtaining the assent of the
8. Instances of bad and indifferent performance of other to such act or abstinence, he is said to make a
public Sector Undertakings, when noticed, should be proposal or offer. In a sale or purchase by tender,
brought to the notice of the Ministry/Department the tender signed by the tenderer is the proposal.
controlling the Undertaking. The invitation to tender and instructions to tenderers
do not constitute a proposal.
9. When a public Sector undertaking defaults either
in the delivery schedule of material/
equipment/service or does not complete particular
construction/delivery/erection of a project/equipment c)Acceptance of the proposal: When the person
satisfactorily, that public Sector Undertaking need to whom the proposal is made signifies his
not be shown purchases preference for a period of 3 assent thereto, the proposal is said to be
years. This ban of purchase preference to the Public accepted. A proposal when accepted becomes a
Sector Undertaking will be counted from the last promise. In the DGS&D contracts ,this is usually
default/unsatisfactory performance by the Public done by the issue of an advance acceptance
Sector Undertaking and non-eligibility for the letter/telegram or a formal acceptance of tender.
purpose of purchase preference will be applicable
for the entire range of production of the under d) What agreements are contracts: An agreement is
manufacture. a contract enforceable by law when the following are
satisfied. A defect affecting any of the above renders
31.8 General Principal of Entering Into a contract unenforceable.
Contracts
i) Competency of the parties.
31.8.1 INTRODUCTION ii) Freedom of consent of both parties
iii) Lawfulness of consideration
The Contract Manual issued by the Directorate
iv) Lawfulness of object.
General of Supplies and Disposals gives information
with regards to the elements and principles of
contract law and the meaning and import of various 31.9 Competency of Parties:
legal terms used in connection with the contracts.
Some of the salient principles relating to contracts 31.9.1 Under law any person who has attained
generally and those relating specifically to DGS&D majority and is of sound mind or not
contracts are set out briefly in this chapter. For a debarred by law to which he is subject,
may enter into contracts. It,
proper understanding of the general principles of
therefore, follows that minors and
entering into contracts, the Contract Manual should persons of unsound mind cannot enter
be studied. into contracts nor can insolvent person
do so.
Categories of persons and bodies who are parties to
the contact may be broadly sub-divided under the
31.8.2 Elementary Legal Practices :
following heads:
a) What is a contract? The proposal or offer when
accepted is a promise, a promise and every set of (a) Individuals
promises forming the consideration for each other is
an agreement, and an agreement if made with free (b) Partnerships
consent of parties competent to contract, for a lawful
consideration and with a lawful object is a contract. (c) Limited Companies
(d) Corporations other than limited companies
687
(a) CONTRACTS WITH INDIVIDUALS; Individuals contract. Normally, any one of the Directors of the
tender either in their own name or in the name and company is empowered to present the company.
style of their business. If the tender is signed by any Where tenders are signed by persons other that
person other than the concerned individual, the Directors or authorized Managing Agents, it may be
authority of the person signing the tender on behalf necessary to examine if the person signing the
of another must be verified and a proper power of tender is authorized by the company to enter into
attorney authorizing such person should be insisted contracts on its behalf
on . In case, a tender is submitted in business name
and if it is a concern of an individual, the constitution (d) CORPORATION OTHER THAN LIMITED
of the business and the capacity of the individual COMPANIES : Associations of individuals
must appear on the face of the contract and the incorporated under statutes such as Trade Union
tender signed by the individual himself as proprietor Act, Co-operative Societies Act and Societies
or by his duly authorized attorney. Registration Act are also artificial persons in the eye
of law and are entitled to enter into such contracts
(b) CONTRACTS WITH PARTNERSHIPS; A as are authorised by their memorandum of
partnership is an association of two or more association. If any contract has to be entered into
individuals formed for the purpose of doing business with any one or such corporations or associations,
jointly under a business name. It is also called a firm. the capacity of such associations to enter into
It should be noted that a partnership is not a legal contract should be verified and also the authority of
entity by itself, apart from the individuals constituting the person coming forward to represent the said
it. A partner is the implied authority to bind the firm in Association.
a contract coming in the purview of the usual
business of the firm. The implied authority of a 31.10 Consent of Both Parties; Two or more
partner, however, does not extend to enter into persons are said to consent when they
arbitration agreement on behalf of the firm. While agree upon the same thing in the same
sense. When two persons dealing with
entering into a contract with partnership firm care each other have their minds directed to
should be taken to verify the existence of consent of different objects or attach different
all the partners to the arbitration agreement. meanings to the language which they use,
there is no agreement. The
(c ) CONTRACTS WITH LIMITED COMPANIES: misunderstanding which is incompatible
Companies are associations of individual registered with agreement, may occur in the following
under companies Act in which the liability of the cases:
members comprising the association is limited to the (a) When the misunderstanding relates to the
members comprising the association is limited to the identity of the other party to the agreement;.
extent of the shares held by them in such
companies. The company after its incorporation or (b) When it relates to the nature or terms of the
registration, is an artificial legal person which has an transactions;
existence quite distinct and separate from the
(c) When it relates to the subject matter of the
members or shareholders comprising the same. A
agreement.
company is not empowered to enter into a contract
for purposes not covered by its memorandum of 31.11 Free Consent Of Both Parties:
association; any such agreement in excess of power
entered into the company is void and cannot be 31.11.1 The consent is said to be free when it is
enforced. Therefore, in cases of doubt, the company not caused by coercion undue influence,
must be asked to produce its memorandum for fraud, mis-representation or mistake.
verification or the position may be verified by an Consent is said to be so caused when it
would not have been given but for the
inspection of the memorandum from the office of the
existence of coercion, undue influence,
Registrar or Companies before entering into a fraud, misrepresentation or mistake.
688
When consent to an agreement is caused implies injury to the fraudulent property of
by coercion, undue influence, fraud or another or the court regard it as immoral
misrepresentation, the agreement is a or opposed to public policy. In each of
contract voidable at the option of the these cases the consideration or object of
party to a contract, whose consent was an agreement is said to be unlawful. There
caused. A party to a contract whose is hardly any possibility of any of the
consent was caused by fraud or contingencies herein above mentioned
misrepresentation may, if he thinks fit, arising in the case of DGS&D contracts.
insist that the contract shall be
performed, and that he shall be put in the 31.15 Communication of an Offer Or Proposal: The
position in which he would have been if communication of a proposal is complete
the representations made had been true. when it comes to the knowledge of the
person to whom it is made. A time is
31.11.2 In case consent to an agreement has generally provided in the tender forms for
been given under a mistake, the position submission of the tender. DGS&D are not
is slightly different. When both the bound to consider a tender which is
parties to an agreement are under a received beyond that time though there is
mistake as to a matter essential to the no legal prohibition for accepting such a
agreement, the agreement is not voidable tender.
but void. When the mistake is unilateral
on the part of one party only, the
agreement is not void.
31.16 Communication of Acceptance:
31.11.3 Distinction has also to be drawn between
31.16.1 A date is invariably fixed in tender forms
a mistake of fact and a mistake of law.
upto which tenders are open for
acceptance. A proposal or offer stands
31.11.4 A contract is not void because it was revoked by the lapse of time prescribed
caused by a mistake as to any law in in such offer for its acceptance, or if no
force in India time is so prescribed by the lapse of a
reasonable time, without communication
31.11.5 but a mistake as to law not in force in of acceptance.
India has the same effect as a mistake of
fact. 31.16.2 If, therefore, in case it is not possible to
decide a tender within the period of
validity of
31.12 CONSIDERATION : Consideration is
something which is advantageous to the 31.16.3 the offer as origin ally made, the consent
promisor or which is onerous or of the tenderer firm should be obtained
disadvantageous to the promise. to keep
Inadequacy of consideration is, however,
not a ground avoiding the contract. But an 31.16.4 the offer open for further period or
Act forbearance or promise which is periods.
contemplation of law has no value is no
consideration and likewise an act or a 31.16.5 The communication of an acceptance is
promise which is illegal or impossible has complete as against the proposer or
no value. offerer, where it is put in the course of
transmission to him, so as to be out of
31.13 Lawfulness of Object; the power of the acceptor, and it is
complete as against the acceptor when it
31.14 The consideration or object of an comes to the knowledge of the proposer
agreement is lawful, unless it is forbidden or offerer. The medium of communication
by law or is of such a nature that if in DGS&D contacts is generally by post
permitted, it would defeat the provisions of and the acceptance is, therefore,
any law, or is fraudulent of involves or complete as soon as it is posted. So that
689
there might be no possibility of a dispute offer by the tenderer before the specified
regarding the date of communication of period would entitle the DGS&D to forfeit
acceptance, it should be sent to the the earnest money.
correct address by registered post
acknowledgment due. 31.20 Withdrawal of Acceptance:
An acceptance can be withdrawn before such
31.17 ACCEPTANCE TO BE IDENTICAL WITH acceptance comes to the knowledge of the tenderer.
PROPOSAL:
A telegraphic revocation of acceptance which
31.18 If the terms of the tender or the tender, as reaches the tenderer before the letter of acceptance
revised and modified, are not accepted or will be a valid revocation.
if the terms of the offer and the acceptance
are not the same, the acceptance remains 31.21 Changes In Terms of A Concluded
a mere counter offer and there is no Contract:
concluded contract. It should, therefore,
be ensured that the terms incorporated in 31.21.1 No variation in the terms of a concluded
the acceptance are not at variance with the contract can be made without the
offer or the tender and that none of the consent of the parties. While granting
terms of the tender are left out. In case, extensions or making any other variation
uncertain terms are used by the tenderers, the consent of the contractor must be
clarifications should be obtained before taken. While extensions are to be granted
such tender is considered for acceptance. on an application of the contractor, the
If it is considered that a counter offer letter and spirit of the application should
should be made, such counter offer should be kept in view in fixing a time for
be carefully drafted as a contract is to take delivery.
effect on acceptance thereof. If the subject
matter of the contract is impossible of
fulfillment or is in itself in violation of law
31.22 Discharge of Contracts:
such contract is void.
31.22.1 A contract is discharged or the parties
31.19 Withdrawal of An Offer Or Proposal:
are normally freed from the obligation of
a contract by due performance of the
31.19.1 A tenderer firm, who is the proposer may
terms of contract.
withdraw its offer at any time before its
acceptance, even though the firm might A contract may also be discharged:
have offered to keep the offer open for
specified period. It is equally open to the
tenderer to revise or modify his offer
before its acceptance. Such withdrawal, (a) By mutual agreement:-If neither party has
revision or modification must reach the performed the contract, no consideration is required
accepting authority before the for the release. If a party has performed a part of the
acceptance is put in communication. contract and has undergone expenses in arranging
to fulfil the contract, it is necessary for the parties to
31.19.2 No legal obligations arise out of such
agree to a reasonable value of the work done as
withdrawal or revision or modification of
the offer as a simple offer is without a consideration for the value.
consideration. Where, however, a
tenderer agrees to keep his offer open for (b) By breach:-In case a party to a contract breaks
a specified period for a consideration, some stipulation in the contract which goes to the
such offers cannot be withdrawn before root of transaction, or destroys the foundation of the
the expiry of the specified date. This contract or prevents substantial performance of the
would be so where earnest money is contract, it discharges the innocent party to proceed
deposited by the tenderer in further with the performance and entitles him to a
consideration of his being supplied the
subsidiary contract and withdrawal of right of action for damages and to enforce the
690
remedies for such breach as provided in the contract 31.23 Stamping Of Contracts:
itself. A breach of contract may, however, be waived.
31.23.1 Under Article 5 of the Indian Stamp Act,
(c) By refusal of a party to perform:-On a promisor an agreement or memorandum of
refusal to perform the contract or repudiation thereof agreement for or relating to the sale of
goods or merchandise (not being bought
even before the arrival of the time for performance,
or sold not through a broker) is exempt
the promise may at his option treat the repudiation from payment of stamp duty.
as an immediate breach putting an end to the
contract for the future. In such a case the promise 31.23.2 The Stamp Act also provides that no
has a right of immediate action for damages. Stamp Duty shall be chargeable in
respect of any instrument executed by or
(d) In a contract where there are reciprocal on behalf of or in favour of the
promises, if one party to the contract prevents the government in cases where but for such
other party from performing the contract, the contract exemption government would be liable to
pay the duty chargeable in respect of
may be put to an end at the instance of the party so
such instrument, {Cases in which
prevented and the contract is thereby discharged. government would be liable are set out in
Section 29 of the Act}.
31.24 Authority For Execution Of The Contracts

By Dgs&D:
31.24.1 The DGS&D officers are authorised by

the President of India in exercise of the
powers
31.24.2 conferred by Clause (I) of Article 299 of

the Constitution to make contracts for
services,
31.24.3 supply or work on behalf of the Central

Government. Copy of the relevant
notification
31.24.4 issued by the Ministry of Law is given in

Annexure-2
31.24.5 The DGS&D makes similar contracts on

behalf of the State Governments where
so authorised by the State Governments
,and on behalf of governments
sponsored companies or corporation or
local bodies where so authorised by
such companies or corporations or local
bodies.
31.25 Contracts on Behalf of The Central

Government or State Governments :
31.25.1 Article 299 of the Constitution stipulates:

That all contracts made in the exercise of
the executive power of the Union or of a
State shall be expressed to be made by
the President or by Governor of the State
691
as the case may be and all such behalf of the public sector undertakings,
contracts and assurances of property corporations or local bodies. The corporation or local
made in exercise of that power shall be bodies as the case may be, should be named as the
executed on behalf of the President or
purchaser in the Invitation to the Tender and
the Governor by such person and in such
manner as he may direct or authorizes. Acceptance of Tender.
31.25.2 The contracts on behalf of the president (b) There should be an authorization specific or
or the Governor should, therefore, state general in favour of the officers of the Directorate
in express terms that they are made for General of Supplies & Disposals from the concerned
and on behalf of the President or the undertakings or corporations or local bodies to enter
Governor of the State by such officers into contracts on their behalf.
who are authorised to enter into
contracts on behalf of the President of 31.27 Governing Law In Purchases Made By
India or the State Government as the Dgs&D:
case may be.
There is no separate law governing public buying.
31.25.3 The contracts on behalf of Union Therefore, all purchases made and contracts
Territories are also to be executed on entered into therefor by the DGS&D are governed by
behalf of the President of India. the Sales of Goods Act, 1939 and the Indian
Contract Act, 1872.
31.25.4 These provisions are mandatory. If these
are not compiled with the contract is not 31.27.1 GENERAL GUIDELINES FOR ENTERING
binding on or enforceable against the INTO CONTRACTS BY THE DGS&D;
government, though a suit may lie While the various aspects of contract
against the officer who made the contract management in the DGS&D are
in his personal capacity . Such contracts discussed in the respective subject
are also enforceable by the government chapters, the following general
and the government cannot sue the other guidelines for enforcing into contracts
party on the basis of the defective have been laid down by the Government
contract. of India.
31.25.5 By virtue of the provisions of Article (a) Save in exceptional circumstances, no work of
299(2) of the Constitution, the official any kind should be commenced without prior
making or executing such contracts on execution of contract documents. Even in cases
behalf of the President etc. are exempted where a formal written contract is not made, no order
from personal liability for acts done or for supplies etc. should be placed without at least
purported to be done in the exercise of written agreement as to the price.
their official duties.
(b) The terms of a contract must be precise and
31.25.6 There cannot be an oral contract binding
definite and there must be no room for ambiguity or
the government and all contracts with
government must be in writing and all mis-construction thereon.
terms must be specifically provided
therein. (c) No contract involving an uncertain or indefinite
liability or any conditions of an unusual character
should be entered into without the previous consent
31.26 Contracts on Behalf of Parties Other Than of the Ministry of Finance.
The Central Government And The State
Government: (d) Subject to adequate prior scrutiny of terms,
general or special, if any, standard forms of
(a) In case of contracts on behalf of the public sector
contracts should be adopted, wherever possible.
undertakings, corporations or local bodies, all the
The alternatives used in the standard forms, which
documents forming part of the contract are to be
are not applicable, should be invariably scored out in
expressed to be made, issued or acceptance on
692
consultation with the Ministry of Finance and Ministry of notice should not normally be longer than 6
of Law. months.
(e) In cases where standard forms of contracts are (l) All contracts should have a provision for recovery
not used, legal and financial advice should be taken of liquidated damages for defaults on the part of the
in drafting the contracts and before they are finally contractor, unless there are any special instructions
entered into. issued by the competent authority. The terms of
contract for the purchase of perishable stores should
(f) The terms of a contract once entered into should invariably include a (separate) Warranty G.F.R.I This
not be materially varied without the previous consent form may, however, be modified to suit local
of the authority competent to enter into the contract conditions.
as so varied. No payments to contractor by way of
compensation or otherwise, outside the strict terms (m) It should be ensured that in all contracts where a
of the contract or in excess of the contract rates may warranty clause is included, the position regarding
be authorised without the previous approval of the delivery of goods in replacement of rejected ones in
competent authority. made clear beyond doubt by adding the words “Free
of cost at the ultimate destination” after the words by
(g) No relaxation of specifications agreed upon in a the purchaser” in the penultimate sentence of the
contract or relaxation of the terms of an agreement said clause, where the incorporation of such a
entered into by Government should be made without clause is not in consistent with the other conditions
proper examination of the financial effect involved in of the contract.
such relaxation. The interest of the public exchequer
should be taken due care of before agreeing to any (n) A schedule of qualities with their issue rates of
relaxation of agreement or contract. such materials which are supplied departmentally,
and are used in the contract work, should form an
(h) In selecting the tender to be accepted, the essential part of the contract. It should also contain
financial status of the individuals and firms tendering an escalation clause pertaining to rates of such
must be taken into consideration in addition to all materials the prices of which are controlled by
other relevant factors. Government and which the contractor arranges
himself, so that Government may get the benefit of
(i) Before entering into a contract or an agreement,
any saving in the quantities of the material actually
all pros and cons should be considered and validity
used in execution.
of contractual documents should be ensured.
Effective administrative machinery should also be (o) The question whether any sales tax, purchase
set up to keep a vigil on the performance of parties tax, octroi and terminal taxes and other local taxes
concerned. and duties are to be paid and if so, by which party,
should be settled and cleared up before entering into
(j) Provision must be made in contracts for
any contract, involving transfer of movable property
safeguarding Government properly entrusted to a
whatever its nature.
contractor and the recovery of hire charges, if any,
therefore. (p) All contracts for purchase involving import of
materials from abroad should as a rule provide for
(k) When a contract is likely to endure for a long
purchases on F.O.B basis and similarly all sales
period or where the contract provides for a clear
contracts involving transport of materials from India
schedule for the fulfilment of the various stages of
to other countries should be entered into on C.I.F.
the contract, it should include a provision for
basis.
unconditional power of revocation or cancellation at
the discretion of the government at any time on the
expiry of reasonable notice to that effect. The period
693
(q) Provided that a departure from the procedure requirements of all the departments,
prescribed above may be with the prior concurrence identify common items and shall plan for
of the Ministry of Surface Transport. concluding rate contracts for such items.
The consolidated requirement of
(r) No work should be done under an common user items shall be displayed by
DGS&D on its web site by 31st December
agreement/contract beyond the date of expiry of its
of the preceding year..
tenure. Wherever it is considered that the work has
to be continued beyond the date of expiry of the 31.28.2 Type of stores and services
tender timely action should be taken for renewing (i) Cyclic -These are fast moving items of regular
the contract/agreement for the further period consumption and are required repetitively during the
required, after a suitable review of the provisions of year, for example, stationery, petrol, other
the old agreement/contract o see whether any consumables, etc.
modifications therein are required.
(ii) Non-Cyclic - These are those stores which are to
(s) Where escalation in respect of labour overheads, be purchased against a specific requirement and
customs duties, freight etc. is provided for in a may not be required regularly, for example, vehicles,
contract, the basis for the calculation of the same arms, computers, livers and uniforms.
should be clearly indicated.
(iii) Capital -For stores costing Rs. 1 lakh per unit or
(t) “Cost Plus “ Contracts should be avoided except more with a life of more than 1 year and not
where they are inevitable. requiring annual purchases is categorized as capital
store, for example, plant and machinery.
(u) Lump sum, contract should not be entered into
except in cases of absolute necessity. Whenever (iv) Project requirement -These are those stores
such contracts are entered into, all possible which are required for a particular project.
safeguards to protect the interest of Government
should invariably be provided for in the conditions of 31.28.3 Delivery against R/C items - DGS&D shall
the contract. conclude R/C for common user items and
shall ensure that delivery against any
(v) The Comptroller and Auditor General and under supply order placed by DDO against the
his direction other audit authorities have power to R/C within a period of 2 months of such
examine contracts and to bring before the Public order and ordinarily 3 months in remote
Accounts committee any cases where competitive locations.
tenders have not been accepted or where other
31.28.4 Minimum ordered size - Minimum
irregularities in procedure have come to light. ordered quantity should be decided for
all R/Cs by competent authority. DGS&D
31.28 Store Planning and Management shall also specify the minimum order size
quantity while concluding the R/C.
31.28.1 Equipment & Material Budget - Supply order will be for minimum
“Statement of Stores and Services” (3S) size/quantity or more.
required during a financial year should
be prepared along with the Annual 31.28.5 Stocking of Stores -The stock level of
Financial Statement (AFS) which is stores to be maintained shall be decided
required to be submitted to Ministry of by keeping in view the minimum size of
Finance by October of the preceding the order permitted, economy, location,
year. Copy of this “3S” shall be infrastructural considerations, lead time,
forwarded to the Departmental Purchase anticipated requirement, obsolescence,
Wing (DPW) and the DGS&D stock out costs and service leve ls,
simultaneously with the submission of minimum size of the order contracted,
the AFS to Ministry of Finance every etc. Store levels shall be maintained by
year. DGS&D shall consolidate the each department based on such store
694
levels as are fixed out by HOD for on the purchase wing of department for
different locations and formations of the initiating purchase action. Indent should
department. be unambiguous, containing detailed
specification, required delivery schedule,
31.28.6 Maximum Permissible Store Level -As a financial arrangement, etc. The details of
general rule, no department shall stock the past supplies of same or similar
more that 15% of its annual anticipated stores, if made, should be indicated in
requirement at any given point of time. If the indent alongwith the name and
the need arises for higher level of stores, addresses of past suppliers.
decision should be taken by HOD in
consultation with integrated finance and 31.28.11 Stocking of IT and High-tech products -
the maximum limit should be fixed for Obsolescence level for such products is
different locations/formations. This shall very high. Efforts should, therefore, be
be ensured by HOD. made that no stocks are held for such
products and these are purchased as per
31.28.7 Staggering of stores -Generally, firm consumption cycle and project
supply orders should be placed for entire requirements. If, however, the necessity
annual requirement through a Single arises for stocking of such items for a
Supply Order with staggered delivery short period upto 3 months, the same
schedule so that delivery coincides with should be stored with special care under
consumption and no unnecessary the guidance of manufacturer / supplier.
inventory of stores are built up. As far as
possible, delivery and payment for cyclic 31.28.12 Surplus/scrap material -Major changes in
stores should be on monthly basis design and specifications, introduction
keeping in view the prescribed minimum of new standards, procedures,
size of orders. In small obsolescence, excessive stores are the
organizations/offices this cycle can be main factors which contribute to
monthly. accumulation of surplus or obsolete
stores. A committee should be formed by
31.28.8 Stocking of capital stores -Capital stores HOD every year by rotating members for
should be purchased against the specific the purpose of inspecting critically the
requirement and no stock shall be condition and justification of all the
maintained for such capital goods stores held in a stock. The committee
without the specific approval of D.O.E. shall identify obsolete and surplus stores
at various locations. An immediate action
31.28.9 Project requirement -(A) Stores required should be taken to deal effectively for
for a specific project should be disposal of surplus and obsolete stores
segregated into two categories viz., (a) either by sale, issue or transfer to other
those available against DGS&D R/Cs and locations/users. Depending upon the
(b) those requiring ad hoc procurement. estimated value of such stores, the
(B) For stores available on DGS&D R/C method of disposal should be decided by
action should be taken to place supply HOD in consultation with integrated
order against the DGS&D R/C. For other finance and completed within 3 months
stores procurement action should be of such identification. The review of
initiated as per the project plan well in surplus/scrap material should be done by
time as per project procurement the committee every 6 months. If higher
schedule. The procurement action periodicity is required for such review in
should generally conform to the rules respect of specific stores, the same
and guidelines framed by the Central should be decided by HOD in
Purchase Organization. consultation with the integrated finance.
31.28.10 Placement of Indent for Procurement - 31.28.13 Selective inventory control -The concept
After firming up the item, estimated price of economic order quantity and other
and quantity to be purchased, indent in latest material management concepts in
the prescribed format should be placed this regard should be utilized depending
695
upon the type of stores and the costs 6. Requirement of advance sample if any at post
associated with these stores. The contract stage before bulk production
technique of selective stores control
should also be adopted for different type 7. Special requirements of packing and marking if
of stores. This is necessary to avoid any
locking up of unnecessarily capital in the
stores and to take care of fast technical 8. Inspection procedure and criteria of conformity
developments taking place specially in
the field of manufacturing technology 9. Eligibility criteria for tenderers
and product profiles. These techniques
of selective control may be ABC analysis 10. Requirements of special tests if any
(based on annual value of consumption)
HML analysis (based on unit value of the 11. Requirement of type test certificate if any
item), VED analysis (vital essential and
desirable mainly of spares ), SDE
12. Requirement of type approval for compliance of
analysis (scares, difficult and easy), FSN
(fast, slow and non-moving), etc. statutory requirements of noise/emission etc.
13. Warranty requirements

31.28.14 Application of cost reduction techniques
-The application of various costs
reduction techniques like variety 14. Training, technical support, after sales service
reduction, standardization, value and annual maintenance contract requirements, if
analysis, forecasting, etc., should be any
continuous process in store planning
and each Head of Department should set 15. Any other requirements
norms for the same once in three years.
I. Purchase officer shall ensure that the
31.28.15 On-line store management -Each technical particulars are complete and
department shall have computerized correct as above before floating tender and
store planning and management system that a certificate to this effect has been
by 2008 A.D. All depots and users should recorded as under. For this purpose he may
be interlinked to achieve on-line store take assistance from the concerned
control and management. technical department or officer.
II. “It is certified that technical particulars have
been checked and are complete and correct
to meet user requirements fully and that all d
31.29 Technical Particulars for tenders: imensions are expressed in metric units.”
31.29.1 Technical Particulars to be specified in 31.29.2 Specifications and Drawings

the tender shall include the following as 1. The specifications shall be drawn based on
applicable: actual needs of the users for the products
1. Scope of supply available in the market. Specifications
should not over-specify the actual
2. Specifications including technical parameters and requirements.
product requirements 2. Specifications shall be drawn in line with the
latest technology and care shall be taken to
3. Drawings avoid procurement of obsolete and non
standard items. While framing specifications
4. Requirement of BIS mark, where applicable there shall be adequate emphasis on factors
such as efficiency, optimum fuel/power
5. Reference of sealed sample if any consumption, use of environmental friendly
materials reduced noise and emission
levels, low maintenance cost etc.
696
3. In order to ensure that the above aspects 8. The specification shall define the
are taken care of, the specifications may be requirements completely without any
finalized after consultation with trade and the ambiguity.
indenters. 9. Technical parameters shall be specific,
4. Wherever Indian Standards exists for the measurable / verifiable . Drawings may be
stores, they should be invariably adopted for supplied where necessary to show
procurement and the stores shall carry BIS arrangement and finer details. All
(Bureau of Indian Standards) mark. Only in dimensions shall be specified in metric units.
cases where no offers are available with BIS 10. For most of the stores it should be possible
mark or where such sources are not to lay down detailed specifications and
sufficient, stores conforming to Indian drawings for procurement and there should
Standards without BIS mark may be not be any necessity of procurement to
procured. Where Indian Standards specify samples.
more than one option for any raw material to 11. Wherever, the specifications/drawings have
be used a choice can be made for a been laid down, no samples should be
particular raw material against a tender. For asked for long with the tenders. In cases,
any deviations from Indian Standards, for where it is necessary to provide a basis in
any additional parameters or for superior respect of indeterminable parameters such
values of technical parameters, specific as shade, feel, finish, workmanship etc.,
reasons for deviating should be duly reference may be made to the sealed
recorded with the approval of the Head of samples kept with the purchaser or with the
Department and Finance concurrence. In indent or for guidance. In some cases it may
such cases Bureau of Indian Standards shall be necessary to ask for advance samples at
be requested to incorporate necessary post contract stage before giving clearance
changes in the Indian Standards for future. for bulk production, to check indeterminable
5. Some departments publish their own parameters as above.
standards which apart from specifying the
technical parameters also specify special 31.30 Methods of Purchase
requirements of packing, marking inspection The purchase officer should use the method of
etc. The technical parameters in such cases
procurement through the tender proceedings except
may also be marginally different from the
Indian Standards. in case of low value items and those available on
6. In such cases the general principle shall be Rate/ Running contracts of the Central Purchase
to adopt Indian Standards and the Organization (DGS&D). The methods of
departmental specifications could cover only procurement are set forth in the subsequent
such additional details as packing, marking, paragraphs.
inspection etc. as are specially required to
be complied for a particular end use. 31.30.1 Purchase Of Goods Without Quotation:
7. In cases where Indian Standards do not
exist, international standards or Purchase of goods upto a value upto Rs 15,000/-(Rs
departmental standards may alternatively be Fifteen Thousand only) on each occasion may be
adopted. Where no standards exist, made without inviting quotations/ bids by the
specification shall be drawn in a generalized competent authority on the basis of a certificate to
and broad based manner. Care shall be be recorded by him in the following format.
taken to ensure that specifications are not
proprietary of any manufacturer. Reference “I, ________ am personally satisfied that these
to any brand, make or catalogue number
goods purchased are of the requisite quality and
must be avoided and where it is unavoidable
it should only be as a bench mark and specification and have been purchase from a
should be followed with words “or at least reliable supplier at the prevailing market price.”
equivalent” allowing products which are
equivalent or better in performance, also to
be quoted.
697
31.30.2 Purchase Of Goods By Purchase procurement of R/C items by the indenting
Committee: officer shall be laid down by DGS&D in
Purchase of goods costing above Rs 15,000/- (Rs. detail in the DGS&D manual.
Fifteen Thousand only) and upto Rs 1, 00,000/-(Rs. 5. The payment for such items shall be made
only by the Accounts Officer of the Central
One lakh only) on each occasion may be made on Purchase Organisation and on the forms
the recommendations of a duly constituted Local prescribed for the purpose and shall in no
Purchase Committee consisting of three members of circumstances be made by the Indenting
an appropriate level as decided by the Head of officer themselves.
Department. The committee will survey the market to
ascertain the reasonableness of rate, quality and
specifications and identify the appropriate supplier. 31.30.4 Purchase Of Khadi Goods/ Handloom
Textiles:
Before recommending placement of the purchase
order the members of the committee will jointly 1. The Central Government through
Administrative instructions has reserved
record a certificate as under.
hand spun and hand woven (Khadi) goods
for exclusive purchase from Khadi Village
“Certified that we ________________, members of
Industries Commission (KVIC). Handloom
the purchase committee are jointly and individually textiles have also been reserved for
satisfied that the goods recommended for purchase purchase from KVIC and/ or the notified
are of the requisite specification and quality, priced handloom units of ACASH (Association of
at the prevailing market rate and the supplier Corporations and Apex Societies of
recommended is reliable and competent to supply Handlooms). Further, the handloom textile
the goods in question.” items should be purchased from KVIC to the
extent that they can supply, before covering
the demand on handloom units through
ACASH. To the extent these units can make
supplies, purchases shall be made from
31.30.3 Purchase of goods under the Rate them and for the balance quantity, if any,
Contract (R/C): purchases can be made from other sources.
1. The Central Purchase Organization 2. In the case of KVIC, the rates are fixed by
(DGS&D) publishes the specifications, certification committee, and the rates so
prices and the salient details of R/C fixed are reviewed by the Cost Accounts
products/ goods on its website Branch of the Ministry of Finance. In the
(www.dgsnd.gov.in). case of ACASH, the final price will be
2. Ministry/Department shall purchase goods calculated by ACASH and fixed by the
under the Rate Contracts by placement of Ministry of Textiles by associating a
the supply orders on the rates, terms & representative of the Chief Accounts Office
conditions of the R/Cs. The standard Supply of Department of Expenditure, Min. of
Order Form (DGS&D -131) should be used Finance.
for this purpose. 3. DGS&D also enters into long term contracts
3. In all cases of urgent needs where there with KVIC and ACASH for items of recurrent
was likely to be delay in getting supplies of demands and lays down terms and
DGS&D rate contracted items through conditions therein. For other items, the
operation of such R/Cs, the same item could purchase from both KVIC and ACASH
be purchased from the open market as long should be made on single tender basis.
as the price to be paid for such item does Normal inspection and other procedures
not exceed that stipulated in the R/C. Such shall apply for procurement through KVIC/
purchases should not exceed Rs 20,000 at a ACASH.
time and Rs One lakh in a year and are to 4. Testing arrangements will be provided by
be exercised in accordance with the powers KVIC/ ACASH or by their notified units and
delegated from time to time. where the same are not available; testing
4. The procedure to be followed by the Central charges for testing outside at approved
Purchase Organization to conclude R/Cs laboratory should be borne by KVIC/
and method to be adopted in the ACASH/ their units.
698
31.30.5 Purchase of Goods financed by 3. Hyperlinks should be established between
Loans/Grants from International the different procurement/ purchase of
Agencies: individual government departments with the
DGS&D website (www.dgsnd.gov.in).
The Articles of Agreement with International Bank
for Reconstruction and Development (World Bank)
and other International agencies stipulate specific
31.30.8 Advertised Tender Enquiry (ATE):
procurement procedures to be followed by the
1. Invitation to tenders by advertisement
Borrowers. These procurement procedures are should be used for the procurement of
finalised and incorporated in the Agreement after goods of estimated value of Rs 25 lakhs
consideration and approval of the Ministry of (Rupees Twenty Five Lakhs) and above.
Finance and are to be strictly followed. 2. The minimum time for submission of bids
may be 3 weeks from the date of publication
of tender notice or availability of the bidding
documents for sale, whichever is later. In
31.30.6 Purchase of Goods By Obtaining Bids/ cases where the tender notice and complete
Tender: bidding documents are available on the
website of the organisation and can be
Except for the purchase of goods through the
downloaded and in case of urgency of
methods given in the preceding paragraphs, requirement, the time limit of 21 days can be
Ministry/ Department shall procure goods within their reduced with the approval of the Head of
delegated powers by following the standard method Department.
of obtaining bid/ tender as follows:
31.30.9 Tender Notice:

1. The tender notice in case of ATE should be
(i) Advertised Tender Enquiry carefully prepared and contain all the salient
features of the item and the governing
(ii) Limited Tender Enquiry specifications to give a clear idea to the
intending tenderer of the stores to be
(iii) Single Tender Enquiry purchased. The Tender Notice should also
contain:
31.30.7 Publication on the Website I. Quantities and destinations,
1. Organization having its own website should II. cost of the tender/bidding document,
publish all its tender enquiries on their III. place(s) and timing of sale of tenders,
website. Other organizations may publish IV. place and deadline for tender delivery,
their tender notices and tender enquiries on V. place, time & date for opening of bids,
the DGS&D website. Further, wherever VI. bid security, amount & form, etc.
feasible, the organization, immediately after
a decision is taken for the procurement of 2. Superfluous or irrelevant details should not
stores/ group of items (even before be given in the tender notice as it will
finalization of the technical particulars), increase the cost of the advertisement.
should post a general procurement notice of
all such items likely to be purchased by
them on the website. 31.30.10 Forwarding Of Tender Notice
1. The tender notice containing salient details
of items to be procured should be posted on
2. DGS&D should create a separate section in the website of the organization and given in
their website for publishing the tender the Indian Trade Journal (ITJ) published by
notices of the government organizations not the Director General of Commercial
having their own website. This facility should Intelligence & Statistics, Kolkata.
be utilized as far as possible.
699
2. The tender notice should also be published the demand is more than Rs.25 lakhs in the
in at least one national daily having wide following circumstances:
circulation. The organization/ departments (i) When sufficient reasons exist, to be recorded in
publishing it on their website may not writing by the competent authority indicating that it
advertise it in the newspaper upto an will not be in the public interest to call for tenders by
estimated value of Rs 5 Crores.
advertisement.
3. A copy each of the tender notice should also
be sent to NSIC, registered/ known/ likely
ii) When the competent authority certifies that the
suppliers, registered Trade
Associations/Chambers of Commerce for demand is urgent and any additional expenditure
their advance intimation and giving wide involved by the elimination of open competition is
publicity. justified. In all such cases the competent authority
4. Where the Ministry/ Department feels that must place on record the nature of urgency and
the goods of the required quality, reasons why the demand could not be anticipated.
specifications etc. may not be available in
the country and it is necessary to also look iii) When the sources of supply are definitely known
for suitable competitive offers from abroad, and possibility of fresh source beyond those being
the Ministry/ Department may send copies of
tapped is remote, in all such cases approval of the
the tender notice to the Indian embassies
abroad as well as to the foreign embassies competent authority to dispense with advertisement
in India. The selection of the embassies will should be taken.
depend on the possibility of availability of the
required goods in such countries. B. LTE shall be issued to the suppliers borne
on the list of registered/ approved suppliers
for the item (s) being procured and to past
31.30.11 Sale of Bidding Documents successful suppliers. The number of
suppliers should not be less than three and
1. The organisation, whenever feasible, should efforts should be made to identify a higher
also post the complete bidding document on number of approved suppliers to obtain
its web site and permit prospective bidders more responsive bids on competitive basis.
to make use of the document downloaded The copies of the bidding document should
from the web site. There should be clear be sent directly to them, free of cost, by
instructions for the bidder to pay the speed post/ registered post/ courier/ e-mail.
prescribed fees etc either through e-
payment or by demand draft etc along with
the bid. C. Sufficient time is to be given to the bidders
2. The sale of tender against Advertised for preparing their bids and submitting the
Tender Enquiry should not be restricted and same.
the tender documents should be available
for sale freely.
3. Tender sets preferably be sold till the last
D. The organisation having their website should
date and time fixed for receipt of tenders.
publish the notices as well complete
However, competent purchase officer can
downloadable tender documents on the
decide the closure of sale of tender
website for the information of the registered,
documents one day prior to the date of
approved and successful past suppliers of
tender opening and clearly indicate the
the items
same in the bidding documents.
31.30.13 Single Tender Enquiry (STE):

31.30.12 Limited Tender Enquiry (LTE)
Procurement from a single source may be resorted
A. This method should ordinarily be adopted in
cases of orders the estimated value of which to in the following circumstances:
is upto Rs.25 lakhs. However, this can be
adopted even when the estimated value of
700
(a) The goods and related services are available (i) The indented goods are manufactured by
only from a particular supplier or a particular supplier M/s……..………………..
has exclusive rights in respect of these items and no
reasonable alternative or substitute exists; (ii) No other make or model is acceptable for the
following reasons:
(b) There is an urgent need for the goods, and
engaging in tendering proceedings or any other ……………………….
method of procurement would, therefore, be
……………………….
impracticable, provided that the circumstances
giving rise to the urgency were neither foreseeable ……………………….
by the procuring entity nor the result of dilatory
conduct on its part; (iii) Concurrence of finance wing to the proposal
vide: ………………..
(c) Owing to a catastrophic event, there is an urgent
need for the goods making it impractical to use other (iv) Approval of the competent authority vide:
methods of procurement because of the time ………………………
involved in using those methods;
(Signature with date and designation
(d) The organization having procured goods,
equipment, technology or services from a supplier of the procuring officer)'
considers that additional supplies must be procured
from that supplier for reasons of standardization or
because of the need for compatibility with existing (g) The supplier should preferably be asked to
goods, equipment, technology or services, taking submit a proposal through issue of single tender
into account the effectiveness of the original enquiry. An enforceable contract stipulating terms,
procurement in meeting the needs, the limited size conditions, technical details, warranty after sales
of the proposed procurement in relation to the support etc should be entered into with the supplier.
original procurement, the reasonableness of the The procdure to invite tenders and further
price and the unsuitability of alternatives to the processing may be decided by the competent
goods or services in question; purchase officer.
(e) The organization seeks to enter into a contract
with the supplier for the purpose of research,
experiment, study or development, except where the 31.30.14 Purchase of goods through restricted
contract includes the production of goods in tendering/ competitive negotiations in
quantities to establish their commercial viability or to case of extreme emergency such a
recover research and development costs; or national calamity, disaster mitigation:
In extreme emergency situation and for reasons to
(f) Items needed for national defence or national be recorded the competent purchase authority may
security and competent authority determines that undertake the ab-initio negotiations with a sufficient
single-source procurement is the most appropriate number of suppliers to ensure effective competition.
method of procurement. The requirements, guidelines, documents,
clarifications or other information should be
Proprietary Article Certificate in the following form
communicated to all the suppliers called for
(Stipulated in GFR 17) is to be
negotiations preferably in advance. The negotiations
provided before procuring the goods from the single should be confidential and the technical details,
source: prices or other market information provided by one
supplier during the negotiations should not be
communicated to other suppliers without the consent
701
of such suppliers. Following completion of the of receipt but with the stipulation that the
negotiations, all suppliers, remaining in the Price Bid of only responsive bidders will be
proceeding, should be requested to submit their final opened only after the techno-commercial
evaluation of the offers is completed. Both
offer with respect to all aspects of the procurement/
the bids sealed in separate covers should be
their proposals by a specified time and date. The put in a single sealed cover, which should
competent purchase officer should, thereafter, select be super scribed with the details of the
the successful bidder on the basis of such best and tender as per the requirement of the bidding
final offer. document.
3. The technical bids should be opened first on
31.30.15 Consultative Meeting for finalising the prescribed tender opening date. The
product and technical specifications. The price bids (in sealed cover), after the
Purchasing organisation should opening of the technical bids, should all be
undertake a transparent consultation placed in an envelope which should then be
process with the industry/ suppliers sealed and kept in the safe custody till the
before finalising the technical details and date of opening of Price Bids. Further, the
other criteria for the procurement. It tender opening officer/committee should
should be ensured that the procurement sign on the Price Bids envelopes and should
is for the standard product; also obtain signatures of at least two trade
representatives on the sealed price bids
taking into consideration the technical advancement
envelope. The price bids should be opened
and obsolescence, availability in the market of the after technical evaluation has been
competitive products etc. completed on a specified date which should
be made known to the all the responsive
tendering firms.
31.30.16 Single Stage Bidding:

1. In a single stage bidding process, tender 4. Whereas incomplete technical bids and
enquiry containing detailed functional and those having major deviations may be
technical requirements is issued and the ignored, the bids having minor deviations
suppliers submit their tenders containing can be further processed and clarifications
their technical, commercial and financial can be sought or technical discussions held/
proposals at the same time. The purchaser undertaken to determine finally the technical
awards the contract(s) after evaluation of all suitability of the offer (s) before opening
the tenders to the lowest evaluated bidder/s, price bids.
according to the method and criteria 5. Technical specifications, qualification/
specified. eligibility criteria should be finalized after
2. Single stage bidding is commonly used and interaction in the consultative meeting to be
is most appropriate for relatively straight – held before issue of the bidding documents.
forward procurement of fairly standard However, if, based on techno-commercial
technologies and ancillary services. evaluation of bids, major changes are
considered inescapable, the preferred
course, if the time permits, would be to
scrap the tenders and re-invite the bids.
31.30.17 Two Stage Bidding:
However, in case of urgency of requirement,
1. Tenders should be invited in two parts all the bidders may be given the changes
namely: proposed in the technical and other
particulars, deviations observed/
clarifications needed in their offer and
a) Techno-Commercial Bid, and, should be asked to submit their response
along with revised prices within a
b) Price Bid. reasonable period. If the response
6. Needed is simple affirmation, or otherwise,
2. Both the bids should be invited of the technical questionnaire/ details but
simultaneously with the same date and time having price implications, the replies
702
including revised prices may be obtained in incorporated in the bidding documents
one cover. However, if the response to as under:
technical details is again required to be
evaluated and responsiveness decided it
may be desirable to again ask the response I. Instructions to Bidders.
in two covers but with a short time limit and II. Conditions of Contract.
processed accordingly. III. Schedule of Requirements.
7. Two-stage-bidding affords independent and IV. Specifications and allied Technical Details.
objective evaluation of technical proposals V. Price Schedule (to be utilised by the bidders
as well as commercial terms and conditions for quoting their prices).
and also permits revision/addenda to the VI. Contract Form.
technical requirements and bidding VII. Other Standard Forms, if any, to be utilised
documents if considered necessary in the by the purchaser and the bidders.
light of the first stage techno-commercial The guidelines for preparation of the Standard
evaluation. It is more suitable for the
Bidding documents (Tender documents) for different
procurement of highly technical nature and
those requiring extensive technical services. types of goods bidding processes, value of
Two stage bidding may also be adopted in purchases etc are given in the separate chapter.
other cases where tenders are to be Standard Bidding Documents should be adopted as
evaluated to specific technical parameters far as possible for better and competitive response
and qualification/ eligibility criteria prescribed from the industry/ suppliers.
in the tender documents and if the
experience indicates that non-complying/
non-serious bidders might try to subvert the
bidding process by quoting unreasonably 31.30.20 Bid Validity
low prices.
1. The validity period should not ordinarily be
more than three months from the date of
opening of the bids. For complicated /
31.30.18 Tender Enquiries: Preparation and Issue
sophisticated items, this period may be more
Of:
than three months. The required duration of
This is an important document as the supplier’s offer the validity in each case should be decided
to be received in response thereto would be based on merits of each case at the time of
on the information given and called for therein. The planning the purchase.
Tender Enquiry should, therefore, be prepared with 2. Bidders shall be required to submit the bids,
utmost care setting out in unambiguous terms the valid for a period specified in the SBD. The
validity period should be sufficient to enable
requirements of the purchaser as to the quantity,
the purchaser to complete evaluation of
quality, delivery, destination etc. and any information bids, decide placement of contract and
which may be helpful to the tenderers in the award the contract. The period should not
submission of the offers, complete in all respects. All be too long, because longer period may
the important clauses relating to Eligibility Criteria, push up the quoted prices.
Evaluation Criteria, Earnest Money, Delivery
Schedule, pre-despatch inspection, Arbitration,
Liquidated Damages/penalties for the delayed 31.30.21 Signing of Tender Enquiries:
supplies etc should be incorporated in the Bid Tender Enquiry should be issued for and on behalf
documents so as to fully safeguard the interests of of the purchaser named in the schedule i.e. the
the Government and for evaluation of bids on President of India, Governor of State etc. as the
equitable and fair basis. case may be, and not “for and on behalf of the
purchaser”. The offers received in reply would be
31.30.19 Standard Bidding Document GFR 17 deemed to be addressed to the purchaser and it
provides that terms, conditions would be possible to establish a legally concluded
stipulation and information may be contract.
703
31.30.22 Amendment to Bidding Documents/ the bid. The original and the copy(s) of the
Extension of Bid Opening Date At times, bid should be put by the supplier in an
necessity may arise to modify/ amend/ envelope, which will again be put in an outer
clarify the bidding documents. envelope with proper address and
1. Amendment should be clear, unambiguous identification mark. The procedure should be
and specify the clauses/ provisions being specified in the Bidding Documents.
amended. Further, the amendment may
modify the requirement in a major way and /
or where much time is not left for the bidders 31.30.24 Method of Receipt and Custody of Bids:
to respond to such modification and to 1. Receipt, custody and opening of bids should
prepare revised bids. Requests for the not only be done in a transparent manner,
postponement of tender opening date but the procedures and drill for the same
received from the tenderers should normally must also appear transparent.
be discouraged but where necessary for 2. Receipt, care, custody and distribution of
reasons to be recorded, the competent tenders till opening should invariably be
purchase officer shall decide on entrusted to officials not involved in the
postponement of tender opening date on the purchase of the item.
individual merits of each case. In such a
case, the date of submission and opening of
bids should also be extended sufficiently to 3. The best method for receipt of bids is
enable the suppliers to respond as also the through a tender box. A designated official
bid validity and bid security termination should be made responsible for opening of
dated should also be suitably extended. tender box, receiving bulky bids, which
2. Whenever it is considered necessary to cannot be dropped in the tender box and
postpone the tender opening date, quick those received by post, courier etc.
decision must be taken and amendment 4. A bid without inscription on its cover may be
issued. opened in the Receipt Section. The tender
3. In case of LTE, copies of amendment should Enquiry No., time & date of opening of the
be sent to all the suppliers to whom the bid shall be recorded on the original cover of
tenders were sent. In case of ATE, copies of such bids by the receiving official and
the amendment shall be sent, free of cost, to thereafter promptly sealed. The sealed
the bidders who have purchased the bidding original cover will then be put in a new cover
documents through speed post/ courier/ on which the relevant details shall be again
e-mail and attached prominently in all the indicated. Similar procedure shall be
unsold copies. followed in case of bids received in torn
4. Such notice of extension of date of tender cover.
opening of tenders should also be published 5. All bids shall be documented indicating full
on the website without delay. particulars of the TE, bidder and other
related information and kept in safe custody.
All the tenders shall be handed over to
31.30.23 Submission of Bid tender opening officer unopened under
1. While submitting the bid, the bidder will proper acknowledgement on the prescribed
return in original (along with the original time and date.
copy of the bid) the proof of the bidder's 6. Head of Department shall prescribe the
purchasing the document from the system in the organization for opening of
authorized source. tender box at prescribed time, receipt and
2. Sometimes, especially for sophisticated distribution of all tenders so as to maintain
items, the purchase office may need more sanctity of tenders.
than one copies of the bid. The no. of copies
of the bid required to be submitted by the
bidders should be prominently mentioned in 31.30.25 Opening of Tenders:
the tender documents. All pages of the bid, 1. All the bids received on time (i.e. other than
except for un-amended printed literatures, if Late bids) are to be opened on the
any, shall be initialled by the person signing prescribed date, time and place as indicated
704
in the bidding document. The bid opening officer/committee opening the tenders to
time should be immediately after the make it perfectly clear that such alteration
deadline for receipt of bids, without any were present on the tenders at the time of
avoidable gap in between. opening. Wherever any erasing or cutting is
2. The bids should be opened in the presence observed, the substituted words should be
of the authorized representatives of the encircled and initialed and the fact that
bidders attending the bid opening. These erasing/cutting of the original entry was
representatives should bring with them present on the tender at the time of opening
letters of authority from the bidders on their be also recorded.
letterheads to this effect. These provisions 8. In cases where only one tender is received
shall be suitably mentioned in the tender against an advertised or limited tender
documents. enquiry it will be opened in the presence of
3. The bid opening official/s shall prepare a list another officer other than the one who would
of the authorised representatives of the be dealing with the purchase of the item and
bidders attending the bid opening with he will counter sign the tender documents so
details, i.e. their names & addresses as well opened in token of having witnessed the
as bidders' names & addresses and obtain tender opening.
their signatures. This list shall be kept in the
concerned purchase file for record.
31.30.26 Spot Comparative Statement:
1. The officer/committee opening the tender
4. The officer/committee opening the tenders
shall prepare “on the spot” a comparative
will read out following particulars from each
statement of the quotations received
tender opened by him for the information of
indicating the name of the firm, quantity
the representatives attending the opening: offered, Unit price, whether ST/ED/Statutory
(i) Tender No. and the name of tenderers. duties are extra or not, Delivery
2. Period, terms of delivery, discount if any,
(ii) Articles/nomenclature of the stores any other special condition like deviations.
(iii) Quantity offered in the tender.
31.30.27 Late Bids
(iv) Unit price –
1. The bids, or modifications to bids, which are
(v) Taxes & Duties such as Excise duty, sales tax received after the due time & date of receipt
extra or any other duty/ tax of bids are called “Late Bids”. Such Late
bids shall not be considered at all in case of
(vi) Whether any rebate/discount offered. If so, ATE & LTE. However, late bids can be
entertained by competent purchase officer in
quantum and conditions if any.
case of Single Tender Enquiry.
2. Late tenders may be destroyed by the
(vii) Delivery period offered.
organization after the purchase decision has
been finalized, except in cases where
(viii) Terms of Delivery
tenderers have been asked to furnish EMD.
Late tenders in EMD cases shall be returned
(ix) Any other special conditions like packing unopened to the bidders.
charges, deviations etc.
5. Each tender shall be numbered serially,

31.31 Earnest Money and Performance Security
initialed, and dated on the first page.
6. Each page of the schedule or letter attached
to it shall also be initialed with date. Further,
imported details such as the prices, delivery 31.31.1 Earnest Money
period etc. shall be circled and initialed. A. Earnest money deposit (EMD) is a token
7. Alterations in tenders, if any, made by the security demanded from a tenderer who
firms, should be initialed legibly by the intends to submit his offer against a tender
705
enquiry issued by the purchaser specifying For Rate Contracts (based on the total estimated
required conditions for the same. drawls)
Up to Rs 1 Cr. Rs. 10,000/

B. As per the General Financial Rules (Note-2,
Rule 273), EMD should be called for from 1 Cr. To 5 Cr. Rs. 25,0000/5
the Tenderers, who are participating against
tender enquiry. Cr. To 10 Cr. Rs. 50,000/More
than Rs. 10 Cr. Rs. 1,00,000/

C. Objective of taking EMD
Note: All values to be rounded off to nearest 100/
I. The objective of calling the earnest money

deposit alongwith tender is to deter non-
serious suppliers to participate against the E. Forms of EMD: EMD may be accepted in
tender enquiries. The value of the EMD the form of Demand Draft, fixed deposit
should be so fixed as not to act as barrier to receipts and banker’s cheques only.
genuine tenderers at the same time should F. Validity of EMD: EMD should normally
not be so low that it fails to deter the non- remain valid for a period of 45 days beyond
serious tenderers. the final bid validity period.
G. Offers of the firms submitted without EMD
as demanded are summarily to be ignored.
D. Amount of Earnest Money Deposit (EMD) H. The EMD of successful tenderers shall be
refunded after the Performance Security as
called for in the contract is furnished, unless
1) Quantum of EMD required to be incorporated in it is adjusted towards Performance Security.
the tender enquiry will depend on the gross EMD furnished by all unsuccessful tenderers
estimated value of tender. EMD should be will be returned as early as possible after the
calculated taking into account the value of all the expiration of the period of tender validity but
components and the exact amount of EMD is to be not later than 30 days of the award of the
contract. Failing to do will attract payment of
indicated in the Invitation to the Tender interest on the prevailing bank rate on the
Enquiry/Tender Notice. EMD beyond 30 days by the department to
the tenderer.
2) As per GFR 17, EMD can be fixed by the Head of I. EMD by Foreign Suppliers should be
the Department, on case to case basis, subject to furnished through Nationalized Banks only.
the provision of the GFR 17 which says that it should J. EMD will be forfeited, if the tenderer
ordinarily be 2% and may not exceed 5% of the withdraws or amends impairs or derogates
estimated value. Keeping in view the basic objective from the tender in any respect within the
period of validity of his tender or o award of
outlined above, suitable stipulations should be
contract fails to furnish the required
devised and incorporated by departments for Performance Security.
earnest money deposit while issuing tender
enquiries. The competent authority of respected
ministry shall decide the quantum of earnest money. 31.31.2 PERFORMANCE SECURITY
A. Performance Security (PS) is security
3) As a guiding principle it is advisable that EMD is demanded after placement of contract from
fixed on a reducing scale as proposed below: a successful tenderer whose offer has been
accepted. Performance Security is taken
Up to Rs 1 Lakh – No EMD is necessary Up to Rs. from the contractor for due performance of
10 Lakh – 2% & a minimum of 2500/For subsequent the contract. General Financial Rules (Rule
Rs.10 lakhs to 1 Cr – 1% For subsequent More than 273), stipulates that all firms contracting with
Rs. 1 Cr. – 1/2%
706
government has to submit PS unless 5% 7.5% 10% 0.75% For subsequent Rs.1 crore to
exempted by Finance Ministry. 5 Crore 3.5% 5% 7.5% 0.5% For portion more
than Rs.5 crore 2.5% 3.5% 5% 0.25%

B. Objective of taking performance Security:
I. The objective of incorporating Performance * All values to be rounded off to nearest
Security in contracts is to safeguard 1000/Exemption from submitting PSD
government interest in case of breach of
contract by the contractor and is a tool to 1) Submission of PSD may be exempted in
bind the contractor for fulfilling the
exceptional cases by Competent Authority
contractual obligations as laid down in the
contract. It is guaranteed pre-estimated
2) Petty purchases/contract of value less than 1
damages which can be recovered from the
contractor in case of default. The PS is not lakh.
meant to compensate for the loss to the
purchaser in the event of delay/non
performance/breach of contract etc, which
may be enormous but should act as D. Forms of PS
deterrent for the contractor for default on
flimsy grounds.
1. Performance Security is acceptable in any
one of the forms mentioned below:
C. Value of Performance Security Deposit i) Demand Draft on Banks
(PSD):
I. GFR 17 stipulates the limits of PS ( Rule ii) Bank Deposit /Fixed Deposit Receipt on
273) which stands at minimum of 5% and a Nationalized Banks.
maximum of 10% of the contracted value.
HOD’s should decide the amount of the PS iii) Bank Guarantee executed on the prescribed
depending on the case, keeping in view the format through Nationalized Banks.
basic objective outlined above. It should be
stiff enough to deter default but at the same 2. Detailed conditions stipulated against each
time should not tend to block the finances of of them are in Annexure 6.1
the contractor especially in the context of 3. Performance Security has to be submitted
bigger contracts. The competent authority of within 30 days of issue of contract failing
respected ministry shall decide the quantum which contract can be cancelled.
of SD. 4. Validity of PS: PS should remain valid for a
II. Guiding principles to work out PS are period of 60 days beyond the date of
illustrated below: completion of contract.
Gross Value of the Contract or Estimated
E. Verification of Bank Guarantee as PS
Drawls in case of Rate Contracts 1. Bank Guarantee submitted as Performance
Security Deposit needs to be verified from
Supply contract Supply with installation & the issuing bank. Only on receipt of
commissioning Integrated Contracts involving confirmation from the bank same can be
supply, installation, Commissioning & integration accepted.
2. Performance Security demanded can be
with other works For Rate Contracts for DGS&D only adjusted against EMD furnished along with
the tender and/or against the pending bills of
(no PS is to be taken by DDO’s saperately)
the contractor.
3. Purchase Officer shall not clear any of the
For the first 1
firm’s bills before it is ensured that
Performance Security has been furnished by
Crore
the tenderer and have been verified. If
Performance Security is to be adjusted from
707
the firm’s bills it should be adjusted fully purchaser towards Guarantee/Warranty
before any payment is released. security. In such cases validity of the
4. No inspection of store should take place security should 60 days beyond the
before PS has been deposited & verified. Guarantee/Warranty period.
The contractors are not expected to offer the 2. In situations where amount of the
stores prior to submission of the Performance Security (PS) and
Performance Security Guarantee/Warranty Security is identical,
5. A mechanism for Safe custody & monitoring Performance cum Guarantee /Warranty
of PS, should be in place to keep a watch on security deposit can be taken as PS, which
the date of validity of the securities under will be valid up to 60 days beyond the expiry
custody. Heads of the department should of Guarantee/Warranty period.
issue detailed procedure/guidelines on this.
6. All organizations shall set up institutional
arrangements for taking action well ahead of
the date of expiry of the validity of the
Performance Security for its renewal.
7. In case of failure on the part of the

contractor to comply with the requirement of H. ANNEXURE 6.1
Performance Security, it shall be lawful for Form In whose name to be obtained Condition of
the competent purchase officer to cancel the acceptance Custody
contract or any part thereof and invoking the
relevant provisions of Conditions of Contract 1 Demand Draft on Nationalized Banks
for breach of contract.
HEAD OF OFFICE
F. Refund of PS : Performance Security is Government will not pay interest on any deposit held
taken for the due performance of an in the form of cash Will be deposited into
individual contract should be immediately
Government Treasury for credit, in favor of the
refunded when the contractor duly performs
and completes the contract in all respects &
not later than 30 days of completion of the Department
contract. Failing to do so will attract payment
of interest on the PS on prevailing bank 2 Bank Deposit / Fixed
rates beyond 30 days by the purchaser to
the contractor. Deposit Receipt on Nationalized Banks.
1. Performance security taken for the due
performance of the contract should be HEAD OF OFFICE
forfeited and credited to the Government, in
the event of a breach of contract by the a) The deposit receipt should be made out in
contractor, in terms of the relevant the name of pledgee. If it is made in the
agreement. The decision to invoke the PS name of the pledger the bank should certify
should be taken as far as possible by an on it that the deposit can be withdrawn only
officer higher in the rank than the one who on the demand or with the sanction of the
accepted the guarantee. pledgee.
b) The Depositor should agree in writing to
undertake any risk involved in the
G. Performance cum Guarantee/Warranty investment. The bank should agree that on
security deposit receiving signed
1. In contracts where specified security is to be c) Treasury challan and withdrawal order from
deposited against Guarantee/Warranty the pledgee in respect of the deposit or any
obligation before release of final payment, part thereof, it will at once remit the amount
contractor can submit fresh securities or specified to the pledgee. The responsibility
request for adjustment of PS lodged with the of the pledgee in connection with the deposit
708
and interest on it will cease when issues a (ii) Statutory Duties & Taxes
final withdrawal order to the Depositor and
sends intimation to the bank that he has (iii) Freight
done so. Should be kept in the safe custody
of the departmental authority which takes (iv) Transit Insurance
the security deposit in accordance with the
provisions the General Financial Rules. Note: The goods must be supplied by DVAT
These should be kept safe custody as registered dealer as per GNCTD guidelines.
valuable documents.
d) Deposits at Call Receipts should be B. IMPORTED STORES:
encashed and deposited into Government (i) C.I.F. Price (including agency commission, if any)
Treasury for credit in favour of the
department. (ii) Statutory Duties & Taxes
3 Bank Guarantee through Nationalized Banks (iii) Landing and clearing charges; and
a) In the name of the Purchaser name in the (iv) Inland Freight/ Insurance
schedule to the contract Bank Guarantee
will be accepted in the prescribed format
only The Guarantee as well as revalidation
letters if required should be accepted only 25.7.2 Price Variations:
on non-judicial stamp paper.
b) The Bank Guarantee should be valid up to (a) It is the general policy that, as a rule, prices
60 days after the date of completion of
should be firm & fixed, and no contract involving any
performance.
c) Acceptance of the Bank Guarantee shall be uncertain or indefinite liability or any condition of an
subject to verification as follows:The Bank unusual character is entered into without the
Guarantee shall be subject to verification for approval of the competent Financial Authority.
its genuineness. For this purpose, the
purchaser shall address a registered A.D (b) However, under the following exceptional
letter to the concerned Branch of the Bank circumstances, price variations on account of (1)
with a copy to the Manager of the Head raw-materials, (2) wages, (3) central excise duty, (4)
Office of the Bank, enclosing a photocopy of Customs duty, and (5) foreign exchange, should be
the Bank guarantee with each letter
accepted for ensuring that the prices are in line with
requesting them to confirm within 10 days
that the Bank Guarantee has been issued by the market, and both the seller & buyer are equally
them. compensated:
d) The Bank Guarantee should be kept in safe
custody after retaining a photocopy thereof I. Where the cost of one of the raw materials is
for reference and any action which may more than 50% of the price of the stores; or
arise thereon. II. Where there is an abnormal increase/
decrease (i.e. 25% & above) in the prices of
any of the raw materials; the cost of which
31.32 Elements of Price and Their Variations constitute more than 30% of the price of the
stores; or
31.32.1 Elements of Price: The evaluation of III. Where the delivery period is spread over for
tenders is made on the basis of ultimate more than one year.
cost to the user. The quoted price (c) Standardized “Price Variation” clauses,
comprises of the following elements: · incorporated in the Instructions to Tenderers (Form
A. INDIGENOUS Store/ Goods of foreign origin DGS&D-229), should be used for reference
located within India.: purposes.
(i) Basic Price (including packing and forwarding
charges) I. However, the purchase officers of different
government departments may suitably draft
709
the price variation clause in consultation with any such stipulation it is to be assumed that
their respective Finance Wing. the prices quoted include these elements
and no claim for the same will be
entertained after opening of tenders.
31.32.2 PRICE VARIATION CLAUSE RELATING 3. Where the tender mentions that the prices
TO RAW – MATERIAL: are exclusive of statutory duties & taxes
which will be payable extra, it should be
The purchase officers shall ensure to indicate in the
definitely stated in the Acceptance of the
tender enquiry, the base price on which the firms Tender that the duties & taxes are payable
should base their rates in respect of variable price at specified rates, in addition to the cost of
quotation, otherwise there will be difficulty in stores, instead of mentioning their payment
comparison of the quotations on equitable basis if in an indirect manner.
different tenderers base their prices differently. For
the purpose of determining the base prices & their
variation, they should take the assistance of
commodity prices/ commodity indices (in case 31.32.5 Duties / Taxes on Raw-Materials:
commodity prices are not ascertainable), which are
The purchaser is not liable to any claim on account
published regularly by (1) Central Statistical
of fresh imposition and/or increase of statutory
Organization, (2) Economic Advisor to the Ministry of
duties or taxes on the raw materials and/or
Commerce & Industry,(3) Public Sector Units, (4)
components used directly in the manufacture of the
London Metal Exchange, or (5) Any other suitable
contracted stores taking place during the pendency
index.
of the contract, unless otherwise specifically agr eed
to in terms of the contract Moreover, no provisions to
31.32.3 PRICE VARIATION CLAUSE RELATING
TO WAGES ESCALATION: this effect exist in the Section 64A of the Sale of
Goods Act, 1930.
It is considered inappropriate to fix any wage
escalation clause for any type of stores
31.32.6 Statutory Duties & Taxes On
manufactured indigenously. Where, however, it has Replacement Supplies:
been decided to allow wage escalation, the
Where the replacement supplies is made under a
escalation factor should be carefully worked out to
contract, Section 64A of the Sale of Goods Act is
ensure that no undue advantage accrues to the
attracted and increased duties & taxes are payable
supplier.
by the buyer. However, as delivery of the goods is
delayed , the increase in duties & taxes would not
31.32.4 Considerations of Duties And Taxes In
Government Purchases: have been payable, if the original supplies had not
proved defective and been rejected or lost or
1. The duties and taxes as levied by the
Governments vary from item to item. As a damaged in transit, therefore, required to be
general policy, the statutory variations in the replaced, the additional expenditure on account of
duties & taxes on the stores should be increased duties & taxes is a loss directly
allowed both during the currency of the occasioned by the delay in supplies. However, the
ongoing contract as well as between the purchaser is entitled to recover the liquidated
date of tender and the Acceptance of the damages at the contract rate upto a sum equal to
tender so that both the seller and buyer are
the amount of extra expenditure incurred on account
equally compensated for rise or fall in the
prices of the stores on account of such of the increased duties & taxes. Therefore, the extra
variations. This is also in accordance with amount on account of increased duties & taxes need
the Section 64A of Sale of Goods Act, 1930. not be paid to the supplier, as the same is required
2. In the Tender Enquiry conditions, the to be adjusted against the liquidated damages for
tenderers should be asked to specifically the delay in supplies.
state in their offer whether they intend to ask
for the duties/taxes as extra over and above
the prices being quoted. In the absence of
710
31.32.7 OCTROI AND LOCAL TAXES: 5. Price preference to priority sectors
Stores supplied to Government Departments against 6. Competition, reasonableness of prices
Government Contracts are exempted from levy of including negotiations
7. Availability of adequate funds
town duty, Octroi Duty, Terminal Tax and other 8. Finalisation of purchase proposals
levies of local bodies. Contractors should ensure 9. Deciding the lowest evaluated bidder (s)
that stores ordered against contracts placed by this 10. Award of contract (s)
office are exempted form levy of Town Duty/Octroi
Duty, Terminal Tax or other Local Taxes and duties. 31.33.3 Responsive/ Non-responsive Bids
This should be specifically mentioned in the Tender 1. The bid, which does not conform to all the
Enquiry/ Contract. essential and mandatory requirements and /
or contains reservations with regard to the
critical and essential terms & conditions of
the SBD, is termed as non-responsive bid
31.33 Evaluation of Tenders and Formulation of and is not to be considered for placement of
Purchase Proposal contract. The bid, which meets all such
requirements, terms & conditions, is termed
31.33.1 The bids after their opening are required as responsive bid. There may be some bids,
to be evaluated in accordance with the which are prima facie responsive but contain
terms and conditions of the bidding some minor omissions / missing points.
documents. The methodology for bid These are substantially responsive bids and
evaluation and terms and conditions are should be processed further for rectifying the
to be incorporated in the tender minor deficiencies.
documents in a transparent manner so 2. In the very first step the bids, which are
that the bidders and also the purchaser straight away unacceptable e.g. bids without
are fully aware of the same. The EMD; are to be considered non-responsive
evaluation of a tender is a crucial stage and should not be taken up for further
and should be undertaken carefully, scrutiny. The reasons for considering such
correctly and fairly by the purchase bids as unresponsive should, however, be
officers with clear cut delegation of duly recorded. The remaining bids should,
powers and responsibilities. Such a thereafter, be scrutinized in greater details to
scrutiny and analysis will enable the find out which of them substantially satisfy
purchaser to take a decision as to which the required terms and conditions of the
of these bids are acceptable and which bidding documents. There may be some
out of them can be utilised for placement bids which have some minor deficiencies
of contract. without having any financial repercussion
and/or impact on other bids, but at the same
time, it is necessary to have proper
31.33.2 In procurement of highly technical and
clarifications from those bidders in
complex goods/ equipments, evaluation
connection with those minor deficiencies.
should be entrusted to a Tender
The purchaser may obtain the required
Evaluation Committee of experts. Such a
clarifications from those bidders in writing.
committee should be invariably
The offers of the bidders, who furnish proper
constituted at the planning stage itself.
and straight forward clarifications, are then
The bid evaluation is to be done step by
to be considered further along with the offers
step in a methodical way. It involves:
which are already straightaway acceptable.
1. Preliminary examination The bids, which remain unacceptable even
2. Evaluation of technical responsiveness and after receiving the response are to be
to eligibility/ performance criteria. considered as unresponsive and may not be
3. Capacity and past performance processed for further scrutiny after duly
4. Preparation of comparative/ ranking recording the deficiencies and reasons for
statements after taking into consideration all the same.
elements of cost such as taxes, duties, 3. The determination of a bid’s
packing, forwarding, transportation responsiveness, or otherwise should be
insurance etc.
711
based on the contents of the bid itself comparable material, price ordinarily is an
without recourse to extrinsic evidence. appropriate deciding factor. In such cases, a
4. Some critical and essential requirements of separate technical evaluation may not be
the SBD are : necessary and a mere checking regarding
I. Bid received on time (i.e. regular bid) supplier’s confirmation to supply the goods
II. Bid includes complete requirement as to the required/ governing specifications
specified in a schedule. should be sufficient.
III. Bid signed by authorised representative. 2. However, in case of purchases of goods of
IV. Provision of bid security technical and complex nature and/ or
V. Terms of delivery requiring furnishing of literature/ documents/
VI. Delivery schedule information regarding technical parameters
VII. Registration status, wherever required, and qualification/ eligibility criteria, clause by
eligibility and qualification criteria. clause compliance of the specifications/
VIII. Completeness of price structure with requirement should be checked. In important
reference to the terms of delivery. cases the details as to how the bidder would
IX. Payment term. meet the requirement of the particular
X. Applicable law. clause should be called for in the bidding
XI. Any other mandatory directive incorporated document and checked.
in the SBD. 3. In complex cases, format of compliance
statements should also be formulated and
included in the bidding documents clearly
31.33.4 Preliminary Examination stipulating that the firms should submit the
1. The purpose of this examination is to details/ statement in the form and indicate
exclude bids from further and more the clause by clause compliance giving
complicated consideration if they do not complete details as to how the requirements
meet the minimum standards of acceptability are met, failing which their offer would be
as set out in the bidding documents and are, treated as incomplete and unresponsive and
therefore, not substantially responsive. The would be liable to be ignored.
bid should however, not be rejected on trivial 4. Based on technical evaluation of the offers,
procedural grounds. such of the technical bids as are incomplete
2. It shall be ascertained whether the bids or indicate major deviations should be
conform to critical and essential requirement ignored. The proposal should bring out
of bidding documents such as: clearly the deficiency in the bid with respect
I. has been properly signed by the authorised to specifications/drawing or other particulars
representative governing the requirements. Deviations from
II. Are accompanied by required Earnest the specifications should be clearly brought
Money Deposit (EMD) or other securities. out in a separate Deviation Statement. Bids
III. Has valid registration status, Eligibility received without these statements should
criteria & Qualification criteria also be treated as unresponsive and ignored
IV. Are responsive to ITB requirements and without any further reference to the bidder.
other bidding documents. 5. In case of procurement of plant and
machinery or stores of specialized nature or
3. Incomplete bids should be straightaway scientific equipment, the tender evaluation
ignored. References should not be made for committee should record in detail the
seeking Clarifications or asking for reasons for acceptance/rejection of technical
document(s) that have an effect on the proposals analysed and evaluated by it.
substance or essentials or price of the bids 6. The offers having minor deficiencies, without
or their relative ranking. having any financial repercussions can be
further processed and clarifications sought,
if such clarifications will not put the
concerned bidder in an unduly favourable
31.33.5 Technical Responsiveness
position at the cost of the bidders and/ or the
1. In the procurement of simple commodities, purchaser. The clarifications may be
semi-finished raw materials and goods, obtained by giving a reasonable target date
where the offers are for identical and
712
and if the response is not received by the Registration Branch of the
stipulated date, the offer may be ignored. DGS&D/NSIC/DGQA/the concerned
7. In case of two bid system, however, a view Department or any other agency specified
may have to be taken based on responses for this purpose as specified in the Schedule
received if it is inescapable to modify the to Tender.
technical requirements. In case it is decided 4. A firm shall be considered to have registered
to substantially alter the technical status if the date of registration is prior to the
requirements, either the tender process date of opening of bids (as distinct from the
should be repeated or the tendering firms date of opening of revised bids). The bidding
given further opportunity after clearly firms securing registration subsequent to the
indicating the final requirement and the original date of bid opening should be
deviations noticed in each case. treated as unregistered.
5. In respect of an item allied to the items for
which the bidding firm is registered, the
31.33.6 Eligibility/ Qualification Criteria potential of the bidding firm should be taken
to decide its capacity to produce that
1. The eligibility criteria in respect of the
particular item and registration status of the
following are normally required to be
firm with respect to the item may be
checked:
determined accordingly.
I. Registration of the firm for the item
6. For the procurement of stores with ISI
(s) being procured & its validity
marking, the status of a firm as to whether
II. Availability of valid ISI mark and its
they hold valid BIS license to supply stores
validity
with ISI mark will be determined as
III. Statutory/ mandatory certifications
prevailing on the date of date of bid opening.
such as drug licence, pollution/
emission certificates etc. specified in
the bidding documents.
IV. Performance requirements with 31.33.7 Comparative Statement
supporting documents A comparative statement of all the tenders opened
V. Complaints/ rejections in earlier should be prepared especially when large numbers
supplies, if any of bids have been received. It is a statement
VI. Capacity and present load in hand
containing the relevant details of all the tenders and
the contracts are to be placed on
firms who have the technical and would assist in ensuring that no tender is lost sight
the financial capabilities to execute of. It should indicate the details concerning the
them and with proven performance. offers, such as rates, taxes & duties, delivery,
quantity offered, any other information relevant to
the decision of the tender. The status of the firms
2. In respect of registered firms, the technical regarding their registration, SSI/ Large scale/ Public
and financial capacities checked at the time
sector unit and the last purchase price etc should
of registration, which is granted for specific
items and specifications and incorporates also be given therein.
the assessed capacities. Procurement of
stores should normally be made from
registered manufacturers/suppliers. Each
Department should maintain a list of 31.33.8 Ranking Statement
approved suppliers and their vendor rating. After a comparative statement has been prepared,
This list should be updated regularly every the ranking statement should be prepared in
calendar year. ascending order of the prices (i.e. lowest to highest)
on equitable basis, taking the incidence of all
3. A firm is considered registered for such elements of price upto destination for inter-se
items of stores for which the registration has comparison. Wherever a comparative statement has
been specifically granted and should be in been prepared, Ranking statement may be prepared
the approved list maintained by the upto three (3) eligible responsive bidders.
713
31.33.10 REASONABLENESS OF PRICES:
A. Evaluation of tenders is made on the basis
31.33.9 CAPACITY AND PAST PERFORMANCE: of the ultimate cost to the user and is the
A. The Purchase Officer should prepare a major factor in the decision for placement of
statement in the following Performa: contract. The reasonability of prices may be
i. Name of Firm judged based on the factors as follows:
ii. Capacity I. Last Purchase price of same (or
iii. Past Performance, similar) article. The last purchase
indicating the proven price is to be suitably updated due
performance to price variation clause (if any) and
iv. Load in hand examined with reference to rate (s)
v. Complaints/ rejections in of inflation, price indices of finished
past supplies if any. products as well as raw materials
vi. Vendor Rating: etc. while making such comparison.
B. Bids or modification of Bids received after II. The current market price of same
the due time and date of receipt of bids (late (or similar) article.
bid) shall not be considered at all. Bidder III. If raw material(s) covers the major
should not be permitted to modify his bid portion of the cost of the item the
after the expiry of deadline for receipt of the movement of the prices of the raw
bid. If a bidder revises his bid after bid material(s),
opening and which has an effect on the IV. Terms of delivery – if supply is to be
substance or essentials the bid shall be made at a distance and/ or difficult
ignored as late bid. place, the overall price of the article
C. Deviation in delivery schedule: Contracted to be supplied will be comparatively
stores are required to be delivered/ more.
dispatched within an acceptable range say 3 V. Quantity involved – generally higher
months and which should be specified in the the quantity, the unit cost of the
Schedule of Requirements. No credit should article is lower, and vice-versa.
be given to deliveries earlier than minimum VI. The delivery period- In case of
indicated. Further, bids with delivery beyond emergency purchases, higher price
specified range should be treated as might have been paid in the past.
unresponsive. On the other hand, on some
D. Within this acceptable range, for evaluation, occasions suppliers clear their
a price adjustment per month calculated at surplus stock by offering lower price.
the rate of leviable L/D, or pre-estimated Such purchase/ sale prices are not
damages, say 2% per months or 0.5% per the normal prices payable for the
week as specified in the Bid document can stores. The purchaser officer while
be added to the quoted price of bids offering comparing the prices in the tenders
deliveries later than the earliest minimum should factor in such peculiarities in
delivery period mentioned in the Schedule of last procurement price paid.
Requirements, if and only if such a loading VII. Keenness of competition amongst
is specified in the evaluation criteria in the the responsive bidders against
bidding documents. advertised tender enquiry should be
E. For urgent requirements (to be specified in the most appropriate criteria for
the Schedule of Requirements), heavy pre- judging the reasonableness of the
estimated damages be specified in the prices. If the prices received from
bidding documents and the resultant responsive bids indicate keen
contract and no relaxation for late deliveries competition amongst the bidder and
be allowed. For such requirements, the bids, there are adequate higher priced
which are not meeting the required delivery bids, the price can be termed as
period, may be treated as unresponsive. reasonable, provided the same
prices are not abnormally higher in
comparison to last purchase prices,
movement of prices of raw
materials, estimated prices etc as
714
per broad guidelines mentioned number of acceptable bids never
above. Thus, the reasonability of the exceed two.
price proposed to be accepted has 2. Depending on the merits of the case, the
to be established by taking into following course of action may be adopted to
account the competition observed deal with the situations: If the number of
from the response of the trade to the offers received are less than three (3), the
enquiry, last purchase price, purchaser shall examine whether all
estimated value and market price standard procedures like wide publicity of
wherever available. the demand, projection of clear cut
B. Unless price variation formula is given in specifications without any ambiguity,
Bidding Documents, bidders should quote providing sufficient time for obtaining the
firm prices. Contract should either be bids, etc were followed and also whether the
entered on firm price basis or based on a prices quoted by the bidders are reasonable.
price variation formula specified in the If all these aspects are satisfied the
bidding documents. Where a bid on variable purchaser can proceed for placement of
price is considered, the price variation order even if the number of acceptable
formula should be clearly spelt out indicating offers received is less than three (3).
the base price on which the variation is to be 3. In case of pool/cartel formation, the
allowed. purchaser should consider taking
C. Bids with variable prices, where ITB is appropriate administrative action such as
seeking firm prices, should ordinarily be against bidders forming pool/ ring/ cartel. In
treated as unresponsive and ignored. If case it is seen that the ring prices quoted
inescapable, contract on variable prices can are reasonable but the cartel has been
be considered on the merit of the case. Offer formed to divide the quantities amongst the
involving any uncertain or indefinite liability members of the pool, and the requirement is
or any condition of unusual character should urgent requiring early finalisation of case,
not be considered. cartel may be broken by selecting bidder (s)
D. Where the standard price variation clauses whose terms and conditions as well as
are not available and if the purchase credential and past
decision is to place order on variable prices 4. Experience is most favourable compared to
basis, a suitable price variation clause has other bidders in the pool/ cartel and award
to be drafted in consultation with Finance the contract to such bidder (s) so as to break
allowing price variation in the raw material the cartel/ pool.
with a suitable price variation factor
preferably on net weight of raw material and
a suitable time lag (say 30 days). 31.33.12 LAST PURCHASE PRICE (LPP):
1. To ascertain the reasonability of the prices,
these should be compared with the prices
31.33.11 LACK OF COMPETITION: paid in the last contract, if any, for the same
1. Lack of competition exists in the following item, on the following lines:
circumstances: a) The LPP will be the price paid in
a. Number of acceptable bids are less the latest contract of a similar
than three; magnitude, which is not more
b. Price(s) quoted by the bidders in than three years old.
pool or through ring/ cartel b) Where the firm holding the LPP
formation, even if the number of contract has defaulted, the fact
bidders may be large. should be highlighted in the
c. Although there are other quality purchase proposal and the price
manufacturers of the required goods paid against the latest contract
the product of only one placed prior to the defaulting
manufacturer has been offered by LPP contract where supplies
all the bidders; irrespective of have been completed, should
number of quotations; be indicated.
d. Store under purchase is chronically c) Where the price indicated in the
in short supply against which a LPP is subject to variation,
715
besides indicating the original E. The proposal should be formulated for
price as of the LPP contract, the coverage so as to ensure that;
updated price as computed in a. Contracts are awarded to the
terms of the price variation tenderers who have the requisite
clause, may also be indicated. financial, technical and production
d) Where the supply against the capabilities necessary to perform
LPP contract is yet to the contract;
commence i.e. delivery is not b. The quantities are covered in
yet due, it should be indicated in keeping with the quantitative
the purchase proposal, whether capacity meeting the delivery
the LPP contract holder is a requirement.
past supplier/registered F. The ranking statements prepared vis-à-vis
supplier/ new supplier. In case the bids received sho uld be checked so as
of new supplier, the price paid to avoid possibility of any mistake and
against the previous contract as examined carefully.
in the case of (ii) above should G. A comprehensive proposal for conclusion of
be indicated. contract should be formulated. The
2. Indication of the percentage of increase over proposals should begin with relevant facts
LPP should invariably be given in the and information, which are necessary for
purchase proposals. arriving at a prudent decision as under:
31.33.13 Submission of Purchase Proposal for BASIC DATA

Coverage:
A. With the above initial analysis, a 1. ITEM
comprehensive proposal should be
formulated by evaluating the responsive bids (a) Description
received, keeping in view the following
parameters: (b) Specification
a. The technical acceptability of the
bids, (c) Whether requirement urgent
b. The technical and financial
capability of firms coming in the (d) Delivery period required:
zone of consideration,
c. The delivery period offered vis-à-vis
delivery requirement as stipulated in
the bidding documents. 2. BIDDING DETAILS
d. Reasonability of the prices quoted,
e. Purchase and / or Price (a) Type of Bidding
Preferences.
B. The proposal will also discuss the non- (b) Date of Bid invitation
responsive bids coming in the zone of
consideration, clearly indicating the reasons (c) Date of Bid opening
for ignoring them.
(d) No. of Bids received
C. It shall be ensured that the contracts are

placed on firms whose performance is
satisfactory and who are offering delivery 3. Last Purchase Price
nearest to that stipulated in the Bidding
Documents. 4. The terms and conditions offered by the bidder (s)
D. Purchase officer should avoid the tendency within the zone of consideration should be clearly
to place orders on bidders offering low discussed by highlighting those which are at
prices but with poor or no prospect of supply
as per the delivery requirements;
716
variance with Bidding Documents. Such bids as a 6. However, these requirements and
rule should be ignored methodology of evaluation should be clearly
spelt out in the bidding documents.
5. The proposal should not only discuss the merits of 7. Purchase decisions may also be taken by
all the offers lower than the one to be accepted but way of Tender Purchase Committee (TPC)/
Tender Advisory Committee (TAC). The
also the merits of the higher offers from SSI/PSUs
competent authority must decide whether to
which come within the range of price/purchase hold TPC or TAC before the bid opening
preference allowed under Government policies. The date.
purchase proposals should also certify that no
quotation from an SSI unit or PSU within the
prescribed range of preference has been left out of 31.33.14 POST TENDER NEGOTIATIONS:
consideration. 1. Negotiations, after tenders have been
opened, should be severely discouraged as
(a) Bring out the reliability of the bidders in the zone this methodology vitiates the sanctity of the
of consideration for the supply of stores to required tender system and reduces the credibility of
specification, whether they possess necessary the purchase organisation. Further, quality
technical capacity/ capability, financial status etc; becomes the causality. Unless some definite
evidence is forthcoming to show that the
(b) Gives due consideration to the price aspect - prices received are unreasonably high or
there is tendency to obtain unreasonably
whether firm or subject to any variation and ensuring
higher prices by ring formation or on account
that the elements affecting the price have been of the lack of capacity, negotiations should
reasonably asked for; not be resorted to at all.
2. Post tender negotiations are banned in ad
(c) Analyze the reasonability of prices being hoc procurement except in case of
considered for acceptance comparing with LPP, negotiations with L1 [(Lowest eligible and
market price etc., responsive bidder(s)].
3. Counter offer of a price by the Purchaser is
(d) Give due consideration to the delivery period also covered by the term “negotiations”.
offered vis-à-vis the Schedule of Requirement, Counter-offers on the basis of unestablished
prices for small gains should be
(e) Analyses the past performance of the firm, if they discouraged.
have executed any order, the load they are carrying,
if they are in the process of executing any
31.33.15 EXTENSION OF VALIDITY OF OFFERS
contract(s), NB: Placement of a second order on a
1. All efforts should be made to see that the
firm who have not started supplies against their
purchase decision is taken as early as
earlier order. possible and in any case within the original
validity period of the bids. This is of
(f) Leads to placement of order on firm(s) who have considerable importance, for, apart from the
agreed to abide by the terms and conditions of ITB. delay which would invariably occur in
covering the demand, and thereby cause
(g) Consider the concept of “Value for Money”. This delay in the receipt of stores by the
would include consignee, there is also a risk of the firms
refusing to accede to the request for
i) Operational costs for a prescribed period of time, extension or the firms withdrawing their bids,
or extending the bid with revised rates, all of
ii) cost of consumables, such as fuel, power, etc, which might lead to avoidable expenditure.
iii) Quantifiable benefits.

2. In cases where seeking extension of the
validity of bids becomes inescapable, it is
advisable to take action well in advance of
717
the expiry of validity of bids, so that the bids CANCELLED/SCRAPPED
of firms who do not agree to the extension SUBSEQUENTLY: Such tenders may be
will still be available for consideration. returned on request with the approval of
Tenderers whose bids are substantially the competent authority.
unresponsive should not be requested for
extension of their bids.
3. Where only part quantity/items of the bids
31.33.18 INTIMATION OF ACCEPTANCE OF
are accepted and for the remaining
TENDER (A/T):
quantity/items the bidder(s) are required to
keep their bid(s) open up to a subsequent 1. The contract is brought into existence upon
date, such quantity/items should be communication of the acceptance, which
specifically mentioned in the communication must be within the time prescribed. Where
addressed to the tendering firm(s) the post is the medium of communication
4. The first extension of validity of bids up to between the parties, the acceptance is
one month may be done by the competent complete as soon as it is posted. Proper
Purchase Officer. The second extension of care should be taken to address the letter or
validity of bid will require the approval of the telegram of acceptance correctly. If the A/T
next higher level. For subsequent is dispatched through the electronic
extensions, the approval of the Head of medium, it must be digitally signed by the
Department will be required. No extension of authorized Officer.
bid validity beyond twice the original period 2. When a specific stipulation has been made
of validity of bids, as sought in the ITB, may by a bidder that he should be informed of
be permitted. the acceptance by a particular date and in a
particular manner, it must be ensured that
the acceptance is issued in time and in the
manner prescribed by the bidder to enable
31.33.16 SCRAPPING OF TENDERS AND ISSUE
him to receive it by the date fixed. If dispatch
OF FRESH ENQUIRIES;
of the intimation is delayed and bidder
receives it after the expiry of the specified
date, the contract will not be a valid one and
1. This contingency should be exception rather it will be open to the bidder to refuse to
than a rule Re-invitation to Bid can be accept the same. It should, therefore, be
justified only where there has been a ensured that in all such cases, the decision
material change in the basic specification is communicated sufficiently in advance so
after receipt of bids or where the bids that the tenderer will definitely receive it
received do not conform to specifications in before the due date.
important respects or where prices quoted 3. After a purchase decision has been taken,
are unreasonably high or because of a formal A/T must be issued as quickly as
sudden slump. possible. Where the time left in the expiry of
the offer is short, an Advance A/T may be
issued by telegram or letter, but this should
2. N.B. (1) In cases where inquiries against the be avoided as far as possible. The Advance
same demand are sent in the second or A/T should incorporate the essential
subsequent round, the previous one having requirements, viz prices, specifications,
been scrapped for one reason or the other, it terms of delivery, taxes and duties, delivery
should be made clear to the bidders, who period, performance security, advance
may have quoted against the previous ITB, sample due date, etc. and the following:
that the fresh ITB is in super session of the 4. “The Contract is concluded by this
previous one. acceptance. A formal Acceptance of Tender
3. (3) ITB/Notices should also be sent to those will follow."
firms who had participated in the ITB 5. N.B: There should be no material difference
subsequently scrapped. in the advance and formal A/T.
31.33.17 RETURN OF TENDERS RECEIVED

AGAINST TENDER ENQURIES
718
31.33.19 DESPATCH OF CONTRACT: 31.34 Rate Contracts
31.34.1 The Directorate General of Supplies &

1. The A/T, Advance A/Ts by letters, and Disposals (DGS&D) which is the Central
Supply Orders against the DGS&D Rate Purchase Organization is responsible for
Contracts should be dispatched under conclusion of rate contracts with
Registered post with acknowledgement due registered suppliers for goods and items
or through the electronic medium duly of standard type which are identified as
signed digitally. common user items and are needed on
2. The postal A.D or the acknowledgement recurring basis by various Central
slip, on return from the contractor, will be Government Ministries / Departments.
pasted on the reverse of the office copy of The items on rate contracts with relevant
the A.T/ Supply Order. If no details are published on DGS&D Website:
acknowledgement is received from the http//dgsnd.gov.in.
contractor within 7 days from the date of
issue of A/T/ Supply order, then the 1. What is a rate Contract: A Rate Contract
contractor should be reminded and the is an agreement between the Purchaser and
matter pursued till acknowledgement is the Supplier to supply the specified stores
received from him. and services at the specified prices and
3. Copies of Acceptance of Tender/ Supply terms and conditions for the quantities those
Order must be endorsed to various may be ordered by the authorised
authorities specified in the contract as well Government entities [known as Direct
to others concerned. Demand Officers (DDO)] during the currency
4. All A/Ts and Supply Orders must be posted of the rate contract.
on the DGS&D website (http://dgsnd.gov.in) 2. The rate contract is in the nature of a
with a view to bring transparency in standing offer. Minimum drawls are not
procurement actions. guaranteed in the Rate Contract. A legally
valid contract would come into existence
with the placement of individual order in the
31.33.20 INTIMATION TO UNSUCCESSFUL prescribed format by an authorized Direct
TENDERERS: Demanding Officer in the Ministry/
Department. Such an order is called “Supply
The unsuccessful bidders should, as far as possible,
Order” and each “Supply Order” constitutes
are informed of the reasons for non-acceptance of a separate legally enforceable contract.
their tenders. However, where any exceptions are to
be made, decisions in this regard should be taken at
an appropriate level. In such cases, the 31.34.2 Stores for which Rate Contracts are to be
unsuccessful tenderers should be informed of the concluded:
non-acceptance of their tender without assigning 1. Commonly used items needed on
any reason. recurring basis by Govt.
organizations (more than one).
2. Items for which prices are likely to
be stable or where Rate contracts
31.33.21 PRESERVATION OF REJECTED could be finalized with provision of
QUOTATIONS: Rejected quotations price variations to account for
should be preserved in a separate folder fluctuation of market rates of raw-
along with the relevant purchase file. DV materials etc.
manual revamp 3. Items for which R/C is convenient to
operate and annual drawals are
economical, say above Rs 25 lakhs.
In case of items of low value and
which are required by indentors in
small quantities, rate contracts may
not be concluded.
719
4. Rate Contract may not be prospective bidders, etc. to consider
concluded for the scarce / critical/ bringing new items on the Rate Contact.
perpetually short. 2. In respect of new items being brought on
5. Supply items. rate contract for the first time where there is
not adequate competition despite public
notice, the requirement of registration can
A. Advantages to Users: be relaxed with the approval of competent
authority. The award of rate contract will,
I. Competitive and economical price however, be subject to the firm’s satisfactory
due to aggregation of demands. technical and financial capability.
II. Saves time, efforts, man-hours and
related costs involved in tedious and
repetitive tendering. 31.34.5 Procurement outside Rate Contracts:
III. Availability of quality goods with full 1. In all cases of urgent needs where there is
quality assurance back-up.
likely to be delay in getting supplies through
IV. Enables procurement as and when
the operation of such rate contracts, the
required and thus reduction in
same items could be procured from the
inventory cost.
open market as long as the price to be paid
V. Advantages even to small users and for such items does not exceed those
those located in remote areas. stipulated in the rate contract. Such
VI. Provides one single point of contact
purchases should not exceed Rs. 50,000 at
to procure such items.
a time and Rs. Two lakhs aggregated in the
whole year and are exercised in accordance
with the powers delegated under the
B. Advantages to Suppliers: Delegation of financial Powers Rules, 1978.
Ceiling/ Monetary limit in this regard shall be
I. Reduces marketing cost and efforts.
adhered to.
II. Elimination of repetitive tendering
2. DGS&D concludes Rate Contracts to
and follow up with multiple
standard specifications after a wider
authorities. consultation process and checking product
III. Provides single point contact for availability in market. Ministries/
Govt. supplies.
Departments shall not modify/ change the
IV. Aggregation of Govt. demand leads
specification/ requirement of the items with
to economic production.
the intention to procure such items outside
V. Leads to most competitive prices
Rate Contracts. They shall consult DGS&D
being offered. in case a need for change in
VI. Lends credibility. specifications/requirement arises.
VII. Promotes quality discipline.
VIII. Facilitates sale to State Govt./
PSUs.
31.34.6 Conclusion of Rate Contracts/
agreements for most favoured prices/ for
31.34.3 Bringing more and more common user Automobiles, sophisticated hi-tech items.
items on the rate contract: 1. DGS&D concludes rate contracts fro
Automobiles, Machine tools, Information
31.34.4 It is enjoined upon the DGS&D to bring technology products etc. OEM and ancilliary
more and more common user items on spares and similar products where the
rate contracts. design feature, performance parameters etc.
of such products/ items differ between the
1. Regular interactions should be held by
product of different manufacturers and even
DGS&D with the trade and the user
between different models of manufacturer
departments to bring more items on rate
and where an equitable comparison of
contracts. There shall be a Standing Review
prices of different product/ model is not
Committee (SRC) consisting of
feasible. Such DGS&D R/Cs are concluded
representatives of Major indenting
on discounts on net dealer prices etc.
departments, trade organizations,
720
a. The comparison of the quoted
prices with the current R/C prices,
2. DGS&D would also be concluding indicating probable reasons for
agreements for Most Favoured Prices for variations in price, e.g. material
sophisticated/ non-standard items such as costs / labour index, market trend,
servers, net-working equipment, diagnostic technological changes etc.
instruments, ICU/CCU instruments, earth- b. The R/C price behaviour over the
moving machinery etc. with reputed last 3 R/Cs and price criteria for
manufacturers. award of these R/Cs.
3. These common user items are also required c. The behaviour of the Economic
in large quantities by different departments/ Indices / Price index for that item
organizations in Govt. sector. The design over that period.
features and the performance parameters of d. In case the current R/C prices are
such stores differ from product to product subject to price variation, these are
and from model to model. Each model to be adjusted in relation to base
introduced in the market goes through the rate and the price variation factors/
grind of extensive design and R&D efforts, clause, vis-à-vis the tenders so that
users trials etc. The users have to meet their the comparison is equitable.
specific needs from amongst the available e. Parameters which are relevant to
products/ models and equitable price determine the reasonableness of
comparison of these models is not feasible. the prices such as the movement of
DGS&D would conclude agreements for prices or main raw materials
most avoured prices with reputed demand-supply scenario,
manufacturers, as per procedure finalised by technological changes in products/
DGS&D in consultation with Deptt. of processes should be ascertained in
Expenditure. advance so that at the time of
opening of tenders, all necessary
information is available to make an
31.34.7 Criteria for award of Rate Contracts: appropriate evaluation of offers and,
thus, conclude rate contract in time
1. Rate Contract shall be awarded to only
at reasonable and justifiable prices.
registered firms having laid down eligibility
f. A reasoned explanation of what can
criteria such as availability of ISI mark,
be an acceptable increase in price
service centres across the country etc.
(s) to be allowed.
2. The Rate contract holders should meet the
performance criteria specified in the bidding
documents against the past rate contracts.
3. In respect of items being brought on rate
contract for the first time, a thorough and
detailed scrutiny would be made in arriving
at the reasonableness of the prices,
31.34.8 Procedure for conclusion of Rate
estimated drawals etc. as it would set the
Contract:
basis for all future rate contacts.
1. The Rate Contracts are concluded based on
competitive tenders through a transparent 4. The procedure to be followed by DGS&D to
Advertised Tender Enquiry procedure conclude R/Cs and method to be adopted in
published on DGS&D web-site. the procurement of R/C items by the
2. The proposal should invariably discuss the indenting officer shall be laid down by
price aspect, fully supported by market DGS&D in detail in the DGS&D manual.
rates, unit price of rate contract, raw material DGS&D shall regularly streamline and
cost analysis, relevant price increases, upgrade their procedures so as to eliminate
market intelligence report, reasons for avoidable delays in the areas concerning
variation in prices by giving due projection of the requirement, placement of
consideration to; order, confirmation of funds, inspection of
goods, payments to the suppliers etc.
DGS&D would also lay down clear
721
guidelines for the benefit of the user price range (say 5%) depending upon the
departments regarding uses of the rate merits of individual case. The price range
contracts and their rights and duties under should be based on the lowest price (L-1) of
the rate contract system. eligible established/ proven supplier with
significant share of drawals (say over 10%)
against the past rate contracts.
31.34.9 Conclusion of Parallel Rate Contracts:
31.34.10 Negotiation / Counter-offer:

1. Proposals should be worked out for entering 1. Post Tender Negotiations should be avoided
into parallel rate contracts with minimum and efforts should be made to conclude rate
number of firms, which in any case be not contracts with adequate number of firms at
less than two by considering;
prices within reasonable range to meet the
a. The proven/ established capacities
of the tendering firms against past estimated drawls without resorting to
rate contracts negotiations.
b. The quantity committed against the
existing Rate Contracts. 2. In the rate contract system, where a number
c. The estimated annual requirement of firms are brought on rate contract for the
and the actual drawls of the rate same item, negotiation as well as counter
contract though not routed through offering of rates are permitted with the
the DGS&D rate contracts, may be bidders in view and for this purpose special
much more. On the assumption that
permission has been given to the
drawls by state government, PSUs
& other organizations who also Directorate General of Supplies & Disposals
utilize DGS&D R/Cs is generally (DGS&D).
equal or more than the drawls of the
Central Govt. organizations and the 3. In cases where the prices of L1 firms for
firms may commit 50% of the different item/ sizes etc are considered
assessed capacity for supply acceptable, but there are not enough firms
against rate contracts, the annual within the reasonable price range, R/Cs
drawl of rate contract should be should be concluded with L1 firm (s) and its
taken as four times the actual
drawls of the current rate contract price, counter offered to other higher quoting
by Central Govt organizations. firms to be decided based on a price criteria
d. Reasonable price range so as to to be specified in the procedures/ bidding
include products of established and document s L1 firms shall also be given an
reputed manufacturers as also items opportunity to reduce their price and the
produced by different sectors so as price bids of all firms to whom counter-offers
to afford wider choice to the
have been made and L1 firm shall be
Government Departments while
deciding the reasonableness of the opened like regular bid. Those who accept
price range. The DGS&D on merits the counter offered prices or quote lower
of each case shall decide the prices may be awarded parallel rate
number of firms to be awarded Rate contracts to meet the estimated drawals.
Contracts for an item, so that
Government Departments will have 4. Where, however, the price of L1 is not
wider choice. acceptable, the negotiation in the first
e. Efforts shall be made to conclude instance may be carried out with L1 only for
rate contracts with the firms located
arriving at a reasonable / acceptable price.
in different parts of the country.
In situations where new comers or firms with
unfavorable reports happen to quote an
2. The parallel rate contracts with different unreasonably low price, such offers may not
firms may be concluded within a reasonable
722
be ignored. However, if such offers are 31.34.12 Fall Clause:
made, it may not be desirable to treat such The fall clause is a price safety mechanism in the
offers as L1 for negotiations and the Rate Contract. The Fall Clause provides in terms
technically acceptable and reasonable L1 and conditions governing the rate contract that of the
firm may be decided based on the Contractor sells or even offers to sell the stores at a
established past performance against earlier price lower than the rate contract price to any person
R/Cs with the approval of the competent or organization during the currency of the Rate
authority for the purpose of above exercise. Contract the rate contract price will be automatically
On successful conclusion of negotiations reduced. Other rate contract holders would be given
with L1, R/C may be awarded to the L1 at equal opportunity to reduce their price as well.
the agreed negotiated price and the same However, the purchaser should satisfy himself that
may be counter offered to the other higher the fall clause or reduction in the price is genuine
quoting firms and the parallel R/Cs and it is market driven/ oriented and not solely
concluded in the same manner as above. It limited to under cut other R/C holders who had
may not be desirable to negotiate/ make originally offered lower rates. Attempts to change
counter-offers to firms who have quoted their relative ranking should be dealt with firmly. A
abnormally high prices than L1(say over mechanism would also be prescribed to check
30%). unethical and manipulative price reductions.
5. If the negotiations with L1 are not

successful, the price considered as
reasonable may be counter offered to the 31.34.13 Period of Rate Contract:
higher quoting firms including L1 The 1. The period of the rate contract should
process may be repeated depending on the normally be one year for stable technology
response received till adequate number of products. However, for items where
firms are on Rate Contracts. technologic changes are fast/ frequent, a
shorter or longer period may be considered.
The periods of different rate contracts
should be fixed in such a manner that they
31.34.11 Cartel formation / Pool rates:
are properly staggered throughout the year
Pool/Cartel formation is against the basic principle of to avoid rush of work in any one month. The
competitive bidding and defeats the very purpose rate contracts should not expire towards the
and objective of open and competitive tendering end of the financial year the user
system. Such practices are unethical and firms who departments in procuring their requirement
indulge in such practices should be dealt with within the allocated funds.
severity. In case it is found that all the firms or a
group of firms have quoted the prices in pool, the 2. BIS specifications, should as it would lead to
offers of such firms may be ignored and suitable better competition. If any special
administrative action initiated against them, such as requirement of packing, marking, inspection
removal of such firms from the list of registered etc., has been included in their
suppliers the application from such firms for renewal specifications, the same should be
of their registration may be considered only after a mentioned so that these could be included in
lapse of two years. If the proprietor/ Managing the tender enquiry by way of special
partner/ Managing Director etc. form new company requirements. It shall be ensured that the
and apply for registration, the same shall also be specifications are environment friendly and
considered only after two years. Industry/ Trade energy efficient.
should be duly warned in this regard.
723
31.34.14 Issue of Rate Contracts: months. While extending the rate contract, it shall be
The rate contracts shall be issued in the prescribed ensured that the price trend is not lower.
format. It shall contain the following important
details: 31.34.18 Buy back prices:
Wherever feasible, the rate contracts should provide
(a) Product specification for provision for buy back of the existing
/obsolete/condemned items that may be available
(b) Price with details of taxes and duties
with the Government Departments. The buy back
(c ) Slab discounts, if any prices will be applicable for the items in the following
categories:
(d) Validity period of rate contract
(a) Less than 1 year
(e) Terms of delivery
(b) 1-2 years
(f) Delivery period
(c ) 2-3 years
(g) Minimum quantity/ value restriction, if any
(d) 3-4 years
(h) Payment terms
(e) 4-5 years
(i) Paying authority
(f) More than 5 years
31.34.15 Maintenance of Pre-inspected stocks:
The above buy- back prices shall be quoted by the
The Supplier shall maintain pre-inspected stocks of
Suppliers for working and non-working equipment.
the stores to meet the urgent requirements of the
indentors.
31.34.16 Mandatory inspection of stores against 31.34.19 Concurrent issue of Rate Contracts:
DGS&D rate Contracts:
As soon as the decision to award rate contract to
All the stores supplied against DGS&D rate more than one firm is taken, contracts should be
contracts will be inspected by the Quality Assurance issued to all the firms simultaneously and not on
Officer of the area concerned prior to despatch/ different dates. Where, however, decision to
delivery to the consignee. The rate contract will conclude parallel rate contract is taken on different
accordingly contain the following information: dates, parallel rate contracts can be issued on
different dates as and when decision is taken.
(a) Scope of inspection
(b) Inspection authority 31.34.20 Revocation of Rate Contract:

A Rate Contract being a standing offer, the same
(c ) Place of inspection can be revoked at any time by the rate contract
holder during its currency after serving notice of
minimum 30 days to the purchaser. However, all
Supply Orders placed prior to receipt of the notice
31.34.17 Renewal of Rate Contracts: will be binding and executed by the suppliers.
The rate contracts should not be extended as a Similarly, the Purchaser can withdraw the Rate
matter of routine. The rate contract wo uld be Contract at any time during the currency of the
extended only in exceptional circumstances for the contract after giving due notice of 30 days to the rate
reasons to be recorded in writing, with the approval contract holder.
of competent authority in consultation with
Integrated Finance for a maximum period of 3
724
31.34.21 What is a Supply Order: e. Date of Delivery by which supplies
are required.
A Supply Order is an order that can be placed on f. Designation and the full address of
any of the rate contract holding firms either directly the DDO along with telephone. No.,
by the Direct Demanding Officers or by the DGS&D Fax No. and E. mail address.
subject to such restrictions as are mentioned in the
rate contract. g. Complete and correct designation
and full postal address of
31.34.22 Who can Place the Supply Order: Consignee(s) along with telephone
Any officer of the Central Government/ Ministry/ No., Fax No. and E. mail address.
Department called as “Direct demanding Officers”
h. Complete designation and full postal
(DDOs) can place the Supply Order provided he
address of stores receiving officer
certifies that he has been fully authorized by the
along with telephone number, Fax
Department to sign the Supply Order and incur the
No. & E. mail address.
financial liability in respect of the stores ordered.
i. Nearest Railway siding (NRS).
31.34.23 Placement of Supply Orders:
1. A Supply Order can be placed during the j. Despatch instructions
currency of the Rate Contract. The DDOs
are advised to cover their requirements k. Correct designation and complete
against the rate contract in a phased postal address of Accounts Officers
manner and not to place orders for bulk along with complete Head of
quantities, so that the firms are able to Accounts, to whom the debits are to
deliver the stores as per the agreed time be raised.
schedule. The placement of supply orders at
l. Name and address of the Paying
the fag end should also be avoided. The
Authority to whom the bills are to be
supply order placed as per the rate contract
raised by the supplier.
shall remain executable even after expiry of
validity of rate contract till the supplies are m. Authorization Certificate
completed.
n. Financial certificate
2. The Supply Order shall be issued to the R/C
holder in the prescribed format i.e. DGS&D o. Certificate that copy of supply order
Form No. 131. It shall contain the following has been sent to:
important details:
I. DGS&D
a. Rate Contract No. and date
II. Paying authority
b. Name and complete address of R/C
holder III. Quality Assurance officer
c. Quantity (in case of more than one 31.34.24 Stipulation of Delivery period in Rate
consignee, the quantity to be Contracts:
dispatched to each consignee to be The DDOs should provide a definite date of delivery
indicated) in the Supply order based on the delivery period
stipulated in the rate contract. They should not
d. Price indicate the delivery period as “immediately”,
“urgently”, “as early as possible” etc.
725
31.34.25 Options available to DDOs in case of non- 31.34.26 Monetary limit / Annual turn-over in Rate
materialization of supplies within the delivery Contract:
period indicated in supply order: When the Based on the conditions stipulated in the letter of
supplies do not materialize by the stipulated registration, the rate contracts are issued stipulating
date of delivery, the DDO has the following
options depending upon the condition and the monetary limit/annual turn-over of the R/C
circumstances of the case: holder. While deciding the quantity and value of the
i) To extend the delivery date: supply order to be issued, the monetary limit/annual
turn-over indicated in the rate contract may be kept
When the supplier fails to adhere to the date of in view. The past performance of R/C holder
delivery and apply for extension to DDO giving indicating value of the orders received and executed
reasons for delay and also date up to which by R/C holder against previous R/C will also be
extension is required, the DDO may consider such indicated in the Rate Contract for the guidance of
request and may extend the date of delivery suitably the DDOs while placing Supply Orders.
in the prescribed format reserving the rights to levy
liquidated damages and to deny any increase in the 31.34.27 Performance Security:
price, which takes place after the agreed date of Under no circumstances the DDO will ask the R/C
delivery. holder to deposit the performance security. DGS&D
shall consider obtaining a reasonable sum of
ii) To refix delivery period: Performance Security against the R/C from each
successful bidder (i.e. the bidder selected for issue
Normally in the following categories of cases the
of Rate Contracts). This will ensure the successful
delivery period should be refixed:
bidder alertness and sincerity towards fulfilling their
a) Cases where the manufacturer of stores is obligation as per the Rate Contract. In the event of
dependent upon the approval of advance sample breach of contract the performance security may be
and delay occurs in approving the samples those forfeited and credited to the Government. The
submitted in time. DGS&D will also in future indicate the performance
of the R/C holder indicating the value of the orders
b) Where the date of delivery is stipulated on received by R/C holder in past. DGS&D will also
account of omission on the part of the DDO. obtain the performance security from the R/C holder
at the time of issue of the rate contract to them and
iii) To withdraw the supply order and cover on other in case of any default reported by the DDOs, the
parallel R/C holder: DGS&D will consider to forfeit the performance
security submitted by the R/C holder.
At times the supplies are not made by the rate
contract holders within the delivery period stipulated
in the supply order, the DDO shall have right to
withdraw the supply order after the expiry of the date 31.34.28 Instructions to the DDOs and
of delivery stipulated in the supply order and cover Consignees:
the demand against any other parallel rate contract A. Instructions to DDOs to be followed while
concluded by DGS&D. In case of such withdrawal of placing Supply Order:
the supply order by the DDO, the same will be
reported to DGS&D. The failure to make supplies in I. To ensure that expenditure involved in
such a case will be considered by DGS&D as the procuring stores has received the sanction
failure/non-performance on the part of the supplier of competent financial authority and that
and will be taken into consideration in performance funds are available under proper Head of
assessment before award of next rate contract. Account.
II. Supply Order(s) against R/C should be

prepared in the Standard Form i.e. DGS&D
726
Form No. 131. All particulars mentioned in the firm with copy to the Purchase Officer
the standard Form including those indicated and Controller of Accounts concerned
in para 22.2 above should be carefully typed regarding receipt in full and in good
or filled so as to avoid any ambiguous condition or otherwise of the stores
interpretation. indicating shortages, damages and
recoveries, if any, under registered post
III. To ensure that all columns of DGS&D Form (A.D.). The period for transmission of
No. 131 have been filled in and are aforesaid information is 90 days in the case
complete in all respects. Failing which the of items of plant and machinery. The
Paying Authority will not accept the supply adherence to period mentioned above for
order and return by the Paying Authority different types of stores is mandatory
under intimation to DGS&D and the supplier. because the consignee loses the right of
rejection of stores on the expiry of the
IV. To place supply order for their requirement
specified period due to the operation of the
on phased delivery basis to enable the
provisions clause 4(2) of the General
supplier to supply stores in time. DDO
Conditions of Contract DGS&D-68
should provide a definite date of delivery by
(Revised).
which supplies are required. The DDO
should not stipulate the vague terms of II. Timely return of the Inspection Note : The
delivery. consignee will ensure that receipt portion of
copy No. 1 (Advance Payment Copy) of
V. The DDOs who are authorized to operate
Inspection Note in case of provisional
R/C should sign the supply order placed by
receipt of stores delivered locally or by road
them and the communications relating
shall be completed and handed over to the
thereto with their own designation. The
carrier or authorized representative of the
name of the officer signing supply order
supplier within 24 hours of receipt of stores.
should be indicated in block letters.
In case this is not possible for the reasons to
VI. The full and clear instructions regarding be recorded in writing, the provisional
dispatch shall be given in supply order. Any receipt will be dispatched as expeditiously
changes in dispatch or delivery instructions as possible by speed post / courier /
should be notified to the supplier under registered A.D. post but not later than seven
intimation to Paying Authority and Inspection days of receipt of the stores.
Authority.
III. Similarly, the consignee should ensure to
VII. The DDO will ensure that all documents like complete receipt portion of copy No. 1, copy
‘D” form required for claiming concessional No. 2 (Balance Payment Copy ) and copy
rate of Sales Tax, etc. are issued along with No. 5 (Accounts office copy) of Inspection
the supply order. The DDOs shall be Note in case of 100% payment or copy Nos.
responsible for obtaining the Road permits 2 &5 in case of balance payment, as the
from the Sales tax authorities immediately case may be, and return the same to the
on receipt of dispatch details from the contractor as expeditiously as possible after
Supplier. receipt of stores. Delay in issue of these
Receipt Certificates delays the payment to
B. Instructions to be followed by the the supplier and this may ultimately lead to
consignees: increase cost of stores to the purchaser and
also invite uncalled for criticism from the
I. Timely intimation of receipt of stores: The trade. The consignee should, therefore,
consignee within a period of 60 days from
the date of receipt of the stores will inform
727
avoid any delay in furnishing the Receipt VI. The consignee should invariably incorporate
Certificate to the supplier. a certificate on the Receipt certificates on
the following lines:“
C. Drill to be followed by the consignee
regarding receipt of stores: Consignment/s was/were dispatched under
I. The consignee should be watchful regarding ……………..+………………………………

the arrival of consignment immediately on
receipt of Railway Receipt and despatch
details from the contractor.
+ Indicate any one of the following:(
II. In case entire consignment is not received
a) Clear R/R
within 30 days of its despatch, the
consignee should immediately take up with b) Said to Contain R/R
Railways and lodge claim with them.
Simultaneously, the consignee should c) Railway/Owner’s risk.
advise the contractor asking them to take up
the matter with the Railways for follow up VII. In case the consignee observes some
action. shortage/damage they should ensure to take
Open Delivery invariably and lodge the claim
III. The consignee is responsible for taking with the Carriers immediately under
prompt delivery of the goods immediately on intimation to contractor, DGS&D and the
arrival at destination and any delay in this Paying Authority. Failure to act properly may
respect results in payment of demurrage result in losing their claim of shortage
charges. Should any demurrage, wharf age /damage, if any observed at a later date.
or other charges whatsoever be claimed by
the Railway on account of delay or default
on the part of the consignee in taking
VIII. If there is evidence of loss or damage, the
delivery as aforesaid, he shall be
consignee sho uld arrange to secure
responsible for such payment to the
necessary certificates from the appropriate
Railway”.
railway officials before taking delivery. The
IV. Any amount paid by the consignee, due to loss or damage should in every case, be
demurrage charges, under charges etc. on promptly reported to the contractor,
behalf of the contractor should be Purchase Officer who placed order, as well
immediately reported to them, under as the concerned Controller of Accounts
intimation to the Paying Authority to enable responsible for payment for the stores as
him to retrench the amount from any of the otherwise the consignee will be deemed to
bills due to the contractor. have accepted the stores. In any event, the
consignee should not give Receipt
V. The consignee is responsible for verifying at Certificate to the contractor before checking
the time of taking delivery from the Railway and verifying the stores.
Authorities that the stores have been
received intact without loss or damages pos. IX. The consignee should ensure that any loss
When the stores are dispatched in full or damage to the stores that have occurred
wagon loads, consignee should verify that during Transit should be notified to the
the seals on the wagons are intact. Contractor within 45 days of the date of
arrival of the stores at destination. Failure to
do so would render Purchaser’s claim for
728
such loss/damage being rejected by the Inspection Notes after making necessary
contractor. endorsement and completing the Receipt
Certificates there in and the normal
X. If there are any discrepancies such as procedure for final 100 per cent payments
stores having been damaged, found will be followed in such cases.
deficient or below standard, the consignee,
after taking into account special terms and XIII. Regarding (ii) -The same procedure as in
condition, if any, that might have been the case (i) will apply except where
stipulated in the contract regarding rectifications are carried out at the
responsibility for breakage etc., in transit, consignee’s premises. In the latter event if it
should make the endorsement in the space is not possible for the contractor to have the
provided in the Receipt Form against stores reinspected by the Quality Assurance
“Details of recoveries proposed by the Officer named in the Acceptance of Tender,
consignees’ together with amounts to be the consignee may inspect the stores and
recovered from the contractor. Brief reasons issue the Inspection Note endorsing it with
as to why the amount is to be recovered the Retrenchment Slip number and date for
from the contractor such as ‘bad packing’ cross references. He will complete the
etc. should be stated as guide to the Paying Inspection Certificate and Receipt Certificate
Authority regarding the action to be taken. and distribute copies of the Inspection Note
in the normal manner.
XI. The consignee will then ascertain from the
contractor whether he is going to :- XIV. Regarding (iii) - The contractor will be
debited with the actual cost of such
a. make good any deficiency in store; rectification. No issue of any further
Inspection Note is necessary.
b. carry out rectifications; or
XV. The rejection of stores based on general
c. agree to the rectification being
remarks like “Inferior quality or Poor quality”
carried out by the consignee.
creates complications in case of disputes.
XII. Regarding (i) -in the event of replacement When the stores are rejected by the
after rejection of stores, the consignee consignee, it should be done in attached
should address a letter to the supplier for format giving full details of supply order, R/R
replacement giving details of stores rejected No., date of receipt, etc. While reporting the
and endorse copies to the Controller of deviations, the consignee should give such
Accounts, Department of Commerce and the deviations for each parameter/clause,
Quality Assurance Officer concerned. On clearly giving values/requirements as per
receipt of the copy of the letter, the Quality contract specification and those found in
Assurance Officer will carry out inspection of goods supplied. All communications by the
stores tendered by the firm and issue consignee pertaining to such rejection
inspection Notes. The Quality Assurance matters should therefore be sent in the
Officer must mention in the Inspection Note proforma attached through Fax/Speed
that the stores are supplied in replacement Post/Registered letter endorsing copy to
of rejection made against his Inspection DDO, DGS&D, Paying Authority and the
Note NO.___________dated__________ as Quality Assurance Officer.
per letter
XVI. Where stores are rejected on arrival on
No._______________dated__________fro
destination, these will be re-booked to, the
m_____________________. The consignee
contractor, if he so desires, “Freight to Pay”
will also as usual, return to the ‘firm’ the
at Public Tariff rates.
729
XVII. Where the rejected stores are returned as XVIII. booked at concessional rate, the charges
above, and goods are not required to be actually incurred by the consignee only will
replaced, the freight paid by the consignees, be recovered. If the contractor does not
if any, on the original consignment will be want the consignment to be re-booked, and
recovered from the contractor either in cash the original consignment was booked at
or from their bills. In case original concessional tariff, the contractor shall be
consignment was liable to pay the difference between the
public tariff and the concessional tariff.
31.34.29
ANNEXURE
To
-------------------(The Supplier)---------.
-----------------------------------------------------.
-----------------------------------------------------.
Sub: S.O .No.______________________dated_____________placed Under DGS&D Rate Contract

No.____________________for Supply of__________________; Rejection of Stores.
Ref: Supplies made by you under RR/LR No.____________________ Dated_________covered by I/Note

Nos.__________________dated ________________ - Rejection thereof.
Sir,
730
The stores supplied by you as per details under reference and received by this office on _______________are
rejected to the extent and for the reasons as detailed hereunder:
1) Name of Stores:
2. Quantity ordered:
3. Quantity dispatched as per RR/LR:
4. Quantity received:
5. Date of receipt:
6. Quantity received short:
7. Quantity where inspection mark is not available or where it does not match with the mark indicated on the
I/Notes:
8. Details of deviations from contract specifications:
9. Details of test/examination conducted to check conformity to contract specifications :
10. Quantity rejected due to:
11. Total quantity rejected/short supplied (6+7+10):
2. You are requested to refund the payment for__________ [quantity as per (11) above] and remove the rejected
goods within 30 days of the receipt of this letter after showing proof of refund payment equivalent of advance
payment received on account of the stores rejected or withholding of equivalent amount by Controller of
Accounts.
3. In case, however, the purchaser through the Inspection Authority decides to conduct joint investigations, the
rejected stores shall be removed within 30 days of decision of joint investigation.
4. The rejected stores would be kept at consignee’s premises at supplier’s risk and ground rent shall be charged
from the suppliers at specified rates if the rejected stores are not removed within the specified period.
5. This is, however, without prejudice to the terms & conditions of the contract.
Yours faithfully
[Consignee]
Copy to:
1. Indentor / D.D.O
2. D.G.S.& D. -He is requested to advise Controller of Accounts to Withhold an amount equal to the advance
payment made on account of stores rejected/shortfall in quantity received.
731
3. Controller of Accounts.
4. Quality Assurance Officer - He is requested to advise if joint investigation is required to be carried out and if so,
to fix a suitable date under intimation to all concerned.
DRAFT 31.35.3 DATE OF DELIVERY

I. Time and the date of delivery of
stores/services stipulated in the contract
shall deemed to be the essence of the
31.35 Post Contract Management
contract and it is required that delivery shall
be completed by the agreed date.
31.35.1 ACKNOWLEDGMENT OF CONTRACT: II. The contract comes to an end, by way of a
1. Contractor shall acknowledge the contract breach, on the failure of the contractor to
within 14 days from the date of issue of the deliver the goods or service by the agreed
contract/supply order by either of the date; and the
following way of actions:
III. Purchaser may refuse to take delivery of
I. Signing of the agreement goods or accept services, if offered after the
agreed delivery date.
II. Acknowledging the contract in writing
IV. The delivery completion date in the contract
III. Submission of the Performance security
shall be stipulated in accordance with the
IV. It is the responsibility of the purchase officer provisions thereof in the accepted tender.
to ensure that the contracts placed are duly Definite date for supply of stores shall be
acknowledged by the contractor and if no stipulated and expressions, such as
acknowledgment is received from the “Immediate”, “ex-stock”, “as early as
contractor then matter be pursued till possible” etc. should not be used.
acknowledgment is received.
V. Exact interpretation of “Delivery date” in
respect of contracts shall be in variance
depending upon the terms of delivery
31.35.2 PERFORMANCE SECURITY specified in the contract. This is explained in
The purchase officer should also watch whether the annexure 12.1
contractor has complied with the requirement of
VI. Terms Of Delivery In An Installment
furnishing the Performance Security as per the terms
Contracts:
and conditions of the contract. If not, timely action
should be taken as per the guidelines given in VII. In the case of a installment/severable
Chapter-6. contract, each installment constitutes a
separate contract and extension in delivery
period etc. shall be dealt separately as in
would be necessary for each installment.
732
31.35.6 RE-FIXATION OF DELIVERY DATE:
Normally, when delay is on the purchaser
31.35.4 MONITORING OF UPPLIES/CONTRACT: account the delivery period should be re-
fixed.
I. Post tender management of contract is by
no means less important than the process of
award of contract. For proper execution of
31.35.7 EXTENSION OF DELIVERY PERIOD
the contract and to ensure that
supplies/works are completed in stipulated 1. Extension of delivery period can be done by
time purchaser shall ensure that follow up of the Competent Authority (CA) only on the
the contract is done and all requisite steps expressed request of the supplier by
are taken in time. reserving the right of the purchaser to levy
liquidated damages for delay and with denial
II. HOD (Head of the Dept.) shall devise and of increase in price, taxes, duties etc. taken
implement a well documented system for place during the extended period. While
monitoring and review of performance of the granting extension of time on application
contracts for their department, incorporating from the contractor, the letter and spirit of
special watch for critical contracts and in the application should be kept in view in
cases where delivery has been delayed. fixing the extended time for delivery.
III. The purchase officer should ensure effective

and reliable monitoring mechanism to
assess the actual ground position of the 2. The purchase officer empowered for
contracts and he shall be responsible for Acceptance of Tender of that value will be
any lapses in taking timely remedial action. competent to grant extension/re-fixation of
delivery period.
IV. Inspecting Officer should also be prompt/
vigilant and there shall not be any avoidable
delay in inspection of stores in such cases.
3. Whether the extension of delivery date is to
All stores should be inspected within 15
be granted or the contract is to be cancelled,
days from date of offer. Corresponding
shall be decided on the merits of each case.
benefit of delay should be given to the
The factors influencing this decision shall
vender in delivery/completion period if delay
be:
is on purchaser’s account.
I. Time required re-processing the
procurement/contract.
31.35.5 REVIEW OF PERFORMANCE AND II. Urgency of the requirement of the user
VENDER ASSESSMENT:
All departments shall formulate a well drafted and III. Trends of the rates /New supplies/services
publicized vender rating and appraisal mechanism to may be available at cheaper or higher rates.
grade the venders according to their performance.
The firms shall be graded / classified accordingly 4. Extension should be granted only where the
and a record kept, so that in future-contracts, past competent purchase officer is convinced that
performance of the firms can be linked. supplies/services would come forward
Bad/inadequate performance of the registered firms during the extended period. Where purchase
should be reported to the concerned registering officer is convinced that there are no
authorities. prospects of supplies forthcoming,
particularly after granting one extension, it
would be advisable to cancel the contract
733
with a view to making repurchase as per the 31.35.11 CORRESPONDENCE AFTER EXPIRY /
provisions of the Conditions of Contract. BREACH OF CONTRACT:
31.35.12 The Purchaser, Inspecting Officer or the

consignee should not enter into any such
31.35.8 ACCEPTANCE OF DELIVERY correspondence that would have the
EXTENSION BY FIRM: effect of keeping the contract alive after
the date of expiry of the contract.
An extension issued shall be legal only if there is an
acceptance by the firm, absolute and unqualified to
all the terms and conditions of extension. Such an
31.35.13 COMPLETION OF CONTRACT /
extension can be evidenced either by SUPPLIES:
correspondence or by conduct i.e. by making Delivery shall deem to be completed
supplies without raising any objection. Mere when the consignee certifies that the
acknowledgement of the letter of extension is not stores have been
adequate. supplied/delivered/commissioned in all
respects in conformity with the terms
and conditions of the Contract.
Thereafter any request for effecting
31.35.9 Non Acceptance of Extension by firm:. replacement of stores or supplies will be
made under guarantee/warrantee clause
In case of non-acceptance of the extension of where extension of delivery period is not
delivery date subject to the conditions stipulated in necessary.
the extension letter (i.e. R/R and denial clauses) by
the contractor, purchaser may cancel the contract or 31.35.14 TERMINATION OF CONTRACT: The
review the of extension/ terms and conditions purchaser may, without prejudice to any
depending upon the case by approval of CA. other remedy for breach of contract, by
written notice of default sent to the
supplier, terminate the contract in whole
or in part:
31.35.10 PERFORMANCE NOTICE- NOTICE-CUM- (1) If the supplier fails to deliver any or all of the
EXTENSION LETTER: stores within the time period(s) specified in the
In a bona-fide effort, to give last chance to the contract, or any extension thereof granted by the
defaulting firm, CA depending upon merits of the Purchaser; or (2) If the supplier fails to perform any
case may issue NOTICE-CUM-EXTENSION other obligation under the contract. In the event of
LETTER (PERFORMANCE NOTICE) to the firm in termination of the contract in whole or in part:
the prescribed form. If there is still lack of
(a) The Performance Security furnished shall be
satisfactory response or performance from the
forfeited;
contractor, notice for termination of contract may be
issued to the firm after expiry of 15 days of issuing (b) The purchaser may procure, upon such terms
performance notice. and in such manner as it deems appropriate, stores
similar to those undelivered, and the supplier shall
be liable to administrative action in terms of the
contract.
(c) The supplier shall continue performance of the

contract to the extent not terminated.
31.35.15 Monitoring of progress of departmental

works/site preparation Purchaser shall
also monitor the progress of other
734
prerequisite works/supplies related to the that supplies are utilized in proper
installation and commissioning of the manner. Any delay in
supply under the contract. Works s.a. installation/commissioning of the plant &
site, foundations should be ready before machinery on this reason will be on
the supply of the material are received so purchaser’s account.
h) C.I.F. Contracts, The date on which the stores
actually arrived at the Indian Port unless otherwise
31.35.16 Annexure 12.1 stated.
TERMS OF
31.36 Inspection of Stores Preamble:
DELIVERY
31.36.1 The General Financial rules of Govt. of
DATE OF DELIVERY India , under Rules 3 and 5 (Appendix 8,
Part I), emphasize the importance of
(a) Local Delivery The date on which the delivery is ensuring that stores purchased for the
actually effected to the consignee. public services, conform to the
prescribed specifications, and the
(b) Where Inspecting Officer is also the consignee necessity of careful inspection of all
stores before acceptance. This applies to
Where the Inspecting officer and the authority stores obtained or manufactured both in
nominated for the purpose of taking delivery of the India / abroad and to inspection during
anufacture at the supplier’s premises as
goods/services is the same, the date of
well as after erection / commissioning at
delivery/services will be the date on which the goods site where necessary or desirable. That
are tendered for inspection provided always that requirement for such inspections shall
they are found acceptable to the Inspecting officer – be made a part of the contract and
cum-consignee. inspection arranged by the department.
With a view to satisfying that the stores
{Note: This definition will hold good only in cases supplied by a contractor against the
where inspection is carried out at the consignees’ contract, are of the required quality and
premises and will not apply to cases where the conform to the contract specifications,
shall be subjected to physical inspection
inspection is carried out at firms premises}
by an authority known as Inspection
Authority . The stores thus accepted by
c) F.O.R station of despatch The date on which the the Inspection Authority named in the
goods are placed on rail i.e. R.R. date, after contract or his authorized representative
inspection and acceptance by the Inspecting Officer, can only be dispatched by the contractor
if relevant for delivery to the indenter/ consignee(s)
named in the contract.
d) By post parcel The date of postal receipt 1. Inspection of stores shall comprise of
various steps as are necessary to ensure
e) Despatch by air The date of Air-way Bill
that the item produced conforms to contract
f) F.O.R. Destination, The date on which the goods specification and that while manufacturing
reach the destination, unless otherwise stated. the stores, the use of correct raw materials
and correct manufacturing process has been
g) F.O.B. / F.A.S. contracts The date on which the followed by the manufacturer.
goods are put on board and ship/aircraft is the date
of delivery, i.e. Bill of Lading date. 2. The functions and the organizational set up
of Quality Assurance Wing of the
Department and its Directorates shall be laid
down. While Inspection Authority functions
735
may be performed by the HQ set up of QA Purchase Organization for Civil requirements,
Wing, the field Directorates shall carry out whether on Rate contracts or otherwise, the
their functions in their respective Additional Director General (QA) of the Central
jurisdictions. However, by a general or Purchase Organization shall be the Inspection
special order by the head of the QA wing, a Authority, unless stated otherwise.
Directorate may be allocated the field work
not covered in its jurisdiction 31.36.5 FUNCTIONS OF INSPECTION
AUTHORITY :
3. The head of the Inspection wing of the The functions of inspection authority are to manage
Department shall have the overall the contracts from technical angle. At the pre
responsibility and shall act as appellate contract stage , to ensure that the technical
authority on all aspects of policies and particulars of the tender are broad based ,detailed,
procedures, functions and technical issues. correct and complete in all respects and
The delegation to various levels of unambiguous in respect of scope of supply, quality
functionaries shall be worked out and given parameters etc. for contracting purposes and the
in Schedule separately scope of inspection, the criteria of conformity, test
methods etc. are well defined to form part of the
4. In this Chapter are stated the General tender and contract, advising indenters on Standard
administrative instructions on inspection of specns. and other requirements with reference to
stores. Departmental Technical instructions Tender Advance Samples and the scopes of
on inspection of various classes of stores references etc. At the post contract stage these shall
shall be issued departmentally, from time to include administrative arrangements for inspection
time as and when necessary, for the of stores rendering advices on technical issues that
guidance of the Inspecting officers. may crop up during execution of the contract, advice
on waiver of physical inspection ,Recommendations
31.36.2 INSPECTION AUTHORITY / INSPECTING
for amendments to contract in respect of technical
OFFICER:-All contracts shall indicate
therein, the Inspection authority for the specifications, Price reduction etc.
contract as well as the Inspecting officer
who will actually carry out inspection of 31.36.6 INSPECTING OFFICERS
stores in question In their purchases, the Department shall get the
stores inspected through their technically qualified
31.36.3 DEFINITIONS officers to ensure quality of stores . Wherever, the
1. INSPECTION AUTHORITY is also the Department is unable to arrange inspection through
authority holding sealed particulars (AHSP), its work force, it may approach the Central Purchase
samples, drawings, specifications governing Organization or any other specialized authorized
the stores being procured. inspection agencies. In respect of procurements
against all contracts concluded by the Central
2. INSPECTION OFFICER is the officer
Purchase Organization for Civil requirements,
responsible for carrying out the actual
whether on Rate contract basis or otherwise,
inspection of stores to be nominated by the
Inspecting officer shall be of the Central Purchase
concerned Inspection authority .
Organization. For stores required by Defence,
against DGS&D R/Cs, as an exception, DG (QA),
31.36.4 INSPECTION AUTHORITIES
Ministry of Defence will be the agency for inspection
The Department, in their direct purchases shall
except for the items for which, DG(QA) authorizes
nominate their own Inspection Authority. For all
DGS&D to carry out bulk inspection.
stores procured by the Central Purchase
Organization directly or by the Departments through
the operation of contracts concluded by Central
736
31.36.7 INSPECTION OF STORES WHERE contract, the Inspecting Officer concerned
INDENTOR DESIRES TO ASSOCIATE: shall satisfy himself that he is in a position to
1. Where the Indentor desires to be associated undertake inspection w.r.t. arrangements.
with the inspection at the pre-despatch He will also satisfy himself that the
stage, they shall specifically give a clear particulars governing the stores are
indication in the indents itself. Such complete , otherwise the same shall be got
requirement, if agreed to shall be clarified from the concerned Purchase
incorporated in the Contract . The Inspecting Officer before undertaking inspection.
officer shall be final authority for acceptance Inspection visits to the extent possible shall
of the stores and issue of the Inspection be arranged by combining tours , to achieve
Notes in such cases. The procedure / drill in economy.
this regard shall also form a part of the
contract to enable firm to co-ordinate. 2. The Inspecting officer shall be entitled to
inspect work during the course of
2. The Contractor shall be notified / informed manufacture and during the currency of the
through provisions in the contract that contract and should take advantage of such
inspection shall be undertaken by the visits to offer advice and explain any points
nominated inspection agency, during on which the contractor may be in doubt.
manufacture, and / or before/ after shipment
as the case may be and should be asked to 31.36.10 ACCEPTANCE / REJECTION OF
communicate directly with that officer. STORES BY INSPECTION AUTHORITY:
After satisfactory inspection and tests,
31.36.8 INSPECTION PROCEDURE : The the acceptable materials shall be
inspection will be guided by the stamped, labelled, marked, or sealed,
provisions contained in the governing according to the circumstances in such a
specifications and contract as regards to way as to make subsequent identification
the scope of inspection and tests , of accepted lots easy by the consignee.
sampling criteria to be followed, etc. and Detailed departmental instructions shall
the Departmental regulations, at the pre- be followed in this regard. For stores, not
despatch stage and/or during final meeting the contract requirements the
inspection, as the case may be. The rejection Inspection Notes will be issued
material actually inspected and accepted immediately. A time limit shall be fixed
shall be double stamped/sealed and for issue of Inspection documents.
balance single stamped and the
Inspection Note will be endorsed to this 31.36.11 INSPECTION PROCEDURE FOR PLANT
effect. However, the Quality Assurance AND MACHINERY: In all cases of
Officer shall be responsible for the inspection of plant and machinery at
inspection of the whole consignment as manufacturers’ works, and at site after
per the contract. erection and commissioning, the
procedure to be followed shall be laid
down by the department.
31.36.9 PREPARATION FOR INSPECTION ON

RECEIPT OF THE CONTRACT/SUPPLY
ORDER: 31.36.12 APPELLATE AUTHORITY AGAINST
REJECTION MADEVBY THE INSPECTING
OFFICER: The appellate authority for
any grievance of the contractor against
1. The copy of contract or Supply Order placed such rejections made by the inspecting
by the Department shall be endorsed to the officer shall be one level above that of
Inspecting Officer, so that inspection is the officer who approved the rejection.
carried out by him and Inspection Note The outcome of the appeal shall be
issued. On receipt of the copy of the
737
reported to the Purchase officer for his 31.36.13 . STAMPING/ SEALING OF ACCEPTED
final contractual action. STORES: All accepted articles should
be sealed, labelled or stamped according
to their nature in a conspicuous manner
in such a way that the material cannot be
interfered with after sealing. Facsimile of
the Inspection stamps and their position
should be put on the Inspection Notes to
help identifying the stores at the
consignee’s end. Departmental
instructions shall be followed in this
regard.
31.36.14 INSPECTION DOCUMENTS:
31.36.15 Inspection Notes in the form prescribed

by the Department shall be issued in
significance of the acceptance of the
stores against which payments are made
by the Paying Authority of the contract.
Consignee’s receipt certificate portion of
the Inspection Notes shall require to be
filled by the consignee after receipt of the
stores, verification of quantity and
inspection marks on the accepted stores
and taking the supplies in their stocks,
signifying their acceptance. Inspection
Note shall have markings on it, regarding
period of validity for dispatch of the
accepted stores by the contractor,
special payment copy endorsements etc,
on them The number of copies of the
inspection notes and their distribution /
issue, in different types of inspections,
when supplies are accepted or rejected,
shall be as prescribed by the Department
. Each Inspection Note copy issued shall
invariably bear the name , stamp with
Designation and Code No. of the officer
authorised to sign and issue Inspection
Documents. No ‘Certified true copy’ of
the lost original payment copies shall be
issued until a ‘ Non Payment Certificate’
is obtained from the Accounts Officer
concerned that “payment has not been
made and will not be made against the
original Inspection Notes even if received
subsequently”.
1. Procedure for extensions of validity dates of
inspection notes and of issue of inspection
notes against replacement supplies or
where only a part quantity under a particular
Inspection Note could be dispatched within
738
the validity period ,shall be shall be as laid samples tested at outside laboratories as
down by the department applicable in various situations.
31.36.16 SANCTION TO MODIFICATIONS BY 4. In cases where the samples are to be tested

INSPECTING OFFICERS: at firm’s cost on account of non-availability
The Inspecting officers shall not sanction of their own testing arrangements, the
any modification to the governing responsibility of depositing the testing fee
specifications, approved drawings or
would rest with the contractor. The
samples against any contract. Deviations
from the contract Inspecting Officer shall accordingly ensure
specifications/requirements not affecting the same.
price, quality, performance and other
terms of contract may be allowed at the 31.36.18 PROCEDURE PERTAINING TO
level of DQA with or without consultation SAMPLES.
with the Indentor/Consignee on merits/ 1. When a contract is concluded on the basis
nature of deviations. In all other cases, of an approved sample the same shall bear
the stores shall be rejected giving full
seals / signatures of the approval of the
reasons by issuing a rejection Inspection
Note. different agencies as appropriate, for
guidance related to its contractual scope.
Samples of other types , like Standard
31.36.17 UTILISATION OF SERVICES OF Sample, Tender Sample, Advance Sample,
OUTSIDE TESTING LABORATORIES Bulk Supply Sample, Complaint Sample,
1. As part of the inspection of stores, at times,
2. Quality, Audit Sample, Reference Sample
it becomes necessary for the Inspecting
etc. may be encountered during the
officer to conduct type / acceptance or
procurement processes. These shall be
special tests , at outside laboratories , when
drawn, retained , classified and disposed in
facilities for these tests are not available in-
accordance with the instructions issued by
house with the supplier or carrying out of
the Department. A Register of Samples shall
confirmatory tests is considered desirable
be maintained. A gazetted officer shall be
before accepting the stores.
made the in charge of the Sample Room
2. Department shall draw up a list of approved and will be responsible for all activities in the
laboratories comprising of reputed and Sample Room.
adequately equipped independent
3. Unless otherwise directed, samples sealed
Government laboratories / Institutions /
and issued for departmental use shall be
research organisations or other NABL
returned after the order is completed. There
approved laboratories , to whom samples
shall be a system of Physical verification of
drawn from the lots offered can be sent for
samples , which shall be done annually and
tests. The list of approved laboratories shall
a certificate regarding the physical check will
also prescribe those laboratories, which can
be recorded in the Sample Register.
be used as referral / appellate laboratories
Samples which have completed the
for retest, when stores tested at one
retention period and no longer required shall
laboratory are decided to be retested.
be set aside for public auction periodically
3. The Department shall lay down a Liability
31.36.19 HANDLING OF INSPECTION
Statement for cost of samples expended in
STAMPS/INSPECTION DOCUMENTS:
tests, Dispatch of samples, transportation
Each Inspecting Officer shall be supplied with
costs, test charges etc. in respect of
Acceptance stamps, Lead Seals, Pliers, rubber
Stamps, Stencils, Labels, Stickers , Holograms etc.
739
according to the requirements, to signify that the 31.36.22 QUALITY AUDIT PROGRAMME:
articles marked or sealed, have been accepted by 1. Departments may also consider establishing
him. He will be responsible for the use of these, suitable auditing systems / set ups in their
being in his charge and shall ensure that they are Inspection wings for Audit of the inspection
not used by unauthorized persons or in any other work done in determining the effectiveness
irregular manner. Unserviceable Seals, Pliers, of the measures taken for conformance of
Stamps, stickers, Holograms etc. shall be returned the quality of goods inspected
to the Officer In charge. A Gazetted Officer shall be
responsible for the correctness of all Receipts and 2. And verification of correctness of the
Issue of such Appliances which should be noted sampling methods and procedures adopted
down in a Register. Department shall lay down by the Quality Assurance Officers for their
detailed guidelines for purchase , issue , re-issue of effect on the ultimate quality. These may be
surrendered equipments on transfers/ retirements, under the charge of their zonal HODs, under
safe custody , periodic physical verifications and whose directions test checks /audit checks
disposal of these inspection equipments , when can be initiated . Complaint prone areas
these become unserviceable / worn out etc.. could be identified and subjected to such
audits to begin with. If , during audit ,it is
31.36.20 CUSTODY OF INSPECTION NOTES found that the stores supplied were
These should be machine numbered, for reasons of substandard, the inspection officers can
security and traceability to avoid irregular or inform the consignee, purchase officer and
incorrect issue/ use of any of these and will be the supplier of the defects noticed in the
signed for by individual responsible for their safe supply made, to enable the consignees to
custody at the time of their receipt . An account of decide whether or not to consume the stores
the Inspection Notes issued with serial number wise or not to release the balance copies of the
details shall be given in an appropriate format, on it’s Inspection Notes. Detailed instructions in
cover page. this regard shall be issued departmentally.
31.36.21 JOINT INVESTIGATION AGAINST 31.36.23 . AVAILING OF INSPECTION BY QUALITY

COMPLAINTS RELATING TO QUALITY ASSURANCE WING OF DGS&D.
OF STORES: The Quality Assurance Wing of DGS&D, a
1. When a complaint pertaining to quality is professional and premier inspection agency of the
received from the consignee requesting for Govt of India is authorized to undertake inspection
investigation in respect of the stores against orders placed by all Departments of the
accepted by the departmental inspecting Central Government, State Governments and Public
officer, the same shall be jointly investigated Undertakings etc.. Their independent third party QA
by a team consisting of a senior services may be availed for important and high value
representatives of inspecting officer ,who is contracts . In such cases, the contracts shall
well conversant with the stores and the incorporate inspection clause in it’s favour and
consignee. The supplier firm shall also be DGS&D Standard terms and conditions may be
informed about the intention to conduct the made a part of the bids / contracts suitably.
investigation and opportunity shall be given
to them to be present during the joint 31.37 Payment of Cost of Stores Supplied
investigation. Detailed regarding the Against Contracts
procedure to be followed , Format of JIR 1. In order to be a complete contract, it must
shall be as prescribed by the Department. be accompanied by a consideration. In the
case of supply contracts, the consideration
is the payment of the stores by the buyer.
740
2. The paying authorities should devise in view, all delayed payments after the
appropriate Forms for Payment. The bills are received in complete
standard Forms available with the Chief documented form will attract an
Controller of Accounts, Supply Division, interest of PLR+2% on the delayed
Department of Commerce can be adopted portion, to be paid by the Government
for making the payments to the suppliers. department.
The contracts must indicate the Paying
Authority and the address of the office from 31.37.2 CHANGE IN THE PAYING AUTHORITY:
where the payment is to be obtained on Where a change becomes unavoidable this will be
submission of required documents. allowed only with the prior approval of the Head of
the Department in consultation with the Financial
31.37.1 Methods of Processing of Payment of Adviser.
Bills: The paying authorities in respect of
contracts placed by the Department and 31.37.3 TERMS OF PAYMENT AGAINST
the sub-ordinate offices will be the VARIOUS TYPES OF CONTRACTS
designated Pay & Accounts Officers.
A. PLACED BY THE DEPARTMENT:
1. Before making payments, it is
necessary for the paying authority to 1. FIXED QUANTITY (AD-HOC
ascertain that funds are available in CONTRACTS): In the case of fixed quantity
the budget approved for the (ad-hoc contracts), the following steps are
department/office. to be taken to ensure payment:
2. The Paying authority will ensure that I. For bills lesser than a value of Rs.
all payments are cleared within 21 10 lakhs, the payment terms will be
days from the receipt of bills in the 100% payment after acceptance at
office. If on account of any lacunae site.
the payments are inadmissible, they
can be returned to the seller. No II. For bills of a value of Rs. 10 lakhs or
piecemeal objection should be more, the payment terms will be
resorted to while processing the bills. 100% payment after receipt at site
in good condition against the
3. The bills for payment will be supplier executing a bank guarantee
processed by the “first-in-first-out” of 10% of the amount of the
method with regard to receipt in the contract.
office of the Paying Authority. Only in
exceptional circumstances can the 2. TERMS FOR CONTRACTS FOR PLANT
Head of Department ask for an out of AND MACHINERY: The payment terms for
turn payment by a signed written contracts for Plant & Machinery items will
memorandum addressed to the depend on the conditions in the contract for
Paying Authority due to extenuating supply:
circumstances, e.g. contractual
obligations, urgency of the material, i. When the contract is for the supply of P&M
etc. of lower value or of less complicated nature
and no performance is required to be
4. Time is of essence in the discharge of shown, the terms of payment will be 90% on
contracts by the suppliers. Similarly, it proof of despatch and the remaining 10% on
is also of utmost importance that the receipt and acceptance at site.
organizations supplying goods to the
Government are paid in time. With this
741
ii. When the contract is for the supply of P&M vii. For the despatches made beyond the
where erection and commissioning is original/refixed date of delivery, the supplier
involved, the payment terms will be 80% of will receive full payment reduced by 2 % (of
material cost on proof of despatch and the price being paid) for every month or part
submission of 10% Bank Guarantee by the thereof of delay beyond the due date of
firm valid till warranty period. The remaining delivery subject to a maximum of 10%.
20% material cost and erection &
commissioning charges in full will be paid 3. PAYMENT TERMS FOR CONTRACTS
after complete commissioning. If the FOR SUPPLY OF TIMBER: The payment
contract includes a period of trouble free terms in respect of contracts concluded with
running (normally for a period of 15-30 State Forest Departments will be negotiated
days), the payment will be processed only and settled by the respective departments
after the completion and certification of the while entering into Memorandum of
same by the concerned authority. Understanding keeping in view the
guidelines issued by Ministry of
iii. In case there is a warranty period of the Environment and Forest from time to time.
machine supplied as per above, the
contract should provide for a Warranty Bank 31.37.4 PAYMENT TERMS FOR CONTRACTS
Guarantee clause of 10% that will be valid FOR JUTE: The payment terms will be
for the period of warranty. The endeavour decided by the departments concerned
after negotiation, taking due care that the
should be to have a composite Bank interests of the Government are
Guarantee where the 10% Bank Guarantee safeguarded.
received for payment of 80% material cost
should automatically be converted to a
Warranty Bank Guarantee. 31.37.5 PAYMENT TERMS FOR RATE
CONTRACTS:
iv. In case of turnkey contracts or for contracts
A. RATE CONTRACTS FOR STORES OTHER
where due to their longer gestation period,
THAN POL, CEMENT, PAPER AND PAPER
stage payments are involved, such
BOARD: The payment terms will be 98% on
payments should be negotiated care being
proof of despatch and the remaining 2% on
taken that the payment terms safeguard the
receipt of Inspection Notes from the
interests of the Government. However, in no
consignee. In case the Inspection Notes are
case should a payment of more than 80% of
not received and the consignee has not
material cost be agreed upon before the
complained about non-receipt, shortage or
erection and commissioning is completed.
defects in the supplies made, the balance
Only the Head of Department, if required,
amount of 2 % may be paid by the Paying
can agree upon any higher terms of
Authority without consignee’s receipt
payment.
certificate after 30 days from the receipt of
v. In case of P&M where there are a large material at the location indicated subject to
number of items to be supplied and stage the following conditions.
payments are involved, the contract should
I. The contractor will make good any
include a clause indicating the sequence of
defect or deficiency that the
supply. No payment will be made at any
consignee may report within six
given stage unless all previous items in the
months from the date of despatch of
sequence are supplied.
stores.
vi. Liquidated Damages should be imposed on
all delayed supplies.
742
II. Delay in supplies, if any, has been I. 95 % on proof of despatch and balance 5 %
regularised. after receipt in good condition by the
consignee.
III. The contract price where it is
subject to variation has been II. 100% against consignee’s receipt certificate
finalised. for local deliveries.
IV. The contractor furnishes an III. Payment of balance 5 % in respect of item

undertaking regarding the above. No. (i) may be made without consignee’s
receipt certificate if the same is not received
B. PAYMENT TERMS FOR COMPLAINT within 120 days from the date of supply in
PRONE ITEMS: In respect of complaint the case of reeled paper and 75 days in the
prone items, to be identified by the purchase case of sheet paper.
section of the Department, where quantity of
rejection by the consignee is between 5 % to 31.37.6 In all the above items of rate contract,
10 % and replacement of the rejected the Head of the Department in
quantity is difficult, the payment terms consultation with the Financial Adviser
should be 90 % on proof of despatch and may decide on more stringent payment
terms if the circumstances of the case
balance 10 % on receipt of consignee’s
warrant such a decision.
receipt certificate. In case the complaint
continue to persist, the question of making 31.37.7 The Head of the Department in
payment only after receipt of consignee’s consultation with the Financial Adviser
certificate may be considered with the may also decide on payment against
approval of Head of the Department. Bank Guarantee for depending upon the
specific nature of the goods being
C. RATE CONTRACTS FOR POL supplied or the past history of the firm.
PRODUCTS: The payment terms are 100 % The period of the Bank Guarantee will be
decided on the circumstances of the
payments on proof of despatch along with
case.
relevant copies of Inspection Note for
despatches by rail etc. and receipt certificate 31.37.8 CONTRACTS PLACED ON OVERSEAS
in a special form prescribed for the purpose SUPPLIERS ON F.O.B./F.A.S. BASIS ON
in the case of local deliveries. BEHALF OF AUTHORITIES IN INDIA.
Payment will be made as prescribed in
D. RATE CONTRACTS FOR CEMENT: following paras to the principals/foreign
Payment terms are: manufacturers of the net F.O.B./F.A.S.
price excluding the Indian Agent’s
I. 98 % on proof of despatch and balance 2 % Commission on presentation of the
after receipt in good condition by the required documents.
consignee.
31.37.9 CASES WHERE INSTALLATION
ERECTION AND COMMISSIONING IS
II. 100 % payment against consignee’s receipt
NOT THE RESPONSIBILITY OF THE
certificate for local deliveries. SUPPLIERS. : 100 per cent net
F.O.B./F.A.S. price will be paid against
III. In respect of item No. (a), payment without inspection certificate (where applicable),
consignee’s receipt certificate may be made manufacturers’ test certificate, shipping
if the same is not received within 2 months documents and a bank guarantee for 10
from the date of despatch. per cent of the value of the contract
indemnifying the purchaser against all
E. RATE CONTRACTS FOR PAPER AND losses incurred by the purchaser during
PAPER BOARD: Payment terms are:
743
the guarantee period stipulated in the only after releasing full payment to the
warranty clause. supplier. Payment to the Indian Agent
will be made in Indian Rupees only.
31.37.10 CASES WHERE INSTALLATION
ERECTION AND COMMISSIONING IS THE 31.37.15 PAYMENT OF AIR FREIGHT CHARGES:
RESPONSIBILITY OF THE SUPPLIERS: Stores that are required to be air lifted
90 % net F.O.B./F.A.S. price will be paid due to urgency of receipt should be
against inspection certificate (where dispatched through Air India/Indian
applicable) and shipping documents and Airlines only on a `Charge forward basis’.
balance 10 % within 30 days of the All air freight charges, which are shown
successful completion of proving test in on the relative consignment note as
which the machine’s performance would chargeable to the consignees are paid to
have been demonstrated by the supplier Air India/Indian Airlines in Rupees and
or his agent, after the commissioning at adjusted against the consignees/indentor
the consignee’s premises and in the same manner as other clearance
submission of bank guarantee for 10% of charges etc.
the value of the contract indemnifying
the purchaser against all losses incurred 31.37.16 SYSTEM OF PAYMENT IN CASES
by the purchaser during the guarantee WHERE STORES ARE ACCEPTED
period stipulated in the warranty clause. UNDER FIRMS’ WARRANTY/
GUARANTEE. : In cases where physical
31.37.11 Provided that where the installation and inspection of stores has been waived of
commissioning of the machine is delayed and stores are accepted under firm’s
or put off beyond 90 days of the receipt warranty/guarantee, the Paying Authority
of goods at the ultimate destination due will pay 95 % of the cost of stores (98 %
to express written instructions of the in case of rate contracts) on proof of
purchaser or the consignee, the balance despatch i.e. R/R No. and date etc. and
10 % payment shall be released to the the balance 5 % (2 % in the case of rate
supplier on his furnishing the bank contracts) on the authority of the special
guarantee afore mentioned. consignee’s receipt certificate devised
for the purpose.
31.37.12 Where the bank guarantee is obtained
from a foreign bank, it shall be got
confirmed by a scheduled Indian Bank 31.37.17 MODE OF PAYMENT TO SUPPLIERS IN
and shall be governed by Indian Laws INDIA:
and be subject to the jurisdiction of
courts of the place of issue of the I. Payments to Indian Contractors are made
Acceptance of Tender. by cheque/demand draft drawn on a
Government treasury or Branch of the
31.37.13 For items of imported nature, where Reserve Bank of India or the State Bank of
payment is in foreign currency, the India transacting government business.
evaluation of the tender will be as per the
TT Selling Rate of the foreign currency II. The payment to contractors against their
involved on the day of tender opening. bills for supplies against contracts can also
The payment will, however, be based on
the TT Selling Rate of the date of be paid to their bank if the bills are endorsed
advance contract. This should be clearly in favour of the Bank with a pre-receipt
indicated in the tender notice. embossed on the bills with the words,
“Received payment” and both the
31.37.14 AGENCY COMMISSION PAYMENT endorsement and pre-receipt are
TERMS AGAINST F.O.B./F.A.S. authenticated by the signatures of the
CONTRACTS: In case of imported items, contractor. In addition, an irrevocable power
sometimes an Indian Agent’s
commission is also involved. Payments of attorney is to be granted by the supplier in
of such commission should be made favour of the Bank.
744
III. E-PAYMENT: E-banking and e-payments paying authority is to verify such
are now routinely used by banks by through documents received from the supplier
facilities like electronic clearing system with the corresponding stipulations
made in the contract.
(ECS) and electronic fund transfer (EFT).
CVC has directed that payments to all 31.37.20 PAYMENT AGAINST TIME BAR CLAIMS:
suppliers/vendors, refunds of various nature,
I. Ordinarily all claims against Government are
and other payments which organisations
time barred after a period of 3 years
routinely make shall be made through
calculated from the date when the payment
electronic payment mechanism at all centres
falls due. However, limitation is saved if
where such facilities are available in banks.
there is an admission of liability to pay, and
(Auth: CVC Order no. 98/ORD/1 dt.
fresh period of limitation starts from the time
06.04.2004). Accordingly, Paying Authorities
such admission is made. Hence, if liability is
will stop paying through cheques and start
admitted and payment is delayed, the claim
e-payment mechanism at all metro cities
would be time barred only after 3 years from
and other urban centres where banks
the date of the admission of liability and not
provide ECS/EFT and similar other facilities
from the date of concurrence of the cause of
latest by 31.12.2004.
action for payment. Claims for the recovery
of which the remedy of Action in a civil court
31.37.18 MODE OF PAYMENT TO OVERSEAS
SUPPLIERS: is barred under the Law of Limitation are not
ordinarily to be rejected on the ground of
I. Payments to overseas suppliers will
limitation alone.
ordinarily be made by Letters of Credit (LC)
opened by the State Bank of India. II. The drill to be followed while dealing with
time barred claims will be decided by the
II. Where opening of letter of credit is not
individual Departments concerned in
possible due to certain constraints (such as
consultation with the Payment Authority.
material having been shipped prior to
opening of letter of credit), payment may be III. However, the Paying Authority is to ensure
made through cheque. The Paying Authority that payments against the Supply Order has
will authorise Reserve Bank of India for not been made and will issue a non-
remitting the said amount endorsing a copy payment certificate to that effect.
to the Foreign Exchange Division of the
State Bank of India on receipt of a request IV. In cases where original inspection note or
from the firm, duly countersigned by the receipt certificate is lost or misplaced and a
procuring authority. Reserve Bank of India non-payment certificate is issued by the
will authorise the State Bank of India, who Payment Authority, the period of limitation
will in turn advise their Branch in the foreign would be counted from the date of the
country concerned for further payment to the receipt certificate mentioned in the duplicate
overseas suppliers and payment will be copy of the Inspection Note.
made by the Embassy of India in the foreign
country through a cheque in favour of the V. If the bills are presented after the expiry of
overseas suppliers. In such cases the the limitation of 3 years, from the date when
function of the Embassy of India is just to the payment becomes due as stated in sub
deliver the cheque to the correct person. para 1 above, the Paying Authority will refer
the matter to the Purchasing Authority to
31.37.19 DOCUMENTS FOR PAYMENT: The ascertain whether the limitation has been
documents, which are needed from the saved by acknowledgement and if not for
supplier for release of payment, are to be obtaining sanction of the Government for
clearly specified in the contract. The
745
admitting and payment of the time barred 31.37.23 GENERAL:
claim. While referring the bills to the I. 14.1 Terms of payment will depend on the
Purchasing Authority, the Paying Authority delivery period, nature of the item, incidental
will conduct a preliminary investigation and services to be undertaken by the supplier in
certify that the payments claimed in the bills addition to supplying the item etc. However,
referred by him are due to the firms while evolving the terms of payment, the
concerned and that they have not been paid most important consideration is that no
previously. The power to authorise such payment should be made to the supplier
payment upto 7 years will be with the Head without safeguarding the interest of the
of the Department, but in all such cases the supplier.
concurrence of the Financial Adviser will be
required. II. 14.2 The terms of payment are to be clearly
defined in the tender enquiry / bidding
VI. Claims bills which are submitted after an documents to enable the prospective
abnormal delay i.e. more than 7 years tenderers to quote accordingly.
beyond the normal limitation period of three
years, should not be considered ordinarily,
unless there are some compelling
circumstances that should be clearly stated, 31.38 Purchase of Stores Manufactured In
Foreign Countries
while obtaining Government’s sanction for
admission of such claims.
31.38.1 A government buyer should endeavour
to make purchases from within the
VII. Petty value time-barred claims which are to country in order to encourage
be rejected straightaway and which are not indigenous industry. However, where it is
defined in the GFR 17s in terms of money, inescapable and absolutely necessary to
will be taken as bills for an amount of Rs. meet with the requirements of the users,
500/-or less. imports will have to be resorted to.
1. Due to liberalisation of imports, most of the
31.37.21 DEDUCTION OF INCOME TAX, SERVICE items are now covered under Open General
TAX, ETC. AT SOURCE FROM License. The Imports and Exports (Control)
PAYMENTS TO CONTRACTORS AND Act, 1947 empowers the Central
SUBCONTRACTORS:
Government to prohibit, restrict or otherwise
This will be done as per the existing law in force control imports and exports. In exercise of
during the currency of the contract. the powers conferred by this Act, the
Imports (Control) Order, 1955 was issued.
31.37.22 RECOVERY OF PUBLIC MONEY FROM
Schedule 1 to the said Order contains the
CONTRACTOR’S BILL:
list of articles of which import is controlled.
Sometimes, requests are received from a different
The import of such items is prohibited
department/wing of the Government for withholding
except (i) under and in accordance with the
of payments from a contractor. In all such cases, it
license or (ii) if they are covered by an
will be responsibility of the department/wing of the
Open General License. The Purchase
Government asking for withholding of payment to
Officer should ensure to obtain OGL
defend the Government against any legal
Certificate from the actual user so that the
procedures arising out of such request as also for
onus of correctness of the OGL item vis-à-
payment of any interest. The power to issue such
vis notification in the Import Policy remains
recovery certificate will be with the Secretary of the
with the indentor. In the case of items
concerned department.
covered under OGL, no Import License is
necessary. Buyers can place orders without
746
obtaining actual foreign exchange, letters of countries located in India can also be
credit can be opened through any requested through the same circular to
nationalized bank. inform the manufacturers in their countries
for participating against these tenders.
31.38.2 Methods of Purchase:-On most of the
occasions, the requirement of imported
stores will be of considerable high value
goods. It should be decided by the 31.38.3 Evaluation of tenders and submission of
competent authority whether single bid proposals :Generally, the goods of
or two-bid system should be followed as imported nature are such where the
generally stores to be imported will be specifications are complicated and
highly technical and sophisticated in exhaustive requiring numerous items to
nature. The procedure for two-bid system different specifications. It is essential to
is available in Chapter, ‘Methods of go through the specifications and
Purchase. assimilate in all its details. As such, the
I. Organisation having its own Web Site study and proper understanding of the
should publish all its tender enquiries on various drawings/ specifications
their Web Site. Other organisations may becomes an essential prerequisite.
publish their tender notices and tender
31.38.4 The offers which are not conforming to
enquiries on the DGS&D Web Site. Hyper the specifications of the tender enquiry
links should be established between the should be ignored straightaway. The
different procurement/ purchase of individual technical deficiencies in the offers
government departments with the DGS&D should be clearly brought out for proper
Web Site (www.dgsnd.gov.in). appreciation by the competent authority.
In the procurement of plant and
II. In almost all cases involving import, machinery the tenderer should be asked
to furnish a deviation statement clearly
advertised tender enquiry(ATI) or global
bringing out there in the positive and
tender enquiry (GTI) should be floated. negative deviations for appropriate
However, there is no bar to resort to limited consideration by the buyer.
tender enquiry (LTI) in case of urgency. In
case LTI mode of purchase is resorted to, 31.38.5 References of tenders to indentor:-
the purchase officer should ensure that Consultation with the indentor may
tender enquiry is issued to fairly sufficient become necessary in case of stores of
specialised nature (and not in case of
number of likely and known suppliers by
common user items). The following are
consulting the list available with the the broad categories of cases where
purchase section and Registration Branch of tenders may have to be referred to
DGS&D. indentor.
a) Stores of specialised nature and scientific
III. Publicity in foreign countries:-In case of
equipment;
imported stores tender notice requiring
global participation for heavy equipment b) Where none of the offers received or those
etc., a circular letter may be sent to all the proposed to be accepted are
Indian Embassies by Diplomatic Bag
indicating the stores demanded, c) strictly in conformity with the specifications;
specifications, quantity, delivery period
along with a copy of the tender set. These d) Where suitable alternatives are offered to
circulars should be sent to the Indian save foreign exchange.
Embassies of only those countries from
1. In cases where tenders are referred to the
where offers can be expected.
indentor, they should be accompanied as far
Simultaneously, the embassies of foreign
747
as possible, by a self-contained note giving II. Purchase of varied range of products has
the specific recommendations of the made it impossible for laying down a uniform
purchase office, as also comments or rate of agency commission. The amo unt of
technical assessment of the offers. The note agency commission agreed to between the
should also indicate clearly the points on principals and his agent will, therefore, be
which the comments of the indentors are accepted on merits of each case. What is to
sought. A target date should be given for be ensured is that the amount of agency
reply and the following clause should be commission agreed to between the foreign
incorporated in all such communications: principal and the Indian Agent is spec ifically
disclosed and the agency commission is
2. “Please note that tenders are valid for paid in Indian rupees only.
acceptance up to (date). You are requested
to ensure that your reply to this letter is sent III. All particulars relating to agency commission
by (date) positively. You will appreciate that shall be reported to the Enforcement
the entire responsibility due to delay in reply Directorate who in turn, will further
beyond the target date which may result in communicate the information to the Central
payment of higher rates will rest on you. Board of Direct Taxes, Central Board of
Please therefore ensure that your reply Excise and Customs and Reserve Bank of
reaches us by the stipulated date indicated India to prevent leakage of foreign exchange
above.” and tax evasion on agency commission.
3. Care should be taken to see that a 7. The payment terms of the agency
reasonable period is given in fixing the commission to the Indian Agents are given
target date for reply from the indentors in the Chapter titled ‘Payment of Cost of
taking into account the date of expiry of Stores Supplied against Contracts’.
validity of offers.
8. The quotations from the foreign principals
4. Consideration of offers from Agents of and or from their Indian Agents are required,
Foreign Manufacturers/Firms: inter alia, to state besides the F.O.B./F.A.S.
price of the stores offered, the amount of
Agency Commission payable to the Indian
Agent in terms of the agreement between
5. The agents of foreign firms have an
the foreign principals and their Indian
important role to play, particularly when
Agents, both in foreign currency as well as
after-sales service of sophisticated
in Indian rupees to be converted by applying
equipment or training in operation and
TT buying rate of exchange ruling on the
maintenance is required.
date of offer. It is further to be provided that
6. Following instructions should be noted while the agency commission finally payable
dealing with such cases; under the contract will be converted in
Indian rupees at the TT buying rate of
I. The agency arrangements and the amount exchange ruling on the date of placement of
of commission payable should be brought the order and which shall not be subject to
on record and made explicit so as to ensure any further exchange variation. Accordingly,
compliance of Tax Laws and to prevent in the resultant contract either of the
leakage of foreign exchange. An appropriate clauses should be inserted
authenticated photocopy of the agency under the Special Conditions of
agreement shall mandatorily be filed by the F.O.B./F.A.S. contracts, as the case may be.
agent.
748
9. In such cases the purchase officer will manufacture to obtain report on the
ensure to get the break up of the price viz. technical and financial competence of the
net F.O.B./F.A.S. value, insurance, freight, firm. The order should be placed only on
clearing, handling charges, profit margin and receipt of a satisfactory reply. It is also
charges up to destination. Standard helpful to check the standing of the firm in
exchange rate variation clause given in the Thomas Register, Dun and Brand Street
Chapter, “Drafting of Contracts”, should be Register. These are reliable books giving
incorporated in the resultant contract. various details in respect of companies loca
ted in Europe and USA.
10. Agents quoting on behalf of their principals
should:
i. Produce their foreign principals’ pro- 13. Payment of Customs Duty:-Generally,

forma invoice indicating educational institutes, research institutes,
commission, payable to the Indian hospitals, serving the public at large are
Agent, nature of after-sales service exempt from payment of customs duty.
to be rendered by the Indian Agent. Customs Duty Exemption Certificate has to
be furnished at the time of clearance of the
ii. Clearly indicate, if their offer is on stores at the port of entry. It is the
F.O.R. basis, the breakup of the responsibility of the actual user to obtain or
prices viz. net F.O.B./F.A.S. value, issue such a certificate for production to the
insurance, freight and customs authorities. It should be explicitly
clearing/handling charges at the made clear to the indentor that the
Indian Port, profit margin and responsibility for obtaining the Customs Duty
charges for despatch up to Exemption Certificate will be that of the
destination. iii) Produce copy of the actual user.
Agency Commission with their
foreign principals. 14. At a time of clearance of the goods from the
port of entry Customs Duty may have to be
iii. Give particulars regarding precise paid. Care should be taken to ensure that all
relationship with their foreign necessary documentation is completed well
principals and their mutual interest before the arrival of the stores at the port of
in the business. entry.
11. Offers which do not disclose any information 15. Elements of Price relating to imported
with regard to the price, terms of agency stores:-The elements of price and their
agreement, Agency Commission payable as variations relating to imported stores are
per the agreement are liable to be ignored. discussed below:
For both ignoring the lower offers on this
account and for accepting the same, the
approval of Finance will be taken by the
competent purchase officer. i. Net F.O.B. price in foreign currency i.e. the
price ex-port of shipment in country of origin.
12. Capacity Report for Imported Stores :- In
case of offers from unregistered firms(both ii. Agency Commission, if any.
Indian Agent/Stockists/Foreign
iii. Ocean/Air freight and insurance.
manufacturers being unregistered), a
reference may be made to the Indian
Embassy located in the country of
749
iv. Customs Duty in India in case the following items subject to fulfilment of
indentor/consignee is not exempted from conditions and production of certificates.
payment of the same.
i. Scientific and technical instruments imported
v. Landing and clearing charges; and by Research Institutes.
vi. Inland freight/ insurance/ Octroi Duty/ ii. Hospital equipments imported by
Terminal Tax. Government
16. Exchange Rate for decision making:-In iii. Hospitals.

respect of purchase of imported stores
where the purchase decision is to be taken iv. Consumable goods imported by a public
in DGS&D, the exchange rate prevailing on funded Research Institution or a University.
the date on which the competent authority
2. In respect of these exempted categories of
approves the proposal will apply. The
stores the Ministry of Finance (Department
purchase officer concerned would indicate in
of Revenue) have issued instructions to the
the margin that on the basis of the exchange
Customs Authorities that the consignments
rate i.e. BC Selling Rate of Exchange of
which constitute replacement made by the
State Bank of India prevailing on that day,
foreign suppliers on “no -charge” basis
the proposal holds good.
should be passed provisionally duty free and
17. In other cases requiring the approval of the get a suitable guarantee from the indentors;
Government the exchange rate prevailing on ;and a) Fresh Customs Duty Exemption
the date when Head of Department Certificate as well as b) Not manufactured in
approves the proposal would apply. India Certificate Should be obtained from
them subsequently within a reasonable time.
18. Once decision has been taken for placement It may be noted that even in the case of free
of order, the purchase officer should check replacement the production of these two
whether the funds provided are adequate certificates is absolutely necessary.
and should inform the indenting department
for any additional requirement of funds to 3. Where customs duty is payable the contract
meet the deficit. should clearly stipulate the quantum of duty
payable in unambiguous terms so that the
19. An appropriate exchange variation clause be Controller of Accounts has not to make any
stipulated in the resultant contract if the reference. The standard clause to be
same is necessary and asked for by the incorporated in the contract regarding
tenderer. customs duty has been given in “Drafting of
Contract”.
31.38.6 Customs Duty:- In respect of imported
stores offered against forward delivery
the tenderer shall quote the prices
exclusive of customs duty. The tenderer 31.38.7 Customs Duty On Replacement Supplies
shall specify separately the C.I.F. prices :
and the total amount of customs duty
1. Drawback on Re-export of Imported Goods:-
payable. The tenderer will also indicate
correctly the rate of customs duty Under the existing law, no exemption from
applicable along with Indian Customs duty on “No charge shipment” can be given,
Tariff Number. as duty has to be paid on each importation
1. The Government have allowed exemption whether original or replacement. However,
from payment of customs duty in respect of in terms of Section 74 read with Section 76
of the Customs Act, 1962 drawback is
750
allowable on re-export of duty paid goods to 1. Sales Tax is not leviable on transactions of
the extent and subject to the fulfilment of the sale in course of import. Categories of cases
conditions stated therein. constituting sale in course of import.
2. Goods re-exported without use within a i. Where the movement of goods from the
period of two years are eligible for drawback foreign country to India is occasioned
up to 98% and goods re-exported after use directly as a result of the sale.
are eligible to drawback of import duty on
slab rates according to drawback of import ii. Where there is a privity of contract between
duty on slab rates according to the length of the foreign supplier and the buyer.
period between the date of clearance for
whom consumption and the date when the
goods are placed under Customs Control for iii. Where the Indian supplier acts as the agent
export. Extract of Section 74 and Section 76 of the foreign manufacturer in the agreement
of the Customs Duty Act, 1962 and the of the sale. Categories of cases not
Notification No.19-Cus. Dated 6th February, constituting sale in the course of import:
1965 as amended are given in Appendix 24
for reference. a. Sales of imported goods which are
supplied from the already existing stock.
3. Entitlement of the Purchaser to Recover
Damages on Excess Customs Duty Paid on b. Import of raw materials and components
account of Replacement: which have been utilized by the
suppliers in assembling or
4. Where the replacement supply is made manufacturing the goods ordered for
under the contract, according to legal sale where price of such raw materials,
opinion, Section 64-A of Sale of Goods Act components and accessories have not
is attracted and the increased customs duty been shown separately.
is payable by the buyer. However, as the
delivery of the goods is delayed and the c. Sales of imported goods which have
increased customs duty would not have been further processed in India before
been payable if the original supplies had not supply to the consignee.
damaged in transit and therefore, required to d. Sales of goods which are to be imported
be replaced, the additional expenditure on against firm’s own ‘Stock and Sale’
account of the customs duty is a loss directly licence for supply to various customers.
occasioned by the delay in supply.
e. The good have moved from foreign
Consequently the purchaser is entitled to
country to India as a result of the Indian
recover liquidated damages at the contract
supplier purchasing the goods from the
rate up to a sum equal to the amount of the
foreign supplier i.e.
extra expenditure on account of increased
customs duty. Proper notice be given in  the movement of good has been
accordance with the terms and conditions of occasioned by the contract for
the contract. purchase which the Indian Supplier
entered with the foreign seller.
 there was no privity of contract

31.38.8 Sales Tax On Transactions Relating to
Imported Goods : between the buyer and the foreign
seller.
751
 The foreign seller has not entered will commence from the date of opening of
into the contract by himself or letter of credit. This would require L/C to be
through the agenc ies of the Indian opened at the earliest to obtain the supplies
supplier. within the stipulated delivery period.
2. The Sales Tax Clause in the Acceptance of 4. Letter of Credit is usually kept valid for 21
Tender for imported stores:-In all cases days beyond the contractual delivery date to
where it is finally decided to admit Sales facilitate the banks to retire the documents.
Tax, the rate of Sales Tax and the amount
payable as Sales Tax should be shown as a 5. If the suppliers specifically request that the
separate item in the Acceptance of Tender L/C be confirmed then efforts should be
to enable Controller of Accounts to pay made to ensure that cost of confirmation is
firm’s bill for Sales Tax. The relevant borne by the supplier. Further, if it becomes
clauses to be incorporated in the contract necessary to extend/reinstate or amend L/C
are given in the Chapter, “Drafting of for reasons not attributable to the purchaser,
Contract.” the charges for the same should be borne
by the supplier. In order to open letter of
3. Payment of Imported Stores:- The most credit a letter is written to the paying
common method of payment to the foreign authority named in the contract along with
supplier is through a letter of credit. It is a copies of the contract. The L/C pro-forma
letter issued by the Purchaser’s bank to the devised by the bank has also to be filled up.
supplier’s bank authorising the letter to The purchase officers are also required to
release payment to the supplier for the give a standard letter to the State Bank of
supplies made by them, on receipt of India, London undertaking thereby that the
specified documents from the seller and the documents will be retired by the buyer and
purchaser’s bank reimburses the required that L/C amount would be sufficient for
amount as it receives an intimation about payment of stores ordered. A specimen
the payment for the supplies having been copy of each of above 3 documents is
made to the supplier by the supplier’s bank. enclosed as Annexure to this Chapter.
The foreign suppliers generally insist for
opening of irrevo cable letter of credit 6. The documents to be submitted by the
confirmed by an international bank. The supplier have to be clearly brought out in the
foreign suppliers also insist on part shipment body of the letter of credit so that the
and part payment for supplies made. While supplier meets with the contractual
opening the letter of credit the banks levy commitments. Regardless of this, a clause
two types of charges viz. L/C opening should always be stipulated requiring the
charges, foreign bank charges and supplier to confirm that he has abided by all
confirmation charges. The banks generally the terms and conditions stipulated in the
charge on quarterly basis (3 months). It contract.
would be prudent to open the letter of credit
in such a way that validity of L/C is kept bare
minimum. L/C should be opened only for net
FOB/CIF value i.e. excluding agency
commission which will be paid in Indian
rupees in India. At the same time ensure
that entire transaction for the L/C is done
within its validity. On many occasions, the
suppliers put a condition that delivery date
752
Sub: Opening of Letter of Credit against Contract
No.__________
Dated______________placed on
M/s.___________________
Sir,
You are requested to arrange for opening of letter of

credit for the next amount______________ subject
to ceiling of________________ payable to the
beneficiary ( i.e. foreign principals –
M/s._________________) through their advising
bank______________________(Address________
______) as per clause 18 and 20 of the schedule to
subject contract. Following documents are enclosed:
No. (i) Two signed cop ies of kthe A/T
Government of India (ii) Letter addressed to the State Bank of India,

London (in duplicate)
(iii) Letter of credit will remain valid up

to_______months and 21 days from the date of
Dated: opening.
(iv) credit.
To Last date of shipment_________months from the

date of letter of
(v)
The Chief Controller of Accounts,
(vi)
shipment.
New Delhi – 110 011.
Beneficia ry to present documents: within 21 days
from the date of List of documents against which
payment is to be released to foreign suppliers will
(Through Authentication Cell) comprise of:
753
(a) Complete set of clear bill of lading consigned to d. Goods are to be shipped by sea/ air from
the port consignee as per clause____of A/T ___________and delivered in satisfactory condition
evidencing despatch of goods on freight and to port / ultimate consignee as per clause 13 of
insurance paid basis also showing the letter of credit contract.
and contract number with date.
5. A confirmation from the beneficiary that they have
(b) Certified copy of FAX / CABLE sent by the complied with all the terms and conditions of the
beneficiary to the Indian port/ ultimate consignee contract.
giving full particulars of despatch of goods with
name of carrier, date of despatch, date and number 6. It is confirmed that sanction of funds are sufficient
of bill of lading, place of loading and unloading, for stores ordered. This issues with the approval
quantity and description of goods. of___________.
(c) Beneficiary’s Invoice in Duplicate also showing Purchase Officer

Name(s) of Consignee(s) and value.
Copy to:
(d) Packing list in triplicate
By Airmail 1. ( Name and Address of the foreign
(e) Certificate of Origin stating that goods of supplier)
_________origin.
(f) Manufacturer’s guarantee/ warranty certificate.

2. Indentor
(g) Manufacturer’s works test certificate.
3. Consignee
(h) Certificate from the beneficiary that one set of
4. Port consignee at regional office
documents has been sent to the port consignee
direct. 5. The Inspection Authority
(i) Pre-despatch inspection certificate for ordered 6. Inspection Officer
stores will be issued by the following nominated
officers as Inspecting Officers as per clause 17(a), Purchase Officer
17(b) and 17(c) – Inspection:
The above mentioned officers are from the office

of_______________________and they shall
discharge the role of inspecting officers/ inspection
authority for pre-despatch inspection.
(j) Copy of Insurance Policy covering 110% of CIP

value.
4. Special instructions applicable to letter of credit

will be:
a. Part shipment : Not allowed / allowed
b. Transshipment :- Not allowed / allowed
c. In terms of clause 9 of A/T – Performance

Security has been received and accepted.
754
No. PS: Please invariably quote above stated A/T
number and date while making reference(s) of this
Government of India office on the subject.
Dated:
To
The State Bank of India
1, Milk Street,
London, UK.
Sub: Opening of letter of credit against contract vide
A/T No._________________
Sir,
With reference to opening of letter of credit details

for which will be sent to you by the Chief Controller
of Accounts, Supply Division, Department of
Commerce, New Delhi.
a) We hereby unequivocally /undertake to retire the

document drawn under this credit notwithstanding
total partial loss of goods during voyage and or pay
general average, if declared.
b) It is further certified that the amount of L/C would

be sufficient for payment of stores ordered.
c) Complete details of letters of credit may be

intimated to this office immediately after the L/C is
established by you.
d) This issues with the approval of_____________.
Yours faithfully,
Purchase Officer
755
31.38.9 PURCHASE OF STORES procedure for two-bid system is available in
MANUFACTURED IN FOREIGN para________.
COUNTRIES
A. As government buyer should endeavour to I. As a rule DGS&D does not make
make purchases from within the country in purchases of proprietary stores.
order to encourage indigenous industry.
However, where it is inescapable and II. Therefore, indents with proprietary article
absolutely necessary to meet with the certificate should not be considered;
requirements of the users, imports will have
III. In almost all cases involving import,
to be resorted to.
advertised tender enquiry(ATI) or global
I. Due to liberalisation of imports, most of tender enquiry (GTI) should be floated.
the items are now covered under Open However, there is no bar to resort to
General License. The Imports and limited tender enquiry (LTI) in case of
Exports (Control) Act, 1947 empowers urgency. In case LTI mode of purchase is
the Central Government to prohibit, resorted to, the purchase officer should
restrict or otherwise control imports and ensure that tender enquiry is issued to
exports. In exercise of the powers fairly sufficient number of likely and known
conferred by this Act, the Imports suppliers by consulting the list available
(Control) Order, 1955 was issued. with the purchase section and Registration
Branch.
II. Schedule 1 to the said Order contains the
list of articles of which import is IV. Publicity in foreign countries :- In case of
controlled. imported stores tender notice requiring
global participation for heavy equipment
III. The import of such items is prohibited etc., a circular letter may be sent to all the
except (i) under and in accordance with Indian Embassies by Diplomatic Bag
the license or (ii) if they are covered by indicating the stores demanded,
an Open General Licence. The Purchase specifications, quantity, delivery period
Officer should ensure to obtain OGL along with a copy of the tender set. These
Certificate from the actual user so that circulars should be sent to the Indian
the onus of correctness of the OGL item Embassies of only those countries from
vis-à-vis notification in the Import Policy where offers can be expected.
remains with the indentor. In the case of Simultaneously, the embassies of foreign
items covered under OGL, no Import countries located in India can also be
License is necessary. DGS&D on behalf requested through the same circular to
of the indentors can place orders without inform the manufacturers in their countries
obtaining actual foreign exchange, letters for participating against these tenders.
of credit can be opened through any
nationalised bank. C. Evaluation of tenders and submission of
proposals: Generally, the goods of imported
B. Methods of Purchase:-On most of the nature are such where the specifications are
occasions, the requirement of imported complicated and exhaustive requiring
stores will be of considerable high value numerous items to different specifications. It
goods. It should be decided by the is essential to go through the specifications
competent authority whether single bid or and assimilate in all its details. As such, the
two-bid system should be followed as study and proper understanding of the
generally stores to be imported will be highly various drawings/specifications becomes an
technical and sophisticated in nature. The essential prerequisite.
756
D. The offers which are not conforming to the duplicate copies of tenders to indentors is
specifications of the tender enquiry should not necessary.
be ignored straightaway. The technical
deficiencies in the offers should be clearly VII. Where the inspection authority is
brought out for proper appreciation by the ADG(QA) and it is proposed to refer
competent authority. In the procurement of tenders in such cases to the indentor for
plant and machinery the tenderer should be technical scrutiny and comments, the
asked to furnish a deviation statement reasons why technical evaluation cannot
clearly bringing out there in the positive and be done by DGS&D or Quality Assurance
negative deviations for appropriate Wing should be recorded.
consideration by the buyer.
VIII. Where the responsibility for technical
E. References of tenders to indentor:- Tenders particulars checking is that of the
should not ordinarily be referred to the indentor but the Inspection Authority is
indentor even if the indentor has asked ADG(QA), the observations of the
these should be shown to him before indentor on the technical aspects of the
placement of order. Consultation with the tenders should invariably be referred to
indentor may, however, become necessary Quality Assurance Wing for comments,
in case of stores of specialised nature (and particularly where a lower offer is
not in case of common user items). The proposed to be ignored on technical
following are the broad categories of cases grounds.
where tenders may have to be referred to
IX. The recommendation of the indentor
indentor.
should be examined in an objective
I. Stores of specialised nature and scientific manner because the ultimate
equipment; responsibility for accepting or ignoring
any offer lies with DGS&D. In cases
II. Where none of the offers received or where there is honest and genuine
those proposed to be accepted are difference of opinion between the
strictly in conformity with the indentor and the DGS&D over accepting
specifications; or rejecting any lower offer on technical
or other grounds, a dialogue with the
III. Stores of which technical scrutiny rests indentor should be arranged at the
with DG (Shipping) and other indentors; earliest to iron out the differences and
reach mutual accord. Where the
IV. Where suitable alternatives are offered to
differences persist, the case may be
save foreign exchange.
shown to the next senior officer for
V. Where it is considered necessary to refer decision in consultation with Finance.
duplicate tenders to indentor for technical
X. In cases where tenders are referred to
scrutiny and comments, prior approval of
the indentor, they should be
DDG concerned should be obtained. In
accompanied as far as possible, by a
the case of Regional Offices, prior
self-contained note giving the specific
approval of the Head of the Regional
recommendations of this office, as also
Office may be obtained.
comments or technical assessment of the
VI. When the responsibility for checking offers. The note should also indicate
technical particulars and for inspection is clearly the points on which the comments
that of the indentor, prior consultation of the indentors are sought. A target date
with Quality Assurance Wing for referring should be given for reply and the
757
following clause should be incorporated agency agreement shall be obtained by the
in all such communications: purchase officer before considering the
tender.
XI. “Please note that tenders are valid for
acceptance up to (date). You are G. Purchase of varied range of products has
requested to ensure that your reply to made it impossible for laying down a uniform
this letter is sent by (date) positively. You rate of agency commission. The amount of
will appreciate that the entire agency commission agreed to between the
responsibility due to delay in reply principals and his agent will, therefore, be
beyond the target date whic h may result accepted on merits of each case. What is to
in payment of higher rates will rest on be ensured is that the amount of agency
you. Please therefore ensure that your commission agreed to between the foreign
reply reaches us by the stipulated date principal and the Indian Agent is specifically
indicated above.” disclosed and the agency commission is
paid in Indian rupees only.
XII. Care should be taken to see that a
reasonable period is given in fixing the H. All particulars relating to agency commission
target date for reply from the indentors shall be reported to the Enforcement
taking into account the date of expiry of Directorate who in turn, will further
validity of offers. communicate the information to the Central
Board of Direct Taxes, Central Board of
XIII. Consideration of offers from Agents of Excise and Customs and Reserve Bank of
Foreign Manufacturers/Firms: India to prevent leakage of foreign exchange
and tax evasion on agency commission.
XIV. The agents of foreign firms have an
important role to play, particularly when I. The payment terms of the agency
after-sales service of sophisticated commission to the Indian Agents are
equipment or training in operation and given in Form DGS&D-237 and same will
maintenance is required. apply.
XV. The Special Conditions for imported II. As per the provisions of the Special
stores given in form DGS&D 237 Conditions of Tender Enquiry given in
contains provisions governing the Indian Form DGS&D-237 the quotations from
Agents, the documents to be obtained the foreign principals and or from their
and the payment of agency commission Indian Agents are required, inter alia, to
to them. Following further instructions state besides the F.O.B./F.A.S. price of
should be noted while dealing with such the stores offered, the amount of Agency
cases; Commission payable to the Indian Age nt
in terms of the agreement between the
F. The agency arrangements and the amount
foreign principals and their Indian Agents,
of commission payable should be brought
both in foreign currency as well as in
on record and made explicit so as to ensure
Indian rupees to be converted by
compliance of Tax Laws and to prevent
applying TT buying rate of exchange
leakage of foreign exchange. An
ruling on the date of offer. It is further
authenticated photocopy of the agency
provided that the a gency commission
agreement shall mandatorily be filed by the
finally payable under the contract will be
registered agent while bringing on record the
converted in Indian rupees at the TT
agency agreement. If this has not been done
buying rate of exchange ruling on the
at the time of registration, a copy of the
date of placement of the order and which
758
shall not be subject to any further IV. Give particulars regarding precise
exchange variation. Accordingly, in the relationship with their foreign principals
resultant contract either of the and their mutual interest in the business.
appropriate clauses should be inserted
under the Special Conditions of
F.O.B./F.A.S. contracts, as the case may
J. Officers which do not disclose any
be.
information with regard to the price, terms of
III. Para 1 of the Special Conditions agency agreement, Agency Commission
contained in Form DGS&D-237 provides payable as per the agreement are liable to
that offers should be submitted by the be ignored. For both ignoring the lower
tenderers on the basis of F.O.B./F.A.S. offers on this account and for accepting the
Port of shipment of their principals/C.I.F. same, the approval of Finance will be taken
Indian Port/F.O.R. and that the purchaser by the competent purchase officer.
reserves the right to place order on any
K. The purchase officers should satisfy that in
such basis. The said clause also requires
the case of offers from Indian Agents a
the tenderers to disclose the agency
proper Agency Agreement for a certain
commissio n payable to the Indian Agent.
period and not for that particular tender only
IV. In such cases the purchase officer will is to be produced at the time of tender or the
ensure to get the break up of the price Indian Agent should be registered with the
viz. net F.O.B./F.A.S. value, insurance, DGS&D as an authorised regular Indian
freight, clearing, handling charges, profit Agent of the principals.
margin and charges up to destination.
L. Capacity Report for Imported Stores:-In
Standard exchange rate variation clause
case of offers from unregistered firms(both
given in the Chapter, “Drafting of
Indian Agent/Stockists/Foreign
Contracts”, should be incorporated in the
manufacturers being unregistered), a
resultant contract.
reference may be made to the Indian
I. Agents quoting on behalf of their principals Embassy located in the country of
should: manufacture to obtain report on the
technical and financial competence of the
I. Produce their foreign principals’ pro- firm. The order should be placed only on
forma invoice indicating commission, receipt of a satisfactory reply. It is also
payable to the Indian Agent, nature of helpful to check the standing of the firm in
after-sales service to be rendered by the Thomas Register, Don and Brand Street
Indian Agent. Register. These are reliable books giving
various details in respect of companies
II. Clearly indicate, if their offer is on F.O.R. located in Europe and USA.
basis, the break up of the prices viz. net
F.O.B./F.A.S. value, insurance, freight M. Payment of Customs Duty:- Generally, educ
and clearing/handling charges at the ational institutes, research institutes,
Indian Port, profit margin and charges for hospitals, serving the public at large are
dispatch up to destination. exempt from payment of customs duty.
Customs Duty Exemption Certificate has to
III. Produce copy of the Agency Commission be furnished at the time of clearance of the
with their foreign principals. stores at the port of entry. It is the
responsibility of the actual user to obtain or
issue such a certificate for production to the
759
customs authorities. It should be explicitly Q. In other cases requiring the approval of the
made clear to the indentor that the Government the exchange rate prevailing on
responsibility for obtaining the Customs Duty the date when DG approves the proposal
Exemption Certificate will be that of the would apply.
actual user.
R. Once decision has been taken for placement
N. At a time of clearance of the goods from the of order, the purchase officer should check
Customs, AD(Shipping) located at Kolkata, whether the funds provided by the indentor
Mumbai and Chennai do the customs would be adequate and should inform the
clearance and pay the Customs Duty which indenting department for any additional
is later on reimbursed by the indentor. Care requirement of funds to meet the deficit.
should be taken to ensure that all necessary
documentation is completed well before the S. Exchange Rate Variation Clause in the
arrival of the stores at the port of entry. contract:-The Special Conditions of Tender
contained in Form DGS&D-237 provide that
O. Elements of Price relating to imported in respect of C.I.F./F.O.R. contracts in the
stores:-The elements of price and their event of variation by more than 1% (up or
variations relating to imported stores are down) between the base rate and the rate of
discussed below: remittance to foreign principals the contract
prices (limited only to that portion of
I. Net F.O.B. price in foreign currency i.e. C.I.F./F.O.R. prices that are required to be
the price ex-port of shipment in country of remitted according to the contractual terms
origin. to the firm’s foreign principals in foreign
currency) will be subject to the adjustment (
II. Agency Commission, if any.
up or down ) in accordance with the TT
III. Ocean/Air freight and insurance. Selling rate of exchange as quoted by any
Nationalised Bank ruling on the date the
IV. Customs Duty in India in case the payment is made by the firm to their
indentor/consignee is not exempted from principals abroad which should not be
payment of the same. beyond two weeks from the date on which
initial payment is made by the purchaser to
V. Landing and clearing charges; and the contractor. No variation in price will,
however, be allowed, if the variation in the
VI. Inland freight/ insurance/ Octroi Duty/
rate of exchange remains within the limit of
Terminal Tax.
1% plus or minus.
P. Exchange Rate for decision making:-In
T. The exchange variation clause to be
respect of purchase of imported stores
stipulated in the resultant contract is given in
where the purchase decision is to be taken
the Chapter, “Drafting of Contract”.
in DGS&D, the exchange rate prevailing on
the date on which the co mpetent authority U. Customs Duty:- In respect of imported
approves the proposal will apply. The stores offered against forward delivery the
purchase officer concerned would indicate in tenderer shall quote the prices exclusive of
the margin that on the basis of the exchange customs duty. The tenderer shall specify
rate i.e.BC Selling Rate of Exchange of separately the C.I.F. prices and the total
State Bank of India prevailing on that day, amount of customs duty payable. The
the proposal holds good. tenderer will also indicate correctly the rate
of customs duty applicable along with Indian
Customs Tariff Number.
760
V. The Government have allowed exemption 4. In respect of Defence contracts the payment
from payment of customs duty in respect of of customs duty is to be arranged by the
following items subject to fulfilment of indentor himself and it will be paid by the
conditions and production of certificates. Controller of Defence Accounts.
5. In respect of cases where DGS&D is

responsible for arranging clearance from
31.38.10 Scientific and technical instruments major ports on behalf of other
imported by Research Institutes. Ministries/Departments, CCA, Supply
Division, Department of Commerce, will
initially pay the customs duty and seek
31.38.11 Hospital equipments imported by reimbursement from the Accounts Officer of
Government Hospitals. the concerned Department.
6. Since, clearance of imports by the DGS&D

31.38.12 Consumable goods imported by a public and payment of Customs Duty by the
funded Research Institution or a Accounts Officers of the Supply Division,
University.
Department of Commerce are agency
1. In respect of these exempted categories of functions on behalf of the
stores the Ministry of Finance (Department Ministries/Departments, the provision of
of Revenue) have issued instructions to the funds by the latter will be assumed. The
Customs Authorities that the consignments Accounts Officer of Ministries/Departments
which constitute replacement made by the should reimburse the Customs Duty
foreign suppliers on “no-charge” basis immediately on receipt of the claims from
should be passed provisionally duty free and the Accounts Officers of the Supply Division,
get a suitable guarantee from the indentors; Department of Commerce without raising
;and a) Fresh Customs Duty Exemption any question regarding the correctness of
Certificate as well as b) Not manufactured in the levy and claims should not be rejected
India Certificate. Should be obtained from on grounds of excess levy of duty or
them subsequently within a reasonable time. incorrect rates or any similar grounds.
It may be noted that even in the case of free Appeals against the duty levied should be
replacement the production of these two directly preferred to the concerned Customs
certificates is absolutely necessary. Authorities and refunds, if found due, should
also be claimed directly from them.
Necessary instructions in the DGS&D
2. Where customs duty is payable the contract Manual for Shipping and Clearance may be
should clearly stipulate the quantum of duty followed.
payable in unambiguous terms so that the
7. Customs Duty On Replacement Supplies :
Controller of Accounts has not to make any
reference. The standard clause to be 8. Drawback on Re-export of Imported Goods:-
incorporated in the contract regarding Under the existing law, no exemption from
customs duty has been given in “Drafting of duty on “No charge shipment” can be given,
Contract”. as duty has to be paid on each importation
whether original or replacement. However,
in terms of Section 74 read with Section 76
3. Authority for making payment of Customs of the Customs Act, 1962 drawback is
Duty: allowable on re-export of duty paid goods to
761
the extent and subject to the fulfillment of 13. Sales Tax not leviable on transactions of
the conditions stated therein. sale in course of import. Categories of cases
constituting sale in course of import.
9. Goods re-exported without use within a
period of two years are eligible for drawback I. Where the movement of goods from the
up to 98% and goods re-exported after use foreign country to India is occasioned
are eligible to drawback of import duty on directly as a result of the sale.
slab rates according to drawback of import
duty on slab rates according to the length of II. Where there is a privity of contract
period between the date of clearance for between the foreign supplier and the
whom consumption and the date when the buyer.
goods are placed under Customs Control for
III. Where the Indian supplier acts as the
export. Extract of Section 74 and Section 76
agent of the foreign manufacturer in the
of the Customs Duty Act, 1962 and the
agreement of the sale.Categories of cases
Notification No.19-Cus. Dated 6th February,
not constituting sale in the course of
1965 as amended are given in Appendix 24
import.
for reference.
IV. Sales of imported goods which are
10. Entitlement of the Purchaser to Recover
supplied from the already existing stock.
Damages on Excess Customs Duty Paid on
account of Replacement: V. Import of raw materials and components
which have been utilized by the suppliers
11. Where the replacement supply is made
in assembling or manufacturing the goods
under the contract, according to legal
ordered for sale where price of such raw
opinion, Section 64-A of Sale of Goods Act
materials, components and accessories
is attracted and the increased customs duty
have not been shown separately.
is payable by the buyer. However, as the
deliver y of the goods is delayed and the VI. Sales of imported goods which have been
increased customs duty would not have further processed in India before supply to
been payable if the original supplies had not the consignee.
damaged in transit and therefore, required to VII. (ix) Sales of goods which are to be
be replaced, the additional expenditure on imported against firm’s own ‘Stock and
account of the customs duty is a loss directly Sale’ licence for supply to various
occasioned by the delay in supply. customers.
Consequently the purchaser is entitled to
recover liquidated damages at the contract VIII. The good have moved from foreign
rate up to a sum equal to the amount of the country to India as a result of the Indian
extra expenditure on account of increased supplier purchasing the goods from the
customs duty. Proper notice be given in foreign supplier i.e.
accordance with the terms and conditions of
a. the movement of good has been
the contract.
occasioned by the contract for
12. Sales Tax On Transactions Relating to purchase which the Indian Supplier
Imported Goods : entered with the foreign seller.
b. there was no privity of contract

between the DGS&D and the
foreign seller.
762
c. The foreign seller has not entered rupees in India. At the same time ensure
into the contract by himself or that entire transaction for the L/C is done
through the agencies of the Indian within its validity. On many occasions, the
supplier. suppliers put a condition that delivery date
will commence from the date of opening of
14. The Sales Tax Clause in the Acceptance of letter of credit. This would require L/C to be
Tender for imported stores:-In all cases opened at the earliest to obtain the supplies
where it is finally decided to admit Sales within the stipulated delivery period.
Tax, the rate of Sales Tax and the amount
payable as Sales Tax should be shown as a 16. Letter of Credit is usually kept valid for 21
separate item in the Acceptance of Tender days beyond the contractual delivery date to
to enable Controller of Accounts to pay facilitate the banks to retire the documents.
firm’s bill for Sales Tax. The relevant
clauses to be incorporated in the contract 17. If the suppliers specifically request that the
are given in the Chapter, “Drafting of L/C be confirmed then efforts should be
Contract.” made to ensure that cost of confirmation is
borne by the supplier. Further, if it becomes
15. Payment of Imported Stores:-The most necessary to extend/reinstate or amend L/C
common method of payment to the foreign for reasons not attributable to the purchaser,
supplier is through a letter of credit. It is a the charges for the same should be borne
letter issued by the Purchaser’s bank to the by the supplier. In order to open letter of
supplier’s bank authorising the letter to credit a letter is written to the paying
release payment to the supplier for the authority named in the contract along with
supplies made by them, on receipt of copies of the contract. The L/C pro-forma
specified documents from the seller and the devised by the bank has also to be filled up.
purchaser’s bank reimburses the required The purchase officers are also required to
amount as it receives an intimation about give a standard letter to the State Bank of
the payment for the supplies having been India, London undertaking thereby that the
made to the supplier by the supplier’s bank. documents will be retired by the buyer and
The foreign suppliers generally insist for that L/C amount would be sufficient for
opening of irrevocable letter of credit payment of stores ordered. A specimen
confirmed by an international bank. The copy of each of above 3 documents is
foreign suppliers also insist on part shipment enclosed as Annexure to this Chapter.
and part payment for supplies made. While
opening the letter of credit the banks levy 18. The documents to be submitted by the
two types of charges viz. L/C opening supplier have to be clearly brought out in the
charges, foreign bank charges and body of the letter of credit so that the
confirmation charges. The banks generally supplier meets with the contractual
charge on quarterly basis (3 months). It commitments. Regardless of this, a clause
would be prudent to open the letter of credit should always be stipulated requiring the
in such a way that validity of L/C is kept bare supplier to confirm that he has abided by all
minimum. L/C should be opened only for net the terms and conditions stipulated in the
FOB/CIF value i.e. excluding agency contract.
commission which will be paid in Indian
763
31.38.13
31.38.14 No.
Government of India
Directorate General of Supplies & Disposals
Parliament Street: New Delhi-110 001
Dated:
To
The Chief Controller of Accounts,
Supply Division,
Department of Commerce,
Akbar Road Hutments,
New Delhi – 110 011.
(Through Authentication Cell)
Sub: Opening of Letter of Credit against Contract No.__________
Dated______________placed on M/s.___________________
Sir,
You are requested to arrange for opening of letter of credit for the next amount______________ subject to ceiling
of________________ payable to the beneficiary ( i.e. foreign principals – M/s._________________) through their
advising bank______________________(Address______________) as per clause 18 and 20 of the schedule to
subject contract. Following documents are enclosed:
(vii) Two signed copies of kthe A/T
764
(viii) Letter addressed to the State Bank of India, London (in duplicate)
(ix) Letter of credit will remain valid up to_______months and 21 days from the date of opening.
(x) Last date of shipment_________months from the date of letter of credit.
(xi) Beneficiary to present documents: within 21 days from the date of shipment.
(xii) List of documents against which payment is to be released to foreign suppliers will comprise of:
(a) Complete set of clear bill of lading consigned to the port consignee as per clause____of A/T evidencing
despatch of goods on freight and insurance paid basis also showing the letter of credit and contract number with
date.
(b) Certified copy of FAX / CABLE sent by the beneficiary to the Indian port/ ultimate consignee giving full
particulars of despatch of goods with name of carrier, date of despatch, date and number of bill of lading, place of
loading and unloading, quantity and description of goods.
(c) Beneficiary’s Invoice in Duplicate also showing Name(s) of Consignee(s) and value.
(d) Packing list in triplicate
(e) Certificate of Origin stating that goods of _________origin.
(f) Manufacturer’s guarantee/ warranty certificate.
(g) Manufacturer’s works test certificate.
(h) Certificate from the beneficiary that one set of documents has been sent to the port consignee direct.
(i) Pre-despatch inspection certificate for ordered stores will be issued by the following nominated officers as
Inspecting Officers as per clause 17(a), 17(b) and 17(c) – Inspection:
The above mentioned officers are from the office of_______________________and they shall discharge the role
of inspecting officers/ inspection authority for pre-despatch inspection.
(j) Copy of Insurance Policy covering 110% of CIP value.
10. Special instructions applicable to letter of credit will be:
a. Part shipment : Not allowed / allowed
b. Transshipment :- Not allowed / allowed
c. In terms of clause 9 of A/T – Performance Security has been received and accepted.
d. Goods are to be shipped by sea/ air from ___________and delivered in satisfactory condition to port / ultimate
consignee as per c lause 13 of contract.
11. A confirmation from the beneficiary that they have complied with all the terms and conditions of the contract.
12. It is confirmed that sanction of funds are sufficient for stores ordered. This issues with the approval
of___________.
765
Asstt./Dy. Director (Supplies)
For Director General of Supplies and Disposals
Copy to:
By Airmail 1. ( Name and Address of the foreign supplier)
2. Indentor
3. Consignee
4. Port consignee at regional office
5. The Inspection Authority
6. Inspection Officer
766
Asstt./Dy. Director (Supplies)
For Director General of Supplies and Disposals
No.
Government of India
Directorate General of Supplies & Disposals
Parliament Street: New Delhi-110 001
Dated:
To
The State Bank of India
1, Milk Street,
London, UK.
Sub: Opening of letter of credit against contract vide A/T No._________________
Sir,
With reference to opening of letter of credit details for which will be sent to you by the Chief Controller of
Accounts, Supply Division, Department of Commerce, New Delhi.
a) We hereby unequivocally /undertake to retire the document drawn under this credit notwithstanding total partial
loss of goods during voyage and or pay general average, if declared.
b) It is further certified that the amount of L/C would be sufficient for payment of stores ordered.
c) Complete details of letters of credit may be intimated to this office immediately after the L/C is established by
you.
767
d) This issues with the approval of_____________.
Yours faithfully,
Asstt.Director (Supplies)
For Director General of Supplies & Disposals
PS: Please invariably quote above stated A/T number and date while making reference(s) of this office on the
subject.
768
31.39 Delegation Of Purchase Powers Preamble 4. any purchase which has normally to be
effected through the Central Purchasing
Organization, but which is proposed to be
This chapter contains the general rules for delegation made direct on grounds of emergency, if the
of powers for purchase/procurement applicable to all value exceeds rupees[fifty lakhs]
ministry and departments and guiding principles
thereof. All the rules and powers are derived from
General Financial Rule (GFR 17) and Delegation of
Financial Power (DFPR). 31.39.2 SCHEDULES OF POWERS WITHIN THE
DEPARTMENTS:
Whereas above mentioned powers are for the
ministries, delegation of powers (DOP) within the
31.39.1 Powers delegated to Ministries and ministries has been clearly defined by MOF in GI, MF,
Department Delegation of powers of OM No. F 10(4)-E/62 dated 1st June 1962. According
purchase has been defined in para 21 of to which all departments shall issue detailed
DFPR as under: Schedules of Power (SOP) within the limits prescribed
for Ministries, for their ranks in consultation with
Integral Finance as per the provision of GFR 17 and
1. "Subject to the provisions of these rules and
other instructions of Government.
the provisions of the General Financial Rules,
1963, governing the purchase of stores for the
31.39.3 Fundamental Principle for Delegation of
public service and subject to the purchasing Powers (DOP) : All departments will work
powers delegated from time to time to the out SOP depending upon their nature of
Central Government Indenting Departments work and requirement. These SOP take
for making purchases directly and not through into account the nature of purchase,
the Central Purchase Organization), a organizational structure and priorities. To
promote efficient and responsive
Department of the Central Government shall
organizations, over centralization of
have full powers to sanction expenditure for powers should be discouraged and
purchases and for execution of contracts: following fundamental principles should
form the backbone of all financial
2. Provided that the previous consent of the delegation:
Finance Ministry shall be obtained in the a. Authority with responsibility
following cases, namely:
b. Delegation of financial powers to the
3. any purchase or contract the value of which functional level
exceeds rupees [twenty crores]; if a contract
extends over a period of time, the total value c. Decentralization of purchases &
over the entire period of its currency shall be
taken as the value for the purpose of applying d. Total budget under disposal
the limit; any negotiated or single tender
contract exceeding rupees [five crores] in
value; a limited or open tender which results
31.39.4 DOP should cover all gamut of
in only one effective offer shall be treated as a procurement: There should be well defined
single tender contract for this purpose; any SOP for various stages of procurement
indent for stores of a proprietary nature, the process. For the purpose of delegation of
value of which exceeds rupees [five crores]; powers, process of procurement can be
divided in following stages:
I. Pre sanction stage : which can be further sub
divided as:
769
a. Preparation the indent/requirement 2 Signing of indent/requirement & finalization of mode
of procurement Functional Head of the ranks of Dy.
b. Signing of indent/requirement & HOD and above & Budget controlling officer Would
finalization of mode of procurement consolidates and record justification of purchase and
ensure that purchase is unavoidable and in the
c. Finalization of technical specifications
interest of the department. He shall also ensure that
d. Sanction of Purchase budget provision for the intended purchase exists.
II. Post sanction & pre contract stage : which 3 Finalization of technical specifications Technical
can be further sub divided as: Head of the ranks of Sr. Scale and above He shall
assess the technical requirement of the indenting
a. Approval/issue of Tender official 4 Sanction of Purchase An authority
empowered to incur contingent expenditure or as
b. Tender finalization & Approval of authorized by SOP issued by the department, subject
Order to overall limitations stipulated in DOFP Powers
delegated through SOP issued by the department
c. Signing of Contract/Purchase order
shall take into account the mode of purchase while
III. Post contract stage : which can be further sub fixing DOP at different levels. The guiding principles
divided as: for these delegation are in para 19.4.1. & 19.4.2
a. Execution of Contract V. DOP to sanction Purchases when purchases

are being done Through Tenders Mode of
b. Inspection of Tender Rank of Officer SOP
Stores/Acceptance/rejection of stores
1 Open/Advertised
c. Extension/Re-fixation of delivery
period /Global Tender
d. Cancellation of contract Dy. HOD/DS and above
e. Variations/Amendments/review of Full delegated powers as per SOP

contract term and conditions f)
2 Limited tenders -do1/
Release of Payment
4th of Full delegated
f. Settlement of dispute
powers as per SOP
IV. DOP AT PRE SANCTION STAGE:
3 Single tender -Dy. HOD/DS and
These delegations shall be decided by the department
concerned. For ease of the departments guiding above
principles are given below:
-HOD/JS and above
-AS and above

A. Activity Delegation of Power Process
-Upto 1 Lakhs
1 Preparation the indent/requirement
-Upto 25 lakhs
User/Store in-charge/Consignee Shall be empowered
to identify, prepare and forward indent/requirement on -More than 25 lakhs
the prescribed format to the indent signing authority.
770
4 Procurement on As delegated in SOP with
R/C following limits:
Dy. HOD/DS and
above quotations or
Double of the full delegated more
powers as in -Dy. HOD/DS & above
Open/Advertised/ Global -HOD/JS and above
Tender Upto 1 Lakhs
Upto 2 lakhs
VI. DOP to sanction Purchases when purchases 2 Spot Purchase by

are not being
a nominated
done Through Tenders
committee of at
Mode of
least 3 members
Purchase
Committee of officers
Rank of Officer SOP
in the rank of:
1 Direct
-Dy. HOD/DS & above
Purchases/
-HOD/JS & above
purchase with
As delegated in SOP subject
out calling
to following limits:
quotations
Upto 1,00,000/- in each case
-Dy. HOD/DS & above
Upto 5,00,000/- in each case
-HOD/JS & above
VII. Annual Ceiling for the Direct Purchases/
As delegated in SOP subject purchase without tender:
to following limits: All SOP mentioned in para 19.4.2 above shall be

subject to an annual ceiling limit which will be worked
Upto 5000/-in each case out based on operational exigencies. Certain
percentage of overall annual budget can be fixed as
Upto 15000/- in each case
annual ceiling. In any case it should not be more than
2 Purchase by 10% of the total budget allotted
calling 3
771
VIII. Constitution of Spot Purchase Committee: 2. Delegation of power in finalization of tenders
HOD in consultation with Integrated finance Finalization of tenders can be done in one of
may decide upon constitution of Spot the following methods:
Purchase committee empowered to make on
the spot purchases based on the market
survey to deal with procurement of emergent/
I. Direct Approval by CA of not less than the
urgent or store of peculiar nature in
rank of US
exceptional circumstances. The committee
will constitute of at least three members, one II. Approval by CA on recommendation of
of which will be representing finance. Tender
IX. Emergent Purchases Extraordinary powers III. Recommendatory Committee (TRC)
can be delegated to officials to deal with the
emergencies/ security/event of national or IV. Approval through proceeding of Tender
international importance. Nature and extent of Purchase Committee (TPC)
the delegation will be highly department
specific and shall be worked out by ministries. V. Constitution of tender Committee:
Departments through in consultation with their
HOD and IF should finalize SOP and
constitution of the above
X. DOP AT POST SANCTION & PRE committees/sanctioning authority for various
CONTRACT STAGE tendering process/values vide para 19.2.1.
Following guiding principles can be adopted
These delegations shall be decided by the department
for the above SOP:
concerned. For ease of the departments guiding
principles are given below: a. Committee system of tender finalization
shall be adopted for all purchases beyond
10 lacs.
1. Activity Delegation of Power Process
b. Committee so constituted should preferably have 3
a) Approval of Tender Purchaser/Dy. HOD or members (not less than the ranks of US) or more and
above one of them should represent IF.
b) Tender finalization & Approval of Order c. For L/T and single tenders constitution of committee
Approving authority should not be less than should be at least one step higher.
that of sanctioning authority as per para 19.4.
d. For purchase on proprietary basis need for
These powers will depend upon the mode of
committee system of purchases may not be
tender and have been indicated in para 19.4.1
necessary, however vetting of IF should be
& 19.4.2.
necessary for financial proprietary.
c) Signing of Contract/Purchase order Officers in
e. TPC should be adopted as a matter of exception in
the ranks of US/ STS or above As per article
cases where the competent purchase officer feels
299 of constitution of India, person
that more than one view is possible and discussion in
empowered to enter into contract on behalf of
the Tender Purchase Committee would be useful or
President of India are notified by special
in cases where there is possibility of delay through
notification through gazette of India
TRC or if requisite number of officers are not present
to constitute a TRC.
772
3. Purchases at rates higher than LPR (Last d. Cancellation of contract CEA empowered to
Purchase Rates): enter into contract on behalf of President of
India as delegated by the Ministry All
No guidelines or % are prescribed in cases of cancellation of contract shall be notified to the
accepting higher rates then LPR. The competent next higher officer
purchase officer has to decide the case on its merit
and circumstances. However if it is recommended to e. Release of payment The contract executing
make purchase at rates higher than the last purchase officials shall be delegated full powers to
rates where the increase is beyond 10% vetting by release the payment to the supplier/contractor
Integrated Finance will be essential. as per the contract conditions, without the
financial concurrence All payment shall be
4. Cases where Integrated Finance will be within the available budget of the CEA
consulted:
f. Sanctioning Of Variation Once a contract has
a) Purchase by Single Tender, been concluded between the Government
and a contractor, the competent purchase
b) Purchase where competition is lacking
officers shall have authority to revise the rates
c) Deviation(s) from standard terms and conditions of only in situations where a revision is required
contract d) Allow deviation in respect of force majeure due to increase/decrease in charges/levies
clause and transit insurance clauses. like duties, tax, etc, as a result of an act of
Legislature or other Government actions over
XI. DELEGATION OF POWERS AT POST- which the contractor has no control.
CONTRACT STAGE
g. Settlement of dispute All dispute not resolved
These delegations shall be decided by the department by the contracting parties will be first put up to
concerned. For ease of the departments guiding the next higher authority of not less than the
principles are given below: ranks of JS In case dispute is still not resolved
parties can take action as per the contract
conditions.
1. Activity DOP Remarks XII. DELEGATION OF MISCELLANEOUS

POWERS RELATED TO PURCHASE
a. Execution of Contract CA empowered to enter
CONTRACT:
into contract on behalf of President of India as
delegated by the Ministry are fully empowered Ministries /departments may also issue SOP with
to execute and operate the contract. respect to other miscellaneous powers required to
operate purchase contact in general:
b. Inspection of Stores/Acceptance/rejection of
stores Nominated officer/agency by the 1. Payment of Freight Charges:
contract executing authority (CEA) Any
dispute arising out of inspection of store may If provided in the contract purchaser should be empo
be referred to CEA who’s decision will be final wered to allow freight charges payable in contract as
per the following rates:
c. Extension/Re-fixation of delivery period CA
empowered to enter into contract on behalf of a. Rail Fare (General parcel) Full powers
President of India as delegated by the
Ministry. However in case of abnormal delay b. Road Fare limited to double of Full powers with
(to be defined as beyond 50% of the original justification Rail Fare (General Parcel) of delivery by
delivery period) higher authority not below the road
ranks of JS/Sr. A.G. should be informed.
773
b. Road Fare on Actual by an in exceptional cases DOP once delegated by ministries shall not be re-
justifying reputed carrier need with prior financial delegated down below.
concurrence and approval of authority 1 step higher.
VIII. CALCULATION OF GROSS VALUE: The
Note: These provisions will not be applicable to bulky monetary limits of purchase powers will be for
items when road transport will be highly the gross value (i.e. inclusive of taxes, duties
uneconomical. and other incidentals). Cases in which a
revision in taxes/ duties is made after the
2. Payment of Demurrage Charges: contract is placed thereby increasing the
gross value of the quantity of stores to be
Demurrage charge shall be paid without any delay to
purchased and exceeding the monetary limits
avoid further liability. Hence full power to release
of purchase powers delegated, will have to be
demurrage charge is to be given to the competent
got regularized with the approval of the
purchase officer. In retrospect, for all payment of
competent purchase officers in consultation
demurrage it has to be certified by CA
with Finance, wherever necessary.
whether the demurrage paid was unavoidable or not.
*
Post-facto sanction of demurrage charge needs to be
taken depending upon the amount of demurrage. For
31.40 Registration of Firms Preamble:
all demurrage charges beyond Rs. 1 lakh post-facto
sanction of HOD shallbe taken.
3. Payment of Testing charges related to 31.40.1 The General Financial rules of Govt. of
India , under Rules 4 (Appendix 8, Part I),
Inspection Inspecting/purchase officer needs emphasize the importance of ensuring that
to be given full powers upto 25,000/-in each important plant, machinery and Iron &
case subject to an annual ceiling, for steel work as defined in Schedule “A”
conducting tests by the nominated test shall be obtained only from firms
laboratories s.a. NABL, NTL etc for the tests registered as approved suppliers by the
required as per the contract conditions. Director General, Supplies & Disposals.
Over the years, in the changed scenario
4. Payment of Handling/ loading/leading with decentralisation of procurement
activity of different user specific items to
Charges related to receipt/ inspection of
various administrative ministries,
supplies Full powers upto 1% of the value of redefining the role of DGS&D as an agency
the supplies upto a maximum of Rs 5000/- in to mainly concentrate on handling
each case, provided no departmental facility common user items on Rate contracts,
is available . Pre sanction of CA and vetting of emergence and recognition of Service
IF will be essential if higher handling charges sector industry as an equally important
are to be paid. segment of requirements in Public
services and with a trend for their
VI. PERIODICAL REVISION OF DOP: outsourcing , it has become important that
, there should be a readily available
database of reliable and established
Periodical review of provision of DOP should be
suppliers / operators for supply of specific
automatically affected in line with inflation with a goods and services respectively , who
minimum slab of 25% and 6 months. For this, MOF could be relied upon by the Government
should issue instructions from time to time and organisations. The Central Purchase
concerned ministry shall further revise their DOP. Organisation i.e. DGS&D already operates
a system of Registration of suppliers for
VII. RE-DELEGATION OF POWER primary items mainly of engineering
nature , on behalf and for the use of Govt.
organisations. System of Registration of
774
User specific items of individual firms as suppliers of stores in the following
departments shall be operated by the broad categories :
departments themselves for their
exclusive use. 1. MANUFACTURERS, WHO SUPPLY
INDIGENOUS ITEMS :
31.40.2 Department may prescribe specific
requirements relating to manufacturing / 2. Agents/ Distributors of such manufacturers,
operational aspects, after sales service,
who desire to market their production only
financial soundness and performance
aspects in their schemes of Registrations, through their agents
both for initial registrations or for its
continuance, as appropriate .Firms shall 3. Foreign manufacturer with / without their
be registered for fixed periods. The accredited agents agent in India.
registration shall be subject to be review /
renewal periodically. 4. Stockiest of imported spares or other
specified items
5. Supplier of imported stores as are having

31.40.3 ELIGIBILITY FOR REGISTRATION:
regular arrangement with manufacturers.
1. Any firm, situated in India or abroad, who are
foreign
in the business of manufacturing, stocking or
marketing of stores and operating operator of B. AUTHORITIES COMPETENT TO DEAL
services of specified categories , shall be WITH THE APPLICATIONS FOR
eligible for registration. REGISTRATION AND GRANT
REGISTRATION:
2. Where registration is granted based on partly
outsourced arrangements / agreements, it 1. The Department shall notify the authorities
shall be the responsibility of the registered competent to deal with the applications and
unit, to keep such arrangements / agreements grant registrations , along with their
renewed / alive at all times, to keep their jurisdictions .
registration valid for the period for which , it
has been granted. Any failure in this regard 2. The Appellate Authority shall be at least one
may make the registration null and void / level above the Registering authority or as
ineffective retrospectively, from any such designated by the Department .
dates, which the registering authority
considers appropriate. 31.40.5 PROVISIONS RELATING TO APPLICATION
FORMS AND PROCESSING :
3. Firm, against whom punitive action has been 1. The application forms for registration , shall
taken, shall not be eligible for re-registration be issued with un ambiguous and clear cut
for a period of two years or as prescribed. requirements for registration and of the
supporting documents / processing fee, in the
4. Registration requests may not be entertained form of “Guidelines”, which shall also include
from such firms , stake holders of whom have the code of conduct expected out of the firms
any interest in deregistered / banned firms. Registered as Approved Contractors .
31.40.4 CATEGORIES FOR REGISTRATION 2. The application form , complete in all respects
A. The different categories of registration and and accompanied with the requisite
grades thereof, shall be as prescribed / processing fee and required documents, shall
notified by the Department concerned . The be entertained by the registering authority in
Central Purchase Organisation , ie, DGS&D, whose jurisdiction the registered office of the
have been authorized by the Govt. to register firm falls.
775
3. Registration shall be granted after obtaining or uninspected stores rendered services of inferior
an inspection report from a technically quality than the contracted ones.
qualified officer of the Department. Wherever,
the Department is unable to obtain such c. Failed to execute a contract or failed to
assessments through its work force, it may execute it satisfactorily.
approach the Quality Assurance Wing of
d. When the required technical / Operational
Central
staff or equipment are no longer available or there is
4. Purchase Organization or any other change in the production / Service line.
specialized authorized agencies and after
e. Is declared bankrupt or insolvent? failed to
fulfilling the other requirements, as
submit the required documents /information for
prescribed.
review of registration, where required, or any ground
5. Registration Certificates shall be issued with which, in the opinion of the registering authority, the
the approval of competent authority as per retention of the firm’s name in the list of registered
delegation of powers. contractors is not in Public Interest.
31.40.6 COMMUNICATION OF DEFICIENCIES TO 31.40.8 BANNING AND SUSPENSION OF

FIRMS: BUSINESS DEALINGS WITH THE
In cases where the firm is not considered capable and CONTRACTORS:
registration cannot be granted, concerned authority
1. Business dealings with a firm, whether it is
shall communicate the deficiencies or shortcomings
registered or not registered, may be ordered
direct to the firms under intimation to the Appellate
to be suspended or banned, in public interest
authority. Where request for re-verification and review
by the competent authority.
is made by the firm , along with any fee as prescribed
and within the period prescribed by the department , 2. The Competent authority to order banning of
review shall be undertaken. Requests for re- business dealings of a firm with the
verification after expiry of the said period would be Department in the non statutory sphere, shall
treated as fresh application and processing fee be the Chief Vigilance Officer of the
charged accordingly. Department. References in the form of self-
contained notes, indicating therein the specific
31.40.7 REMOVAL OF FIRMS FROM THE LIST OF items of allegations along with relevant
APPROVED CONTRACTORS;
documents to be relied upon in respect of
A. In case of violation of terms and condition of
each such allegation shall therefore be made
the registration, the registration of firm will be
to the CVO for the conduct of the proceedings
cancelled by giving prior notice. The
against the firms.
registration granted for a term period may be
cancelled, if necessary, with the approval of 3. Where CVO of the Department feels that the
the designated authority. allegations of malpractice etc. against the firm
are very serious enough, so as to warrant
B. The registered firms are liable to be removed
banning of Business Dealings of the firm ,
from the list of approved contractors, when,
with all the Government Departments, he
shall refer such proposals to the CVO of the
Deptt of Commerce, in charge of Supply
a. They fail to abide by the terms and conditions Division.
under which the registration has been given.
b. Makes any false declaration to Government

Department/ agency supplied stores of inferior quality
776
31.40.9 GROUNDS FOR SUSPENSION OF servant, dismissed, removed on account of
BUSINESS DEALINGS WITH FIRMS: corruption or employs a non-official convicted
A. Suspension of business dealings may be for an offence involving corruption or
ordered where pending full enquiry into the abetment of such an offence, in a position
allegation, it is considered not desirable that where he could corrupt government servants.
business with the firm should continue. Such
an order may be passed: 31.41 Settlement of Disputes
1. If the firm is suspected to be of doubtful 31.41.1 Normally, there should not be any scope
loyalty to India. of disputes between the Purchaser and the
Supplier after concluding the valid
2. If the Central Bureau of Investigation or any contract. However, practically due to many
other investigating agency recommends such unforseen problems dispute arises and
contract may get frustrated which lead to
a course in respect of a case under
litigation. Therefore, the conditions
investigation and governing the contract shall contain very
clearly a suitable provision for settlement
3. If a prima-facie case is made out that the firm of such disputes/differences as per
is guilty of an offence involving moral applicable law of the land, which shall be
turpitude in relation to business dealings binding on both the parties. When a
which, if established, would result in business dispute or difference arise both the
dealings with it being banned. purchaser and the supplier should first try
to sort out amicably. However, if the
dispute remains unresolved, there is no
31.40.10 GROUNDS FOR BANNING OF BUSINESS
alternative but to resolve through the
DEALINGS: The grounds on which
mechanism provided in the contract.
banning may be ordered are:
1. If security considerations including question of 31.41.2 MODE OF SETTLEMENT
loyalty to the State so warrant. 1. In case of disputes/differences arising out of
contract between the purchaser and the
2. If the proprietor of the firm, is employee
supplier, the matter shall be referred to the
partner or representative is convicted by a
designated officer. The highest level of the
court of law following prosecution for offences
designated officer will be HOD of the
involving moral turpitude in relation to the
Department who shall be one level above the
business dealings.
purchase officer. The designated officer shall
3. If there is strong justification for believing that call from Purchaser and Supplier all relevant
the proprietor or employee or representative documents for scrutiny and examination. He
of the firm has been guilty of malpractices shall, in a joint sitting, proceed to freeze the
such as bribery, facts of the case in a document titled
“Summary of Facts as per records”. The
4. Corruption, fraud, substitution of tenders, summary shall be signed by all the three
interpolation, mis-representation, evasion or functionaries, i.e., Purchaser, Supplier and
habitual default in payment of any tax levied Designated officer in token of it being the
by law; etc. accurate full and final narration of facts of the
case. After examining all the facts, he shall
5. If the firm continuously refuse to return also propose a settlement. Normally, the
government dues without showing adequate decision/proposal should be acceptable to the
cause and government are satisfied that this office/Deptt. However, in case the proposal is
is not due to reasonable dispute which would not acceptable to both or any of the party,
attract proceeding in arbitration or court of they shall go for settlement of dispute through
law, and (vi)If the firm employs a government arbitration.
777
2. The summary before the Officer shall form the place from where contract has been
part of the arbitration proceedings and no issued.
additional documents shall be considered by
the arbitrator. The decision of the officer shall 2. Accordingly, a stipulation shall be made in the
not be subject to any scrutiny of Vigilance and contract as under:
Audit.
“This contract is subject to jurisdiction of Court at
………only”. (The name of the place from which
contract is issued shall be inserted in the blank
31.41.3 APPOINTMENT OF ARBITRATOR space.)
The arbitrator shall be appointed by HOD/Secretary
on receipt of reference/nomination by the purchaser
and/or the supplier. In case of sole arbitration, the
arbitrator shall be appointed by HOD/Secretary from
the panel being maintained by DGS&D. In case of
dual arbitration, the purchaser shall nominate the
arbitrator(s) from the panel being maintained by
DGS&D and supplier may nominate either from the
panel maintained by DGS&D or by Indian Council of
Arbitrators(ICA). The two nominated/appointed
arbitrators shall appoint the third arbitrator either from
the panel of DGS&D or from the ICA.
31.41.4 PANEL OF ARBITRTORS

DGS&D shall maintain a panel of arbitrators from the
officers of various departments (retired at the level of
DDG in DGS&D in the scale of SAG and above)
having handled procurement functions at any level, for
minimum five years. The panel shall be reviewed
every year by DGS&D and posted on DGS&D
website. INTRA GOVT. DISPUTE
31.41.5 Intra Government disputes shall be dealt

as prescribed by the Govt. from time to
time.
31.41.6 VENUE OF ARBITRATION

The venue of arbitration shall be the place from which
the contract has been issued.
31.41.7 SETTLEMENT OF DISPUTE THROUGH

COURT OF LAW OF COMPETENT
JURISDICTION
1. Where a contractor has not agreed to
arbitration, the dispute/claims arising out of
the contract entered with him shall be subject
to the jurisdiction of the competent Court at
778
31.42 Reorder Level Policy
31.42.1 Objectives: To ensure adequate supplies of drugs and consumables in the hospital
31.42.2 Methodology: The levels have been determined on the basis of:
31.42.2.1 Consumption pattern
31.42.2.2 Lead Time
31.42.2.3 Storage space and conditions (few required cold chain hence more no. of orders with lesser
quantity)
31.42.2.4 Following policy is being used for procurement of drugs and consumables with reorder levels as
described below:
31.42.2.5 Demand for drugs/consumables is placed on Nirantar Portal of Central Procurement agency through
Central Store, CNBC as per CPA instruction.
31.42.2.6 Sufficient buffer stock as per CPA instruction maintained by the Central Store, CNBC.
31.42.3 Representative table

REORDER LEVEL BASED ON PREVIOUS YEARS CONSUMPTION
REORDER QUANTITY
S. No. Item Item Description ANNUAL MONTHLY LEVEL DEMAND
1 POW 1655 138 552 552
2 POW 1367 114 456 456
3 INJ 2733 228 911 911
4 INJ 42893 3574 14298 14298
5 INH 93 8 31 31
779
31.43 Maintenance Plan and Department
31.43.1 Purpose: This Manual serves to describe the policies and processes in place to have proper
functioning of all the equipment and furniture of the hospital
31.43.2 The purpose of this Maintenance chain is to ensure proper care and repair of wear and tear of
various items of the hospital
31.43.3 Scope:
1. The Management Plan defines the mechanisms for maintenance of various equipments and
furniture of hospital in general.
2. Keep records of the new equipments installed in C.N.B.C.
3. Integration of demands of repair calls from of all hospital departments and medical services.
4. Renewing CMC/AMC of the equipments
31.43.4 Hierarchy
Director
Dr. B.L.Sherwal
Head of office
Dr. Mamta Jajoo
M.O. I/C Maintenance

Dr. Niyaz Ahmed Khan
Pharmacist
Mr. Amit Kumar
nd th
31.43.5 Maintenance procurement policy committee (MPPC) meeting is held on every 2 and 4 Friday of
every month in the Maintenance Department at 2:30 PM. The committee members include MO I/C
Maintenance, MO I/C Purchase, AO and representative from the Department whose demands are
to be discussed.
31.43.6 Maintenance Plan
Maintenance Plan
Facility Furniture All Departmental equipments Ventilator /Air-conditioning Electrical system
780
31.43.7 Maintenance plan of Facility
31.43.7.1 Maintenance of facility includes outside hospital, inside hospital, Roof top, all patient care units,
garden area, vehicle parking area, basement etc.
31.43.7.2 Complete building and outside area of the hospital is under camera surveillance for safety
purpose.
31.43.7.3 Outside Hospital; designated sanitation supervisor is responsible for cleanliness of outer areas of
hospital.
31.43.7.4 One gardener is designated for plantation and watering of plants kept in hospital area.
31.43.7.5 Inside hospital: Wall painting /white wash of all the areas including patient care areas will be
done once in a year and as and when required.
31.43.7.6 Floor tile and wall tiles will be replaced whenever complaints received from the user dept.
31.43.8 Medical Equipment Management Policy
31.43.8.1 Purpose:
31.43.8.1.1 Ensure efficient patient care delivery using medical equipments available at CNBC.
To fulfill the purpose, equipment management policy has been designed. Operation and
maintenance of medical equipment is done under well defined programme so that quality service
is provided to the patients on a continuous basis.
31.43.8.2 Scope:
Smooth functioning of all medical equipments of CNBC and its peripherals.
31.43.8.3 Responsibility:
User departments, Hospital Store, Purchase departments, Maintenance departments.
31.43.8.4 Policy:
1. Procurement of equipment: As per purchase policy. Ref. Apex manual
2. Installation of equipment: Installation of equipment is done through hospital stores in coordination

to user department.
3. All user departments shall maintain log book/file for each equipment in their possession with below
mentioned information:
a. Name of equipment
b. Make and model
c. Date of purchase
d. Date of Installation
e. Period of warranty
f. Name and address of supplier with contact no.
781
31.43.9 Maintenance of equipment during warranty period:
Equipment procured on hospital rate contract costing up to 2 lakh have warranty of THREE years and
costing more than 2 lakh & upto 5 lakhs have warranty of FIVE years. Now Equipment costing more than 5
lakh is procured by the hospital through open e-tender, previously the same was done through EPC
(Equipment procurement cell Govt. of NCT of Delhi;) and has have of 5 years comprehensive warranty and
further 2 years paid CMC (including all spares, consumable accessories, wires etc.)
31.43.10 Maintenance of equipment after warranty period:

After warranty period, equipments are covered under AMC/CMC
31.43.10.1 Process of AMC:

1. Through open tender rate contract
2. Awarding AMC/CMC to concerned manufacturer or supplier.
31.43.10.2 Preventive and breakdown maintenance

1. First action for breakdown of equipment shall be initiated by user department, by telephonic
information to concerned firm who is responsible for warranty/AMC of the equipment.
2. If complaint is not attended within 72 hours, user department shall forward complaint to
maintenance department.
31.43.10.3 Quarterly preventive maintenance of equipments.

1. Role of maintenance department:
2. Attending complaint of user department which is not solved at their level.
3. Awarding AMC/CMC contract.
4. Issue related to payment of firm in r/o AMC/CMC after obtaining performance certificates from the
user departments
31.43.11 Condemnation Process:

1. Equipment need to be condemned and disposed off at regular interval.
2. Minimum criteria to be followed for condemnation of equipment:
3. Equipment got non-functional and beyond economical repair.
4. Non-functional and obsolete equipment
31.43.11.1 Condemnation committee:

Condemnation committee shall assess whether or not equipment should be condemned based on the
history sheet and recommendations of the user department.
31.43.12 Medical Equipment recall policy

Equipment recall will be based on letter issued from manufacture or any regulatory authorities .In
such cases of recall action will be immediately taken by hospital maintenance /purchase department
and said department .The equipment should not be put into further clinical use till the issue is
resolved.
782
31.43.12.1 Repair of equipment
1. The complaint of any equipment going non-functional is maintained by the user department to the
designated service provider. Information is also sent to the maintenance department for keeping
records and following the complaint.
2. The service engineer of the concerned service provider visit the facility as per the terms and
conditions of purchase of the equipment or awarding the maintenance contract. He/she visit the
facility and inspect the equipment in presence of designated person by the MO I/C of the
concerned area. The service report is prepared by the engineer and signed by the MO I/C in
triplicate. The copies are retained by the service provider and the user department and
maintenance department respectively.
3. For equipment under warranty/CMC, the service provider do the necessary repair and a service report
duly certified by the MO I/C is sent to the Maintenance Department for records purpose.
31.43.13 Maintenance plan of Furniture
31.43.13.1 User department will inform the Maintenance Department about any new furniture installed
in the facility with order copy & challan. A new file comprising of the documents shall also be
maintained in the department. The relevant documents may be procured from the Purchase
Department and hospital Store as required.
Log book of furniture is to be maintained by user department and must included following
:-
 Name of Furniture
 Total number
 Repair if any.
31.43.13.2 The routine care/inspection of the furniture is to be done by sister incharge of user
department.
31.43.13.3 Beds, Tables & Side tables to be painted once a year.
31.43.14 SOP for Repair of furniture:-
31.43.14.1 The record of complaint of any furniture being damaged will be maintained by the user
department & should be sent to workshop which is stationed in the basement & a copy of
complaint must be sent to the maintenance department for keeping records.
31.43.14.2 All Departmental equipments: Departmental head and maintenance dept is responsible
for maintenance of equipments available in the dept. ( eg .OT,PICU ,NICU , Radiology, Lab,
blood bank etc.)
31.43.14.3 Maintenance plan of equipments available in CSSD and Gas Plant is documented in
respective manual.
31.43.14.4 Ventilator /Air-conditioning: Ventilators and air conditioning system of the hospital is
maintained by the Electrical dept of PWD. Responsible person for maintenance are medical MO
Ic, Sister Ic, concerned head and electrical Engineer posted at organization.
31.43.14.5 Electrical system: User dept head, sister Ic, MO Ic and electrical Engineer are responsible
for maintenance of all the electrical equipments available in hospital.
783
32 Department of Speech Therapy
Date created: October 2014
Responsibility of Department of Speech Therapy

updating:

updated on:
(CNBC/Speech Therapy/33/Ver. 1)
784
32 Department of Speech Therapy .................................................................................................................... 784
32.1 Amendment Record Sheet ................................................................................................................ 786
32.2 Introduction ........................................................................................................................................ 787
32.3 Scope ................................................................................................................................................. 787
32.4 Techniques: ....................................................................................................................................... 787
32.5 Process summary .............................................................................................................................. 788
32.6 Departmental procedures .................................................................................................................. 789
32.7 Statutory Requirements ..................................................................................................................... 792
32.8 Initial assessment of patients............................................................................................................. 792
32.9 Patient safety ..................................................................................................................................... 793
785
S. no. Clause Date of Amendment Reasons Sign of QM
no Amendment Made Of
Amendment
1.
786
speaker is saying. Fluency is when
32.2 Introduction
there are problems with the pattern of
32.2.1 The Speech and Language Therapy
speech, most commonly in the form of a
aims to enable children with language,
stutter. Resonance covers problems
communication and speech difficulties to
which affect the qualities of the voice’s
communicate to the best of their ability
sound, for example the volume or pitch.
and as effectively as possible. Our
These problems can both distract the
approach is based on the principle that
listener from the message being
children’s communication skills are best
communicated, and may also cause
developed through interaction with
physical pain to the speaker.
people who are most familiar to them
32.4.3 There are three main categories
and in everyday situations.
of speech therapy techniques. The most
32.2.2 Children affected by illness, disease,
appropriate technique will depend not
traumatic injury or other medical
only on the specific problem, but also its
conditions can experience a variety of
causes and the patient's personal
impairments which affect the child's
circumstances.
ability to communicate. Speech
32.4.4 The best known category is articulation
Therapists identify these impairments
therapy. This involves the therapist
and provide rehabilitation and
concentrating on explicitly teaching the
intervention services to develop speech
patient how to produce particular
and language skills.
sounds and syllables. This can include
physical demonstrations of how to use
32.3 Scope
the tongue and mouth for specific
32.3.1 Our services are offered to babies,
sounds. The exercises will usually be
children and their families. We
built into play techniques appropriate for
provide a service to patients
the child’s age.
attending Consultants in the
32.4.5 A second category is language
following clinical areas:
intervention. This can appear much
1. Neurology more play- and activity-based and less
2. Ear, Nose and Throat formal. The goal of such techniques is
3. Medicine usually to encourage the child to talk
4. Pediatric Surgery more to help develop their language
5. NICU & PICU abilities. The therapist will then use this
6. Special Clinics activity to make sure the child
a) Neurology clinic pronounces words correctly.
b) Development Clinics 32.4.6 The final category is oral motor therapy.
This is more of a physical exercise
32.4 Techniques: routine designed to develop the muscles
32.4.1 Speech Therapy techniques are used to in and around the mouth.
treat a variety of problems affecting the These techniques are more appropriate
clarity of a person’s speech. where the speech problems are caused
The techniques vary depending on the by a physical issue rather than
particular problem. There are three underdeveloped skills. Some therapists
major types of problem which could will also use these techniques for
require speech therapy techniques. problems which don’t necessarily
32.4.2 Articulation involves difficulties involve speech issues, for example
producing sounds clearly enough for where a child has trouble with eating
other people to understand what the or swallowing.
787
5. stammering
6. Voice problem.
32.5 Process summary
32.5.1 Speech and language therapists assess 32.5.2 These problems may have been caused
and treat speech, language and by a range of diseases and disabilities:
communication problems in people of all
ages especially children to help them 1. learning disability
better communicate. Speech therapist 2. neurological disorders
uses standardized tests (e.g. REELS, 3. head injury
etc) to assess children of their language 4. hearing loss and deafness
abilities. They’ll also work with people 5. cleft palate
who have eating and swallowing
problems. Speech Therapist assists 32.5.3 All children treated by Speech
children who have the following types of Therapist here must be under the care
problems: of a Consultant in C.N.B.C. A written
referral from the Consultant is required.
1. difficulty producing and using speech 32.5.4 Outpatient Services: Hours 9:00 am –
2. difficulty understanding language 4:00 pm, Monday – Friday; Hours 9:00
3. difficulty using language am- 2:00pm. on Saturday.
4. difficulty with feeding, chewing or
swallowing
788
Speech therapy department

Speech therapy department with
card
Entry/recording done in speech

therapy register
Patient assessment and

evaluation done

Plan of treatment and treatment

starts
Home training program
Follow-Up & Review as

per diagnosis and set
goals
Discharge
789
Referral from
consultants

register and
by the therapist
Treatment given and

giver
Progress notes in
referral sheet
periodically
Discharge
the status of the
patient in OPD
790
32.6.3 Other Activities:
Consultants Physiotherapist Speech therapist
Rehabilitation
Occupational Therapist Parents / Care Takers Psychologist
791
32.7.1 Scope: Speech Therapy
32.7.2 Distribution list: Speech Therapy
32.7.3 Policy: All Speech therapists should have completed Bachelors Degree

32.8.1 Scope: Speech therapy
32.8.2 Distribution list: Speech therapy
32.8.3 Policy:
1. An initial assessment of every patient will be done by Speech therapist to determine a

treatment plan based on the diagnosis and present clinical condition of the patient.
a. Initial assessment will include information gathered by the Speech therapist as
follows:
i. Past medical, surgical history, present history and forms of treatment
iv. Assessments using standardized tests
v. Treatment plan
b. Patient’s progress will be reviewed and entered and will exhibit overall response to
the initial treatment plan.
792
Prepared by: Speech Therapist
32.9 Patient safety
Policy Type: Departmental Approved by: Director
Dept: Speech therapy
1. Speech therapist is responsible for maintaining safety standards, developing safety rules,
supervising and training staff in departmental standards.
2. Speech therapist is responsible for informing facility in case of any safety hazard.
b. Proper storage of all equipment and supplies. Do not store heavy items on top
shelves. Scissors, knives, pins, razor blades and other sharp instruments must be
safely stored and used.
d. Notification to facilities department immediately of improper illumination and
ventilation.
e. Arrangement of furniture and equipment must be arranged to allow passage and
access to exits at all times.
j. Safety precautions such as closing file drawers and cabinet doors when not in use.
Open only one drawer at a time. Even distribution of material to prevent the file
cabinet from being unbalanced and tipping over.
k. Frequently inspect cords, plugs, switches, sockets and outlets for damage. Report
any defects such as frayed cords, broken plugs, etc. immediately.
when not in use.
793
33 Department of Medical Social Worker
Date created: Jan 2105
Responsibility of Department of PICU

updating:

Updated on:
Version (CNBC/MSW/34/Ver.1.1)
794
33 Department of Medical Social Worker ......................................................................................... 794
33.1 Amendment Sheet .................................................................................................................... 796
33.2 Services Provided by the Social Worker ................................................................................... 797
33.3 Details of the activities undertaken by the Medical Social Worker:......................................... 799
795
1
796
33.2 Services Provided by the Social Worker
33.2.1 CASE MANAGEMENT
33.2.1.1 To study the psycho-social situation of the patients and provide necessary support.
33.2.1.2 To help the patients to adjust himself/ herself to his/ her illness.
33.2.1.3 To remove/ diminish the social problems which prevent the patients from making maximum use
of the medical services to arrange medical aid for them if necessary.
33.2.1.4 To deal with medico-legal cases related to children in need of care and protection.
a) Individual Counseling
b) Supportive Intervention
c) Grief Counseling
d) Crisis Intervention
e) Financial aid
f) Referral to Private Hospitals under EWS, Integrated School
g) Medico-Legal Cases/ Cases of Children in Need of Care and Protection
33.2.2 Group Work
a) To conduct health education sessions with the attendants/mothers in the ward/OPD.
33.2.3 Networking
a) Networking with statutory, voluntary agencies and corporate sector, private hospitals,
integrated schools and NGO’s for the welfare of the patients.
33.2.4 Advocacy and Mediation
a) To mediate between the doctors/health professionals and patients / attendants to deal with
their issues and concerns during the stay in the hospital.
33.2.5 Dissemination of Information
a) To disseminate the important information related to health care in the hospital like posters,
Notices, Events, and Workshops etc.
797
33.2.6 Human Resource Training and Development
a) To conduct sessions on communication, stress management, motivation, involvement of patients

in health care and prevention of Sexual harassment at Workplace.
b) To supervise and guide Social Work Trainees and Volunteers from Delhi University and IGNOU.
33.2.7 Miscellaneous
a) To organize events/programs for the patients and Hospital employees for the Health
Promotion like Blood Donation Camps, World Health Day, AGE Week, Breast Feeding
Week, Mental Health Week, World Cerebral Palsy Day, Save Girl Child Week, World Hand
Hygiene Week etc.
b) To make arrangements to create healthy and child friendly atmosphere in the hospital.
33.2.8 Activities undertaken by the Social Worker in CNBC
The Social Worker deals with all the four aspects of comprehensive health care i.e. preventive,
curative, promotive and rehabilitative.
Preventive
Curative
Role of Social
Worker in CNBC Promotive
Rehabilitative
1. Preventive-
a) Conducted Health Education Sessions with the
attendants/ mother s in the OPD/ Ward.
b )Took Sessions with Hospital Employees on communication, Sexual Harassment at Workplace to

prevent cases of conflicts and sexual harassment.
33.2.9 Curative: The Social Worker also provided therapeutic/treatment services to the patients and
their caregivers.
33.2.9.1 Types of cases dealt by the Social Worker
a) Physical and Intellectual disability

b) Sexual abuse/ Incest
c) Abounded child/Unknown baby
d) Behavioral problems
e) EWS Referral Patients(Pvt. Hospitals)
f) Financial assistance for the purchase of drugs, aids and appliances
g) Domestic Violence
798
h) Child in need of care and protection
33.2.9.2 Interventions done by the Social Worker
a) Counseling
b) Behavior modification therapy
c) Family Counseling
d) Play Therapy
e) Ice-Breaking Exercises
f) Referral Services
g) Collaboration with NGOs , Child Welfare Committee, Integrated Schools, Walt Disney company,
Police Personnel
33.2.10 Promotive
33.2.10.1 Collaborated with NGOs, NRHM, Walt Disney Company for organizing health promotional
events and making the Hospital Child friendly.
33.2.10.2 Patient Satisfaction Survey in OPD/IPD
33.2.10.3 Events organized by the social Worker
a) Hand Hygiene Week in collaboration with HICC

st th
b) Breast Feeding Week(1 - 7 August) in Collaboration with National Rural Health Mission
st nd
c) World Population Week (21 -22 July) in Collaboration with CDMO office, East Delhi
d) Children’s Day- Blood Donation Camp, Painting Competition
e) Baby Show
f) Disney Artwork
g) Sessions on prevention of Sexual Harassment at Workplace
33.2.11 Rehabilitative- To provide Comprehensive health care and development of the patients after
assessing the needs which includes psycho-social, emotional, educational, financial needs of the
patients/caregivers.
33.3 Details of the activities undertaken by the Medical Social Worker:
33.3.1 Conducted Health Education sessions on Health Schemes, Patients’ rights and responsibilities,
Hand Hygiene, Immunization, Blood Donation, Diarrhea Management, Antenatal and Post Natal
care, HIV/AIDS etc. in OPD and IPD.
33.3.2 Provided Case Management Services in OPD and IPD
33.3.3 Undertook sessions on Life skills with Nursing staff, Doctors and other hospital employees of
CNBC.
33.3.4 Organized events like painting competition , Baby Show, Quiz competition, Exhibition of
paintings, Puppet Show, Magic Show and awareness programs on the occasions of Asthma
Awareness week, Breast feeding week, World Hand Hygiene day, World Population Week,
799
Independence Week, Children’s Day, Mock Drill on Disaster Management, , Blood Donation
Camp etc.
33.3.5 Supervision and training of Social work interns/trainees from Delhi University and IGNOU.
33.3.6 Investigated child abuse /Sexual abuse and neglected cases and took authorized protective
action when necessary and Collaborated with Child Welfare Committee/ Child line and Police
Personnel for the children in need of care and protection.
33.3.7 Advocated for clients /patients to resolve crises.
33.3.8 Restoration for unknown patients.
33.3.9 Provided referral services to patients.
33.3.10 Provided rehabilitation services to the patients with special needs.
33.3.11 Referred patients/ clients, or families to avail community resources to assist in recovery from
mental or physical illness and to provide access to services such as financial assistance, legal
aid, housing, or education.
33.3.12 Counseled clients and patients in individual and group sessions to help them overcome
dependencies recover from illness, and adjust to life.
33.3.13 Identified environmental impediments to client /patient progress through interviews and review of
patient records.
33.3.14 Networking with Govt. Departments, Corporate sector, N.G.O’s and individual donors to enlist
their help for the disabled, poor and needy patients of the hospital and to make hospital
environment more children friendly.
33.3.15 Presently a member/Co-coordinator of a Sexual Harassment Committee at Workplace
33.3.16 Also a member of Grievance Committee and looking after grievances/complaints of the patients
in the hospital.
33.3.17 Designated as a Nodal Officer under EWS Scheme- Collaborated with all the private hospitals in
Delhi under EWS Scheme of Directorate of Health Services to provide free treatment facilities to
BPL Patients.
33.3.18 Collaborated with Walt Disney for an artwork to be done in the Hospital to make it more children
friendly.
800
34 Department of Clinical Psychology
Date created: Dec 2014
Responsibility of Department of Clinical Psychology

updating:

updated on:
(CNBC/ Clinical Psychologist /34/Ver.

1)
801
34 Department of Clinical Psychology ............................................................................................... 801
34.1 Amendment Sheet .................................................................................................................... 803
34.2 Introduction ............................................................................................................................... 804
34.3 Scope ........................................................................................................................................ 804
34.4 Intervention/techniques ............................................................................................................. 805
34.5 Department procedures ............................................................................................................ 805
34.6 Process Summary..................................................................................................................... 805
34.7 Department work process ......................................................................................................... 806
34.8 Other Activities: ......................................................................................................................... 807
34.9 Processes – Administrative ...................................................................................................... 808
34.10 Statuary requirements .............................................................................................................. 808
34.11 Initial assessment of Patients ................................................................................................... 808
34.12 Departmental safety .................................................................................................................. 809
34.13 Patient safety ............................................................................................................................ 809
34.14 Patient Confidentiality ............................................................................................................... 810
34.15 Cleaning and Disinfection ......................................................................................................... 810
34.16 Reports ..................................................................................................................................... 810
34.17 Quality Plan ............................................................................................................................... 810
34.18 Forms Document And Stationary .............................................................................................. 811
802
S. no. Clause Date of Amendment Reasons Sign of QM
no Amendment Made Of
Amendment
1. 34.3.1 Jan 2016 Addition of referral Previously was not
from special clinics mentioned.
2. 34.17 Jan 2016 Change made in To identify the

KPI from drop out department performance
rate to 2 new KPIS
3.
803
34.2 Introduction
34.2.1 Clinical Psychology aims to understand, prevent and relieve psychologically based distress or
dysfunction and to promote subjective and behavioral well being and personal development.
34.2.2 Children affected by various developmental disorders, physical illness, family problems can
experience a variety of cognitive, emotional, behavioral anomalies (both excesses and deficits)
which affect child’s ability to perform everyday activities and lead to limitations in functional
abilities. Clinical psychologists identify, assess these problems; and provide required intervention
and rehabilitation to develop/ enhance these identified areas.
34.3 Scope
34.3.1 Our services are offered to neonates, children and their families. We provide services to patients
attending Consultants in the following clinical areas:
1. Neurology
2. Orthopedics
3. Medicine
4. Pediatric Surgery
5. NICU & PICU
6. Special Clinics
a) High Risk Clinic
b) Development Clinic
c) Nephrology
d) Gastroenterology
e) Chest clinic
34.3.2 Psychological assessment services
1. Developmental assessment
2. Diagnostic clarification
3. Cognitive functions
4. Neuropsychological assessment
5. Specific learning disability
6. Behavioral assessment
7. Assessment of developmental disorders
8. Family assessment
9. Emotional problems
804
34.4 Intervention/techniques
1. Cognitive enhancement techniques
2. Cognitive behavior therapy
3. Behavior therapy
4. Supportive therapy
34.5 Department procedures
1. Psychological assessments
2. Psychotherapies
a. Behavior modification
b. Cognitive behavior therapy
c. Supportive psychotherapy
3. Attention enhancement training
4. Memory enhancement training
5. Visuospatial skill enhancement training
6. Stress Management
7. Relaxation training
8. Social skill training
9. Study skill training
10. Parent & family psycho education
11. Assertiveness training
12. Contingency Management

34.6.1 Clinical psychologists assesses & treat patients with a wide variety of diagnoses including but not
limited to psychiatric, neurological ,orthopedic, surgical, emotional, & behavioral problems .
34.6.2 All children treated by Clinical Psychologists here must be under the care of a consultant in
CNBC. A written referral from the consultant is required.
34.6.3 Outpatient services: Mon-Fri 9:00 AM – 4:00 PM
Sat 9:00 AM – 2:00 PM
805
34.7 Department work process
Clinical Psychology department
Patient with referral enters the

Clinical Psychology department with
OPD card
Entry done in register
Patient assessment and evaluation

done
If required, intervention begins
Home assignments/ techniques

given
Follow-Up &Review as per

diagnosis and set goals
Therapy termination
806
34.8 Other Activities:
Consultants Physiotherapist Occupational

Therapist
Nurses Clinical
Psychologist
Rehabilitation
Speech therapist Parents / Care Takers Dietician
807
34.9 Processes – Administrative
Stations/ Counter /Area Process- Department
Department orientation All new staff joining the hospital is oriented for the
department work process & uses of test material.
34.10 Statuary requirements

34.10.1 Scope : Clinical Psychologist
34.10.2 Distribution : Clinical Psychologist
34.10.3 Policy : All Clinical Psychologist should have completed their M.Phil (Clinical Psychology) from
RCI registered institute.
34.10.3.1 All Clinical Psychologists should be RCI registered.
34.11 Initial assessment of Patients

34.11.1 Scope : Clinical Psychologist
34.11.2 Distribution List: Clinical Psychology
34.11.2.1 An initial assessment of every patient will be done by Clinical Psychologist to determine a
treatment plan based on the diagnosis and present clinical conditions of the patients.
34.11.2.2 Initial assessment for developmental disorders by Clinical Psychologists includes :-

a. Prenatal history
b. Perinatal history – including term of pregnancy, delivery related information, birth cry, birth weight.
c. Postnatal history
d. Developmental Milestones
e. Current level of functioning including motor, speech & Activities of daily living
f. School history
g. Medical history
h. Behavior problems
34.11.3 Testing details - Tests administered, test behavior, test findings, summary impression,
recommendations.
34.11.3.1 For intervention, the initial assessments include:-
a. Chief complaints with duration

b. Past medical, surgical, present history
c. Doctor provided primary & secondary diagnosis
d. History as per informants.
e. Treatment plan
f. Patient progress will be reviewed & overall response would be considered to evaluate the initial
treatment plan.
808
34.12.1 Scope: Clinical Psychology
34.12.2 Distribution list: Clinical Psychology
34.12.3 Policy:
1. Clinical Psychologist is responsible for maintaining safety standards, developing safety

rules, supervising and training staff in departmental standards.
2. Clinical Psychologist is responsible for informing facility in case of any safety hazard.
3. Clinical Psychologist shall report defective equipment, unsafe conditions and acts, or
safety hazards to the head of the department.
and used.
e. Giving information regarding minor spills, such as water to cleaning team by the
f. Reporting faulty equipment to the Facilities Department or vendor as per policy.
g. Obey warning signs.
h. Usage of appropriate personal protective equipment.
i. Safety precautions such as closing file drawers and cabinet doors when not in use. Open
being unbalanced and tipping over.
j. Frequently inspect cords, plugs, switches, sockets and outlets for damage. Report any
when not in use.

34.13.3 Policy:
1. Patient’s safety is at all times our highest priority. No action should be undertaken
which would knowingly be harmful or potentially harmful to patient
2. All patients shall receive the utmost care and attention from the Occupational therapy
staffs. All patients shall be assured of their privacy and dignity while on their
treatment.
3. Explanation of the procedure is to be given before the assessment/ intervention.
4. Obtain the necessary assistance to safely aid the patient with physical disability.
5. Do not leave patients unattended on assessment tables.
809

34.14.3 Policy:
2. As a condition of employment, Clinical Psychologists and the trainees are cautioned not to
discuss any such information with others,
and violate the trust others have placed in Clinical Psychologists.
34.15 Cleaning and Disinfection

34.15.3 Policy:
regularly.
3. All linen are changed every day and soiled linen are replaced immediately as per BMW
policy.
5. Mopping and sweeping done twice a day with soap water solution.
34.16 Reports
REPORT TITLE: Statistics
For the Month of New Patients Follow-Up Total
34.17 Quality Plan

34.17.1 Quality Indicator:
810
a) Percentage of Initial assessments completed.
b) Percentage of intellectual disability assessments (IQ/DQ/SQ) completed.
34.18 Forms Document And Stationary

34.18.1 Patient related forms
S No: Form
1 Referral form
2 Clinical Psychology card
34.18.2 Registers
S. No Registers
1 New Referral Register
2 Patients’ Register
811
35 Endoscopy Unit
Created on: 2019
Responsibility of Updating: Department of Endoscopy
Created on November 2019
Revised on:- August 2020
812
35 Endoscopy Unit............................................................................. 812
35.1 Amendment Record Sheet .............................................814
35.2 Hierarchy of the Endoscopy Unit...................................815
35.3 Job Responsibility: .........................................................815
35.4 Policy: ............................................................................816
35.5 Scope ..............................................................................816
35.6 Procedure .......................................................................816
35.7 Personnel ........................................................................816
35.8 Equipment and Supplies.................................................816
813
S.no. Clause no. Date of Amendment Reasons Sign of QM

Amendment Made Of
Amendment
1.
2.
814
35.2 Hierarchy of the Endoscopy Unit
M.O.I/C
Endoscopy
Trained Staff Endoscopy

Nurse Technician
Nursing
Orderly
35.3 Job Responsibility:

35.3.2 Staff Nurse :
35.3.1 M.O. In-charge:
35.3.2.1 Putting intravenous canula
35.3.1.1 : Selection of patients for endoscope
35.3.2.2 Monitoring of vitals during procedure
35.3.1.2 Informed consent
35.3.2.3 Administration of medication
35.3.1.3 Sedation
35.3.2.4 Data recording and maintenance
35.3.1.4 Performance of procedure
35.3.2.5 Assisting in procedure
815
35.3.3 Technician 35.6.1.1 MOIC of pediatric endoscopy unit or any other
trained doctor or trained staff takes informed
35.3.3.1 Maintenance and disinfection of endoscopes consent and put intravenous cannula. after that
35.3.3.2 Cleaning and disinfection of other instruments moderate sedation is given. Then endoscopy is
performed under continuous vital monitoring.
used during endoscopy
35.6.1.2 Trained nursing staff is responsible for
35.3.3.3 Transport of samples to histopathology lab
monitoring of vitals and assists in procedure.
35.4 Policy:
35.6.1.3 Trained NO is responsible for cleaning and
35.4.1 Strength disinfection of endoscopes.
35.4.1.1 This unit of CNBC has neonatal size upper GI 35.7 Personnel
endoscope, Pediatric Upper GI Endoscope,
Pediatric colonoscope .and two trained nursing 35.7.1 Proper hand washing technique is essential
before and after procedure.
staffs, one trained NO for role of technician and
two pediatric gastroenterologist.
35.7.2 Personnel must not eat or drink in endoscopy
area.
35.5 Scope
35.7.3 Personnel will wear disposable gloves and gown
35.5.1 This unit provides diagnostic and therapeutic during procedure.
endoscopic services to neonates and children till
12 years of age. It includes diagnostic upper GI 35.7.4 Staff shall wear gloves and disposable gown
endoscopy, therapeutic upper GI endoscopy such during procedure.
as esophageal stricture dilatation, sclerotherapy,
variceal band ligation. Colonoscopy is also done 35.7.5 Patients first meet pediatric gastroenterologist in
for diagnostic purpose in cases of lower GI bleed opd, who decides for need of performing
and therapeutic as Polypectomy. Endoscopies endoscopy, then they get date from endoscopy
are routinely performed on three days in a week room and gets admitted on their scheduled date
and on emergency basis whenever needed. On with 6 hours of fasting. They are checked for not
routine days in cases of upper gi endoscopy having fever/respiratory illness before performing
children are called in hospital at 8 am and gets procedure.
admitted in endoscopy unit as short admission.
Procedure starts from 9 am after putting iv 35.8 Equipment and Supplies
cannula and taking informed consents with
parents. In cases of colonoscopy patients are 35.8.1 Disposable Equipment and Supplies:
admitted one day prior to procedure for bowel
preparation and procedure is performed next day 35.8.1.1 .Contaminated needles and syringes will be
at 9 am. Fasting of 6 hours is ensured in both the
disposed of in rigid, puncture-proof containers.
procedures. After procedures patients are
observed in hospital for six hours. Case sheet of Gloves are disposed in red dustbin after each
the patient with a copy of discharge is sent to procedure.
MRD, whereas a copy of clinical record Performa
is retained in the endoscopy unit. 35.8.2 Non-disposable Equipment and Supplies:
35.6 Procedure
35.6.1 Upper GI Endoscopy
816
35.8.2.1 All equipment maintenance is performed by the 35.8.3 Specimen Collection and Handling
contracted company. Endoscopes are cleaned
in water, multienzyme and then in cidex for 10 35.8.3.1 Samples collected during procedure are kept in
10% formalin and transported to histopathology
minutes after each procedure. In case of
hepatitis B or C infected cases it is kept for 30 department after procedure of that day is
minutes. Cidex is changed after two weeks. finished. Blood spills will be cleaned immediately
Date of preparation and date to be changed is with a 1:10 solution of bleach/water. During
mentioned in register and one slip is also pasted cleaning, gloves will be worn.
over cidex container to prevent use after two
weeks. Gloves will be worn during the cleaning
procedure. After procedure is finished 35.8.3.2 Specimens should be clearly labeled and should
endoscopes are kept in their designated area. include the following information: name of
patient, name of sample CR number and
35.8.2.2 All counter tops will be cleaned as needed with
accompanied with form mentioning name, CR
a hospital approved disinfectant. Daily room
number, short clinical history and differentials.
cleaning will also be provided by Housekeeping
Services.
35.8.3.3 Bowel Preparation Its mandatory before colonoscopy. Polyethylene glycol with electrolytes is used. Prescription is
written by doctor
35.8.3.4 Post procedure care and discharge All patients after endoscopy are kept in designated post endoscopy care are for
six hours for observation. Vitals and sensorium is monitored by staff. They are discharge once they are fully
conscious and starts accepting orally. In case any patients develop any complication as persistent pain abdomen,
persistent vomiting then they are admitted in ward under unit one and further management is done.
817
36 SARI (Severe Acute Respiratory Illness)
Responsibility of Dr D Saikia,
Updating:
Mo I/c Department SARI

updated on:
Version 1.0

819
36 SARI (Severe Acute Respiratory Illness) ........................................................................................ 819
36.1 SOP for SARI ward at the time of Covid-19 pandemic .............................................................. 821
36.2 Background ............................................................................................................................... 822
36.3 Surveillance case definitions for SARI ....................................................................................... 822
36.4 Close contact ............................................................................................................................. 823
36.5 Clinical syndromes associated with COVID - 19 infection......................................................... 823
36.6 Purpose of SARI ward................................................................................................................ 824
36.7 Scope of services- ..................................................................................................................... 825
36.8 Human resources- ……………………………………………………………………………………………………………….825
36.9 Immediate implementation of appropriate IPC measures ....................................................... 825
36.10 How to implement infection prevention and control measures for patients with suspected
or confirmed COVID - 19 infection ........................................................................................................ 825
36.11 Laboratory Diagnosis............................................................................................................. 827
36.12 Admission criteria for SARI ward from emergency / Inpatient Department ........................ 827
36.13 Flow Chart Registration Process: .......................................................................................... 827
36.14 Early supportive therapy and monitoring ............................................................................. 828
36.15 Points to remember .............................................................................................................. 829
36.16 Transfer of confirmed Covid –19 patients to Covid designated hospital ............................. 829
36.17 Discharge criteria- ................................................................................................................. 830
36.18 Death -................................................................................................................................... 830
36.19 Constant surveillance ............................................................................................................ 830

820
36.1 SOP for SARI ward at the time of Covid-19 pandemic
1. Background
2. Surveillance case definition of SARI
3. Definition of close contact
4. Clinical syndromes associated with COVID - 19 infection
5. Purpose of SARI ward
6. Scope of services
7. Human resource
8. Implementation of appropriate IPC measures
9. How to implement infection prevention and control measures for patients with suspected
or confirmed COVID - 19 infection
10. Laboratory diagnosis
11. Admission criteria for SARI ward from emergency / Inpatient Department
12. Flow chart of the registration process
13. Early supportive therapy and monitoring
14. Points to remember
15. Transfer of confirmed Covid –19 patients to Covid designated hospital
16. Discharge criteria
17. Death
18. Constant surveillance

821
36.2 Background
Coronavirus disease 2019 (COVID-19) is caused by SARS-CoV-2, a newly emergent coronavirus, that
was first recognized in Wuhan, China, in December 2019. Genetic sequencing of the virus suggests that
it is a betacoronavirus closely linked to the SARS virus. By way of definition, a symptomatic COVID-19
case is a person who has developed signs and symptoms suggestive of COVID-19.
Symptomatic transmission refers to transmission of SARS-CoV-2 from persons with symptoms.

Epidemiology and virological studies suggest that transmission mainly occurs from symptomatic people to
others by close contact through respiratory droplets, by direct contact with infected persons, or by contact
with contaminated objects and surfaces. Shedding of SARS-CoV-2 is highest in the upper respiratory
tract early in the course of the disease, within the first 3 days from onset of symptoms. The incubation
period for COVID-19, which is the time between exposure to the virus and symptom onset, is, on
average, 5–6 days, but can be up to 14 days. During this period, also known as the “presymptomatic”
period, some infected persons can be contagious, from 1–3 days before symptom onset. It is important to
recognize that presymptomatic transmission still requires the virus to be spread via infectious droplets or
by direct or indirect contact with bodily fluids from an infected person. An asymptomatic case is a person
infected with SARS-CoV-2 who does not develop symptoms.
While most people with COVID-19 develop only mild (40%) or moderate (40%) disease, approximately
15% develop severe disease that requires oxygen support, and 5% have critical disease with
complications such as respiratory failure, acute respiratory distress syndrome (ARDS), sepsis and septic
shock, thromboembolism, and/or multiorgan failure, including acute kidney injury and cardiac injury.
There are few data on the clinical presentation of COVID-19 in specific populations, such as children.
Clinical manifestations of COVID-19 are generally milder in children compared with adults. Relatively few
cases of infants confirmed with COVID-19 have been reported; infants also experience mild illness.
However, most recently, an acute presentation with a hyperinflammatory syndrome leading to multiorgan
failure and shock has been described, now described as multisystem inflammatory syndrome temporally
associated with COVID-19 in children and adolescents. Robust evidence associating underlying
conditions with severe illness in children is still lacking.
36.3 Surveillance case definitions for SARI

An ARI with history of fever or measured temperature ≥38 C° and cough; onset within the last ~10 days;
and requiring hospitalization.
A.SARI in a person, with history of fever and cough requiring admission to hospital, with no other etiology
that fully explains the clinical presentation1 (clinicians should also be alert to the possibility of atypical
presentations in patients who are immune-compromised); AND any of the following:
a) A history of international travel in 14 days prior to symptom onset; or
b) The disease occurs in a health care worker who has been working in an environment where patients
with severe acute respiratory infections are being cared for, without regard to place of residence or history
of travel; or
c) The person develops an unusual or unexpected clinical course, especially sudden deterioration despite
appropriate treatment, without regard to place of residence or history of travel, even if another etiology
has been identified that fully explains the clinical presentation
B. A person with acute respiratory illness of any degree of severity who, within 14 days before onset of
illness, had any of the following exposures:

822
a) Close physical contact with a confirmed case of COVID – 19 infection, while that patient was
symptomatic; or
b) A healthcare facility in a country where hospital-associated COVID - 19 infections have been reported;
Testing should be according to local guidance for management of community-acquired pneumonia.

Examples of other etiologies include Streptococcus pneumoniae, Haemophilus influenza type B,
Legionella pneumophila, other recognized primary bacterial pneumonias, influenza viruses, and
respiratory syncytial virus.
36.4 Close contact

1. Health care associated exposure, including providing direct care for COVID – 19 patients, working with
health care workers infected with COVID – 19, visiting patients or staying in the same close environment
of a COVID - 19 patients.
2. Working together in close proximity or sharing the same classroom environment with a COVID - 19
patient
3. Travelling together with COVID - 19 patient in any kind of conveyance.
4. Living in the same household as a COVID - 19 patients.
The epidemiological link may have occurred within a 14-day period before or after the onset of illness in
the case under consideration COVID–19 may present with mild, moderate, or severe illness; the latter
includes severe pneumonia, ARDS, sepsis and septic shock. Early recognition of suspected patients
allows for timely initiation of IPC. Early identification of those with severe manifestations allows for
immediate optimized supportive care treatments and safe, rapid admission (or referral) to intensive care
unit according to national protocols. For those with mild illness, hospitalization may not be required unless
there is concern for rapid deterioration. All patients discharged for home should be instructed to return to
hospital if they develop any worsening of illness.
36.5 Clinical syndromes associated with COVID - 19 infection
Uncomplicated illness Patients with uncomplicated upper respiratory

tract viral infection, may have non-specific
symptoms such as fever, cough, sore throat,
nasal congestion, malaise, headache. The elderly
and immunosuppressed may present with atypical
symptoms. These patients do not have any signs
of dehydration, sepsis or shortness of breath.
Mild pneumonia Patient with pneumonia and no signs of severe
pneumonia. Child with non-severe pneumonia has
cough or difficulty in breathing/ fast breathing:
(fast breathing - in breaths/min): <2 months, ≥60;
2–11 months, ≥50; 1–5 years, ≥40 and no signs of
severe pneumonia
Severe pneumonia Adolescent or adult: fever or suspected
respiratory infection, plus one of the following;
respiratory rate >30 breaths/min, severe

823
respiratory distress, SpO2 <90% on room air.
Child with cough or difficulty in breathing, plus at
least one of the following: central cyanosis or
SpO2 <90%; severe respiratory distress (e.g.
grunting, chest in-drawing); signs of pneumonia
with any of the following danger signs: inability to
breastfeed or drink, lethargy or unconsciousness,
or convulsions. Other signs of pneumonia may be
present: chest indrawing, fast breathing (in
breaths/min): <2 months ≥60; 2–11 months ≥50;
1–5 years ≥40. The diagnosis is clinical; chest
imaging can exclude complications.
Acute Respiratory Distress Syndrome Onset: new or worsening respiratory symptoms
within one week of known clinical insult. Chest
imaging (radiograph, CT scan, or lung
ultrasound): bilateral opacities, not fully explained
by effusions, lobar or lung collapse, or nodules.
Origin of oedema: respiratory failure not fully
explained by cardiac failure or fluid overload.
Need objective assessment (e.g.
echocardiography) to exclude hydrostatic cause of
oedema if no risk factor presentOxygenation
(children; note OI = Oxygenation Index and OSI =
V or
CPAP ≥5 cm H2O via full face mask: PaO2/FiO2
(invasively ventilated): 4 ≤ OI < 8 or 5 ≤ OSI < 7.5
(invasively ventilated): OI ≥ 16 or OSI ≥ 12.3

Sepsis Children: suspected or proven infection and ≥2
SIRS criteria, of which one must be abnormal
temperature or white blood cell count
Septic shock Children: any hypotension (SBP <5th centile or >2
SD below normal for age) or 2-3 of the following:
altered mental state; bradycardia or tachycardia
(HR <90 bpm or >160 bpm in infants and HR <70
bpm or >150 bpm in children); prolonged capillary
refill (>2 sec) or warm vasodilation with bounding
pulses; tachypnea; mottled skin or petechial or
purpuric rash; increased lactate; oliguria;
hyperthermia or hypothermia
36.6 Purpose of SARI ward
The purpose of triage and establishment of SARI ward is to recognize and sort all patients with COVID -
19 at first point of contact with health care system (such as the emergency department). Consider COVID
– 19 as a possible etiology under certain conditions. Triage patients and start emergency treatments
based on disease severity and appropriate management and timely referral to Covid designated
hospitals.

824
36.7 Scope of services- This policy is applicable to all patient Transferred / Admitted to SARI
from following areas:
A. Emergency Department B. Wards/ Inpatient Department
36.8 Human resources- Treating consultant, Medical officer, Residents and Nursing staff
Ancillary staff – ICU Technician, Physiotherapist, Dietician, Radiographer
SARI ward at CNBC offers comprehensive care 24 hours a day. Qualified Pediatricians with good airway
and pediatric advances life support skills and offer round the clock service in SARI ward. Medical officer
on duty call consultant in case of Critical situation of patient apart from routine working hours of CNBC
and consultant attend the case.
36.9 Immediate implementation of appropriate IPC measures

IPC is a critical and integral part of clinical management of patients and should be initiated at the point of
entry of the patient to hospital (typically the Emergency Department). Standard precautions should always
be routinely applied in all areas of health care facilities. Standard precautions include hand hygiene; use
of PPE to avoid direct contact with patients’ blood, body fluids, secretions (including respiratory
secretions) and non-intact skin. Standard precautions also include prevention of needle-stick or sharps
injury; safe waste management; cleaning and disinfection of equipment; and cleaning of the environment.
36.10 How to implement infection prevention and control measures for patients with suspected
or confirmed COVID - 19 infection
At triage Ask the suspected patient to wear a medical mask
and direct the patient to a separate area, ideally
Instructions for patients an isolation room/area if available. Keep at least 1
m distance between patients. Instruct all patients
to cover nose and mouth during coughing or
sneezing with tissue or flexed elbow, dispose of
tissues safely immediately after use in a closed
bin and perform hand hygiene after contact with
respiratory secretions.
At triage Give suspect patient a triple layer surgical mask
and direct patient to separate area, an isolation
room if available. Keep at least 1meter distance
between suspected patients and other patients.
Instruct all patients to cover nose and mouth
during coughing or sneezing with tissue or flexed
elbow for others. Perform hand hygiene after
contact with respiratory secretions
Apply droplet precautions Droplet precautions prevent large droplet
transmission of respiratory viruses. Use a triple
layer surgical mask if working within 1-2 metres of
the patient. Place patients in single rooms, or
group together those with the same etiological
diagnosis. If an etiological diagnosis is not
possible, group patients with similar clinical
diagnosis and based on epidemiological risk

825
factors, with a spatial separation. When providing
care in close contact with a patient with
respiratory symptoms (e.g. coughing or sneezing),
use eye protection (face-mask or goggles),
because sprays of secretions may occur. Limit
patient movement within the institution and ensure
that patients wear triple layer surgical masks
when outside their rooms
Apply contact precautions Droplet and contact precautions prevent direct or
indirect transmission from contact with
contaminated surfaces or equipment (i.e. contact
with contaminated oxygen tubing/interfaces). Use
PPE (triple layer surgical mask, eye protection,
gloves and gown) when entering room and
remove PPE when leaving. If possible, use either
disposable or dedicated equipment (e.g.
stethoscopes, blood pressure cuffs and
thermometers). If equipment needs to be shared
among patients, clean and disinfect between each
patient use. Ensure that health care workers
refrain from touching their eyes, nose, and mouth
with potentially contaminated gloved or ungloved
hands. Avoid contaminating environmental
surfaces that are not directly related to patient
care (e.g. door handles and light switches).
Ensure adequate room ventilation. Avoid
movement of patients or transport. Perform hand
hygiene
Apply airborne precautions when performing Ensure that healthcare workers performing
an aerosol generating procedure aerosol-generating procedures (i.e. open
suctioning of respiratory tract, intubation,
bronchoscopy, cardiopulmonary resuscitation) use
PPE, including gloves, long-sleeved gowns, eye
protection, and fit-tested particulate respirators
(N95). (The scheduled fit test should not be
confused with user seal check before each use.)
Whenever possible, use adequately ventilated
single rooms when performing aerosol-generating
procedures, meaning negative pressure rooms
with minimum of 12 air changes per hour or at
least 160 litres/second/patient in facilities with
natural ventilation. Avoid the presence of
unnecessary individuals in the room. Care for the
patient in the same type of room after mechanical
ventilation commences
Abbreviations: ARI, acute respiratory infection; PPE, personal protective equipment
36.11 .Laboratory Diagnosis
Guidance on specimen collection, processing, transportation, including related biosafety procedures, is

available at: https://www.mohfw.gov.in/pdf/5Sample%20collection_packaging%20%202019-nCoV.pdf

826
Sample collection Preferred sample Throat and nasal swab in viral transport
media (VTM) and
transported in cold chain.
Alternate Nasopharyngeal swab, BAL or endotracheal

aspirate which has to be mixed with the viral
transport medium and transported in cold
chain.
36.12 Admission criteria for SARI ward from emergency / Inpatient Department
Fever with cough and / or shortness of breath
Fatigue / Sore throat / poor oral acceptance
Diarrhoea and vomiting
Immunocompromised children with respiratory or GI symptoms
Immunocompromised children with non-specific or unexplained symptoms
Unexplained meningoencephalitis
Kawasaki disease
Children with acute history with multi-organ involvement
Any sick patient with unusual or unexplained symptoms
36.13 Flow Chart Registration Process:
Admission slip filled by the registration counter staff
Relatives sign consent for admission for not keeping any valuables with them.
Patient record file containing the registration slip, admission form, case Papers and visitor passes
over to attendant
Patient shifted to SARI as indicated after stabilization in emergency ward

827
High risk consent taken and prognosis explained to attendants
36.14 .Early supportive therapy and monitoring

Children with suspected or confirmed COVID-19 infection should be kept together with caregivers
wherever possible (if caregivers also have suspected or confirmed COVID-19 infection), and cared for in
child-friendly spaces, taking into account specific medical, nursing, nutritional, and mental health and
psychosocial support needs of children.
A. Give supplemental oxygen therapy immediately to patients with SARI and respiratory distress,
hypoxaemia, or shock: Initiate oxygen therapy at 5 L/min and titrate flow rates to reach target SpO2 ≥90%
in non-pregnant adults and SpO2 ≥92-95 % in pregnant patients. Children with emergency signs
(obstructed or absent breathing, severe respiratory distress, central cyanosis, shock, coma or
convulsions) should receive oxygen therapy during resuscitation to target SpO2 ≥94%; otherwise, the
target SpO2 is ≥90%. All areas where patients with SARI are cared for should be equipped with pulse
oximeters, functioning oxygen systems and disposable, single-use, oxygen-delivering interfaces (nasal
cannula, simple face mask, and mask with reservoir bag). Use contact precautions when handling
contaminated oxygen interfaces of patients with COVID – 19.
B. Use conservative fluid management in patients with SARI when there is no evidence of shock: Patients
with SARI should be treated cautiously with intravenous fluids, because aggressive fluid resuscitation
may worsen oxygenation, especially in settings where there is limited availability of mechanical
ventilation.
C. Give empiric antimicrobials to treat all likely pathogens causing SARI. Give antimicrobials within one
hour of initial patient assessment for patients with sepsis: Although the patient may be suspected to have
COVID - 19, Administer appropriate empiric antimicrobials within ONE hour of identification of sepsis.
Empirical antibiotic treatment should be based on the clinical diagnosis (community-acquired pneumonia,
health care-associated pneumonia [if infection was acquired in healthcare setting], or sepsis), local
epidemiology and susceptibility data, and treatment guidelines. Empirical therapy includes a
neuraminidase inhibitor for treatment of influenza when there is local circulation or other risk factors,
including travel history or exposure to animal influenza viruses. Empirical therapy should be de-escalated
on the basis of microbiology results and clinical judgment
To exclude other common diseases - Patients with fever should be tested for the presence of malaria
or other co-infections with validated rapid diagnostic tests (RDTs) or thick and thin blood films and treated
as appropriate. Arbovirus infection (dengue/chikungunya) should also be considered in the differential
diagnosis of undifferentiated febrile illness, particularly when thrombocytopenia is present. Co-infection
with COVID-19 virus may also occur and a positive diagnostic test for dengue (e.g. dengue RDTs) does
not exclude the testing for COVID-19. If TB is also suspected, collect sputum with specific instructions
(e.g. to be done in open area outside the home and away from others) or in an open, well-ventilated
space – preferably outside of the health facility.
D. Do not routinely give systemic corticosteroids for treatment of viral pneumonia or ARDS outside of
clinical trials unless they are indicated for another reason. Given lack of effectiveness and possible harm,
routine corticosteroids should be avoided unless they are indicated for another reason.

828
E. Closely monitor patients with SARI for signs of clinical deterioration, such as rapidly progressive
respiratory failure and sepsis, and apply supportive care interventions immediately: Application of timely,
effective, and safe supportive therapies is the cornerstone of therapy for patients that develop severe
manifestations of COVID – 19.
F. Understand the patient’s co-morbid condition(s) to tailor the management of critical illness and
appreciate the prognosis: During intensive care management of SARI, determine which chronic therapies
should be continued and which therapies should be stopped temporarily.
G. Communicate early with patient and family: Communicate pro-actively with patients and families and
provide support and prognostic information. Understand the patient’s values and preferences regarding
life-sustaining interventions.
Collection of specimens for laboratory diagnosis
Guidance on specimen collection, processing, transportation, including related biosafety procedures, is

available on https://mohfw.gov.in/media/disease-alerts
36.15 .Points to remember
1.Collect blood cultures for bacteria that cause pneumonia and sepsis, ideally before antimicrobial
therapy. DO NOT delay antimicrobial therapy to collect blood cultures
2.Collect specimens of nasopharyngeal and oropharyngeal swab for RT - PCR. Clinicians
may also collect LRT (Lower Respiratory Tract) samples when these are readily available (for example, in
mechanically ventilated patients).
3.Use appropriate PPE for specimen collection (droplet and contact precautions for URT specimens;
airborne precautions for LRT specimens). When collecting URT samples, use viral swabs (sterile Dacron
or rayon, not cotton) and viral transport media. Do not sample the nostrils or tonsils. In a patient with
suspected COVID - 19, especially with pneumonia or severe illness, a single URT sample does not
exclude the diagnosis, and additional URT and LRT samples are recommended. Sputum induction should
be avoided due to increased risk of increasing aerosol transmission.
Dual infections with other respiratory viral infections have been found in SARS and MERS cases. At this
stage we need detailed microbiologic studies in all suspected COVID - 19 cases. Both URT and LRT
specimens can be tested for other respiratory viruses, such as influenza A and B (including zoonotic
influenza A), respiratory syncytial virus, parainfluenza viruses, rhinoviruses, adenoviruses, enteroviruses
(e.g. EVD68), human metapneumovirus, and endemic human coronaviruses (i.e. HKU1, OC43, NL63,
and 229E). LRT specimens can also be tested for bacterial pathogens, including Legionella pneumophila.
36.16 .Transfer of confirmed Covid –19 patients to Covid designated hospital
Inform the local health authorities about the case
Assess the clinical status of the patient prior to referral to a designated COVID facility
If the clinical status of the case permits, transfer such case to a COVID-19 isolationfacility (Dedicated
COVID Health Centre or dedicated COVID Hospital), informing thefacility beforehand about the transfer,

829
as per his/her clinical status, test results (ifavailable), with information to local health authority. Complete
case records of suchpatients must be made available to the receiving hospital.
Follow appropriate standard precautions while transporting the patient
This should be followed by disinfection procedures at the facility and the ambulance
36.17 .Discharge criteria-
A.For mild/very mild/pre-symptomatic cases –
Patient can be discharged after 10 days of symptom onset and no fever for 3 days
No need for testing prior to discharge
Patient will be advised to isolate himself/herself at home & self-monitor his/her health for further 7 days
B. For moderate cases patient can be discharged
If asymptomatic for 3 days and
After 10 days of symptom onset
No need for testing prior to discharge
Patient will be advised to isolate himself/herself at home & self-monitor his/her health for further 7 days
C.For severe cases
Clinical recovery
Patient tested negative once by RT-PCR (after resolution of symptoms)
36.18 .Death -
36.19 .Constant surveillance
A. Ensure that active screening of all staff at the hospitals is done daily (by means of
thermal screening especially at the start of shift)
B. All healthcare and supportive staff is encouraged to monitor their own health at all the
time for appearance of COVID-19 symptoms and report them at the earliest.
C. Be on the lookout for atypical presentation (or clinical course) of admitted patients
D. Standard precautions to be followed diligently by all.
E. Follow all guidelines regarding triaging of patients in hospital emergency and outpatient
departments.

830

Apex Manual

Uploaded by

Copyright:

Available Formats

Apex Manual

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Apex Manual

Uploaded by

Copyright:

Available Formats

CHACHA NEHRU BAL CHIKITSALAYA

APEX MANUAL VERSION 4.7

CHACHA NEHRU BAL CHIKITSALAYA

3 INPATIENT SERVICE (PEDIATRIC MEDICINE) 26

4 PEDIATRIC INTENSIVE CARE UNIT (PICU) 36

5 NEONATAL INTENSIVE CARE UNIT (NICU) 50

8 DEPARTMENT OF PEDIATRIC SURGERY 79

9 DEPARTMENT OF ORTHOPEDIC SURGERY 91

10 DEPARTMENT OF OPHTHALMOLOGY 101

11 DEPARTMENT OF ENT 107

12 DEPARTMENT OF DENTAL SURGERY 114

13 DEPARTMENT OF ANESTHESIA 119

14 DEPARTMENT OF CSSD 149

15 OPERATION THEATRE 164

16 NURSING PROCEDURES 217

17 LABORATORY DIVISION 252

18 DEPARTMENT OF RADIOLOGY AND IMAGING SERVICES 337

CNBC Manual Version 4.7

20 DEPARTMENT OF PHYSIOTHERAPY 386

21 DEPARTMENT OF OCCUPATIONAL THERAPY 400

23 MEDICAL RECORDS 440

24 CODE PINK POLICY 458

25 MANUAL FOR OPERATIONS (SECURITY) 464

26 DEPARTMENT OF TRANSPORTATION (AMBULANCE) 486

27 PRIVATE WARD 493

28 HOSPITAL WIDE POLICIES 499

30 DEPARTMENT OF GAS MANIFOLD 661

31 MATERIAL MANAGEMENT (PURCHASE, STORE AND MAINTENANCE) 680

32 DEPARTMENT OF SPEECH THERAPY 784

33 DEPARTMENT OF MEDICAL SOCIAL WORKER 794

34 CLINICAL PSYCHOLOGY 801

CNBC Manual Version 4.7

Date created: 1st May 2008

Approved by: Director

Responsibility of Department of Outpatient

Last reviewed/ August 2020

CNBC Manual Version 4.7

CNBC Manual Version 4.7

S.No. Clause Date of Amendment Amendment Made Reason s of Sign of QM

CNBC Manual Version 4.7

1.2.1 Chacha Nehru Bal Chikitsalaya is super- 1.4 Scope:

1.1.1 In addition to routine OPD, other facilities 1.4.4 Immunization services

1.7.2 In case of any clarification sort by the

CNBC Manual Version 4.7

CNBC Manual Version 4.7

Patient comes to registration counter.

Entry in the computer by the person at this

Unique patient ID Registration no. is

entered in the OPD card

OPD card with patient’s name, gender, age,

Height & weight is checked and recorded in the OPD card

(NOW A DAYS NO TOKEN IS GIVEN- THIS LINE MAY BE OMITED)

Goes to laboratory /x-ray dept.for

Goes to the dispensary to Scheduled for Admission

CNBC Manual Version 4.7

Patient comes with old OPD card at the registration counter.

OPD card is stamped and dated by the registration staff

and handed over to the patient.

Height and weight of patient is done

Token number for concerned OPD room is provided